Combining insulins with oral antidiabetic agents: effect on hyperglycemic control, markers of cardiovascular risk and disease

Activity prediction, structure-based drug design, molecular docking, and pharmacokinetic studies of 1,4-dihydropyridines derivatives as α-amylase inhibitors

Objectives

Diabetes places a substantial economic burden on countries worldwide. The costs associated with diabetes management, including healthcare services, medications, monitoring equipment, and productivity losses, are substantial. The International Diabetes Federation has estimated that global healthcare expenditures associated with diabetes and its complications exceed hundreds of billions of dollars annually. Therefore, a critical need exists to develop drugs that are highly effective, affordable, and easily accessible to society.

Methods

This study explored the structural modification of 1,4-DHP derivatives to identify specific α-amylase inhibitors, with the aim of developing more effective and accessible drugs for diabetes. We evaluated the activity and binding ability of the designed compounds. In addition, we performed drug-likeness and pharmacokinetic studies on the modified compounds.

Results

Equation (1) had the highest accuracy, on the basis of internal and external assessment parameters, including R2int = 0.852, R2adj = 0.803, Q2cv = 0.731, and R2ext = 0.884. Moreover, the five potent analogs identified through structure-based drug design demonstrated a more favorable interaction than observed for the template or acarbose. Additionally, comprehensive studies on the drug-like properties and pharmacokinetics of the designed compounds supported their oral safety and favorable pharmacokinetic profiles.

Conclusions

The designed analogs show promise for developing new hypoglycemic agents. Their positive attributes and performance suggest that they may potentially serve as candidates for further research in improving treatments for high blood sugar-associated conditions.

Insulin therapy among diabetic patients in rural communities of Sub-Saharan Africa: a perspective review

In this perspective review, we describe a brief background on the status quo of diabetes mellitus-related therapies and glycemic control among patients in rural communities in sub-Saharan Africa. The article discusses insulin therapy as well as the difficulties in obtaining insulin and oral hypoglycemic medications for diabetic patients living in sub-Saharan Africa. We wrap up our discussion with suggestions on solutions and opportunities for future research to tackle this health challenge in these impoverished communities. We conducted a literature search from PubMed and Google Scholar up until August 2023. Key words were used to generate search terms used to retrieve the required information. All types of literature with pertinent information on the current topic were included in the study. Diabetes mellitus is on the rise in sub-Saharan Africa. Several studies have reported poor glycemic control, low screening rates for diabetes mellitus, cigarette smoking, high alcohol consumption, prescription of antidiabetic therapy, and associated costs as contributors to the uptake of antidiabetic treatment. Although there is paucity of data on the extent of insulin therapy uptake and its possible modifiable contributors among the diabetic patients in the region, the anticipated increase in the number of people with diabetes on the continent makes it critical for global leaders to address the research gaps in insulin therapy among rural communities of sub-Saharan Africa, thus reducing the burden of diabetes in these populations.

Design, synthesis, and evaluation of benzofuran-based chromenochalcones for antihyperglycemic and antidyslipidemic activities

A series of benzofuran-based chromenochalcones (16-35) were synthesized and evaluated for in vitro and in vivo antidiabetic activities in L-6 skeletal muscle cells and streptozotocin (STZ)-induced diabetic rat models, respectively, and further in vivo dyslipidemia activity of the compounds was evaluated in a Triton-induced hyperlipidemic hamster model. Among them, compounds 16, 18, 21, 22, 24, 31, and 35 showed significant glucose uptake stimulatory effects in skeletal muscle cells and were further evaluated for in vivo efficacy. Compounds 21, 22, and 24 showed a significant reduction in blood glucose levels in STZ-induced diabetic rats. Compounds 16, 20, 21, 24, 28, 29, 34, 35, and 36 were found active in antidyslipidemic studies. Furthermore, compound 24 effectively improved the postprandial and fasting blood glucose levels, oral glucose tolerance, serum lipid profile, serum insulin level, and the HOMA-index of db/db mice, following 15 days of successive treatment.

Synbiotics and Gut Microbiota: New Perspectives in the Treatment of Type 2 Diabetes Mellitus

The number of people with type 2 diabetes mellitus (T2DM) has increased sharply over the past decades. Apart from genetic predisposition, which may cause some of the diagnosed cases, an unhealthy diet and lifestyle are incentive triggers of this global epidemic. Consumption of probiotics and prebiotics to gain health benefits has become increasingly accepted by the public in recent years, and their critical roles in alleviating T2DM symptoms are confirmed by accumulating studies. Microbiome research reveals gut colonization by probiotics and their impacts on the host, while oral intake of prebiotics may stimulate existing metabolisms in the colon. The use of synbiotics (a combination of prebiotics and probiotics) can thus show a synergistic effect on T2DM through modulating the gastrointestinal microenvironment. This review summarizes the research progress in the treatment of T2DM from the perspective of synbiotics and gut microbiota and provides a class of synbiotics which are composed of lactulose, arabinose, and Lactobacillus plantarum, and can effectively adjust the blood glucose, blood lipid, and body weight of T2DM patients to ideal levels.

Aldose reductase and protein tyrosine phosphatase 1B inhibitors as a promising therapeutic approach for diabetes mellitus

Diabetes mellitus is a metabolic disease characterized by high blood glucose levels and usually associated with several chronic pathologies. Aldose reductase and protein tyrosine phosphatase 1B enzymes have identified as two novel molecular targets associated with the onset and progression of type II diabetes and related comorbidities. Although many inhibitors against these enzymes have already found in the field of diabetic mellitus, the research for discovering more effective and selective agents with optimal pharmacokinetic properties continues. In addition, dual inhibition of these target proteins has proved as a promising therapeutic approach. A variety of diverse scaffolds are presented in this review for the future design of potent and selective inhibitors of aldose reductase and protein tyrosine phosphatase 1B based on the most important structural features of both enzymes. The discovery of novel dual aldose reductase and protein tyrosine phosphatase 1B inhibitors could be effective therapeutic molecules for the treatment of insulin-resistant type II diabetes mellitus. The methods used comprise a literature survey and X-ray crystal structures derived from Protein Databank (PDB). Despite the available therapeutic options for type II diabetes mellitus, the inhibitors of aldose reductase and protein tyrosine phosphatase 1B could be two promising approaches for the effective treatment of hyperglycemia and diabetes-associated pathologies. Due to the poor pharmacokinetic profile and low in vivo efficacy of existing inhibitors of both targets, the research turned to more selective and cell-permeable agents as well as multi-target molecules.

Decisional Balance for Insulin Injection: Scale Development and Psychometric Testing

Background

Insulin-naive patients are often reluctant to receive insulin treatment, and even insulin-treated patients frequently have poor rates of adherence to their prescribed insulin injection regimes. Assessing attitudes toward insulin injection may help in the design of interventions that improve the insulin injection behaviors of patients with type 2 diabetes (T2DM). The concept of decisional balance has been associated with behavior in many studies and may be useful in assessing the attitude of patients with T2DM toward insulin injection. Decisional balance for insulin injection (DBII) has not been widely assessed in patients with T2DM.

Purpose

The aim of this study was to develop an insulin injection (DBII) scale that is valid for insulin-naive and insulin-treated patients and to test the psychometric characteristics of this scale based on the concept of decisional balance.

Methods

This cross-sectional study administered an 18-item DBII scale, including pro and con subscales, to 95 insulin-naive and 237 insulin-treated patients in Taiwan. The decisional balance score was calculated as the mean score of the pro subscale minus the mean score of the con subscale. Construct validity was examined using exploratory factor analysis and confirmatory factor analysis; concurrent validity was assessed by examining the association between the score of the DBII scale and the stages of behavioral change and of hemoglobin A1c for, respectively, insulin-naive patients and insulin-treated patients; and reliability was assessed using internal consistency and test–retest reliability.

Results

A 13-item DBII scale supported by exploratory factor analysis and confirmatory factor analysis was developed. The stages of behavioral change and hemoglobin A1c levels were found to be significantly associated with the scores of decisional balance of the 13-item DBII scale for both insulin-naive and insulin-treated patients. The Cronbach's α ranged between .78 and .92.

Conclusions

The 13-item DBII scale is appropriately short and possesses satisfactory validity and reliability for both insulin-naive and insulin-treated patients with T2DM. Healthcare providers may use this scale as a checklist to guide clinical discussions related to insulin therapy with both insulin-naive and insulin-treated patients with T2DM across time.

Comparison between sodium-glucose cotransporter 2 inhibitors and pioglitazone as additions to insulin therapy in type 2 diabetes patients: A systematic review with an indirect comparison meta-analysis

AIMS/INTRODUCTION

We aimed to evaluate the efficacy and safety of pioglitazone (PIO) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) as additions to insulin therapy for the management of type 2 diabetes mellitus.

MATERIALS AND METHODS

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov through December 2016. Randomized controlled trials published in English that compared SGLT2i plus insulin (SGLT2i/INS) or PIO plus insulin (PIO/INS) with placebo plus insulin (PCB/INS) in type 2 diabetes mellitus patients were included. We compared the efficacy and safety between SGLT2i/INS and PIO/INS indirectly.

RESULTS

A total of 14 randomized controlled trials comparing 7,226 participants were included (8 SGLT2i and 6 PIO studies). SGLT2i/INS achieved similar reductions in hemoglobin A1c (weighted mean difference [WMD] -0.01% [-0.1 mmol/mol], 95% confidence interval [CI] -0.25 to 0.22% [-2.7 to -2.4 mmol/mol]; P = 0.896) and fasting plasma glucose (WMD -0.90 mg/dL, 95% CI: -15.50 to 13.71 mg/dL; P = 0.904), and a similar proportion of participants achieved hemoglobin A1c <7.0% (<53.0 mmol/mol; relative risk 0.98, 95% CI: 0.73 to 1.33; P = 0.917) as compared with the PIO/INS group, with greater weight reduction (WMD -4.54 kg, 95% CI: -5.67 to -3.41 kg; P < 0.001). PIO/INS showed non-significant trends toward a higher risk of hypoglycemia (relative risk 1.15, 95% CI: 0.97 to 1.35; P = 0.102) and higher reduction of total daily insulin doses (WMD -2.45 IU/day, 95% CI: -7.30 to 2.40 IU/day; P = 0.438).

CONCLUSIONS

Both PIO and SGLT2i are feasible adjunctive oral agents to pre-existing insulin therapy in individuals with inadequately controlled type 2 diabetes mellitus.

Links between the Prophet Muhammad (PBUH) recommended foods and disease management: A review in the light of modern superfoods

Nutrition and other bioactive natural products present in specific foods within a balanced diet play an indispensable role in maintaining and promoting human health. Plants are rich sources of a balanced nutrition because of high content of bioactive products; hence, most of them recently have acquired the status of superfoods. It has been used since ancient times for the treatment of various ailments, and these traditional medicines still remain as one of the most affordable and easily accessible sources of treatment in the primary health-care system. The scientifically based use of these superfoods date back to the era of Prophet Muhammad along with other historical uses of plant products. Prescription of a large number of herbal foods such as dates, pomegranate, olives, figs, grapes, and black seeds was successfully proposed by him. These recently have become superfoods with their powerful healing properties and act as favorable dietary interventions for disease prevention as well as for the good maintenance of health. The use of these foods as ingredients of natural origin with fewer side effects seems to be more favorable than the chemical treatment, which is often complicated. The present review is an attempt to provide a brief survey of the literature on scientifically based significance of these superfoods carried out by various researchers and exploration of a wide spectrum of their pharmacological actions which include antidiabetic, anticancer, immune modulator, analgesic, anti-inflammatory, and hepatoprotective properties.

Evaluation of serum ferritin and some metal elements in type 2 diabetes mellitus patients: comparative cross-sectional study

BACKGROUND

The chronic hyperglycemia of diabetes has been associated with an imbalance of some trace metal elements in the blood sample of type 2 diabetes patients.

AIM

To evaluate the status of serum ferritin and some selected metal elements among type 2 diabetes mellitus (T2DM) patients.

METHODS

Facility-based comparative cross-sectional study was conducted from February 15, 2015 to October 30, 2015, at Jimma University Specialized Hospital, Ethiopia. A total of 428 type 2 diabetes and nondiabetes study subjects were recruited to the study. After overnight fasting, 10 mL of venous blood samples were taken for biochemical and trace metal element analysis. Data were entered into EpiData version 3.5.1 and exported to SPSS version 20 for Windows for analysis.

RESULTS

Serum concentration of Zn+2, Mg+2, Cr+3, ferritin, and Fe+3 in patients with type 2 diabetes was significantly lower (p<0.0001) than nondiabetes patients. In contrast, serum Cu+2 was significantly higher (p<0.0001) in type 2 diabetes patients than nondiabetics. In addition, significant differences were not seen in both groups with regard to serum Mn+2, Ca+2, and Po4-3. Waist-to-hip ratio (WHR), serum Fe+3, ferritin, and Mn+2 were significantly higher among oral hypoglycemic agent users of type 2 diabetes patients than the injectable insulin users. Serum Zn+2 had significant positive correlation with serum Mg+2 (r=0.738), Cr+3 (r=0.233), Ca+2 (r=0.238), and Po4-3 (r=0.222). In addition, serum Zn+2 had shown significant and negative correlation with body mass index (BMI, r=-0.331), WHR (r=-0.340), and fasting blood glucose (FBG, r=-0.186). Likewise, serum Mg+2 and Po4-3 are significantly and negatively correlated with BMI, WHR, and FBG.

CONCLUSION

The imbalance of trace metal elements in the blood sample of diabetes is uncertain. Thus, we recommend a prospective cohort study to find out the principal factors behind the problem.

Hypoglycemic agents and potential anti-inflammatory activity

Current literature shows an association of diabetes and secondary complications with chronic inflammation. Evidence of these immunological changes include altered levels of cytokines and chemokines, changes in the numbers and activation states of various leukocyte populations, apoptosis, and fibrosis during diabetes. Therefore, treatment of diabetes and its complications may include pharmacological strategies to reduce inflammation. Apart from anti-inflammatory drugs, various hypoglycemic agents have also been found to reduce inflammation that could contribute to improved outcomes. Extensive studies have been carried out with thiazolidinediones (peroxisome proliferator-activated receptor-γ agonist), dipeptidyl peptidase-4 inhibitors, and metformin (AMP-activated protein kinase activator) with each of these classes of compounds showing moderate-to-strong anti-inflammatory action. Sulfonylureas and alpha glucosidase inhibitors appeared to exert modest effects, while the injectable agents, insulin and glucagon-like peptide-1 receptor agonists, may improve secondary complications due to their anti-inflammatory potential. Currently, there is a lack of clinical data on anti-inflammatory effects of sodium–glucose cotransporter type 2 inhibitors. Nevertheless, for all these glucose-lowering agents, it is essential to distinguish between anti-inflammatory effects resulting from better glucose control and effects related to intrinsic anti-inflammatory actions of the pharmacological class of compounds.

Predictor variables and an equation for estimating HbA1c attainable by initiation of basal supported oral therapy

Aims/Introduction:  A method of estimating HbA1c attained after initiation of basal supported oral therapy (BOT) has not been reported previously. The aim of the present study was to determine which characteristics of patients could influence the effectiveness of BOT introduction, and to obtain an equation to estimate HbA1c after BOT initiation.

MATERIALS AND METHODS

  Sixty consecutive insulin-naive type 2 diabetic patients with poor glycemic control (HbA1c ≥7.5%) started once-daily injections of insulin glargine. Simple correlations were calculated between parameters such as HbA1c at baseline, HbA1c at week 24, reduction rate of HbA1c over 24 weeks (calculated as: [HbA1c level at baseline - HbA1c level at week 24]/HbA1c level at baseline), duration of diabetes, and the number of classes of coadministered oral antidiabetic drugs. Using multiple linear regression models, the independent effects of these parameters on HbA1c at week 24 were evaluated separately.

RESULTS

  Multiple linear regression analysis revealed that duration of diabetes (β = 0.561; P < 0.001) and HbA1c at baseline (β = 0.284; P = 0.006) were significant predictors of HbA1c at week 24. The best fitting multiple regression equation was: HbA1c at week 24 = 0.078 × duration of diabetes + 0.218 × HbA1c at baseline + 4.628 (r (2) = 0.437).

CONCLUSIONS

  The equation based on the multiple linear regression models indicates necessary conditions for type 2 diabetic patients to achieve target HbA1c. The present findings emphasize the principle that early initiation of BOT in type 2 diabetes effectively achieves good glycemic control. (J Diabetes Invest, doi: 10.1111/j.2040-1124.2011.00164.x, 2011).

Evaluation of antidiabetic prescriptions, cost and adherence to treatment guidelines: A prospective, cross-sectional study at a tertiary care teaching hospital

Introduction:

Diabetes mellitus is on alarming rise in India. Drug utilization studies help to identify the adherence to standard treatment guidelines and to evaluate the rational drug usage.

Objective:

To study prescription pattern, calculate the cost of antidiabetic drugs and to evaluate the adherence to treatment guidelines in diabetic patients attending the medicine outpatient department in a tertiary care teaching hospital.

Materials and Methods:

A prospective observational study was carried out for a period of 5 months. The diabetic patients who visited the medicine outdoor department were included. Demographic data and complete prescription details were recorded in the structured case record form. Cost of the drug therapy was calculated from the patient's bills. Indian Council for Medical research guidelines-2005 for diabetes management was used to evaluate the adherence.

Results:

A total of 250 patients were enrolled in the study with mean age 57.91 ± 9.37. Out of 250 patients 126 (50.4%) were male and rest were female. A total of 1,391 drugs were prescribed, with mean of 5.56 ± 2.52 drugs and out of which 539 drugs were antidiabetics with mean of 2.18 ± 0.96. In monotherapy, metformin was frequently 218 (40.45%) prescribed. Glimepiride and metformin was the most frequently prescribed in 119 (76.28%) out of 156 antidiabetic drug combinations. Most commonly used drugs other than antidiabetics were aspirin 146 (18.9%) and atorvastatin 119 (15.41%). Mean cost of therapy for a month for a diabetic patient was 354.60 ± 305.72 INR. Majority 209 (83.6%) of prescriptions was in accordance to guidelines.

Conclusion:

Metformin was the most frequently prescribed drug in the diabetes patient. Metformin and glimeperide being the most frequent combination used. Majority of the prescriptions followed standard guidelines.

Treat-to-target trials in diabetes

Treat-to-target is a therapeutic concept that considers well defined and specific physiologic targets as aims in controlling the pathophysiology of the disease. It has been widely used in diseases that pathophysiology includes, chronic metabolic and physiological disturbances, namely rheumatic conditions, vascular medicine and diabetes. In diabetes, the availability of "gold-standard" quantitative measures like fasting plasma glucose and glycated hemoglobin make the application of treat-to-target trials especially pertinent. Treatment modalities which have used single therapeutic agents or combinations or in combination with a variety of titration algorithms and implementation protocols have broadened our understanding of diabetes management with specific reference to insulin initiation and maintenance. Treat-to-target trials have been used to investigate a wide variety of questions including efficacy, safety, effect of treatment on comorbidities and patient satisfaction, ideal mechanisms to implement insulin initiation etc. A more generalized acceptance and implementation of treat-to-target trials may finally revolutionize diabetes management by combining aspects of individual care with standard treatment protocols.

Stage of change of 6 health-related behaviors among patients with type 2 diabetes

AIMS

Assessing patients' current stage of change toward 6 healthy behaviors related to diabetes control. Behaviors studied were smoking cessation (2) regular exercise; (3) consuming 5 servings or more of fruits and vegetables; (4) decreasing intake of refined sugar; (5) reducing saturated fat; and (6) self monitoring of blood glucose (SMBG).

METHODS

Stage of change (SOC) for several diabetes control-related behaviors was assessed for 737 patients with type 2 diabetes using a staging algorithm. Socio-demographic data were collected by a structured interview-based questionnaire.

RESULTS

There was high degree of readiness toward consuming diets with less saturated fat and simple sugar. Very low degree of readiness was reported for self-monitoring of blood glucose on a regular bases and for practicing physical exercise. Half of the participants (50.9%) were in the precontemplation stage for consuming ≥5 servings of fruits and vegetables every day. Significant correlations were obtained between the degree of readiness for several behaviors (p<0.01). Age, gender, income and education were all related to the stage of change of the studied behaviors (p<0.01).

CONCLUSIONS

Patients with diabetes in Jordan are still in the pre-action stages for practicing exercise, consuming 5 servings or more of fruit and vegetable, and self-monitoring of blood glucose. The current finding suggests a need for nutritional education and interventions to raise awareness of lifestyle factors influencing glycemic control among diabetics.

Clinical Outcomes After Insulin Initiation in Patients with Type 2 Diabetes: 24-Month Results from INSTIGATE

INTRODUCTION

To examine changes in insulin regimens and glycemic control during the 24 months after initiation of insulin in patients with type 2 diabetes mellitus.

METHODS

Data were collected over a 24-month period from patients requiring insulin initiation as part of usual care, in a prospective, observational study. Changes in insulin regimens and hemoglobin A(1c) (HbA(1c)) were examined within countries (Germany, Greece, Spain) and overall.

RESULTS

Prandial insulin only was most commonly initiated in Germany, while basal or premixed formulations were initiated in Greece and Spain. In Germany, compared with Greece or Spain, the patients were slightly younger and had a shorter diabetes duration when initiating insulin. For patients overall, 76.1% did not change their insulin regimen between initiation and 24 months. The most obvious change was a shift from prandial to basal/bolus in Germany, with almost doubling of mean daily insulin dose; in Greece and Spain, more patients stopped using insulin and the trend to more complex regimens was not seen. Overall, mean (SD) HbA(1c) decreased from baseline (9.4 [1.7]%) to 6 months (7.2 [1.0]%), but with little further change through 24 months (7.2 [1.1]%). HbA(1c) change with basal/bolus insulin (-2.6 [2.0]%, baseline 10.1%) was greater than with basal only (-2.0 [1.8]%, baseline 9.3%). Mean HbA(1c) less than 7% was achieved and maintained over 24 months in Germany, but was not achieved at any time in Greece or Spain.

CONCLUSIONS

Within 24 months of insulin initiation, the majority of patients with type 2 diabetes remained on the same insulin regimen initially instigated, despite the well-established progressive loss of prandial and basal endogenous insulin secretion. Adequate glycemic control was best achieved where insulin dosage adjustments and insulin intensification took place.

Clinical outcomes after insulin initiation in patients with type 2 diabetes: 6-month data from the INSTIGATE observational study in five European countries

OBJECTIVES

To examine insulin regimens and factors that affect glycaemic control at 6 months after initiation of insulin therapy in patients with type 2 diabetes mellitus.

RESEARCH DESIGN AND METHODS

Information on patients requiring insulin initiation as part of usual care was collected in a prospective, observational, open-label study in five European countries. Univariate and multiple regression analyses were used to investigate factors associated with HbA1c achieved at 6 months.

RESULTS

Mean HbA1c for all patients at baseline was 9.6 ± 1.8%. Long/intermediate-acting insulin only was most commonly initiated in France and Spain, while long/intermediate or pre-mixed formulations were initiated in Greece and UK. This was consistent with guidelines used in those countries and there was little change in insulin regimen at 6 months in these countries. In Germany, short-acting insulin only was favoured at baseline and there was a shift towards basal/bolus regimens at 6 months, which reflected the local guidelines for insulin initiation in Germany. Mean HbA1c reduction was greatest in Germany (-2.3%), which was the only country to achieve a mean of <7% at 6 months. In all countries, HbA1c achieved at 6 months was associated with baseline HbA1c. Differences between countries were seen for influence of factors such as BMI, duration of diabetes, insulin regimen, insulin dose and number of oral anti-diabetes drugs on HbA1c achieved. Explained variability for the factors ranged from 5.6% to 22.9%.

CONCLUSIONS

Differences in insulin regimen were observed between countries, and appeared to reflect the guidelines and treatment regimens used.

Diabetes management in an Australian primary care population

WHAT IS KNOWN AND OBJECTIVE

Worldwide studies have shown that significant proportions of patients with type 2 diabetes (T2DM) do not meet targets for glycaemic control, blood pressure (BP) and lipids, putting them at higher risk of developing complications. However, little is known about medicines management in Australian primary care populations with T2DM. The aim of this study was to (i) describe the management of a large group of patients in primary care, (ii) identify areas for improvement in management and (iii) determine any relationship between adherence and glycaemic, BP and lipid control.

METHODS

This was a retrospective, epidemiological study of primary care patients with T2DM diabetes, with HbA(1c) of >7%, recruited in 90 Australian community pharmacies. Data collected included demographic details, diabetes history, current medication regimen, height, weight, BP, physical activity and smoking status.

RESULTS AND DISCUSSION

Of the 430 patients, 98% used antidiabetics, 80% antihypertensives, 73% lipid lowering drugs and 38% aspirin. BP and all lipid targets were met by only 21% and 14% of the treated patients and 21% and 12% of the untreated patients respectively. Medication adherence was related to better glycaemic control (P = 0.04).

WHAT IS NEW AND CONCLUSIONS

An evidence-base prescribing practice gap was seen in this Australian primary care population of T2DM patients. Patients were undertreated with antihypertensive and lipid lowering medication, and several subgroups with co-morbidities were not receiving the recommended pharmacotherapy. Interventions are required to redress the current evidence-base prescribing practice gap in disease management in primary care.

Expectations about and experiences with insulin therapy contribute to diabetes treatment satisfaction in insulin-naïve patients with type 2 diabetes

AIM

The aim of this study was to investigate how patients' expectations about and experiences with insulin therapy contribute to diabetes treatment satisfaction.

METHODS

The Expectations about Insulin Therapy (EAITQ) and the Experience with Insulin Therapy Questionnaires (EWITQ) were administered at baseline and end-point, respectively to insulin-naïve patients with type 2 diabetes in a randomised trial comparing treatment algorithms for inhaled insulin. Pearson correlation coefficients were calculated between EAITQ and EWITQ scores, patient characteristics and patient-reported outcomes measures. Wilcoxon Signed Rank test compared EAITQ and EWITQ item score distributions. Differences between EAITQ and EWITQ scores were calculated to categorize patients according to the extent to which their expectations were met by experiences (i.e. unmet, met, exceeded).

RESULTS

EAITQ and EWITQ data were available for 240 patients (61% male, mean age 58 years, mean diabetes duration 10 years, mean baseline HbA(1c) 8.4%). Increasingly positive expectations were significantly associated with greater self-efficacy; greater levels of positive experiences were significantly associated with greater positive expectations, shorter diabetes duration, less symptom distress, greater well-being, self-efficacy and diabetes treatment satisfaction. Overall, patients' experiences with inhaled insulin therapy were significantly more positive than their expectations: 58% patients' experiences exceeded expectations, 29% patients' experiences met expectations and 13% patients' experiences did not meet expectations. Post hoc tests indicated that treatment satisfaction scores differed among these groups (all p < 0.01).

CONCLUSION

Expectations may not independently impact treatment satisfaction, but the relationship with experiences significantly contributes to it. The EAITQ and EWITQ may be useful tools for clinicians to better understand patients' expectations about and experiences with insulin therapy.

Diabetes and obesity: therapeutic targeting and risk reduction - a complex interplay

Obesity is a major risk factor for the development of diabetes and predisposes individuals to hypertension and dyslipidaemia. Together these pathologies increase the risk for cardiovascular disease (CVD), the major cause of morbidity and mortality in type 2 diabetes mellitus (T2DM). Worsening trends in obesity and T2DM raise a serious conundrum, namely, how to control blood glucose, blood pressure, and lipids when many antidiabetic agents cause weight gain and thereby exacerbate other cardiovascular risk factors associated with T2DM. Further, evidence suggests that some established antihypertensive agents may worsen glucose intolerance. Many patients who are obese, hypertensive, and/or hyperlipidaemic fail to achieve blood pressure, lipid and glycaemic goals, and this failure may in part be explained by physician reluctance to utilize complex combination regimens for fear of off-target effects. Thus, a clear need exists for clinicians to understand the risks and benefits of different pharmacologic, and indeed non-pharmacologic, options in order to maximize treatment outcomes. While intensive lifestyle modification remains an elusive gold standard, newer diabetes targets, including the incretin axis, may offer greater cardiovascular risk reduction than other antidiabetes therapies, although definitive clinical trial data are needed. The glucagon-like peptide-1 (GLP-1) receptor agonists exenatide and liraglutide and the dipeptidyl peptidase-4 (DPP-4) inhibitors sitagliptin and vildagliptin effectively lower HbA1c; exenatide and liraglutide reduce weight and blood pressure and improve lipid profiles. Sitagliptin and vildagliptin are weight neutral but also appear to improve lipid profiles. Integration of incretin therapies into the therapeutic armamentarium is a promising approach to improving outcomes in T2DM, and perhaps even in reducing complications of T2DM, such as co-morbid hypertension and dyslipidaemia. Additional long-term studies, including CVD end-point studies, will be necessary to determine the appropriate places for incretin-based therapies in treatment algorithms.

Impact of glycemic treatment choices on cardiovascular complications in type 2 diabetes

As the diabetic population has significant morbidity and mortality from cardiovascular disease (CVD), much of its medical care focuses on CVD prevention and treatment. Some medications used to treat hyperglycemia may have beneficial effects on CV outcomes, others may have negative effects, while still others seem to have no direct effect. Although past epidemiological studies have shown a relationship between glycated hemoglobin levels and CV events in patients with type 2 diabetes, recent large randomized clinical trials (ACCORD, ADVANCE, and VADT) lasting 3.5 to 5.6 years have found that intensive glycemic control either has no impact on CV outcomes or even worsens them. Results of the 10-year follow-up of the UKPDS suggest that tight glycemic control of younger, newly diagnosed patients with type 2 diabetes may have CV benefits many years later. Because the pathogenesis of atherosclerosis spans decades, it may be that beneficial effects of tight glycemic control on CV outcomes are mainly in younger patients without established macrovascular disease. There is an emerging notion that tight glycemic control may be beneficial in primary prevention of CVD in younger patients with diabetes, but may become deleterious in older patients with established or subclinical CVD. Thus, while tight control may lessen microvascular disease, it may increase the risk of hypoglycemia and possibly of adverse CV events. In each patient, the goals of glycemic control need to be individualized based on age, overall prognosis, presence of macrovascular disease, and risk of hypoglycemia.