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Lee DY, Yoo SH, Min KP, Park CY. Effect of Voluntary Participation on Mobile Health Care in Diabetes Management: Randomized Controlled Open-Label Trial. JMIR Mhealth Uhealth 2020; 8:e19153. [PMID: 32945775 PMCID: PMC7532462 DOI: 10.2196/19153] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/07/2020] [Accepted: 08/11/2020] [Indexed: 12/29/2022] Open
Abstract
Background The role of mobile health care (mHealth) in glycemic control has been investigated, but its impact on self-management skills and its psychological aspects have not been studied. Objective We evaluated the efficacy of mHealth-based diabetes self-management education and the effect of voluntary participation on its effects. Methods This study was a randomized controlled open-label trial conducted for 6 months at Kangbuk Samsung Hospital. Participants in the control group (n=31) maintained their previous diabetes management strategies. Participants in the intervention group (n=41) additionally received mHealth-based diabetes self-management education through a mobile app and regular individualized feedback from health care professionals. The primary outcome was change in glycated hemoglobin (HbA1c) level over 6 months between the 2 groups (intervention versus control) and within each group (at 6 months versus baseline). The secondary outcomes were changes in body mass index, blood pressure, lipid profile, and questionnaire scores (the Korean version of the Summary of Diabetes Self-Care Activities Questionnaire, an Audit of Diabetes Dependent Quality of Life, the Appraisal of Diabetes Scale, and Problem Areas in Diabetes) over 6 months between groups and within each group. Results A total of 66 participants completed this study. HbA1c (P=.04), total cholesterol level (P=.04), and Problem Areas in Diabetes scores (P=.02) significantly decreased; total diet (P=.03) and self-monitoring of blood glucose level scores (P=.01), based on the Summary of Diabetes Self-Care Activities Questionnaire, markedly increased within the intervention group. These significant changes were observed in self-motivated participants who were recruited voluntarily via advertisements. Conclusions mHealth-based diabetes self-management education was effective at improving glycemic control and diabetes self-management skills and lowering diabetes-related distress in voluntary participants. Trial Registration ClinicalTrials.gov NCT03468283; http://clinicaltrials.gov/ct2/show/NCT03468283
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Affiliation(s)
- Da Young Lee
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Korea University College of Medicine, Seoul, Republic of Korea
| | - Seung-Hyun Yoo
- Korea University College of Medicine, Seoul, Republic of Korea.,National Health Insurance Service, Wonju-Si, Republic of Korea
| | | | - Cheol-Young Park
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Takai M, Ishikawa M, Maeda H, Kubota A, Iemitsu K, Umezawa S, Kawata T, Takuma T, Takeda H, Tanaka K, Machimura H, Minagawa F, Mokubo A, Motomiya T, Kanamori A, Matsuba I. A Study of Seasonal Variation in the Effect of Add-On Sitagliptin on Blood Glucose Control in Insulin-Treated Patients With Type 2 Diabetes. J Clin Med Res 2020; 12:200-208. [PMID: 32231757 PMCID: PMC7092762 DOI: 10.14740/jocmr4103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/21/2020] [Indexed: 01/21/2023] Open
Abstract
Background There are several reports of seasonal variation in hemoglobin A1c (HbA1c) in patients with type 2 diabetes (T2DM), but no reports of seasonal variation in the effect of add-on drugs on blood glucose control in insulin-treated patients. Methods Using data collected from 630 patients in a multicenter study, we compared the amount of change in HbA1c after 1, 3, 6, 9, and 12 months of add-on administration of sitagliptin in insulin-treated patients divided into four groups based on the month when sitagliptin was started. Results A significantly larger decrease in HbA1c at 6 months from baseline was observed in the group that started add-on sitagliptin in February to April than in the other three groups. However, the amount of change in HbA1c at 12 months did not differ among the groups. Conclusions The consideration of seasonal variation enables more accurate evaluation of a drug’s short-term effect on blood glucose control.
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Affiliation(s)
- Masahiko Takai
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Masashi Ishikawa
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Hajime Maeda
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Akira Kubota
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Kotaro Iemitsu
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Shinichi Umezawa
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Takehiro Kawata
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Tetsuo Takuma
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Hiroshi Takeda
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Keiji Tanaka
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Hideo Machimura
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Fuyuki Minagawa
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Atsuko Mokubo
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Tetsuya Motomiya
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Akira Kanamori
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
| | - Ikuro Matsuba
- Diabetes Committee Study Group, Kanagawa Physicians Association, 1-3 Fujimichou, Nakaku, Yokohama, Kanagawa 231-0037, Japan
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Onishi Y, Ishii H, Oura T, Takeuchi M. Efficacy and Safety of Once-Weekly Dulaglutide in Type 2 Diabetes Patients Using Insulin: Exploratory Subgroup Analysis by Insulin Regimen. Diabetes Ther 2020; 11:735-745. [PMID: 31994009 PMCID: PMC7048887 DOI: 10.1007/s13300-020-00765-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Indexed: 01/15/2023] Open
Abstract
PURPOSE In East Asian patients, type 2 diabetes mellitus (T2DM) is characterized primarily by β-cell dysfunction, with lower insulin secretion than in Caucasian individuals. Therefore, bolus insulin and premixed insulin containing a bolus insulin component are important therapeutic tools in Japan, in addition to basal insulin. This subgroup analysis is stratified by insulin regimen and uses data from a phase 4, randomized, placebo-controlled, double-blind and subsequent open-label study in Japan to assess the efficacy and safety of once-weekly dulaglutide combined with various insulin therapies. METHODS This multicenter study enrolled Japanese patients with T2DM and inadequate glycemic control [glycated hemoglobin A1c (HbA1c) ≥ 7.5% to ≤ 10.5%] on insulin therapy [basal (B), premixed (PM), or basal bolus (BB)] in combination with or without one or two oral antidiabetic agents. Randomized participants received once-weekly dulaglutide 0.75 mg (n = 120) or placebo (n = 39) during a 16-week double-blind treatment period, and dulaglutide during a 36-week open-label extension. In this subgroup analysis, efficacy measures were changes from baseline in HbA1c, 7-point self-monitored blood glucose profiles, and body weight. Safety measures were incidence of adverse events and hypoglycemia during the first 16 weeks. RESULTS At week 16, least squares mean differences (95% CI) regarding changes from baseline in HbA1c for each insulin regimen versus placebo were: B: - 1.62% (- 1.96, - 1.28), PM: - 1.78% (- 2.25, - 1.30), and BB: - 1.15% (- 1.54, - 0.77); p < 0.001 dulaglutide vs. placebo for each subgroup. No significant differences in body weight changes were observed between dulaglutide and placebo for any insulin regimen. Gastrointestinal symptoms were the most commonly observed adverse events in dulaglutide-treated patients. Hypoglycemia incidence rates were: B: dulaglutide 38.5% vs. placebo 23.5%; PM: dulaglutide 38.5% vs. placebo 44.4%; BB: dulaglutide 50.0% vs. placebo 30.8%. CONCLUSIONS Overall, dulaglutide was generally well tolerated and improved glycemic control significantly versus placebo, regardless of insulin regimen. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02750410.
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Affiliation(s)
- Yukiko Onishi
- The Institute for Adult Diseases, Asahi Life Foundation, Tokyo, Japan
| | - Hitoshi Ishii
- Department of Diabetology, Nara Medical University, Kashihara, Nara, Japan
| | - Tomonori Oura
- Eli Lilly Japan K.K., Medical Development Unit-Japan, Kobe, Japan
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Effectiveness and Safety of Sitagliptin in Patients with Beta-thalassaemia Major and Diabetes Mellitus: A Case Series. Mediterr J Hematol Infect Dis 2017; 9:e2017004. [PMID: 28101310 PMCID: PMC5224814 DOI: 10.4084/mjhid.2017.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/12/2016] [Indexed: 01/29/2023] Open
Abstract
Sitagliptin, a modern antidiabetic agent which is weight neutral and associated with low rate of hypoglycaemias, is being increasingly used in type 2 diabetes mellitus (DM). However, there is a paucity of data about its efficacy and safety in beta-thalassaemia major (β-TM). This retrospective case series of five patients (mean age of 45 years) is the first study evaluating the use of sitagliptin in patients with β-TM and DM. Four patients responded well to sitagliptin, as evidenced by a decrease in fructosamine by 77 and 96μmol/L (equivalent reduction in HbA1c of 1.5% and 1.9%) observed in two patients and reduction in the frequency of hypoglycaemia without worsening glycaemic control in two others. One patient did not respond to sitagliptin. No patients reported significant side effects. This study provides evidence that sitagliptin may be considered, with caution, for use in patients with β-TM and DM, under the close monitoring of a Diabetologist.
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Wysham C, Guerci B, D'Alessio D, Jia N, Botros FT. Baseline factors associated with glycaemic response to treatment with once-weekly dulaglutide in patients with type 2 diabetes. Diabetes Obes Metab 2016; 18:1138-1142. [PMID: 27265893 DOI: 10.1111/dom.12702] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/27/2016] [Accepted: 06/01/2016] [Indexed: 11/29/2022]
Abstract
Dulaglutide glycaemic efficacy has been demonstrated in the AWARD clinical trial programme. The objective of the present analysis was to determine the major baseline factors associated with the reduction in glycated haemoglobin (HbA1c) in response to dulaglutide. Baseline covariates from patients receiving dulaglutide in six phase III studies (n = 2806) were analysed using a gradient-boosting method to assess their relative influence on the change in HbA1c after 26 weeks of treatment. Influential variables (relative influence >5%) were further evaluated in univariate and multivariable modelling. The gradient-boosting analysis showed that the top influential baseline factors associated with HbA1c reduction were: HbA1c (48.8%), age (9.1%), fasting serum glucose (FSG; 8.2%), fasting serum insulin (FSI; 6.7%) and estimated glomerular filtration rate (eGFR; 5.4%). Multivariable regression showed that higher baseline HbA1c was the major factor associated with greater HbA1c reduction [coefficient estimates: -0.6% (-6.6 mmol/mol); p < 0.0001]. Age ≤65 years, lower FSG level, FSI level ≤55 pmol/L and eGFR ≤100 mL/min/1.73 m2 were associated with greater decreases in HbA1c, but the effect was very small [coefficient estimates: -0.05% to -0.2% (-0.6 to -2.2 mmol/mol)]. These data indicate that higher baseline HbA1c, reflecting poor glycaemic status, is the major factor associated with greater reduction in HbA1c in response to dulaglutide treatment.
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Affiliation(s)
- Carol Wysham
- University of Washington, Rockwood Center for Diabetes and Endocrinology, Spokane, Washington
| | - Bruno Guerci
- University of Lorraine and the Department of Diabetology, Metabolic Diseases and Nutrition, Brabois Adult Hospital, CHRU of Nancy, Vandœuvre-lès-Nancy, France
| | - David D'Alessio
- Duke University School of Medicine, Department of Endocrinology, Duke Molecular Physiology Institute, Durham, North Carolina
| | - Nan Jia
- Eli Lilly and Company, Indianapolis, Indiana
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Cai X, Yang W, Chen Y, Gao X, Zhou L, Zhang S, Han X, Ji L. Efficacy of hypoglycemic treatment in type 2 diabetes stratified by age or diagnosed age: a meta-analysis. Expert Opin Pharmacother 2016; 17:1591-8. [PMID: 27322963 DOI: 10.1080/14656566.2016.1202921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIM To compare the effects of blood glucose lowering regimens in groups of patients categorized by baseline age and diagnosed age. METHODS Placebo-controlled randomized trials in type 2 diabetes patients with a study length ≥12 weeks were included. RESULTS A total of 246 trials were included. HbA1c changes from baseline corrected by placebo were comparable in sulfonylurea treatment between older and younger patients' groups (weighted mean difference (WMD), -1.28% vs -0.92%, p > 0.05). Treatment with metformin between groups resulted in a comparable change in HbA1c levels (WMD, -0.97% vs -1.23%, p > 0.05). Treatment with α-glucosidase inhibitor (WMD, -0.68% vs -0.67%, p > 0.05), treatment with thiazolidinedione (WMD, -0.74% vs -1.01%, p > 0.05), treatment with DPP-4 inhibitors (WMD, -0.67% vs -0.67%, p > 0.05), and treatment with SGLT2 inhibitors (WMD, -0.54% vs -0.67%, p > 0.05) between groups also resulted in comparable HbA1c changes. Treatment with GLP-1 analogs between groups in HbA1c changes were also comparable (p > 0.05). Regression analysis indicated that the baseline age or diagnosed age was not associated with the HbA1c changes from baseline. CONCLUSION In each hypoglycemic treatment, the baseline age or diagnosed age was not associated with the HbA1c changes from baseline.
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Affiliation(s)
- Xiaoling Cai
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Wenjia Yang
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Yifei Chen
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Xueying Gao
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Lingli Zhou
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Simin Zhang
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Xueyao Han
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Linong Ji
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
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Kushiyama A, Kikuchi T, Tanaka K, Tahara T, Takao T, Onishi Y, Yoshida Y, Kawazu S, Iwamoto Y. Prediction of the effect on antihyperglycaemic action of sitagliptin by plasma active form glucagon-like peptide-1. World J Diabetes 2016; 7:230-238. [PMID: 27326345 PMCID: PMC4909424 DOI: 10.4239/wjd.v7.i11.230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/12/2016] [Accepted: 04/22/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate whether active glucagon-like peptide-1 (GLP-1) is a prediction Factor of Effect of sitagliptin on patients with type 2 diabetes mellitus (GLP-1 FEST:UMIN000010645).
METHODS: Seventy-six patients with type 2 diabetes, who had insufficient glycemic control [Hemoglobin A1c (HbA1c) ≥ 7%] in spite of treatment with metformin and/or sulfonylurea, were included in the investigation. Patients were divided into three groups by tertiles of fasting plasma active GLP-1 level, before the administration of 50 mg sitagliptin.
RESULTS: At baseline, body mass index, serum UA, insulin and HOMA-IR were higher in the high active GLP-1 group than in the other two groups. The high active GLP-1 group did not show any decline of HbA1c (7.6% ± 1.4% to 7.5% ± 1.5%), whereas the middle and low groups indicated significant decline of HbA1c (7.4 ± 0.7 to 6.8 ± 0.6 and 7.4 ± 1.2 to 6.9 ± 1.3, respectively) during six months. Only the low and middle groups showed a significant increment of active GLP-1, C-peptide level, a decreased log and proinsulin/insulin ratio after administration. In logistic analysis, the low or middle group is a significant explanatory variable for an HbA1c decrease of ≥ 0.5%, and its odds ratio is 4.5 (1.40-17.6) (P = 0.01) against the high active GLP-1 group. This remains independent when adjusted for HbA1c level before administration, patients’ medical history, medications, insulin secretion and insulin resistance.
CONCLUSION: Plasma fasting active GLP-1 is an independent predictive marker for the efficacy of dipeptidyl peptidase 4 inhibitor sitagliptin.
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Yuasa S, Sato K, Takai M, Ishikawa M, Umezawa S, Kubota A, Maeda H, Kanamori A, Miyakawa M, Tanaka Y, Terauchi Y, Matsuba I. Factor Analysis of Changes in Hemoglobin A1c After 12 Months of Sitagliptin Therapy in Patients With Type 2 Diabetes. J Clin Med Res 2016; 8:461-71. [PMID: 27222674 PMCID: PMC4852779 DOI: 10.14740/jocmr2540w] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2016] [Indexed: 12/13/2022] Open
Abstract
Background Sitagliptin, a dipeptidyl peptidase-4 inhibitor, is an effective oral antidiabetic agent as both monotherapy and when combined with insulin. Data from three observational studies performed in patients with type 2 diabetes receiving sitagliptin therapy in the routine clinical setting were integrated to conduct factor analysis of the changes in hemoglobin A1c (HbA1c), body weight, and estimated glomerular filtration rate (eGFR) over 12 months. Methods Among patients with type 2 diabetes attending medical institutions affiliated with Kanagawa Physicians Association, those using sitagliptin were followed for 1 year. In the ASSET-K and ASSIST-K studies, patients were managed by diabetologists, while they were managed by non-diabetologists in the ATTEST-K study. Patients were not administered insulin in ASSET-K, whereas insulin was administered in ASSIST-K. HbA1c (National Glycohemoglobin Standardization Program), blood glucose (fasting/postprandial), body weight, and renal function (serum creatinine and eGFR) were the efficacy endpoints. Factor analysis was performed by analysis of variance using the magnitude of the change in HbA1c, body weight, and eGFR after 12 months of sitagliptin therapy as response variables, and the study, sex, and age as explanatory variables. Results Of 1,327 patients registered in ASSET-K (diabetologists/without insulin), 1,167 patients in ASSIST-K (diabetologists/with insulin), and 530 patients in ATTEST-K (non-diabetologists), statistical analysis was carried out on 1,074, 854, and 411 patients, respectively. There were significant inter-study differences in patient characteristics (complications, duration of diabetes, and baseline HbA1c), the sitagliptin dose, and the use of other antidiabetic agents. HbA1c decreased significantly in all three studies. According to factor analysis, the magnitude of the change in HbA1c over 12 months showed significant inter-study differences and was also significantly influenced by the age, duration of diabetes, and baseline HbA1c. Conclusions Comparison of three observational studies identified differences in patient characteristics, treatment of diabetes (use/non-use of insulin), and the level of specialist care (diabetologist/non-diabetologist). Despite such differences, consistent reduction of HbA1c by sitagliptin was demonstrated in all three studies. The patients showing most improvement in HbA1c with sitagliptin therapy were older patients with a short duration of diabetes and high baseline HbA1c level.
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Affiliation(s)
- Shouhei Yuasa
- Study Group of the Hypertension Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Kazuyoshi Sato
- Study Group of the Hypertension Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Masahiko Takai
- Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Masashi Ishikawa
- Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Shinichi Umezawa
- Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Akira Kubota
- Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Hajime Maeda
- Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Akira Kanamori
- Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Masaaki Miyakawa
- Study Group of the Hypertension Committee, Kanagawa Physicians Association, Kanagawa, Japan
| | - Yasushi Tanaka
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Diabetes, Yokohama City University Medical Center, Kanagawa, Japan
| | - Ikuro Matsuba
- Study Group of the Diabetes Committee, Kanagawa Physicians Association, Kanagawa, Japan
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