Borderline ankle-brachial index is associated with increased prevalence of micro- and macrovascular complications in type 2 diabetes: A cross-sectional analysis of 12,772 patients from the Joint Asia Diabetes Evaluation Program

Utilities for Complications Associated with Type 2 Diabetes: A Review of the Literature

INTRODUCTION

Utility values are used in health economic modeling analyses of type 2 diabetes (T2D) to quantify the effect of acute and long-term complications on quality of life (QoL). For accurate modeling projections, it is important that the utility values used are up to date, accurate and representative of the simulated model cohort.

METHODS

A literature review was performed to identify utility values for health states representing acute and chronic T2D-related complications including cardiovascular complications, stroke, renal disease, ophthalmic complications, neuropathy, diabetic foot, amputation and hypoglycemia. Searches were performed using the PubMed, Embase and Cochrane Library databases and limited to articles published since 2010. Supplementary searches were performed to identify data published at congresses in 2019-2023.

RESULTS

A total of 54 articles were identified that reported utility values for T2D-related complications. The most frequently used elicitation method/instrument was the EQ-5D (n = 42 studies) followed by the Short Form-6 dimensions (n = 6), time tradeoff (n = 5), the Health Utilities Index Mark 2 or Mark 3 (n = 2), 15D (n = 1), visual analog scale (n = 1) and standard gamble (n = 1). Stroke and amputation were consistently associated with the largest decrements in QoL. There is a lack of published data that distinguishes between severity of several complications including renal disease, retinopathy and neuropathy.

CONCLUSIONS

Diabetes-related complications can have a profound impact on QoL; therefore, it is important that these are captured accurately and appropriately in health economic models. Recently published utility values for diabetes-related complications that can be used to inform health economic models are summarized here.

Diabetes-Related Macrovascular Complications Are Associated With an Increased Risk of Diabetic Microvascular Complications: A Prospective Study of 1518 Patients With Type 1 Diabetes and 20 802 Patients With Type 2 Diabetes in the UK Biobank

BACKGROUND

Diabetic vascular complications share common pathophysiological mechanisms, but the relationship between diabetes-related macrovascular complications (MacroVCs) and incident diabetic microvascular complications remains unclear. We aimed to investigate the impact of MacroVCs on the risk of microvascular complications.

METHODS AND RESULTS

There were 1518 participants with type 1 diabetes (T1D) and 20 802 participants with type 2 diabetes from the UK Biobank included in this longitudinal cohort study. MacroVCs were defined by the presence of macrovascular diseases diagnosed after diabetes at recruitment, including coronary heart disease, peripheral artery disease, stroke, and ≥2 MacroVCs. The primary outcome was incident microvascular complications, a composite of diabetic retinopathy, diabetic kidney disease, and diabetic neuropathy. During a median (interquartile range) follow-up of 11.61 (5.84-13.12) years and 12.2 (9.50-13.18) years, 596 (39.3%) and 4113 (19.8%) participants developed a primary outcome in T1D and type 2 diabetes, respectively. After full adjustment for conventional risk factors, Cox regression models showed significant associations between individual as well as cumulative MacroVCs and the primary outcome, except for coronary heart disease in T1D (T1D: diabetes coronary heart disease: 1.25 [0.98-1.60]; diabetes peripheral artery disease: 3.00 [1.86-4.84]; diabetes stroke: 1.71 [1.08-2.72]; ≥2: 2.57 [1.66-3.99]; type 2 diabetes: diabetes coronary heart disease: 1.59 [1.38-1.82]; diabetes peripheral artery disease: 1.60 [1.01-2.54]; diabetes stroke: 1.50 [1.13-1.99]; ≥2: 2.66 [1.92-3.68]). Subgroup analysis showed that strict glycemic (glycated hemoglobin <6.5%) and blood pressure (<140/90 mm Hg) control attenuated the association.

CONCLUSIONS

Individual and cumulative MacroVCs confer significant risk of incident microvascular complications in patients with T1D and type 2 diabetes. Our results may facilitate cost-effective high-risk population identification and development of precise prevention strategies.

Prevalence of and Risk Factors for Peripheral Artery Disease in Rural South Africa: A Cross-Sectional Analysis of the HAALSI Cohort

BACKGROUND

The burden of peripheral artery disease (PAD) is increasing in low- and middle-income countries. Existing literature from sub-Saharan Africa is limited and lacks population-representative estimates. We estimated the burden and risk factor profile of PAD for a rural South African population.

METHODS AND RESULTS

We used data from 1883 participants from a rural, low-income cohort of South African adults aged 40 to 69 years with available ankle-brachial index measurements. We defined clinical PAD as ankle-brachial index ≤0.90 or >1.40, and borderline PAD as ankle-brachial index >0.90 and ≤1.00. We compared the distribution of sociodemographic variables, biomarkers, and comorbidities across PAD classifications. To identify associated factors, we calculated unadjusted and age-sex-adjusted prevalence ratios (PRs) with log-binomial models. Overall, 6.6% (95% CI, 5.6-7.7) of the sample met the diagnostic criteria for clinical PAD, while 44.7% (95% CI, 42.4-47.0) met the diagnostic criteria for borderline PAD. Age (PR: 1.9 [95% CI, 1.2-3.1] for ages 50-59 years compared with 40-49 years; PR: 2.5 [95% CI, 1.5-4.0] for ages 60-69 years compared with 40-49 years); diagnosed hypertension (PR: 1.53 [95% CI, 1.08-2.17]); and C-reactive protein (PR: 1.08 [95% CI, 1.03-1.12]) were associated with increased prevalence of clinical PAD. All other examined factors were not significantly associated with clinical PAD.

CONCLUSIONS

We found high PAD prevalence for younger age groups compared with previous research and a lack of statistical evidence for the influence of traditional risk factors for this rural, low-income population. Future research should focus on identifying the underlying risk factors for PAD in this setting. South African policymakers and clinicians should consider expanded screening for early PAD detection in rural areas.

Burden of disease and costs associated with type 2 diabetes in emerging and established markets: systematic review analyses

Objectives: To estimate the clinical and economic burden of type 2 diabetes (T2D) in established (EST) and emerging markets (EMG).Methods: Three systematic literature reviews were conducted in MEDLINE and Embase to capture all relevant publications reporting 1) the epidemiology of T2D and complications in T2D and 2) the economic burden of T2D and associated complications.Results: In total, 294 studies were included in this analysis. Evidence indicates a high and increasing overall prevalence of T2D globally, ranging up to 23% in EMG markets and 14% in EST markets. Undiagnosed cases were higher in EMG versus EST markets (up to 67% vs 38%), potentially due to a lack of education and disease awareness in certain regions, that could lead to important clinical and economic consequences. Poor glycemic control was associated with the development of several complications (e.g. retinopathy, cardiovascular diseases and nephropathy) that increase the risk of morbidity and mortality. Direct costs were up to 9-fold higher in patients with vs without T2D-related complications.Conclusions: The burden of T2D, related complications and inherent costs are higher in emerging versus established market countries. This review explores potential strategies to reduce costs and enhance outcomes of T2D treatment in developing countries.

Predicting Stroke Outcomes Using Ankle-Brachial Index and Inter-Ankle Blood Pressure Difference

Background: This study investigated the association of high ankle-brachial index difference (ABID) and systolic inter-ankle blood pressure difference (IAND) with short- and long-term outcomes in acute ischemic stroke patients without peripheral artery disease (PAD). Methods: Consecutive patients with acute ischemic stroke who underwent ankle-brachial index (ABI) measurement were enrolled. ABID was calculated as |right ABI-left ABI|. IAND and systolic inter-arm blood pressure difference (IAD) were calculated as |right systolic blood pressure – left systolic blood pressure|. Poor functional outcome was defined as modified Rankin Scale score ≥3 at 3 months. Major adverse cardiovascular events (MACEs) were defined as stroke recurrence, myocardial infarction, or death. Results: A total of 2901 patients were enrolled and followed up for a median of 3.1 (interquartile range, 1.6–4.7) years. Among them, 2643 (84.9%) patients did not have PAD. In the logistic regression analysis, ABID ≥ 0.15 and IAND ≥ 15 mmHg were independently associated with poor functional outcome (odds ratio (OR), 1.970, 95% confidence interval (CI), 1.175‒3.302; OR, 1.665, 95% CI, 1.188‒2.334, respectively). In Cox regression analysis, ABID ≥0.15 and IAND ≥ 15 mmHg were independently associated with MACEs (hazard ratio (HR), 1.514, 95% CI, 1.058‒2.166; HR, 1.343, 95% CI, 1.051‒1.716, respectively) and all-cause mortality (HR, 1.524, 95% CI, 1.039‒2.235; HR, 1.516, 95% CI, 1.164‒1.973, respectively) in patients without PAD. Conclusion: High ABID and IAND are associated with poor short-term outcomes, long-term MACE occurrence, and all-cause mortality in acute ischemic stroke without PAD.

The medications and health care utilization of patients newly diagnosed with type 2 diabetes mellitus: A nationwide population-based cohort study

BACKGROUND/PURPOSE

The prevalence of young-onset diabetes (YOD) is increasing in Asia, but little is known about the metabolic control, associated complications, or medical behavior in this population. Our aim was to assess the prevalence of young-onset and late-onset type 2 diabetes mellitus (T2DM) and their associated risk factors and medical behaviors in Taiwan.

METHODS

Data were collected from the National Health Insurance Research Database of Taiwan on 11,244 patients from 2008 to 2013. We classified patients with young-onset diabetes if they were diagnosed before 40 years of age and late-onset diabetes (LOD) if diagnosed at 40 years of age or older. We analyzed the prevalence, medication, and medical behaviors between these groups.

RESULTS

We enrolled 2556 newly diagnosed T2DM patients in 2012. Demographics and comorbidities were recorded from YOD (n = 311) and LOD (n = 2245) patients. Most newly diagnosed patients started with monotherapy and almost half of them with sulfonylurea. The prevalence of YOD in Taiwan is up to 12%. In terms of treatment, 42% of T2DM patients are treated in clinics, 58% in hospital, and 25.2% by an endocrinologist.

CONCLUSION

Our study highlights the rising trend of YOD in Taiwan. National endeavors are urgently needed for early diagnosis, effective management, and primary prevention of diabetes.

Ankle Brachial Index Predicts for Difficulties in Performing Microvascular Anastomosis

PURPOSE

In reconstructive microsurgery, severe arteriosclerosis is a known predictor for free flap failure because of problems with the vascular anastomosis. We investigated whether the ankle brachial index (ABI) could be a suitable preoperative measurement for the prediction of compromise regarding vascular anastomosis in patients undergoing microsurgical reconstruction.

MATERIAL AND METHODS

We conducted a prospective cohort study of patients who had undergone reconstructive microvascular surgery in a tertiary care center from 2015 to 2017. The ABI was preoperatively assessed by dividing the systolic blood pressure measured at the ankle by the brachial systolic blood pressure. Results from 0.9 to 1.3 are within the physiologic range. Values less than 0.9 indicate moderate to severe arteriosclerosis, and those greater than 1.3 indicate the major form of arteriosclerosis with complete calcification of the tunica media. The ABI value correlated with the ease of the anastomosis (rated from 1 [very straightforward] through 5 [very difficult]), gross examination findings (intraluminal plaque [yes vs no]), and the necessity of plaque removal before anastomosis (yes vs no). In addition, cross-sectional specimens were obtained from the arteries and veins of the donor and recipient sites intraoperatively. The specimens were rated histologically for the arteries and veins using an ordinal scale. Histologic evaluation was performed to confirm and objectify the results from the ABI. Statistical analysis was performed using SPSS software, version 24.0 (IBM Corp, Armonk, NY) and t tests, analysis of variance, and χ² tests.

RESULTS

The sample included 41 patients with a mean age of 56.7 years; 59% were men. The mean ABI was 1.06. The mean ease of anastomosis was 1.8. The mean ABI was associated with the ease of anastomosis. A pathologic ABI was significantly related to problems with the arterial anastomosis (P = .004) and increased arteriosclerosis in the arteries from the donor (P = .047) and recipient (P = .036) sites.

CONCLUSIONS

A pathologic ABI was associated with increased difficulty with the microvascular anastomosis.

The ankle brachial index exhibits better association with cardiovascular outcomes than interarm systolic blood pressure difference in patients with type 2 diabetes

Increased interarm systolic blood pressure difference (IASBPD) is associated with cardiovascular prognosis in the general population. This study aimed to evaluate whether IASBPD or ankle brachial index (ABI) is strongly associated with cardiovascular outcomes in patients with type 2 diabetes.Total 446 type 2 diabetes followed up for a mean 5.8 years divided by ABI (<0.9 vs ≥0.9) or IASBPD (<10 vs ≥10 mm Hg). The primary outcome was a composite of all-cause mortality, hospitalization for coronary artery disease, nonfatal stroke, carotid, or peripheral revascularization, amputations, and diabetic foot syndrome. The secondary endpoint was all-cause mortality.Sixty-four composite events and 17 deaths were identified. The primary and secondary outcomes were higher than those in the group with ABI < 0.9 vs ABI ≥ 0.9 (32.8% vs 11.6%, P < .005 for primary outcome; 14.0% vs 2.3%, P < .005 for all-cause mortality) but IASBPD cannot exhibit a prognostic value. ABI < 0.9 was also the dominant risk factor of both endpoints demonstrated by multivariate Cox proportional analysis (composite events: adjusted hazard ratio [HR], 2.39; 95% confidence interval [CI], 1.26-4.53; P = .007; all-cause mortality: adjusted HR, 3.27: 95% CI, 1.91-5.60; P < .001).The ABI was more associated with cardiovascular outcomes in patients with diabetes than IASBPD.

Association between diabetic eye disease and other complications of diabetes: Implications for care. A systematic review

The aim of this systematic review was to examine the associations between diabetic retinopathy (DR) and the common micro- and macrovascular complications of diabetes mellitus, and how these could potentially affect clinical practice. A structured search of the PubMed database identified studies of patients with diabetes that assessed the presence or development of DR in conjunction with other vascular complications of diabetes. From 70 included studies, we found that DR is consistently associated with other complications of diabetes, with the severity of DR linked to a higher risk of the presence of, or of developing, other micro- and macrovascular complications. In particular, DR increases the likelihood of having or developing nephropathy and is also a strong predictor of stroke and cardiovascular disease, and progression of DR significantly increases this risk. Proliferative DR is a strong risk factor for peripheral arterial disease, which carries a risk of lower extremity ulceration and amputation. Additionally, our findings suggest that a patient with DR has an overall worse prognosis than a patient without DR. In conclusion, this analysis highlights the need for a coordinated and collaborative approach to patient management. Given the widespread use of DR screening programmes that can be performed outside of an ophthalmology office, and the overall cost-effectiveness of DR screening, the presence and severity of DR can be a means of identifying patients at increased risk for micro- and macrovascular complications, enabling earlier detection, referral and intervention with the aim of reducing morbidity and mortality among patients with diabetes. Healthcare professionals involved in the management of diabetes should encourage regular DR screening.

Prognostic impact of the ankle-brachial index on the development of micro- and macrovascular complications in individuals with type 2 diabetes: the Rio de Janeiro Type 2 Diabetes Cohort Study

AIMS/HYPOTHESIS

The prognostic importance of the ankle-brachial index (ABI) in individuals with diabetes is controversial. We aimed to evaluate the relationship between the ABI and the occurrence of micro- and macrovascular complications in individuals with type 2 diabetes.

METHODS

The ABI was measured at baseline in 668 individuals with type 2 diabetes, and the individuals were followed-up for a median of 10 years. Multivariate Cox analysis was used to examine associations between the ABI and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration and peripheral neuropathy) and macrovascular (total cardiovascular events, major adverse cardiovascular events [MACE] and cardiovascular mortality) complications, and all-cause mortality. The improvement in risk stratification was assessed using the C statistic and the integrated discrimination improvement (IDI) index.

RESULTS

During follow-up, 168 individuals had a cardiovascular event (140 MACE) and 191 individuals died (92 cardiovascular deaths); 156 individuals newly developed or experienced worsening diabetic retinopathy, 194 achieved the renal composite outcome (122 with newly developed microalbuminuria and 93 with deteriorating renal function) and 95 newly developed or experienced worsening peripheral neuropathy. The ABI, either analysed as a continuous or as a categorical variable, was significantly associated with all macrovascular and mortality outcomes, except for non-cardiovascular mortality. Individuals with a baseline ABI of ≤0.90 had a 2.1-fold increased risk of all-cause mortality (95% CI 1.3, 3.5; p = 0.004), a 2.7-fold excess risk of cardiovascular mortality (95% CI 1.4, 5.4; p = 0.004) and a 2.5-fold increased risk of MACE (95% CI 1.5, 4.4; p = 0.001). The ABI improved risk discrimination over classical risk factors, with relative IDIs ranging from 6.3% (for all-cause mortality) to 31% (for cardiovascular mortality). In addition, an ABI of ≤0.90 was associated with the development or worsening of peripheral neuropathy (2.1-fold increased risk [95% CI 1.1, 4.3]; p = 0.033), but not with retinopathy or renal outcomes.

CONCLUSIONS/INTERPRETATION

A low ABI is associated with excess risk of adverse cardiovascular outcomes, mortality and peripheral neuropathy development or worsening, and improves cardiovascular risk stratification. The ABI should therefore be routinely evaluated in individuals with type 2 diabetes.

The quality of life in Chinese population with chronic non-communicable diseases according to EQ-5D-3L: a systematic review

PURPOSE

Over the past decade, a changing spectrum of disease has turned chronic non-communicable diseases (CNCDs) into the leading cause of death worldwide. During the 2015 in China, there were more than 6.6 million deaths from NCDs, which was the highest rate around the world. In the present study, we performed a systematic review to analyze the health-related quality of life (HRQoL) according to EQ-5D-3L instrument in patients with different kinds of CNCDs in China.

METHODS

We searched PubMed, Embase, Web of Science, Cochrane Library, VIP, WanFang Data, and CNKI databases up to April 12, 2018, to identify all relevant studies that reported on HRQoL assessed by EQ-5D-3L instrument in Chinese patients with CNCDs. Expert consultation and hand-searching of reference lists from retrieved studies were employed to identify additional references. The variation of mean utility values, EQ-VAS score ranges, and responses for each EQ-5D dimension described in relevant studies were extracted.

RESULTS

A total of 5027 English-language articles and 618 Chinese-language articles were identified, among which 38 articles met full inclusion criteria. These 38 studies involved 18 kinds of CNCDs. In this review, the health utility for diabetes mellitus ranged from 0.79 to 0.94 (EQ-5D VAS scores from 61.5 to 78.6), hypertension from 0.78 to 0.93 (70.1-77.4), coronary heart disease from 0.75 to 0.90 (71.0-77.0), chronic obstructive pulmonary disease from 0.64 to 0.80 (55.0-67.0), epilepsy from 0.83 to 0.87 (78.3-79.6), cerebral infarction from 0.51 to 0.75 (49.7-79.0), while children cerebral palsy was 0.44 (27.3).

CONCLUSIONS

EQ-5D-3L is widely used in studies of HRQoL associated with CNCDs in China. Our results suggest that many factors may influence the measurement results of health utilities, including age, gender, sample source, comorbidities, rural/urban, and EQ-5D-3L value sets.

Relationship between Systemic Vascular Characteristics and Retinal Nerve Fiber Layer Loss in Patients with Type 2 Diabetes

Retinal nerve fiber layer (RNFL) loss in diabetic patients is especially common regardless of diabetic retinopathy (DR). The correlations between nonglaucomatous RNFL loss and systemic characteristics in diabetic patients have aroused interests in many aspects. 167 subjects with type 2 diabetes who underwent evaluation for arterial stiffness and cardiovascular autonomic function using heart rate variability (HRV) were included in this study. Arterial stiffness was measured using cardio-ankle vascular index (CAVI) and ankle-brachial index (ABI). Multivariate regression analysis was performed to determine factors influencing the presence of RNFL loss according to age. Factors determining the superior location of diabetic RNFL loss were also investigated. CAVI were worse in patients with RNFL loss, especially in those with old age (≥50 yrs) (p = 0.037). Influential factor of RNFL defect in old group was ABI (p = 0.007). However, in young group (<50 yrs), HRV parameter (low-frequency/high-frequency ratio) determined the presence of RNFL loss (p = 0.040). Significant determinants of superior RNFL defect in old subjects were CAVI and ABI (p = 0.032 and p = 0.024). For young diabetic patients, autonomic dysfunction may have relationship with RNFL loss, but as patients get older, arterial stiffness could aggravate vascular autoregulation and diabetic RNFL loss. RNFL loss in diabetes may be correlated with systemic vascular conditions.

Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017

BACKGROUND

Cardiovascular disease (CVD) is a common comorbidity in type 2 diabetes (T2DM). CVD's prevalence has been growing over time.

PURPOSE

To estimate the current prevalence of CVD among adults with T2DM by reviewing literature published within the last 10 years (2007-March 2017).

METHODS

We searched Medline, Embase, and proceedings of major scientific meetings for original research documenting the prevalence of CVD in T2DM. CVD included stroke, myocardial infarction, angina pectoris, heart failure, ischemic heart disease, cardiovascular disease, coronary heart disease, atherosclerosis, and cardiovascular death. No restrictions were placed on country of origin or publication language. Two reviewers independently searched for articles and extracted data, adjudicating results through consensus. Data were summarized descriptively. Risk of bias was examined by applying the STROBE checklist.

RESULTS

We analyzed data from 57 articles with 4,549,481 persons having T2DM. Europe produced the most articles (46%), followed by the Western Pacific/China (21%), and North America (13%). Overall in 4,549,481 persons with T2DM, 52.0% were male, 47.0% were obese, aged 63.6 ± 6.9 years old, with T2DM duration of 10.4 ± 3.7 years. CVD affected 32.2% overall (53 studies, N = 4,289,140); 29.1% had atherosclerosis (4 studies, N = 1153), 21.2% had coronary heart disease (42 articles, N = 3,833,200), 14.9% heart failure (14 studies, N = 601,154), 14.6% angina (4 studies, N = 354,743), 10.0% myocardial infarction (13 studies, N = 3,518,833) and 7.6% stroke (39 studies, N = 3,901,505). CVD was the cause of death in 9.9% of T2DM patients (representing 50.3% of all deaths). Risk of bias was low; 80 ± 12% of STROBE checklist items were adequately addressed.

CONCLUSIONS

Globally, overall CVD affects approximately 32.2% of all persons with T2DM. CVD is a major cause of mortality among people with T2DM, accounting for approximately half of all deaths over the study period. Coronary artery disease and stroke were the major contributors.

The Relationships of the Fractional Excretion of Uric Acid with Brachial-Ankle Pulse Wave Velocity and Ankle Brachial Index in Chinese Young Adults

BACKGROUND/AIMS

Elevated serum uric acid (UA) was intimately correlated with vascular stiffness and abnormal ankle brachial index (ABI) in various populations. These correlations lost significance after adjustment for estimated glomerular filtration rate (eGFR), indicating that the association of UA and brachial-ankle pulse wave velocity (baPWV) or ABI might be driven by kidney function. UA is predominantly eliminated through the kidneys, and metabolic disorders can influence the clearance of UA. In this study, we aimed to explore the putative correlation between FEUA and baPWV or ABI to determine to what extent the associations with UA were affected by renal function.

METHODS

This cross-sectional study enrolled 2351 participants, who underwent general health screening in Hanzhong people's hospital from March to June of 2017. BaPWV and ABI were measured using a volume-plethysmographic apparatus (BP-203RPEII; Nihon Colin, Tokyo, Japan). FEUA was divided into quartiles: Q1:FEUA≤3.07; Q2: 3.07<FEUA≤5.32; Q3: 5.32<FEUA≤9.19; and Q4: FEUA> 9.19.

RESULTS

Lower FEUA predicted a higher prevalence of high baPWV and low ABI (p for trend <0.001). The respective ORs for high baPWV from the first to the third quartiles of FEUA were 1.777(1.323, 2.387); 1.561(1.158, 2.104); and 1.680 (1.250, 2.259). The prevalence of low ABI was greatly elevated with the decrement of FEUA [ORs for the first to third FEUA quartiles were 6.977(2.062, 23.610); 5.123(1.475, 17.790); and 2.685(0.709, 10.171), respectively]. The association of FEUA and ABI was independent of related confounding factors. However, the association between FEUA and baPWV was greatly influenced by corresponding confounders, especially gender. The efficacy of FEUA in the prediction of low ABI was stronger than that of serum UA. However, serum UA was more powerful in the prediction of high baPWV.

CONCLUSION

Kidney function exerted a profound influence on the relationship between UA and baPWV or ABI, revealing complex interactions among cardiovascular risk factors.

Challenges and unmet needs in basal insulin therapy: lessons from the Asian experience

Basal insulin therapy can improve glycemic control in people with type 2 diabetes. However, timely initiation, optimal titration, and proper adherence to prescribed basal insulin regimens are necessary to achieve optimal glycemic control. Even so, glycemic control may remain suboptimal in a significant proportion of patients. Unique circumstances in Asia (eg, limited resources, management of diabetes primarily in nonspecialist settings, and patient populations that are predominantly less educated) coupled with the limitations of current basal insulin options (eg, risk of hypoglycemia and dosing time inflexibility) amplify the challenge of optimal basal insulin therapy in Asia. Significant progress has been made with long-acting insulin analogs (insulin glargine 100 units/mL and insulin detemir), which provide longer coverage and less risk of hypoglycemia over intermediate-acting insulin (Neutral Protamine Hagedorn insulin). Furthermore, recent clinical evidence suggests that newer long-acting insulin analogs, new insulin glargine 300 units/mL and insulin degludec, may address some of the unmet needs of current basal insulin options in terms of risk of hypoglycemia and dosing time inflexibility. Nevertheless, more can be done to overcome barriers to basal insulin therapy in Asia, through educating both patients and physicians, developing better patient support models, and improving accessibility to long-acting insulin analogs. In this study, we highlight the unique challenges associated with basal insulin therapy in Asia and, where possible, propose strategies to address the unmet needs by drawing on clinical experiences and perspectives in Asia.

Lower Extremity Peripheral Arterial Disease Is an Independent Predictor of Coronary Heart Disease and Stroke Risks in Patients with Type 2 Diabetes Mellitus in China

We aimed to determine the relationship between lower extremity peripheral arterial disease (PAD), 10-year coronary heart disease (CHD), and stroke risks in patients with type 2 diabetes (T2DM) using the UKPDS risk engine. We enrolled 1178 hospitalized T2DM patients. The patients were divided into a lower extremity PAD group (ankle-brachial index ≤ 0.9 or >1.4; 88 patients, 7.5%) and a non-PAD group (ankle-brachial index > 0.9 and ≤1.4; 1090 patients, 92.5%). Age; duration of diabetes; systolic blood pressure; the hypertension rate; the use of hypertension drugs, ACEI /ARB, statins; CHD risk; fatal CHD risk; stroke risk; and fatal stroke risk were significantly higher in the PAD group than in the non-PAD group (P < 0.05 for all). Logistic stepwise regression analysis indicated that ABI was an independent predictor of 10-year CHD and stroke risks in T2DM patients. Compared with those in the T2DM non-PAD group, the odds ratios (ORs) for CHD and stroke risk were 3.6 (95% confidence interval (CI), 2.2-6.0; P < 0.001) and 6.9 (95% CI, 4.0-11.8; P < 0.001) in those with lower extremity PAD, respectively. In conclusion, lower extremity PAD increased coronary heart disease and stroke risks in T2DM.

The Ankle Brachial Index Exhibits Better Association of Cardiovascular Prognosis Than Non-High-Density Lipoprotein Cholesterol in Type 2 Diabetes

OBJECTIVE

The association between ankle brachial index (ABI) and outcomes in diabetic subjects is controversial. The purpose of this study was to evaluate whether the ABI is more strongly associated with cardiovascular outcomes comparing with non-high-density lipoprotein cholesterol (non-HDL-c).

RESEARCH DESIGN AND METHODS

A total of 452 type 2 diabetic subjects followed up for a mean of 5.8 years were grouped by ABI (<0.9 versus ≥0.9) and non-HDL-c (<100mg/dL versus ≥100mg/dL). Primary outcomes were composite events including all-cause mortality, hospitalization for coronary artery disease, stroke, revascularization, amputation and diabetic foot, and the secondary end point was all-cause mortality.

RESULTS

Intergroup differences in percentage of men, duration of diabetes, hemoglobin A1c, total cholesterol, low-density lipoprotein cholesterol, triglycerides and estimated glomerular filtration rate were significant. A total of 64 composite events and 17 deaths were recorded. A higher number of composite events occurred in the group with abnormal ABI but optimal non-HDL-c than in those with suboptimal non-HDL-c but normal ABI (29% versus 11%, P < 0.05). A similar trend was observed in all-cause mortality (11% versus 1%, P < 0.05). The ABI was the dominant risk factor for both end points after adjusting other factors (for composite events, hazard ratio = 0.02, 95% CI: 0.00-0.10, P < 0.001 and for all-cause mortality, hazard ratio = 0.01, 95% CI: 0.00-0.28, P = 0.006).

CONCLUSIONS

The ABI was more strongly associated with outcomes in diabetes than non-HDL-c. The ABI should be routinely screened in diabetes even without symptom.