Historical HbA1c Values May Explain the Type 2 Diabetes Legacy Effect: UKPDS 88

Use of Tirzepatide in Adults with Type 2 Diabetes Mellitus: Scientific Evidence and Practical Aspects

Tirzepatide is a novel antidiabetic medication a single-molecule, agonist to the glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptors. It is approved in the USA and EU for the treatment of type 2 diabetes mellitus (T2DM) and obesity. Due to the potential novelty represented by incorporating tirzepatide to clinical practice, we aim to review practical aspects of tirzepatide use in T2DM and the supporting scientific evidence. A group of ten endocrinologists involved as investigators in the phase 3 SURPASS clinical trial program followed a nominal group technique, a qualitative research methodology designed as a semi-structured group discussion to reach a consensus on the selection of a set of practical aspects. The scientific evidence for tirzepatide has been reviewed with respect to a number of patients' clinical profiles and care goals. Information of interest related to adverse events, special warnings and precautions, and other considerations for tirzepatide use has been included. Finally, information provided to the patients has been summarized. The practical aspects reported herein may be helpful in guiding physicians in the use of tirzepatide and contribute to optimizing the management of T2DM.

Insulin Inertia Among People With Type 2 Diabetes Mellitus in Qatar: The INERT-Q Study

BACKGROUND

Achieving and maintaining adequate glycaemic control is critical to reduce diabetes-related complications. Therapeutic inertia is one of the leading causes of suboptimal glycaemic control.

AIM

To assess the degree of inertia in insulin initiation and intensification in people with Type 2 diabetes mellitus (DM-2).

METHODS

We performed a retrospective longitudinal cohort study and followed DM-2 2 years before and 2 years after the start of insulin. The primary outcome was the proportion of patients who achieved glycaemic targets (HBA1c ≤ 7.5%) at 6th month, 1st year and 2nd year.

RESULTS

We included 374 predominantly male subjects (62%). The mean age was 55.3 ± 11.3 years, the mean duration of DM-2 was 12.0 ± 7.3 years, 64.4% were obese, 47.6% had a microvascular disease, and 24.3% had a macrovascular disease. The mean HBA1c at -2nd year and -1st year was 9.2 ± 2.1% and 9.3 ± 2.0%, respectively. The mean HbA1C at the time of insulin initiation was 10.4 ± 2.1%. The mean HBA1c at 6th month, 12th month and 2nd year was 8.5 ± 1.8%, 8.4 ± 1.8% and 8.5 ± 1.7%, respectively. The proportion of subjects who achieved HBA1c targets at 6th month, 12th month and 2nd year was 32.9%, 31.0% and 32.9%, respectively. Multivariate logistic regression analysis showed that achieving HBA1c targets at 6th month and 1st year increases the odds of achieving HBA1c targets at 2nd year (OR 4.87 [2.4-9.6] p < 0.001) and (OR 6.2 [3.2-12.0], p < 0.001), respectively.

CONCLUSION

In people with DM-2, there was an alarming delay in starting and titrating insulin. The reduction in HBA1c plateaued at 6th month. Earlier initiation and intensification of insulin therapy are critical to achieving glycaemic targets. More studies are needed to examine the causes of therapeutic inertia from physicians', patients' and systems' points of view.

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

Patient-reported outcomes and treatment adherence in type 2 diabetes using natural language processing: Wave 8 of the Observational International Diabetes Management Practices Study

AIMS/INTRODUCTION

We analyzed patient-reported outcomes of people with type 2 diabetes to better understand perceptions and experiences contributing to treatment adherence.

MATERIALS AND METHODS

In the ongoing International Diabetes Management Practices Study, we collected patient-reported outcomes data from structured questionnaires (chronic treatment acceptance questionnaire and Diabetes Self-Management Questionnaire) and free-text answers to open-ended questions to assess perceptions of treatment value and side-effects, as well as barriers to, and enablers for, adherence and self-management. Free-text answers were analyzed by natural language processing.

RESULTS

In 2018-2020, we recruited 2,475 patients with type 2 diabetes (43.3% insulin-treated, glycated hemoglobin (HbA1c) 8.0 ± 1.8%; 30.9% with HbA1c <7%) from 13 countries across Africa, the Middle East, Europe, Latin America and Asia. Mean ± standard deviation scores of chronic treatment acceptance questionnaire (acceptance of medication, rated out of 100) and Diabetes Self-Management Questionnaire (self-management, rated out of 10) were 87.8 ± 24.5 and 3.3 ± 0.9, respectively. Based on free-text analysis and coded responses, one in three patients reported treatment non-adherence. Overall, although most patients accepted treatment values and side-effects, self-management was suboptimal. Treatment duration, regimen complexity and disruption of daily routines were major barriers to adherence, whereas habit formation was a key enabler. Treatment-adherent patients were older (60 ± 11.6 vs 55 ± 11.7 years, P < 0.001), and more likely to have longer disease duration (12 ± 8.6 vs 10 ± 7.7 years, P < 0.001), exposure to diabetes education (73.1% vs 67.8%, P < 0.05), lower HbA1c (7.9 ± 1.8% vs 8.3 ± 1.9%, P < 0.001) and attainment of HbA1c <7% (29.7% vs 23.3%, P < 0.01).

CONCLUSIONS

Patient perceptions/experiences influence treatment adherence and self-management. Patient-centered education and support programs that consider patient-reported outcomes aimed at promoting empowerment and developing new routines might improve glycemic control.

Prevalence and risk factors for diabetic retinopathy at diagnosis of type 2 diabetes: an observational study of 77 681 patients from the Swedish National Diabetes Registry

INTRODUCTION

To assess the prevalence of diabetic retinopathy (DR) in persons with newly diagnosed type 2 diabetes (T2D) to understand the potential need for intensified screening for early detection of T2D.

RESEARCH DESIGN AND METHODS

Individuals from the Swedish National Diabetes Registry with a retinal photo <2 years after diagnosis of T2D were included. The proportion of patients with retinopathy (simplex or worse) was assessed. Patient characteristics and risk factors at diagnosis were analyzed in relation to DR with logistic regression.

RESULTS

In total, 77 681 individuals with newly diagnosed T2D, mean age 62.6 years, 41.1% females were included. Of these, 13 329 (17.2%) had DR.DR was more common in older persons (adjusted OR 1.03 per 10-year increase, 95% CI 1.01 to 1.05) and men compared with women, OR 1.10 (1.05 to 1.14). Other variables associated with DR were OR (95% CI): lower education 1.08 (1.02 to 1.14); previous stroke 1.18 (1.07 to 1.30); chronic kidney disease 1.29 (1.07 to 1.56); treatment with acetylsalicylic acid 1.14 (1.07 to 1.21); ACE inhibitors 1.12 (1.05 to 1.19); and alpha blockers 1.41 (1.15 to 1.73). DR was more common in individuals born in Asia (OR 1.16, 95% CI 1.08 to 1.25) and European countries other than those born in Sweden (OR 1.11, 95% CI 1.05 to 1.18).

CONCLUSIONS

Intensified focus on screening of T2D may be needed in Sweden in clinical practice since nearly one-fifth of persons have retinopathy at diagnosis of T2D. The prevalence of DR was higher in men, birthplace outside of Sweden, and those with a history of stroke, kidney disease, and hypertension.

Nurses' adoption of diabetes clinical practice guidelines in primary care and the impacts on patient outcomes and safety: An integrative review

BACKGROUND

Complications related to diabetes mellitus impose substantial health and economic burdens to individuals and society. While clinical practice guidelines improve diabetes management in primary care settings, the variability in adherence to these guidelines persist. Hence, there is a need to comprehensively review existing evidence regarding factors influencing nurses' adherence to implementation of clinical practice guidelines to improve clinical care and patient safety.

OBJECTIVE

This integrative review seeks to investigate nurses' adherence to clinical guidelines for diabetes management in primary healthcare settings and to explore factors influencing effective implementation, focusing on the role of nurses and impacts on patient outcomes.

METHODS

A comprehensive search was conducted in March 2023 across six electronic databases. The search targeted studies that examined the use of Type 2 diabetes mellitus guidelines by nurses in primary healthcare settings with a focus on clinical management outcomes related to diabetes care or patient safety. Included studies were classified using the Effective Practice and Organisation of Care taxonomy, synthesised narratively and presented thematically. Reporting of the review adhered to PRISMA guidelines. (PROSPERO ID CRD42023394311).

RESULTS

The review included ten studies conducted between 2000 and 2020, and the results were categorised into three themes. These were: (i) Implementation strategies to promote clinical practice guidelines adherence, including health professional development, reminders for clinicians, patient-mediated interventions, health information systems, role expansion, and comprehensive package-of-care. A multifaceted educational approach emerged as the most effective strategy. (ii) Impact of guidelines adherence: These strategies consistently improved clinical management, lowering HbA1c levels, improving blood pressure and lipid profiles, and enhancing patient self-care engagement, along with increased nurses' adherence to diabetes clinical guidelines. (iii) The role of nurses in guideline implementation, enabling independent practice within multidisciplinary teams. Their roles encompassed patient education, collaborative practice with fellow healthcare professionals, program planning and execution, and comprehensive documentation review. Nurse-led interventions were effective in improving patient outcomes, underscoring the necessity of empowering nurses with greater autonomy in providing primary diabetes care.

CONCLUSION

Implementing a diverse range of strategies, focusing on comprehensive education for healthcare providers, is paramount for enhancing guideline adherence in diabetes care, to improve clinical management towards optimal patient health outcomes. Tailoring these strategies to meet local needs adds relevance to the guidelines. Empowering nurses to take a leading role in primary care not only enhances patient safety but also promotes quality of care, resulting in improved overall outcomes.

TWEETABLE ABSTRACT

In primary care, empowering nurses with diabetes guideline education and tailoring strategies to local needs enhance guideline adherence and improve patient outcomes.

Type 2 Diabetes

Type 2 diabetes (T2D) is a prevalent disease that increases risk for vascular, renal, and neurologic complications. Prevention and treatment of T2D and its complications are paramount. Many advancements in T2D care have emerged over the past 5 years, including increased understanding of the importance of early intensive glycemic control, mental health, social determinants of health, healthy eating patterns, continuous glucose monitoring, and the benefits of some drugs for preventing cardiorenal disease. This review summarizes the evidence supporting T2D prevention and treatment, focusing on aspects that are commonly in the purview of primary care physicians.

Intermittent hyperglycaemia induces macrophage dysfunction by extracellular regulated protein kinase-dependent PKM2 translocation in periodontitis

Early fluctuations in blood glucose levels increased susceptibility to macrophage dysfunction. However, the underlying pathological mechanisms linking glucose variations and macrophage dysregulation remains elusive. In current study, we established an animal model of transient intermittent hyperglycaemia (TIH) to simulate early fluctuations in blood glucose levels. Our findings revealed that both TIH and diabetic group exhibited more severe periodontal lesions and increased secretion of pro-inflammatory cytokines compared to healthy controls. In immortalized bone marrow-derived macrophages (iBMDMs), phagocytosis and chemotaxis were impaired with transient and lasting hyperglycaemia, accompanied by enhanced glycolysis. We also found that TIH activated pyruvate kinase M2 (PKM2) through the phosphorylation of extracellular regulated protein kinase (ERK) in vivo, particularly at dimeric levels. In macrophage cultured with TIH, PKM2 translocated into the nucleus and involved in the regulating inflammatory genes, including TNF-α, IL-6 and IL-1β. PKM2 translocation and secretion of inflammatory cytokines were attenuated by PD98059, while PKM2 tetramer activator TEPP-46 prevented the formation of dimeric PKM2 in macrophages. Moreover, inhibition of glycolysis alleviated the TIH-induced pro-inflammatory cytokines. In conclusion, our manuscript provides a rationale for understanding how TIH modulates metabolic rewiring and dysfunction in macrophages via ERK-dependent PKM2 nuclear translocation.

Post-trial monitoring of a randomised controlled trial of intensive glycaemic control in type 2 diabetes extended from 10 years to 24 years (UKPDS 91)

BACKGROUND

The 20-year UK Prospective Diabetes Study showed major clinical benefits for people with newly diagnosed type 2 diabetes randomly allocated to intensive glycaemic control with sulfonylurea or insulin therapy or metformin therapy, compared with conventional glycaemic control. 10-year post-trial follow-up identified enduring and emerging glycaemic and metformin legacy treatment effects. We aimed to determine whether these effects would wane by extending follow-up for another 14 years.

METHODS

5102 patients enrolled between 1977 and 1991, of whom 4209 (82·5%) participants were originally randomly allocated to receive either intensive glycaemic control (sulfonylurea or insulin, or if overweight, metformin) or conventional glycaemic control (primarily diet). At the end of the 20-year interventional trial, 3277 surviving participants entered a 10-year post-trial monitoring period, which ran until Sept 30, 2007. Eligible participants for this study were all surviving participants at the end of the 10-year post-trial monitoring period. An extended follow-up of these participants was done by linking them to their routinely collected National Health Service (NHS) data for another 14 years. Clinical outcomes were derived from records of deaths, hospital admissions, outpatient visits, and accident and emergency unit attendances. We examined seven prespecified aggregate clinical outcomes (ie, any diabetes-related endpoint, diabetes-related death, death from any cause, myocardial infarction, stroke, peripheral vascular disease, and microvascular disease) by the randomised glycaemic control strategy on an intention-to-treat basis using Kaplan-Meier time-to-event and log-rank analyses. This study is registered with the ISRCTN registry, number ISRCTN75451837.

FINDINGS

Between Oct 1, 2007, and Sept 30, 2021, 1489 (97·6%) of 1525 participants could be linked to routinely collected NHS administrative data. Their mean age at baseline was 50·2 years (SD 8·0), and 41·3% were female. The mean age of those still alive as of Sept 30, 2021, was 79·9 years (SD 8·0). Individual follow-up from baseline ranged from 0 to 42 years, median 17·5 years (IQR 12·3-26·8). Overall follow-up increased by 21%, from 66 972 to 80 724 person-years. For up to 24 years after trial end, the glycaemic and metformin legacy effects showed no sign of waning. Early intensive glycaemic control with sulfonylurea or insulin therapy, compared with conventional glycaemic control, showed overall relative risk reductions of 10% (95% CI 2-17; p=0·015) for death from any cause, 17% (6-26; p=0·002) for myocardial infarction, and 26% (14-36; p<0·0001) for microvascular disease. Corresponding absolute risk reductions were 2·7%, 3·3%, and 3·5%, respectively. Early intensive glycaemic control with metformin therapy, compared with conventional glycaemic control, showed overall relative risk reductions of 20% (95% CI 5-32; p=0·010) for death from any cause and 31% (12-46; p=0·003) for myocardial infarction. Corresponding absolute risk reductions were 4·9% and 6·2%, respectively. No significant risk reductions during or after the trial for stroke or peripheral vascular disease were observed for both intensive glycaemic control groups, and no significant risk reduction for microvascular disease was observed for metformin therapy.

INTERPRETATION

Early intensive glycaemic control with sulfonylurea or insulin, or with metformin, compared with conventional glycaemic control, appears to confer a near-lifelong reduced risk of death and myocardial infarction. Achieving near normoglycaemia immediately following diagnosis might be essential to minimise the lifetime risk of diabetes-related complications to the greatest extent possible.

FUNDING

University of Oxford Nuffield Department of Population Health Pump Priming.

Contemporary Clinical Perspectives on Targeting Remission of Type 2 Diabetes

It has long been known that some patients with type 2 diabetes (T2DM) can experience sustained metabolic improvement to near-normal levels of glycemia either spontaneously or after medical intervention. Now recognized as remission of diabetes, this intriguing state is currently more feasible than ever before due to profound advances in metabolic surgery, pharmacologic therapy, and regimens of lifestyle modification. This enhanced capacity to induce remission has revealed new pathophysiologic insights, including the presence of a reversible component of the pancreatic beta-cell dysfunction that otherwise drives the chronic progressive nature of T2DM. In doing so, it has changed the therapeutic landscape by offering new potential management objectives and considerations for patients and providers. However, the excitement around these developments must also be tempered by the sobering realities of our current understanding of remission, including the recognition that this condition may not be permanent (resulting in glycemic relapse over time) and that beta-cell function may not be normalized in the setting of remission. These limitations highlight both the many gaps in our current understanding of remission and the caution with which clinical discussions must be handled for clear patient-directed communication of the pros and cons of targeting this outcome in practice. In this mini-review, we consider this rapidly growing literature, including its implications and its limitations, and thereby seek to provide objective balanced perspectives on targeting remission of T2DM in current clinical care.

Undiagnosed type 2 diabetes is common - intensified screening of established risk groups is imperative in Sweden: the SDPP cohort

BACKGROUND

Undiagnosed type 2 diabetes (T2D) is a global problem. Current strategies for diagnosis in Sweden include screening individuals within primary healthcare who are of high risk, such as those with hypertension, obesity, prediabetes, family history of diabetes, or those who smoke daily. In this study, we aimed to estimate the proportion of individuals with undiagnosed T2D in Stockholm County and factors associated with T2D being diagnosed by healthcare. This information could improve strategies for detection.

METHODS

We used data from the Stockholm Diabetes Prevention Programme (SDPP) cohort together with information from national and regional registers. Individuals without T2D aged 35-56 years at baseline were followed up after two ten-year periods. The proportion of diagnosed T2D was based on register information for 7664 individuals during period 1 and for 5148 during period 2. Undiagnosed T2D was assessed by oral glucose tolerance tests at the end of each period. With logistic regression, we analysed factors associated with being diagnosed among individuals with T2D.

RESULTS

At the end of the first period, the proportion of individuals with T2D who had been diagnosed with T2D or not was similar (54.0% undiagnosed). At the end of the second period, the proportion of individuals with T2D was generally higher, but they were less likely to be undiagnosed (43.5%). The likelihood of being diagnosed was in adjusted analyses associated with overweight (OR=1.85; 95% CI 1.22-2.80), obesity (OR=2.73; 95% CI 1.76-4.23), higher fasting blood glucose (OR=2.11; 95% CI 1.67-2.66), and self-estimated poor general health (OR=2.42; 95% CI 1.07-5.45). Socioeconomic factors were not associated with being diagnosed among individuals with T2D. Most individuals (>71%) who developed T2D belonged to risk groups defined by having at least two of the prominent risk factors obesity, hypertension, daily smoking, prediabetes, or family history of T2D, including individuals with T2D who had not been diagnosed by healthcare.

CONCLUSIONS

Nearly half of individuals who develop T2D during 10 years in Stockholm County are undiagnosed, emphasizing a need for intensified screening of T2D within primary healthcare. Screening can be targeted to individuals who have at least two prominent risk factors.

Optimising renal risk parameters in type 2 diabetes mellitus: Perspectives from a retinal viewpoint

Diabetic retinopathy and nephropathy share pathophysiological mechanisms and there is a defined correlation between the severity of both these microvascular complications from suboptimal glycaemic control. The reno-protective properties offered by sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists should be applicable to diabetic retinopathy as well. However, in patients with pre-existing diabetic retinopathy, sudden improvement in glycaemic control is well documented to cause early worsening of the changes in the retina that is usually transient. This paradoxical phenomenon tends to occur with longer duration of diabetes, higher HbA1c at the outset, rapid improvement of glucose levels and the magnitude of HbA1c reduction with addition of more agents to tighten metabolic control. Interestingly, this progression of pre-existing diabetic retinopathy is not quite observed with newer sodium-glucose co-transporter-2 inhibitors. This article discusses potential further areas of future research where mechanisms of renal protection can be translated to the retina.

International Diabetes Federation Position Statement on the 1-hour post-load plasma glucose for the diagnosis of intermediate hyperglycaemia and type 2 diabetes

Many individuals with intermediate hyperglycaemia (IH), including impaired fasting glycaemia (IFG) and impaired glucose tolerance (IGT), as presently defined, will progress to type 2 diabetes (T2D). There is confirmatory evidence that T2D can be prevented by lifestyle modification and/or medications, in people with IGT diagnosed by 2-h plasma glucose (PG) during a 75-gram oral glucose tolerance test (OGTT). Over the last 40 years, a wealth of epidemiological data has confirmed the superior value of 1-h plasma glucose (PG) over fasting PG (FPG), glycated haemoglobin (HbA1c) and 2-h PG in populations of different ethnicity, sex and age in predicting diabetes and associated complications including death. Given the relentlessly rising prevalence of diabetes, a more sensitive, practical method is needed to detect people with IH and T2D for early prevention or treatment in the often lengthy trajectory to T2D and its complications. The International Diabetes Federation (IDF) Position Statement reviews findings that the 1-h post-load PG ≥ 155 mg/dL (8.6 mmol/L) in people with normal glucose tolerance (NGT) during an OGTT is highly predictive for detecting progression to T2D, micro- and macrovascular complications, obstructive sleep apnoea, cystic fibrosis-related diabetes mellitus, metabolic dysfunction-associated steatotic liver disease, and mortality in individuals with risk factors. The 1-h PG of 209 mg/dL (11.6 mmol/L) is also diagnostic of T2D. Importantly, the 1-h PG cut points for diagnosing IH and T2D can be detected earlier than the recommended 2-h PG thresholds. Taken together, the 1-h PG provides an opportunity to avoid misclassification of glycaemic status if FPG or HbA1c alone are used. The 1-h PG also allows early detection of high-risk people for intervention to prevent progression to T2D which will benefit the sizeable and growing population of individuals at increased risk of T2D. Using a 1-h OGTT, subsequent to screening with a non-laboratory diabetes risk tool, and intervening early will favourably impact the global diabetes epidemic. Health services should consider developing a policy for screening for IH based on local human and technical resources. People with a 1-h PG ≥ 155 mg/dL (8.6 mmol/L) are considered to have IH and should be prescribed lifestyle intervention and referred to a diabetes prevention program. People with a 1-h PG ≥ 209 mg/dL (11.6 mmol/L) are considered to have T2D and should have a repeat test to confirm the diagnosis of T2D and then referred for further evaluation and treatment. The substantive data presented in the Position Statement provides strong evidence for redefining current diagnostic criteria for IH and T2D by adding the 1-h PG.

Mandatory monthly outpatient visits could improve therapeutic inertia in patients with poorly controlled type 2 diabetes

AIMS/INTRODUCTION

Delayed intensification of treatment, or therapeutic inertia, increases the risk of diabetic complications and death. The aim of this study was to determine the effect of mandatory monthly outpatient visits on therapeutic inertia in patients with suboptimal control of type 2 diabetes.

MATERIALS AND METHODS

This retrospective cohort study used data from the Chang Gung Research Database and defined two study periods: the baseline period and the intervention period. The intervention period began when the Kaohsiung branch initiated a mandatory monthly outpatient visits program. Type 2 diabetes patients with baseline glycated hemoglobin (HbA1c) >7% and a follow-up HbA1c measurement were enrolled in each period, and divided into a Kaohsiung branch (intervention) group and the other branches (control) group. Therapy intensification was evaluated by comparing prescriptions after the follow-up HbA1c measurement with the prescriptions after the baseline HbA1c measurement.

RESULTS

A total of 5,045 patients at the Kaohsiung branch and 13,400 participants at other branches were enrolled in the baseline period; and 5,573 and 15,603 patients, respectively, were enrolled in the intervention period. The adjusted odds ratio (AOR) for therapy intensification in patients with baseline HbA1c ≥9% was not significantly higher at 1.21 (95% CI, 1.00-1.47) in the intervention period at the Kaohsiung branch, but was significantly higher (AOR, 1.53; 95% CI, 1.02-2.30) in the subgroup with worsened HbA1c.

CONCLUSIONS

Mandatory monthly outpatient visits could improve therapeutic inertia in patients with poorly controlled type 2 diabetes, especially in those with worsened control. The trajectory of HbA1c could significantly influence the assessment of the prevalence of therapeutic inertia.

Effects of continuous glucose monitoring on glycaemic control in type 2 diabetes: A systematic review and network meta-analysis of randomized controlled trials

AIMS

The aim of this study was to assess the efficacy of continuous glucose monitoring (CGM) versus self-monitoring of blood glucose (SMBG) in maintaining glycaemic control among people with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

The protocol was registered in PROSPERO (CRD42023387583). PubMed, Web of Science, EMBASE and OVID databases were searched from 1 January 2000 until 31 December 2022 for randomized controlled trials comparing CGM with SMBG in glycaemic control among the outpatients with T2DM. The primary endpoint was glycated haemoglobin, while the secondary endpoints included time in range, time below range and time above range. Both traditional and network meta-analyses were conducted to explore the efficacy of CGM on glycaemic control in T2DM.

RESULTS

Eleven high-quality studies, involving 1425 individuals with T2DM, were identified. Traditional meta-analysis revealed that CGM exhibited a significantly decreased [mean difference (MD): -0.31, 95% confidence interval (CI) (-0.45, -0.18)], time above range [MD: -9.06%, 95% CI (-16.00, -2.11)], time below range [MD: -0.30%, 95% CI (-0.49, -0.12)] and a significantly increased time in range [MD: 8.49%, 95% CI (3.96, 13.02)] compared with SMBG. The network meta-analysis showed that real-time CGM can improve the glycaemic control of patients with T2DM to the most extent.

CONCLUSIONS

CGM could provide T2DM with greater benefits in glycaemic management compared with SMBG, particularly in patients using real-time CGM. These findings provide an updated perspective on previous research and offer guidance for CGM use in T2DM.

Challenging Clinical Perspectives in Type 2 Diabetes with Tirzepatide, a First-in-Class Twincretin

Tirzepatide is a first-in-class GIP/GLP-1 receptor agonist ('twincretin')-a single molecule that acts as an agonist at both glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptors. In the SURPASS clinical trial program in type 2 diabetes mellitus (T2D), tirzepatide was associated with unprecedented reductions in HbA1c, clinically significant weight loss and other metabolic benefits, combined with low rates of hypoglycaemia across a wide range of patient characteristics. The safety and adverse event rate for tirzepatide appears comparable to that of GLP-1 receptor agonists. Although results from dedicated cardiovascular (CV) and kidney trials are currently not available, information to date suggests that tirzepatide may have CV and kidney benefits in people with T2D. Tirzepatide has been approved for the treatment of T2D in the USA, United Arab Emirates, European Union, Japan and Australia. Here, we review how tirzepatide will fit into the T2D treatment continuum. We also consider future directions with tirzepatide in T2D, including its potential for targeting cardio-renal-metabolic disease in T2D, and discuss how tirzepatide-and other co-agonists in development-may challenge current approaches for management of T2D.

Effect on Hemoglobin A1c (HbA1c) and Body Weight After Discontinuation of Tirzepatide, a Novel Glucose-Dependent Insulinotropic Peptide (GIP) and Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist: A Single-Center Case Series Study

Introduction The purpose of this study was to examine changes in blood glucose levels and body weight after discontinuation of tirzepatide, a novel long-acting dual glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide-1 receptor agonist (GLP-1 RA). Methods Nine subjects (five males, four females, age 54.3±5.4 years, body mass index 33.5±3.3 kg/m2) participating with type 2 diabetes in the SURPASS J-mono study were included. Subjects were randomized to tirzepatide 5 mg, 10 mg, 15 mg, or a dulaglutide 0.75 mg group. Fifty-two weeks after randomization, study drug administration was discontinued. To investigate progress after the end of administration, changes in hemoglobin A1c (HbA1c) and body weight were further examined two, four, and six months after discontinuation of the study drug. Results After fifty-two weeks, all tirzepatide groups had improved HbA1c and body weight compared with the dulaglutide group. At two, four, and six months after the end of study drug administration, re-elevation of HbA1c was observed in all groups. Furthermore, in the tirzepatide groups, dose-dependent weight regain was observed from an early stage. Conclusions Compared to dulaglutide, tirzepatide exhibited excellent blood-glucose-improving and weight-reducing effects. However, exacerbation of blood glucose and rebound of weight gain occurred relatively early after administration was ended. For type 2 diabetes patients who need weight loss and are prescribed tirzepatide, these findings suggest a necessity for continuous prescription or careful follow-up when stopping.

The legacy effect of hyperglycemia and early use of SGLT-2 inhibitors: a cohort study with newly-diagnosed people with type 2 diabetes

Background

A delay in reaching HbA1c targets in patients with newly-diagnosed type 2 diabetes (T2D) is associated with an increased long-term risk of developing cardiovascular diseases (CVD), a phenomenon referred to as legacy effect. Whether an early introduction of glucose-lowering drugs with proven benefit on CVD can attenuate this phenomenon is unknown.

Methods

Using data derived from a large Italian clinical registry, i.e. the AMD Annals, we identified 251,339 subjects with newly-diagnosed T2D and without CVD at baseline. Through Cox regressions adjusted for multiple risk factors, we examined the association between having a mean HbA1c between 7.1 and 8% or >8%, compared with ≤7%, for various periods of early exposure (0-1, 0-2, 0-3 years) and the development of later (mean subsequent follow-up 4.6 ± 2.9 years) CVD, evaluated as a composite of myocardial infarction, stroke, coronary or peripheral revascularization, and coronary or peripheral bypass. We performed this analysis in the overall cohort and then splitting the population in two groups of patients: those that introduced sodium-glucose transport protein 2 inhibitors (SGLT-2i) during the exposure phase and those not treated with these drugs.

Findings

Considering the whole cohort, subjects with both a mean HbA1c between 7.1 and 8% and >8%, compared with patients attaining a mean HbA1c ≤ 7%, showed an increased risk of developing the outcome in all the three early exposure periods assessed, with the highest risk observed in patients with mean HbA1c > 8% in the 3 years exposure period (hazard ratio [HR]1.33; 95% confidence interval [CI] 1.063-1.365). The introduction of SGLT-2i during the exposure periods of 0-1 and 0-2 years eliminated the association between poor glycemic control and the outcome (p for interaction 0.006 and 0.003, respectively, vs. patients with the same degree of glycemic control but not treated with these drugs).

Interpretation

Among patients with newly diagnosed T2D and free of CVD at baseline, a poor glycemic control in the first three years after diagnosis is associated with an increased subsequent risk of CVD. This association is no longer evident when SGLT-2i are introduced in the first two years, suggesting that these drugs attenuate the phenomenon of legacy effect. An early treatment with these drugs might thus promote a long-lasting benefit in patients not attaining proper glycemic control after T2D diagnosis.

Funding

This work was supported, in part, by the Italian Ministry of Health (Ricerca Corrente) to IRCCS MultiMedica.

The Wedding Bells Sound Really Good! iGlarLixi Fixed-Ratio Combination in the Treatment of Type 2 Diabetes: A Narrative Review

iGlarLixi is a fixed-ratio combination of insulin glargine 100 U/mL and lixisenatide used in the treatment of type 2 diabetes. iGlarLixi has proven clinical benefits in terms of glycemia, weight control, and safety, defined by the risk of hypoglycemia. It simultaneously targets many pathophysiologic abnormalities which are at the root of type 2 diabetes and thus presents a complementary mode of action. Finally, it may also address diabetes treatment burden, and, by decreasing the complexity of treatment, it may improve patient adherence and persistence and fight against clinical inertia. This article reviews the results of major randomized controlled trials in people with type 2 diabetes that compared iGlarLixi to other therapeutic regimens, representing different intensification strategies, such as basal supported oral therapy, oral antidiabetic drugs, and a combination of the latter with glucagon-like peptide 1 receptor agonists. Moreover, as a supplement to randomized trials, data from real-world evidence have also been included.

2023 UPDATE: Luso-Brazilian evidence-based guideline for the management of antidiabetic therapy in type 2 diabetes

BACKGROUND

The management of antidiabetic therapy in people with type 2 diabetes (T2D) has evolved beyond glycemic control. In this context, Brazil and Portugal defined a joint panel of four leading diabetes societies to update the guideline published in 2020.

METHODS

The panelists searched MEDLINE (via PubMed) for the best evidence from clinical studies on treating T2D and its cardiorenal complications. The panel searched for evidence on antidiabetic therapy in people with T2D without cardiorenal disease and in patients with T2D and atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), or diabetic kidney disease (DKD). The degree of recommendation and the level of evidence were determined using predefined criteria.

RESULTS AND CONCLUSIONS

All people with T2D need to have their cardiovascular (CV) risk status stratified and HbA1c, BMI, and eGFR assessed before defining therapy. An HbA1c target of less than 7% is adequate for most adults, and a more flexible target (up to 8%) should be considered in frail older people. Non-pharmacological approaches are recommended during all phases of treatment. In treatment naïve T2D individuals without cardiorenal complications, metformin is the agent of choice when HbA1c is 7.5% or below. When HbA1c is above 7.5% to 9%, starting with dual therapy is recommended, and triple therapy may be considered. When HbA1c is above 9%, starting with dual therapyt is recommended, and triple therapy should be considered. Antidiabetic drugs with proven CV benefit (AD1) are recommended to reduce CV events if the patient is at high or very high CV risk, and antidiabetic agents with proven efficacy in weight reduction should be considered when obesity is present. If HbA1c remains above target, intensification is recommended with triple, quadruple therapy, or even insulin-based therapy. In people with T2D and established ASCVD, AD1 agents (SGLT2 inhibitors or GLP-1 RA with proven CV benefit) are initially recommended to reduce CV outcomes, and metformin or a second AD1 may be necessary to improve glycemic control if HbA1c is above the target. In T2D with HF, SGLT2 inhibitors are recommended to reduce HF hospitalizations and mortality and to improve HbA1c. In patients with DKD, SGLT2 inhibitors in combination with metformin are recommended when eGFR is above 30 mL/min/1.73 m2. SGLT2 inhibitors can be continued until end-stage kidney disease.

Roadmap for the Management of Type 2 Diabetes and Hypertension in the Middle East: Review of the 2022 EVIDENT Summit

Type 2 diabetes mellitus (T2DM) and hypertension are leading risk factors for death and disability in the Middle East. Both conditions are highly prevalent, underdiagnosed and poorly controlled, highlighting an urgent need for a roadmap to overcome the barriers to optimal glycaemic and blood pressure management in this region. This review provides a summary of the Evidence in Diabetes and Hypertension Summit (EVIDENT) held in September 2022, which discussed current treatment guidelines, unmet clinical needs and strategies to improve treatment outcomes for patients with T2DM and hypertension in the Middle East. Current clinical guidelines recommend strict glycaemic and blood pressure targets, presenting several treatment options to achieve and maintain these targets and prevent complications. However, treatment targets are infrequently met in the Middle East, largely due to high clinical inertia among physicians and low medication adherence among patients. To address these challenges, clinical guidelines now provide individualised therapy recommendations based on drug profiles, patient preferences and management priorities. Efforts to improve the early detection of prediabetes, T2DM screening and intensive, early glucose control will minimise long-term complications. Physicians can use the T2DM Oral Agents Fact Checking programme to help navigate the wide range of treatment options and guide clinical decision-making. Sulfonylurea agents have been used successfully to manage T2DM; a newer agent, gliclazide MR (modified release formulation), has the advantages of a lower incidence of hypoglycaemia with no risk of cardiovascular events, weight neutrality and proven renal benefits. For patients with hypertension, single-pill combinations have been developed to improve efficacy and reduce treatment burden. In conjunction with pragmatic treatment algorithms and personalised therapies, greater investments in disease prevention, public awareness, training of healthcare providers, patient education, government policies and research are needed to improve the quality of care of patients with T2DM and/or hypertension in the Middle East.

Efficacy and safety of luseogliflozin in Caucasian patients with type 2 diabetes: results from a phase III, randomized, placebo-controlled, clinical trial

INTRODUCTION

Most data demonstrating the efficacy and safety of luseogliflozin (luseo) in people with type 2 diabetes mellitus (T2DM) originate from the Japanese population. This study evaluated luseo versus placebo (PCB) as add-on to metformin in a Caucasian population with inadequately controlled T2DM.

RESEARCH DESIGN AND METHODS

This was a multicenter, randomized, double-blind, PCB-controlled, parallel-group study. Patients aged 18-75 years with inadequately controlled T2DM (glycated hemoglobin (HbA1c) ≥7% to ≤10% (≥53 to ≤86 mmol/mol)) despite a diet and exercise program and on a stable metformin regimen were eligible. Patients were randomized to one of three luseo groups (2.5, 5.0 and 10.0 mg) or PCB for 12 weeks (W12). The primary endpoint was change in HbA1c expressed as least-square means from baseline (W0) to W12.

RESULTS

A total of 328 patients were randomized: PCB (n=83) and luseo 2.5 mg (n=80), 5.0 mg (n=86), and 10.0 mg (n=79). Mean age (±SD) was 58.5±8.8 years; 64.6% were women; body mass index was 31.5±3.4 kg/m2; and HbA1c was 8.54±0.70. At W12, mean reductions in HbA1c from W0 were -0.98%, -1.09%, -1.18%, and -0.73% in the luseo 2.5, 5.0 and 10.0 mg, and PCB groups, respectively, all of which were statistically significant. Compared with PCB, HbA1c levels were significantly decreased by 0.25% (p=0.045), 0.36% (p=0.006), and 0.45% (p=0.001) in the luseo 2.5, 5.0, and 10.0 mg groups, respectively. In all luseo dose groups, reductions in body weight were statistically significant compared with PCB. Data from the safety analysis were consistent with the known luseo safety profile.

CONCLUSIONS

All doses of luseo as add-on to metformin in Caucasian patients with uncontrolled T2DM demonstrated significant efficacy in decreasing HbA1c after W12 of treatment.

TRIAL REGISTRATION NUMBER

ISRCTN39549850.

HbA1c is related to microcirculation blood perfusion in patients with coronary microvascular disease using stress perfusion cardiac magnetic resonance: An observational study

BACKGROUND

In coronary microvascular disease (CMD) patients, the incidence of major adverse cardiovascular events (MACEs) in patients with myocardial perfusion reserve index (MPRI) ≤ 1.47 is three times higher than that in MPRI > 1.47. We investigated whether the increase of glycated hemoglobin A1c (HbA1c) could increase the risk of MPRI ≤1.47 in diabetic and non-diabetic patients.

METHODS

From November 2019, patients with ischemic symptoms but without obstructive coronary disease were screened. Use MPRI measured by stress perfusion cardiac magnetic resonance (CMR) to reflect microcirculation blood perfusion, and MPRI <2.5 were included. The patients were divided into two groups based on MPRI was greater or <1.47. The risk factors for CMD were explored using logistic regression analysis.

RESULTS

A total of 80 patients with an MPRI of 1.69 ± 0.79 were included. CMD patients with an MPRI of ≤1.47(n = 33) were higher than MPRI of >1.47(n = 47) in age, presence of diabetes mellitus, fasting blood glucose levels and HbA1c levels (P < 0.05). In non-diabetic patients, increased HbA1c was associated with the risk of MPRI≤1.47 (OR = 0.017, 95%CI: 0.050-1.107, P = 0.045). Compared with non-diabetic patients with HbA1c < 6.0, non-diabetic patients with HbA1c ≥ 6.0 increased the risk of MPRI of ≤1.47 (OR = 0.219, 95%CI: 0.069-0.697, P = 0.010). In diabetic patients, HbA1c was not associated with the risk of MPRI of ≤1.47 (OR = 1.043, 95%CI: 0.269, 4.044, P = 0.952). And compared with non-diabetic patients with HbA1c <6.0, diabetic patients with HbA1c <6.0 (OR = 0.917, 95%CI: 0.233-3.610, P = 0.901) or ≥6.0 (OR = 0.326, 95%CI: 0.073-1.446, P = 0.140), the risk of MPRI ≤ 1.47 was not further increased.

CONCLUSIONS

In non-diabetic patients, elevated HbA1c is related to MPRI≤1.47(a value increased incidence of MACEs). Therefore, in patients with undiagnosed diabetes, early management of glycosylated hemoglobin is very important.

TRIAL REGISTRATION

This clinical trial has been registered in the Chinese clinical Trial Registry with an identifier: ChiCTR1900025810.

Dispersion of Serum 1,5 Anhydroglucitol Values in patients with Type 2 Diabetes at goal of HbA1c

AIM

To investigate the relationship of 1,5 anhydroglucitol (1,5 AG) with HbA1c in patients with type 2 diabetes (T2D) with different ranges of glycemic control.

METHODS

One hundred outpatients with T2D ≥ 18 years old were studied. In addition, HbA1c, glycemia, 1,5 AG, lipids, albuminuria, estimated glomerular filtration rate, and clinical data were registered.

RESULTS

The patient's median age was 62.5 years, with a median of 10 years with T2D. Those with HbA1c <7 % had higher 1,5 AG than those with HbA1c ≥ 7 %, 16.8 ug/ml vs. 4.90 (p=0.00001).1,5 AG correlated inversely with HbA1c (r= -0.7910, p=0.00001), glycemia (r= -0.6307, p=0.00001), cholesterol (r= -0.2257, p= 0.0239), LDL-cholesterol (r= -0.2240 , p=0.0266), albuminuria (r= -0.3644, p=0.0002) and heart rate (r= -0.267 ,p=0.0072). Those on insulin therapy also had lower 1,5 AG (p=0.000). The scatter plot of 1,5 AG and HbA1c fitted a second-degree fractional polynomic regression model, with dispersion of 1 5 AG when HbA1c < 7.5%. An HbA1c ≥ 7.5 % predicted a 1,5 AG <10 ug/ml CONCLUSION: Dispersion of 1,5 AG values at HbA1c < 7.5 % indicates postprandial glucose excursions that may impair glucose control and increase the cardiovascular risk in these patients.

Early type 2 diabetes treatment intensification with glucagon-like peptide-1 receptor agonists in primary care: An Australian perspective on guidelines and the global evidence

Early and intensive management of type 2 diabetes has been shown to delay disease progression, reduce the risk of cardiorenal complications and prolong time to treatment failure. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are being increasingly recognized for their potential in early disease management, with recent guideline updates recommending second-line use of this injectable drug class alongside oral glucose-lowering drugs. GLP-1RAs target at least six of the eight core defects implicated in the pathogenesis of type 2 diabetes and offer significant glycaemic and weight-related improvements over other second-line agents in head-to-head trials. In addition, placebo-controlled clinical trials have shown cardiovascular protection with GLP-1RA use. Even so, this therapeutic class is underused in primary care, largely owing to clinical inertia and patient-related barriers to early intensification with GLP-1RAs. Fortunately, clinicians can overcome barriers to treatment acceptance through patient education and training, and management of treatment expectations. In this review we comment on global and Australian guideline updates and evidence in support of early intensification with this therapeutic class, and provide clinicians with practical advice for GLP-1RA use in primary care.

The Effectiveness of an eHealth Family-Based Intervention Program in Patients With Uncontrolled Type 2 Diabetes Mellitus (T2DM) in the Community Via WeChat: Randomized Controlled Trial

BACKGROUND

Intervention based on family support and risk perception can enhance type 2 diabetes mellitus (T2DM) patients' self-care activities. In addition, eHealth education is considered to improve family members' support for patients with T2DM. However, there is little evidence from rigorously designed studies on the effectiveness of an intervention combining these approaches.

OBJECTIVE

This randomized controlled trial (RCT) aimed to assess the effectiveness of an eHealth family-based health education intervention for patients with T2DM to improve their glucose control, risk perception, and self-care behaviors.

METHODS

This single-center, 2-parallel-group RCT was conducted between 2019 and 2020. Overall, 228 patients were recruited from Jiading District, Shanghai, and randomly divided into intervention and control groups. The intervention group received an eHealth family intervention based on community management via WeChat, whereas the control group received usual care. The primary outcome was the glycated hemoglobin (HbA1c) level of the patients with T2DM, and the secondary outcomes were self-management behavior (general and specific diet, exercise, blood sugar testing, foot care, and smoking), risk perception (risk knowledge, personal control, worry, optimism bias, and personal risk), and family support (supportive and nonsupportive behaviors). A 2-tailed paired-sample t test was used to compare the participants at baseline and follow-up within the control and intervention groups. An analysis of covariance was used to measure the intervention effect.

RESULTS

In total, 225 patients with T2DM were followed up for 1 year. After intervention, they had significantly lower HbA1c values (β=-.69, 95% CI -0.99 to -0.39; P<.001). They also had improved general diet (β=.60, 95% CI 0.20 to 1.00; P=.003), special diet (β=.71, 95% CI 0.34 to 1.09; P<.001), blood sugar testing (β=.50, 95% CI 0.02 to 0.98; P=.04), foot care (β=1.82, 95% CI 1.23 to 2.42; P<.001), risk knowledge (β=.89, 95% CI 0.55 to 1.24; P<.001), personal control (β=.22, 95% CI 0.12 to 0.32; P<.001), worry (β=.24, 95% CI 0.10 to 0.39; P=.001), optimism bias (β=.26, 95% CI 0.09 to 0.43; P=.003), and supportive behaviors (β=5.52, 95% CI 4.03 to 7.01; P<.001).

CONCLUSIONS

The eHealth family-based intervention improved glucose control and self-care activities among patients with T2DM by aiding the implementation of interventions to improve T2DM risk perceptions among family members. The intervention is generalizable for patients with T2DM using health management systems in community health centers.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900020736; https://www.chictr.org.cn/showprojen.aspx?proj=31214.

Adjusting the Use of Glucose-Lowering Agents in the Real-World Clinical Management of People with Type 2 Diabetes: A Narrative Review

Despite the availability of new treatment classes, glycaemic control in patients with diabetes remains suboptimal globally. The latter is associated with high risk of premature mortality related to diabetes and its microvascular and macrovascular complications. Practice guidelines typically focus on glycated haemoglobin < 7.0% as a therapeutic goal in type 2 diabetes (T2D). Reducing glycated haemoglobin has been proven to reduce the risk of these complications while early attainment of glycaemic goal can have a legacy effect in later life. Both glucocentric and cardiorenal-centric treatment strategies have complementary effects in reducing the trajectory of cardiorenal diseases. In real-word settings, implementation of practice guidelines developed in the USA and Europe may not be applicable to regions such as Asia, where differences in epidemiology, patient phenotypes, cultures, resource availability, and treatment affordability are important considerations. In the present review, we discuss the need to use a pragmatic, albeit evidence-based approach, to combine glucocentric and cardiorenal risk reduction strategies to improve the outcomes in patients with T2D, with particular relevance to Asia Pacific.

Trends in baseline HbA1c and body-mass index in randomised placebo-controlled trials of type 2 diabetes from 1987 to 2022: a systematic review and meta-analysis

BACKGROUND

Curbing or reversing high glycated hemoglobin (HbA1c) and body mass index (BMI) are two essential parts in the clinical management of type 2 diabetes (T2D). We delineated the changing patterns of the baseline HbA1c and BMI in patients with T2D from placebo-controlled randomised trials to reflect the unmet clinical needs.

METHODS

PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception to December 19, 2022. Placebo-controlled trials of T2D with reports of baseline HbA1c and BMI were included, of which summary data from published reports were extracted. Pooled effect sizes of baseline HbA1c and BMI of from studies published in the same year were computed in Random-effects model due to the high level of heterogeneity among studies. The main outcome was correlations between the pooled baseline HbA1c, the pooled baseline BMI, and study years. This study was registered in PROSPERO as CRD42022350482.

FINDINGS

We identified 6102 studies, of which 427 placebo-controlled trials with 261, 462 participants were finally included in the study. Baseline HbA1c level declined with time (Rs = -0.665, P ＜ 0.0001, I² = 99.4%). Baseline BMI increased over the past 35 years (R = 0.464, P = 0.0074, I² = 99.4%), rising by around 0.70 kg/m² per decade. Patients with BMI ≤25.0 kg/m² dropped substantially from the half in 1996 to none in 2022. Patients with BMI ranging from 25 kg/m² to 30 kg/m² stabilized at 30-40% since 2000.

INTERPRETATION

A substantial decline in baseline HbA1c levels and a constant increase in baseline BMI levels was found in placebo-controlled trials through the past 35 years, which indicated the improvement in glycemic control and the urgency for the management of obesity in T2D.

FUNDING

National Natural Science Foundation of China (No.81970698), Beijing Natural Science Foundation (No.7202216) and National Natural Science Foundation of China (No.81970708).

Cardiovascular outcomes in type 1 and type 2 diabetes

Diabetes is one of the most prevalent cardiometabolic disorders on the planet. Type 1 diabetes accounts for only a minority of all cases (recently estimated to be ~2% globally); however, since this is a disorder with an early onset, many people live with type 1 diabetes for a long time. CVD and premature death are the main long-term outcomes for both types of diabetes; however, the type of diabetes that carries the highest risk of these outcomes is a controversial topic and has not been widely studied. Because of the association between diabetes and CVD, the rise in type 2 diabetes prevalence over the past decades has huge effects on global health. The excess risk in people with diabetes compared with those without depends, to a large extent, on the presence of other factors, such as general cardiovascular risk factors (e.g. elevated LDL-cholesterol, hypertension and smoking) and also factors that are more specific to diabetes (e.g. HbA1c, and micro- and macroalbuminuria). Some contributory factors are modifiable, while others are not, such as age, sex and type of diabetes. Older people with type 2 diabetes who have risk factors that are under control can achieve levels of CVD risk that are similar to that of the general population, while younger individuals with type 1 diabetes are mostly unable to achieve similar levels of risk, probably because of long and cumulative exposure to raised blood glucose levels. Despite reports of declining rates of CVD among people with type 1 and type 2 diabetes, rising rates of both types of diabetes lead to a continuing rise in the number of people with cardiometabolic disorders worldwide, offsetting the progress made in many countries. Comparison between individuals with type 1 and type 2 diabetes with respect to risk of CVD is fraught with difficulties and highly dependent on other, concomitant factors, some of which are modifiable and others not. Nonetheless, as a whole, what matters most in determining the management of diabetes is absolute risk and lifetime risk. Life-long efforts to achieve glycaemic control, control of lipids and hypertension, and not smoking are key to prevention, with a healthy lifestyle and pharmacological therapy to be implemented as needed.

Early intervention and intensive management of patients with diabetes, cardiorenal, and metabolic diseases

Increasing rates of obesity and diabetes have driven corresponding increases in related cardiorenal and metabolic diseases. In many patients, these conditions occur together, further increasing morbidity and mortality risks to the individual. Yet all too often, the risk factors for these disorders are not addressed promptly in clinical practice, leading to irreversible pathologic progression. To address this gap, we convened a Task Force of experts in cardiology, nephrology, endocrinology, and primary care to develop recommendations for early identification and intervention in obesity, diabetes, and other cardiorenal and metabolic diseases. The recommendations include screening and diagnosis, early interventions with lifestyle, and when and how to implement medical therapies. These recommendations are organized into primary and secondary prevention along the continuum from obesity through the metabolic syndrome, prediabetes, diabetes, hypertension, dyslipidemia, nonalcoholic fatty liver disease (NAFLD), atherosclerotic cardiovascular disease (ASCVD) and atrial fibrillation, chronic kidney disease (CKD), and heart failure (HF). The goal of early and intensive intervention is primary prevention of comorbidities or secondary prevention to decrease further worsening of disease and reduce morbidity and mortality. These efforts will reduce clinical inertia and may improve patients' well-being and adherence.

Associations Between Mean HbA1c, HbA1c Variability, and Both Mortality and Macrovascular Complications in Patients with Diabetes Mellitus: A Registry-Based Cohort Study

Background

We investigate the association between mean HbA1c, HbA1c variability, and all-cause mortality and diabetes-related macrovascular complications in patients with diabetes.

Methods

We performed a retrospective cohort study using patients present in the Singapore Health Services diabetes registry (SDR) during 2013 to 2014. We assessed mean HbA1c using three models: a baseline mean HbA1c for 2013-14, the mean across the whole follow-up period, and a time-varying yearly updated mean. We assessed HbA1c variability at baseline using the patient's HbA1c variability score (HVS) for 2013-14. The association between mean HbA1c, HVS, and 6 outcomes were assessed using Cox proportional hazard models.

Results

We included 43,837-53,934 individuals in the analysis; 99.3% had type 2 diabetes mellitus. The data showed a J-shaped distribution in adjusted hazard ratios (HRs) for all-cause mortality, ischemic heart disease, acute myocardial infarction, peripheral arterial disease, and ischemic stroke, with an increased risk of developing these outcomes at HbA1c <6% (42 mmol/mol) and ≥8% (64 mmol/mol). With the addition of HVS, the J-shaped distribution was maintained for the above outcomes, but HRs were greater at HbA1c <6.0% (42 mmol/mol) and reduced at HbA1c ≥8.0% (64 mmol/mol) when compared to models without HVS. The risk for all outcomes increased substantially with increasing glycaemic variability.

Conclusion

Both low (<6.0% [42 mmol/mol]) and high (≥8.0% [64 mmol/mol]) levels of glycaemic control are associated with increased all-cause mortality and diabetes-related macrovascular complications. Glycaemic variability is independently associated with increased risk for these outcomes. Therefore, patients with stable glycaemic level of 6-8% (42-64mmol/mol) are at lowest risk of all-cause mortality and diabetes-related macrovascular complications.

Therapeutic Effects of Switching to Anagliptin from Other DPP-4 Inhibitors in T2DM Patients with Inadequate Glycemic Control: A Non-interventional, Single-Arm, Open-Label, Multicenter Observational Study

INTRODUCTION

The effects of switching DPP-4 inhibitors in type 2 diabetes mellitus (T2DM) patients are being widely studied. However, information of which factors affect the therapeutic response is limited. We evaluated the difference in HbA1c lowering effect by comorbidity and other variables after switching to anagliptin in patients with T2DM inadequately controlled by other DPP-4 inhibitors.

METHODS

In a multicenter, open-label, single-arm, prospective observational study, patients with T2DM, HbA1c ≥ 7.0% who have taken DPP-4 inhibitors other than anagliptin, either alone or in combination (DPP-4 inhibitors + metformin/sulfonylurea (SU)/thiazolidinedione (TZD)/insulin), for at least 8 weeks were enrolled. After the switch to anagliptin, HbA1c and available clinical characteristics were determined.

RESULTS

The change in HbA1c levels from baseline to week 12 and 24 was - 0.40% and - 0.42% in all patients. However, comparing the subgroups without and with comorbidities, the change in HbA1c levels at weeks 12 and 24 was - 0.68% and - 0.89% vs. - 0.27% and 0.22%, respectively. In addition, the proportion of patients achieving HbA1c < 7% from baseline to week 12 and 24 was increased to 70% and 70% vs. 20% and 24%, respectively. Duration of T2DM and different subtype classes of DPP-4 inhibitor did not significantly contribute to the change in HbA1c.

CONCLUSION

In patients with T2DM poorly controlled by other DPP-4 inhibitors, HbA1c levels were significantly decreased after switching to anagliptin. Given that the change in HbA1c was greater in patients without comorbidities than in patients with comorbidities, switching to anagliptin before adding other oral hypoglycemic agents (OHAs) may be an option in patients without comorbidities.

Management of hyperglycaemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycaemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional healthcare team providing diabetes care in the USA and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the healthcare system and physical activity behaviours including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Type 2 diabetes

Type 2 diabetes accounts for nearly 90% of the approximately 537 million cases of diabetes worldwide. The number affected is increasing rapidly with alarming trends in children and young adults (up to age 40 years). Early detection and proactive management are crucial for prevention and mitigation of microvascular and macrovascular complications and mortality burden. Access to novel therapies improves person-centred outcomes beyond glycaemic control. Precision medicine, including multiomics and pharmacogenomics, hold promise to enhance understanding of disease heterogeneity, leading to targeted therapies. Technology might improve outcomes, but its potential is yet to be realised. Despite advances, substantial barriers to changing the course of the epidemic remain. This Seminar offers a clinically focused review of the recent developments in type 2 diabetes care including controversies and future directions.

Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the previous consensus statements on the management of hyperglycemia in type 2 diabetes in adults, published since 2006 and last updated in 2019. The target audience is the full spectrum of the professional health care team providing diabetes care in the U.S. and Europe. A systematic examination of publications since 2018 informed new recommendations. These include additional focus on social determinants of health, the health care system, and physical activity behaviors, including sleep. There is a greater emphasis on weight management as part of the holistic approach to diabetes management. The results of cardiovascular and kidney outcomes trials involving sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists, including assessment of subgroups, inform broader recommendations for cardiorenal protection in people with diabetes at high risk of cardiorenal disease. After a summary listing of consensus recommendations, practical tips for implementation are provided.

Trends in diabetes-related complications in Singapore, 2013-2020: A registry-based study

Background

Diabetes mellitus (DM) is a growing global health problem. In Singapore, the prevalence of Type 2 DM is rising, but comprehensive information about trends in DM-related complications is lacking.

Objectives

We utilized the Singapore Health Services (SingHealth) diabetes registry (SDR) to assess trends in DM micro and macro-vascular complications at the population level, explore factors influencing these trends.

Methods

We studied trends for ten DM-related complications: ischemic heart disease (IHD), acute myocardial infarction (AMI), peripheral arterial disease (PAD) and strokes, diabetic eye complications, nephropathy, neuropathy, diabetic foot, major and minor lower extremity amputation (LEA). The complications were determined through clinical coding in hospital (inpatient and outpatient) and primary care settings within the SingHealth cluster. We described event rates for the complications in 4 age-bands. Joinpoint regression was used to identify significant changes in trends.

Results

Among 222,705 patients studied between 2013 and 2020. 48.6% were female, 70.7% Chinese, 14.7% Malay and 10.6% Indian with a mean (SD) age varying between 64.6 (12.5) years in 2013 and 65.7 (13.2) years in 2020. We observed an increase in event rates in IHD, PAD, stroke, diabetic eye complications nephropathy, and neuropathy. Joinpoints was observed for IHD and PAD between 2016 to 2018, with subsequent plateauing of event rates. Major and minor LEA event rates decreased through the study period.

Conclusion

We found that DM and its complications represent an important challenge for healthcare in Singapore. Improvements in the trends of DM macrovascular complications were observed. However, trends in DM microvascular complications remain a cause for concern.

Advances in Nanomaterial-Based Biosensors for Determination of Glycated Hemoglobin

Diabetes is a major public health burden whose prevalence has been steadily increasing over the past decades. Glycated hemoglobin (HbA1c) is currently the gold standard for diagnostics and monitoring glycemic control in diabetes patients. HbA1c biosensors are often considered to be cost-effective alternatives for smaller testing laboratories or clinics unable to access other reference methods. Many of these sensors deploy nanomaterials as recognition elements, detection labels, and/or transducers for achieving sensitive and selective detection of HbA1c. Nanomaterials have emerged as important sensor components due to their excellent optical and electrical properties, tunable morphologies, and easy integration into multiple sensing platforms. In this review, we discuss the advantages of using nanomaterials to construct HbA1c sensors and various sensing strategies for HbA1c measurements. Key gaps between the current technologies with what is needed moving forward are also summarized.

Association of prediabetes with death and diabetic complications in older adults: the pros and cons of active screening for prediabetes

BACKGROUND

active screening can improve health outcomes for people with prediabetes. However, its efficacy in older adults remains uncertain.

OBJECTIVE

the study aimed to analyse the progression from prediabetes to diabetes in older adults, including associated complications and mortality rates, to determine the benefits of active screening.

DESIGN

retrospective cohort study.

SETTING

Korean National Health Insurance Service claims database.

SUBJECTS

a total of 36,946 adults aged ≥65 years who underwent national health examinations from 2006 to 2008.

METHODS

follow-up was until 31 December 2015. Cox's proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for death and diabetic complications.

RESULTS

over a median follow-up of 8.2 years, 19.3% of older adults with prediabetes progressed to diabetes. Compared with normoglycaemic adults, the multivariable-adjusted HRs (95% CI) for major adverse cardiovascular events were 1.01 (0.95-1.07), 1.08 (0.95-1.23), 1.14 (1.05-1.23) and 1.50 (1.35-1.68) in adults with prediabetes, newly diagnosed diabetes, diabetes not on insulin and diabetes on insulin, respectively. The corresponding HRs (95% CI) for diabetic retinopathy risk were 1.28 (1.15-1.43), 3.16 (2.71-3.69), 6.58 (6.02-7.19) and 9.17 (8.21-10.24). Diabetic nephropathy risk also significantly increased.

CONCLUSIONS

progression from prediabetes to diabetes is an important concern among older adults. Prediabetes is associated with the risk of microvascular complications, but not cardiovascular complications and mortality. Therefore, active regular screening for prediabetes is necessary to prevent microvascular complications.

Association of Dulaglutide Initiation Timing With Treatment Patterns and Clinical Outcomes in Patients With Type 2 Diabetes Mellitus in the United States

PURPOSE

To describe clinical characteristics and treatment outcomes for early or late initiation of dulaglutide therapy in patients with type 2 diabetes.

METHODS

This retrospective, claims-based analysis evaluated adults with type 2 diabetes, ≥1 claim for dulaglutide 0.75 mg or 1.5 mg once-weekly injection (between November 2014 and August 2019), and no prior use of glucagon-like peptide 1 receptor agonists or insulin. Cohorts were defined based on the number of oral antidiabetic drug (OAD) classes used within the 24-month baseline period before dulaglutide therapy initiation: 1 OAD, 2 OADs, or ≥3 OADs. The number of OAD classes used before dulaglutide therapy initiation served as a proxy for timing of initiation, with a higher number of OAD classes indicating a longer duration of T2D. Baseline demographic and clinical characteristics were compared across each cohort. Six-month follow-up outcomes, including change in glycosylated hemoglobin (HbA_1c) and treatment patterns, were descriptively assessed within each cohort.

FINDINGS

The study population consisted of 18,121 patients across the 1 OAD (n = 4822), 2 OADs (n = 6293), and ≥3 OADs (n = 7006) cohorts. Mean age at baseline was 54.7 years. Males were more prevalent in the ≥3 OADs cohort. Most patients (67%-70%) initiated treatment with dulaglutide 0.75 mg. Dose escalation to 1.5 mg was uncommon (15%-20%) but trended higher in the ≥3 OAD cohort. Adherence to dulaglutide at 6-month follow-up (61%-67%) increased with higher baseline OAD use. The HbA_1c assessment (n = 3178) included 761 patients in the 1 OAD cohort, 1088 patients in the 2 OADs cohort, and 1329 patients in the ≥3 OADs cohort. Baseline mean [SD] HbA_1c level increased with number of OAD classes (1 OAD: 8.18% [1.80]; 2 OADs: 8.56% [1.66]; and ≥3 OADs: 8.73% [1.51]). Patients in the early dulaglutide therapy initiator group experienced larger reductions in HbA_1c levels (1 OAD: -1.39%; 95% CI, -1.50 to -1.27; 2 OADs: -1.30%; 95% CI, -1.39 to -1.20; and ≥3 OADs: -1.01%; 95% CI, -1.09 to -0.93) versus the patients in the delayed initiator group. Patients in the early dulaglutide therapy initiator group also achieved HbA_1c <7% at 6-month follow-up more frequently than those in the later initiator group (1 OAD: 68%; 2 OADs: 51%; and ≥3 OADs: 33%).

IMPLICATIONS

Cohorts of dulaglutide therapy initiators, defined by prior OAD use as a proxy of timing of initiation, differed in their baseline characteristics and short-term follow-up outcomes. Earlier dulaglutide therapy initiation was associated with lower mean HbA_1c levels and increased probability of achievement of HbA_1c <7% during the 6-month follow-up period.

[Physical and psychological long-term consequences of diabetes mellitus]

Trotz Verbesserungen in der Therapie des Diabetes und besseren Versorgungbedingungen weisen die Betroffenen aktuell im Vergleich zur Allgemeinbevölkerung noch immer ein deutlich erhöhtes Risiko für physische wie psychische Folgeerkrankungen sowie eine reduzierte Lebensqualität auf. Etwa 21 % aller Todesfälle sind in Deutschland auf Diabetes und seine Folgeerkrankungen zurückzuführen, das Mortalitätsrisiko ist für Menschen mit Diabetes um mehr als das 1,5-Fache gegenüber Menschen ohne Diabetes erhöht. In dieser Übersicht werden die Verbreitung und die Risikofaktoren für die häufigsten körperlichen und psychischen Folgen des Diabetes beschrieben sowie deren Einflüsse auf die Lebensqualität der Patienten. Zusammenhänge zwischen den Folgeerkrankungen und einer erhöhten Mortalität werden aufgezeigt.

In großen Interventionsstudien konnte die Bedeutung einer guten Glukoseeinstellung – vor allem zu Beginn der Erkrankung – in Hinblick auf eine Senkung der Mortalitätsrate gezeigt werden, weitere wichtige Einflussfaktoren sind z. B. Blutdruck, Blutfette und Rauchen. Weltweite Studienergebnisse deuten auf einen stabilen Trend hinsichtlich einer verbesserten Lebenserwartung von Menschen mit Diabetes in den letzten Jahren hin. Zukünftig könnte der positive Trend durch bessere Versorgungsstrukturen und neue Technologien sowie digitale Anwendungen in der Forschung und Therapie fortgesetzt werden. Mithilfe der Präzisionsmedizin könnten individuelle Risikofaktoren und protektive Faktoren erkannt werden, um der Entstehung von Folgekomplikationen noch besser vorzubeugen.

An Innovative Lifestyle Intervention to Reduce Glucose Excursions with the Use of Continuous Glucose Monitoring to Educate, Motivate, and Activate Adults with Newly Diagnosed Type 2 Diabetes: A Paradigm shift

Background

Type 2 diabetes (T2D) is a growing epidemic in the United States, and metabolic control has not been improved over the last 10 years. Glycemic excursion minimization (GEM) is an alternative lifestyle treatment option focused on reducing postnutrient glucose excursions rather than reducing weight. GEM has been proven to be superior to routine care when delivered face to face, and equivalent or superior to conventional weight loss therapy, but it has not been evaluated among patients newly diagnosed with T2D or in a self-administered format.

Objective

This pilot study evaluated the feasibility of a self-administered version of GEM, augmented with continuous glucose monitoring (CGM), to improve metabolic control (hemoglobin A_1c [HbA_1c]) while diminishing or delaying the need for diabetes medications in adults recently diagnosed with T2D. These primary objectives were hypothesized to be achieved by reducing carbohydrate intake and increasing physical activity to diminish CGM glucose excursions, leading to the secondary benefits of an increase in diabetes empowerment and reduced diabetes distress, depressive symptoms, and BMI.

Methods

GEM was self-administered by 17 adults recently diagnosed with T2D (mean age 52 years, SD 11.6 years; mean T2D duration 3.9 months, SD 2.5 months; mean HbA_1c levels 8.0%, SD 1.6%; 40% female; 33.3% non-White), with the aid of a 4-chapter pocket guide and diary, automated motivational text messaging, and feedback from an activity monitor, along with CGM and supplies for the 6-week intervention and the 3-month follow-up. Treatment was initiated with one telephone call reviewing the use of the technology and 3 days later with a second call reviewing the use of the GEM pocket guide and intervention.

Results

At 3-month follow-up, 67% of the participants’ diabetes was in remission (HbA_1c levels <6.5%), and only one participant started taking diabetes medication. Participants demonstrated a significant reduction in HbA_1c levels (–1.8%; P<.001). Participants also experienced significant reductions in high-glycemic-load carbohydrates routinely consumed, CGM readings that were >140 mg/dL, diabetes distress, depressive symptoms, and BMI. Participants felt that use of the CGM was the most significant single element of the intervention.

Conclusions

GEM augmented with CGM feedback may be an effective initial intervention for adults newly diagnosed with T2D. A self-administered version of GEM may provide primary care physicians and patients with a new tool to help people recently diagnosed with T2D achieve remission independent of medication and without weight loss as the primary focus. Future research is needed with a larger and more diverse sample.

Renal Histologic Findings in Necropsies of Type 2 Diabetes Mellitus Patients

BACKGROUND

Very few studies have analyzed early histologic lesions of diabetic nephropathy (DN) in patients without signs of clinical involvement (microalbuminuria). In this study, we analyzed renal histologic lesions in necropsies of diabetic patients with or without previous signs of DN.

METHODS

Histological material was analyzed from 21 autopsies of type 2 diabetes mellitus (T2DM) patients (9 with albuminuria and 12 without albuminuria) and 4 controls. Histologic lesions were evaluated according to the Tervaert classification.

RESULTS

Kidneys of diabetic patients presented significantly higher scores in most histologic indices analyzed (glomerular basal membrane thickening, mild and severe mesangial expansion, nodular sclerosis, interstitial fibrosis, and tubular atrophy) than in nondiabetic controls (p < 0.01 in all cases). In contrast, no significant differences were detected between histologic scores when comparing the 21 diabetic patients with and without albuminuria. A significant percentage of cases without albuminuria showed moderate to severe histologic lesions, particularly severe mesangial expansion and severe glomerular vascular lesions. No significant differences were found in age, blood pressure, diabetes vintage, BMI, HbA1c, cholesterol, triglycerides, or treatments between the two (albuminuric vs. nonalbuminuric) T2DM patient groups.

CONCLUSIONS

Our data suggest that histologic lesions of DN are present in the early stages of the disease, even without albuminuria presence. More precise and earlier metabolic control is recommended in T2DM, and monitoring of risk factors can play a role in DN development.

Diabetes: Concepts of β-Cell Organ Dysfunction and Failure Would Lead to Earlier Diagnoses and Prevention

As the world endures a viral pandemic superimposed on a diabetes pandemic, the latter incorporates most of the comorbidities associated with the former, thereby exacerbating risk of death in both. An essential approach to both pandemics is prevention and unrealized earlier treatment. Thus, in this Perspective relating to diabetes, we emphasize a paradigm of, first, reversible β-cell organ dysfunction and then irreversible β-cell organ failure, which directly indicate the potential for earlier prevention, also unrealized in current guidelines. Four pillars support this paradigm: epidemiology, pathophysiology, molecular pathology, and genetics. A substantial worldwide knowledge base defines each pillar and informs a more aggressive preventive approach to most forms of the disorder. This analysis seeks to clarify the temporal and therapeutic relationships between lost β-cell function and content, illuminating the potential for earlier diagnoses and, thus, prevention. We also propose that myriad pathways leading to most forms of diabetes converge at the endoplasmic reticulum, where stress can result in β-cell death and content loss. Finally, genetic and nongenetic origins common to major types of diabetes can inform earlier diagnosis and, potentially, prevention, with the aim of preserving β-cell mass.

The Beneficial Effects of Earlier Versus Later Implementation of Intensive Therapy in Type 1 Diabetes

OBJECTIVE

The principal aim is to estimate the benefits of earlier versus later implementation of intensive therapy in type 1 diabetes with respect to the long-term risks of progression of a renal (microvascular) and cardiovascular (macrovascular) complication in the Epidemiology of Diabetes Interventions and Complications (EDIC) study.

RESEARCH DESIGN AND METHODS

Cox proportional hazards regression models estimated the 20-year cumulative incidence (absolute risk) and the 20-year relative risk of cardiovascular disease (CVD) and reduced estimated glomerular filtration rate (eGFR) over the first 20 years of EDIC follow-up as a function of the mean HbA1c.

RESULTS

A hypothetical patient treated earlier with 10 years of intensive therapy and a mean HbA1c of 7% (53 mmol/mol) followed by 10 years with a mean of 9% (75 mmol/mol) would have a 33% reduction in the risk of CVD and a 52% reduction in reduced eGFR compared with a patient with a mean HbA1c of 9% (75 mmol/mol) over the first 10 years followed by later intensive therapy over 10 years with an HbA1c of 7% (53 mmol/mol). Despite both patients having the same average glycemic exposure over the 20 years, the patient with the lower HbA1c over the first 10 years had a lower risk of progression of complications over the 20 years than the patient who had the higher value initially.

CONCLUSIONS

While implementation of intensive therapy at any time in type 1 diabetes will be beneficial, within the 20-year period modeled, earlier relative to later implementation is associated with a greater reduction in the risks of kidney and cardiovascular complications.