Intensive integrated therapy of type 2 diabetes: implications for long-term prognosis

Modern Challenges in Type 2 Diabetes: Balancing New Medications with Multifactorial Care

Type 2 diabetes mellitus (T2DM) is a prevalent chronic metabolic disorder characterized by insulin resistance and progressive beta cell dysfunction, presenting substantial global health and economic challenges. This review explores recent advancements in diabetes management, emphasizing novel pharmacological therapies and their physiological mechanisms. We highlight the transformative impact of Sodium-Glucose Cotransporter 2 inhibitor (SGLT2i) and Glucagon-Like Peptide 1 Receptor Agonist (GLP-1RA), which target specific physiological pathways to enhance glucose regulation and metabolic health. A key focus of this review is tirzepatide, a dual agonist of the glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptors. Tirzepatide illustrates how integrating innovative mechanisms with established physiological pathways can significantly improve glycemic control and support weight management. Additionally, we explore emerging treatments such as glimins and glucokinase activators (GKAs), which offer novel strategies for enhancing insulin secretion and reducing glucose production. We also address future perspectives in diabetes management, including the potential of retatrutide as a triple receptor agonist and evolving guidelines advocating for a comprehensive, multifactorial approach to care. This approach integrates pharmacological advancements with essential lifestyle modifications-such as dietary changes, physical activity, and smoking cessation-to optimize patient outcomes. By focusing on the physiological mechanisms of these new therapies, this review underscores their role in enhancing T2DM management and highlights the importance of personalized care plans to address the complexities of the disease. This holistic perspective aims to improve patient quality of life and long-term health outcomes.

The current landscape for diabetes treatment: Preventing diabetes-associated CV risk

Despite the risk of atherosclerosis has progressively declined over the past few decades, subjects with type 2 diabetes mellitus (T2DM) continue to experience substantial excess of atherosclerotic cardiovascular disease (ASCVD)-related events. Therefore, there is urgent need to treat ASCVD disease in T2DM earlier, more intensively, and with greater precision. Many factors concur to increase the risk of atherosclerosis, and multifactorial intervention remains the basis for effective prevention or reduction of atherosclerotic events. The role of anti-hyperglycemic medications in reducing the risk of ASCVD in subjects with T2DM has evolved over the past few years. Multiple cardiovascular outcome trials (CVOTs) with new and emerging glucose-lowering agents, namely SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1-RA), have demonstrated significant reductions of major cardiovascular events and additional benefits. This robust evidence has changed the landscape for managing people with T2DM. In addition to glycemic and ancillary extra-glycemic properties, SGLT2i and GLP1-RA might exert favorable effects on subclinical and clinical atherosclerosis. Therefore, the objective of this review is to discuss the available evidence supporting anti-atherosclerotic properties of SGLT2i and GLP1-RA, with a quick nod to sotagliflozin and tirzepatide.

Lipids as potential mediators linking body mass index to diabetes: evidence from a mediation analysis based on the NAGALA cohort

BACKGROUND

Body mass index (BMI) and lipid disorders are both known to be strongly associated with the development of diabetes, however, the indirect effect of lipid parameters in the BMI-related diabetes risk is currently unknown. This study aimed to investigate the mediating role of lipid parameters in the association of BMI with diabetes risk.

METHODS

We assessed the association of diabetes risk with BMI, as well as lipid parameters including high-density lipoprotein cholesterol(HDL-C), low-density lipoprotein cholesterol(LDL-CF and LDL-CS), triglycerides(TG), total cholesterol(TC), remnant cholesterol(RC), non-HDL-C, and combined indices of lipid parameters with HDL-C (RC/HDL-C ratio, TG/HDL-C ratio, TC/HDL-C ratio, non-HDL/HDL-C ratio, LDL/HDL-C ratio) using data from 15,453 subjects in the NAGALA project. Mediation models were used to explore the mediating role of lipid parameters in the association of BMI with diabetes risk, and mediation percentages were calculated for quantifying the strength of the indirect effects. Finally, receiver operating characteristic curve (ROC) analysis was used to compare the accuracy of BMI and BMI combined with lipid parameters in predicting incident diabetes.

RESULTS

Multivariate regression models, adjusted for confounding factors, demonstrated robust associations of lipid parameters, BMI, with diabetes risk, with the exception of TC, LDL-CF, LDL-CS, and non-HDL-C. Mediation analysis showed that lipid parameters except TC, LDL-CF, LDL-CS, and Non-HDL-C were involved in and mediated the association of BMI with diabetes risk, with the largest mediation percentage being the RC/HDL-C ratio, which was as high as 40%; it is worth mentioning that HDL-C and HDL-C-related lipid ratio parameters also play an important mediating role in the association between BMI and diabetes, with the mediator proportion being greater than 30%. Finally, based on the ROC results, we found that the prediction performance of all lipid parameters in the current study except TC was significantly improved when combined with BMI.

CONCLUSION

Our fresh findings suggested that lipid parameters partially mediated the association of BMI with diabetes risk; this result indicated that in the context of diabetes risk screening and disease management, it is important to not only monitor BMI but also pay attention to lipid parameters, particularly HDL-C and HDL-C-related lipid ratio parameters.

Exercise training and vascular heterogeneity in db/db mice: evidence for regional- and duration-dependent effects

Exercise training (ET) has several health benefits; however, our understanding of regional adaptations to ET is limited. We examined the functional and molecular adaptations to short- and long-term ET in elastic and muscular conduit arteries of db/db mice in relation to changes in cardiovascular risk factors. Diabetic mice and their controls were exercised at moderate intensity for 4 or 8 weeks. The vasodilatory and contractile responses of thoracic aortae and femoral arteries isolated from the same animals were examined. Blood and aortic samples were used to measure hyperglycemia, oxidative stress, inflammation, dyslipidemia, protein expression of SOD isoforms, COX, eNOS, and Akt. Short-term ET improved nitric oxide (NO) mediated vasorelaxation in the aortae and femoral arteries of db/db mice in parallel with increased SOD2 and SOD3 expression, reduced oxidative stress and triglycerides, and independent of weight loss, glycemia, or inflammation. Long-term ET reduced body weight in parallel with reduced systemic inflammation and improved insulin sensitivity along with increased SOD1, Akt, and eNOS expression and improved NO vasorelaxation. Exercise did not restore NOS- and COX-independent vasodilatation in femoral arteries, nor did it mitigate the hypercontractility in the aortae of db/db mice; rather ET transiently increased contractility in association with upregulated COX-2. Long-term ET differentially affected the aortae and femoral arteries contractile responses. ET improved NO-mediated vasodilation in both arteries likely due to collective systemic effects. ET did not mitigate all diabetes-induced vasculopathies. Optimization of the ET regimen can help develop comprehensive management of type 2 diabetes.

The cardiovascular changes underlying a low cardiac output with exercise in patients with type 2 diabetes mellitus

The significant morbidity and premature mortality of type 2 diabetes mellitus (T2DM) is largely associated with its cardiovascular consequences. Focus has long been on the arterial atheromatosis of DM giving rise to early stroke and myocardial infarctions, whereas less attention has been given to its non-ischemic cardiovascular consequences. Irrespective of ischemic changes, T2DM is associated with heart failure (HF) most commonly with preserved ejection fraction (HFpEF). Largely due to increasing population ages, hypertension, obesity and T2DM, HFpEF is becoming the most prevalent form of heart failure. Unfortunately, randomized controlled trials of HFpEF have largely been futile, and it now seems logical to address the important different phenotypes of HFpEF to understand their underlying pathophysiology. In the early phases, HFpEF is associated with a significantly impaired ability to increase cardiac output with exercise. The lowered cardiac output with exercise results from both cardiac and peripheral causes. T2DM is associated with left ventricular (LV) diastolic dysfunction based on LV hypertrophy with myocardial disperse fibrosis and significantly impaired ability for myocardial blood flow increments with exercise. T2DM is also associated with impaired ability for skeletal muscle vasodilation during exercise, and as is the case in the myocardium, such changes may be related to vascular rarefaction. The present review discusses the underlying phenotypical changes of the heart and peripheral vascular system and their importance for an adequate increase in cardiac output. Since many of the described cardiovascular changes with T2DM must be considered difficult to change if fully developed, it is suggested that patients with T2DM are early evaluated with respect to their cardiovascular compromise.

Evaluation of the role of atherogenic index of plasma in the reversion from Prediabetes to normoglycemia or progression to Diabetes: a multi-center retrospective cohort study

BACKGROUND

Atherosclerosis is closely linked with glucose metabolism. We aimed to investigate the role of the atherogenic index of plasma (AIP) in the reversal of prediabetes to normal blood glucose levels or its progression to diabetes.

METHODS

This multi-center retrospective cohort study included 15,421 prediabetic participants from 32 regions across 11 cities in China, under the aegis of the Rich Healthcare Group's affiliated medical examination institutions. Throughout the follow-up period, we monitored changes in the glycemic status of these participants, including reversal to normal fasting glucose (NFG), persistence in the prediabetic state, or progression to diabetes. Segmented regression, stratified analysis, and restricted cubic spline (RCS) were performed based on the multivariable Cox regression model to evaluate the association between AIP and the reversal of prediabetes to NFG or progression to diabetes.

RESULTS

During a median follow-up period of 2.9 years, we recorded 6,481 individuals (42.03%) reverting from prediabetes to NFG, and 2,424 individuals (15.72%) progressing to diabetes. After adjusting for confounders, AIP showed a positive correlation with the progression from prediabetes to diabetes [(Hazard ratio (HR) 1.42, 95% confidence interval (CI):1.24-1.64)] and a negative correlation with the reversion from prediabetes to NFG (HR 0.89, 95%CI:0.81-0.98); further RCS demonstrated a nonlinear relationship between AIP and the reversion from prediabetes to NFG/progression to diabetes, identifying a turning point of 0.04 for reversion to NFG and 0.17 for progression to diabetes. In addition, we observed significant differences in the association between AIP and reversion from prediabetes to NFG/progression to diabetes across age subgroups, specifically indicating that the risk associated with AIP for progression from prediabetes to diabetes was relatively higher in younger populations; likewise, a younger age within the adult group favored the reversion from prediabetes to NFG in relation to AIP.

CONCLUSION

Our study, for the first time, reveals a negative correlation between AIP and the reversion from prediabetes to normoglycemia and validates the crucial role of AIP in the risk assessment of prediabetes progression. Based on threshold analysis, therapeutically, keeping the AIP below 0.04 was of paramount importance for individuals with prediabetes aiming for reversion to NFG; preventatively, maintaining AIP below 0.17 was vital to reduce the risk of diabetes onset for those with prediabetes.

Optimal Control of all Modifiable Vascular Risk Factors Among Patients With Atherosclerotic Disease. A Real-Life Study

The effects of maintaining all classical, vascular risk factors on target among patients with stabilized atherosclerotic cardiovascular disease (ASCVD) are uncertain. Factores de Riesgo y ENfermedad Arterial (FRENA) was a prospective registry of consecutive outpatients with coronary, cerebrovascular, or peripheral artery disease. We analyzed the incidence of recurrent events and mortality according to sustained, optimal control of principal risk factors including the following: LDL cholesterol, glucose, blood pressure, and smoking. As of December 2018, 4285 stable outpatients were eligible for this study. Over a median follow-up of 21 months, 664 (15%) maintained all risk factors on target (Group 1), while 3621 (85%) did not (Group 2). During follow-up, no differences in recurrent major adverse cardiovascular events (MACEs) or death were observed between groups. On multivariable analysis, patients with previous known dyslipidemia (hazard ratio [HR]: 95% confidence interval (95% CI): ([HR]: 1.20 [95% CI, 1.03-1.40]), polyvascular disease ([HR]: 1.98 [95% CI, 1.69-2.32]), insulin therapy ([HR]: 1.56 [95% CI, 1.24-1.95]) and associated conditions ([HR]: 1.47 [95% CI, 1.24-1.74]) were associated with a higher risk for subsequent MACE. The presence of associated medical conditions was also strongly associated with all-cause death ([HR]: 3.49 [95% CI, 2.35-5.19]). Only a minority of patients with atherosclerotic cardiovascular disease achieved sustained optimal control for all principal risk factors although without discernible clinical, therapeutic benefit. The findings of the present study provide some insights into what factors may be used to guide physicians in adapting intensive, multifactorial therapy to the individual patient in clinical practice.

Prevalence of cardiovascular disease risk factors in Chinese patients with type 2 diabetes mellitus, 2013-2018

OBJECTIVE

Coronary heart disease (CHD) is the most common cause of death in patients with type 2 diabetes (T2DM). We aim to estimate the prevalence of CHD and cardiovascular risk factors in Chinese patients with T2DM.

METHODS

A total of 66,536 inpatients with diabetes treated from 2013 to 2018 were investigated, and demographic and clinical data were collected from 30,693 patients with T2DM. Age-standardized prevalence of CHD was calculated on the basis of data from the Chinese population census in 2010. Logistic regression analysis was used to analyze the risk factors.

RESULTS

The crude prevalence of CHD was estimated to be 23.5% and a standardized prevalence was 13.9% (16.0% in men and 11.9% in women). More than half of patients with CHD have four or more of the five traditional risk factors, much higher than the 38.96% of patients without CHD (p < .01). Multivariate regression analysis showed that diabetes duration, hypertension, smoking, underweight, overweight, obesity and hypoglycaemia were significantly associated with increased risk of CHD (all p < .05). The odds ratio of CHD in patients with three, four or five defined CHD risk factors (i.e. diabetes, hypertension, dyslipidaemia, overweight or obese, and smoking) were 2.35 (95% CI 1.81-3.04), 2.96 (95% CI 2.28-3.85) or 5.29 (95% CI 4.04-6.93), compared with diabetes patients without any other risk factors.

CONCLUSIONS

The prevalence of CHD was rather high in Chinese T2DM inpatients, and the aggregation of CHD risk factors was severe. Thus, hierarchical CHD prevention strategies based on risk factors are necessary.

The effect of preventative cardiovascular therapies on coronary artery disease in people with and without type 2 diabetes: a propensity-matched score study

Background

Although it is known that patients with Type 2 Diabetes Mellitus (T2DM) are at an increased risk of coronary artery disease (CAD), the actual coronary artery burden of atherosclerotic disease in patients with and without T2DM in a real-world setting and its possible modification by preventative therapies has not been extensively documented.

Methods

Merged coronary angiography and hospital discharge data between 2013 and 2019 were obtained for analysis and a random sub-sample of patient charts were reviewed for medication use. Propensity scores were estimated using logistic regression models and used to match patients, looking at the effect of severity of CAD over time in years in an ordinal logistic regression model. A separate propensity score was estimated and used to inverse probability weight the ordinal logistic regression looking at the effect of medication use on CAD severity in patients with and without T2DM.

Results

From 3,016 patients in the coronary angiography database, 1421 with T2DM and 1421 without T2DM were matched on propensity score. T2DM patients had more extensive CAD in 2018 compared to 2013 ((adjusted odds ratio) adjOR: 2.06 95% C.I. 1.38, 2.07), but this risk appeared to be attenuated in 2019. In contrast, there was no effect of time on CAD burden in patients without diabetes. In the sub-sample of 760 patients who underwent a chart review of their medication use, there were 367 (48%) with T2DM. For patients with T2DM 69.8% reported taking statins, 64.0% RAS inhibitors and 64.0% anti-platelet drugs. This was significantly higher than patients without diabetes of whom 46.6% reported taking statins, 49.0% RAS inhibitors and 49.9% anti-platelet drugs. As in the full matched sample, patients with diabetes had more extensive CAD (adjOR: 1.32 95% CI: 1.01, 1.74). However, after adjustment for the use of RAS inhibitors, statins and anticoagulants there was no difference in extent of CAD between patients with and without diabetes (adjOR: 1.14 95% CI: 0.85, 1.53).

Conclusions

Although patients with diabetes have a greater extent of CAD in comparison to those without T2DM, preventative medication use decreases this CAD burden significantly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02265-2.

Nationwide Trends in Cardiac Risk and Mortality in Patients With Incident Type 2 Diabetes: A Danish Cohort Study

OBJECTIVE

Trends in cardiac risk and death have not been examined in patients with incident type 2 diabetes and no prior cardiovascular disease. Therefore, we aimed to examine trends in cardiac risk and death in relation to the use of prophylactic cardiovascular medications in patients with incident type 2 diabetes without prior cardiovascular disease.

RESEARCH DESIGN AND METHODS

In this population-based cohort study, we included patients with incident type 2 diabetes between 1996 and 2011 through national health registries. Each patient was matched by age and sex with up to five individuals without diabetes from the general population. All individuals were followed for 7 years.

RESULTS

We identified 209,311 patients with incident diabetes. From 1996-1999 to 2008-2011, the 7-year risk of myocardial infarction decreased from 6.9 to 2.8% (adjusted hazard ratio [aHR] 0.39 [95% CI 0.37-0.42]), cardiac death from 7.1 to 1.6% (aHR 0.23 [95% CI 0.21-0.24]), and all-cause death from 28.9 to 16.8% (aHR 0.68 [95% CI 0.66-0.69]). Compared with the general population, 7-year risk differences decreased from 3.3 to 0.8% for myocardial infarction, from 2.7 to 0.5% for cardiac death, and from 10.6 to 6.0% for all-cause death. Use of cardiovascular medications within ±1 year of diabetes diagnosis, especially statins (5% of users in 1996-1999 vs. 60% in 2008-2011), increased during the study period.

CONCLUSIONS

From 1996 to 2011, Danish patients with incident type 2 diabetes and no prior cardiovascular disease experienced major reductions in cardiac risk and mortality. The risk reductions coincided with increased use of prophylactic cardiovascular medications.

Management of LDL-cholesterol levels in patients with Diabetes Mellitus in Cardiology Practice: Real-life evidence of Under-treatment from the EPHESUS registry

BACKGROUND AND AIMS

Effective treatment of high low-density lipoprotein cholesterol (LDL-C) levels has been shown to improve cardiovascular outcomes of patients with diabetes mellitus (DM). Herein, we aimed to provide insight to the real-life management of patients with DM in terms of LDL-C goal attainment and adherence to lipid management recommendations. Our objective was also to reveal the reasons of poor LDL-C goal attainment by assessing the perceptions of both physicians and patients.

METHODS

We compared the diabetic and non-diabetic patients from the database of a nationwide registry conducted in cardiology outpatient clinics with regard to the demographic characteristics, educational status, comorbidities, medications, laboratory parameters and LDL-C goal attainment. Also, both the patients and attending physicians were surveyed to analyse perceptions and awareness of hypercholesterolemia.

RESULTS

Of the 1868 consecutively enrolled patients, 873 (47%) had DM. Proportion of patients on statins was significantly lower in patients with DM (67.8% vs 55.3%; P < .001). The proportion of patients who attained LDL-C targets were lower among the diabetic patients (17.8% vs 15%; P = .06). The most common causes of the discontinuation of statin therapy were negative media coverage about statins (32.1%), and recommendations of physicians to stop the lipid lowering therapy (29.6%). Analysis of the physician survey revealed that the physicians could determine the off-target patients accurately (negative predictive value 98.4%) while the positive predictive value (48.8%) was low. The reasons for not attaining the LDL-C goals in diabetic patients were not prescription of statins (38%) and inadequate (eg low-dose, non-adherent) statin (28.3%) dosages.

CONCLUSIONS

In real-life clinical cardiology practice, diabetic patients are far below the recommended LDL-C treatment goals. High-intensity statin treatment in diabetic population is still avoided because of the concerns about polypharmacy and drug interactions. Also, the inertia of physicians and even cardiologists is probably a major cause of refraining of prescription of optimal statin dosages.

Ellagic Acid as a Tool to Limit the Diabetes Burden: Updated Evidence

Oxidative stress contributes not only to the pathogenesis of type 2 diabetes (T2D) but also to diabetic vascular complications. It follows that antioxidants might contribute to limiting the diabetes burden. In this review we focus on ellagic acid (EA), a compound that can be obtained upon intestinal hydrolysis of dietary ellagitannins, a family of polyphenols naturally found in several fruits and seeds. There is increasing research on cardiometabolic effects of ellagitannins, EA, and urolithins (EA metabolites). We updated research conducted on these compounds and (I) glucose metabolism; (II) inflammation, oxidation, and glycation; and (III) diabetic complications. We included studies testing EA in isolation, extracts or preparations enriched in EA, or EA-rich foods (mostly pomegranate juice). Animal research on the topic, entirely conducted in murine models, mostly reported glucose-lowering, antioxidant, anti-inflammatory, and anti-glycation effects, along with prevention of micro- and macrovascular diabetic complications. Clinical research is incipient and mostly involved non-randomized and low-powered studies, which confirmed the antioxidant and anti-inflammatory properties of EA-rich foods, but without conclusive results on glucose control. Overall, EA-related compounds might be potential agents to limit the diabetes burden, but well-designed human randomized controlled trials are needed to fill the existing gap between experimental and clinical research.

Evaluating the treatment and control of modifiable cardiovascular disease risk factors among patients with diabetes in the Inner Mongolia, China: A cross-sectional study

Reducing the risk of diabetes has been a great public health challenge in China. In this study, we aimed to estimate the treatment and control of FPG (fasting blood plasma glucose) as well as the other main modifiable cardiovascular disease (CVD) risk factors in patients with diabetes and to identify those characteristics associated with the treatment and control of diabetes, hypertension, and low-density lipoprotein cholesterol (LDL-C). Between 2015 and 2017, participants aged 35 to 75 years from Inner Mongolia in northern China were recruited. A total 13,644 participants with diabetes were enrolled in this study. We calculated rates and 95% confidence intervals for treatment and control of FPG, blood pressure, and LDL-C. We performed multivariate logistic regression to identify characteristics associated with the treatment and control of diabetes as well as hypertension and LDL-C. Overall, the treatment rates of diabetes, hypertension, and dyslipidemia were 30.76%, 50.75%, and 9.17%, respectively. Control rates of FPG, blood pressure, and LDL-C were 4.73%, 4.86%, and 57.83%, respectively. Patients who were younger, Mongol ethnicity and rural residents were less likely to be treated and controlled for diabetes and hypertension. Patients insured by NCMS (new rural cooperative medical scheme) were less likely to be treated and achieve the treatment target of blood pressure. Patients having prior CVD were more likely to be treated and have controlled FPG and blood pressure. Substantial efforts are urgently needed to improve the treatment and control of these modifiable CVD risk factors among patients with diabetes in Inner Mongolia.

Sphingomyelin and progression of renal and coronary heart disease in individuals with type 1 diabetes

AIMS/HYPOTHESIS

Lipid abnormalities are associated with diabetic kidney disease and CHD, although their exact role has not yet been fully explained. Sphingomyelin, the predominant sphingolipid in humans, is crucial for intact glomerular and endothelial function. Therefore, the objective of our study was to investigate whether sphingomyelin impacts kidney disease and CHD progression in individuals with type 1 diabetes.

METHODS

Individuals (n = 1087) from the Finnish Diabetic Nephropathy (FinnDiane) prospective cohort study with serum sphingomyelin measured using a proton NMR metabolomics platform were included. Kidney disease progression was defined as change in eGFR or albuminuria stratum. Data on incident end-stage renal disease (ESRD) and CHD were retrieved from national registries. HRs from Cox regression models and regression coefficients from the logistic or linear regression analyses were reported per 1 SD increase in sphingomyelin level. In addition, receiver operating curves were used to assess whether sphingomyelin improves eGFR decline prediction compared with albuminuria.

RESULTS

During a median (IQR) 10.7 (6.4, 13.5) years of follow-up, sphingomyelin was independently associated with the fastest eGFR decline (lowest 25%; median [IQR] for eGFR change: <-4.4 [-6.8, -3.1] ml min^-1 [1.73 m^-2] year^-1), even after adjustment for classical lipid variables such as HDL-cholesterol and triacylglycerols (OR [95% CI]: 1.36 [1.15, 1.61], p < 0.001). Similarly, sphingomyelin increased the risk of progression to ESRD (HR [95% CI]: 1.53 [1.19, 1.97], p = 0.001). Moreover, sphingomyelin increased the risk of CHD (HR [95% CI]: 1.24 [1.01, 1.52], p = 0.038). However, sphingomyelin did not perform better than albuminuria in the prediction of eGFR decline.

CONCLUSIONS/INTERPRETATION

This study demonstrates for the first time in a prospective setting that sphingomyelin is associated with the fastest eGFR decline and progression to ESRD in type 1 diabetes. In addition, sphingomyelin is a risk factor for CHD. These data suggest that high sphingomyelin level, independently of classical lipid risk factors, may contribute not only to the initiation and progression of kidney disease but also to CHD. Graphical abstract.

Achieving LDL cholesterol target levels <1.81 mmol/L may provide extra cardiovascular protection in patients at high risk: Exploratory analysis of the Standard Versus Intensive Statin Therapy for Patients with Hypercholesterolaemia and Diabetic Retinopathy study

AIMS

To assess the benefits of intensive statin therapy on reducing cardiovascular (CV) events in patients with type 2 diabetes complicated with hyperlipidaemia and retinopathy in a primary prevention setting in Japan. In the intension-to-treat population, intensive therapy [targeting LDL cholesterol <1.81 mmol/L (<70 mg/dL)] was no more effective than standard therapy [LDL cholesterol ≥2.59 to <3.10 mmol/L (≥100 to <120 mg/dL)]; however, after 3 years, the intergroup difference in LDL cholesterol was only 0.72 mmol/L (27.7 mg/dL), and targeted levels were achieved in <50% of patients. We hypothesized that the intergroup difference in CV events would have been statistically significant if more patients had been successfully treated to target.

MATERIALS AND METHODS

This exploratory post hoc analysis focused on intergroup data from patients who achieved their target LDL cholesterol levels. The primary endpoint was the composite incidence of CV events. A Cox proportional hazards model was used to estimate hazard ratios (HRs) for incidence of the primary endpoint in patients who achieved target LDL cholesterol levels in each group.

RESULTS

Data were analysed from 1909 patients (intensive: 703; standard: 1206) who achieved target LDL cholesterol levels. LDL cholesterol at 36 months was 1.54 ± 0.30 mmol/L (59.7 ± 11.6 mg/dL) in the intensive group and 2.77 ± 0.46 mmol/L (107.1 ± 17.8 mg/dL) in the standard group (P < 0.05). After adjusting for baseline prognostic factors, the composite incidence of CV events or deaths associated with CV events was significantly lower in the intensive than the standard group (HR 0.48; 95% confidence interval 0.28-0.82; P = 0.007).

CONCLUSIONS

This post hoc analysis suggests that achieving LDL cholesterol target levels <1.81 mmol/L may more effectively reduce CV events than achieving target levels ≥2.59 to <3.10 mmol/L in patients with hypercholesterolaemia and diabetic retinopathy.

The Importance and Role of Multiple Risk Factor Control in Type 2 Diabetes

PURPOSE OF REVIEW

The importance of composite risk factor control for reducing CVD risk in type 2 diabetes (T2DM) has gained increased attention and here we review the latest findings in the field.

RECENT FINDINGS

The Steno-2 study was the first to show that early intensive risk factor control could improve risk factor status and halve the CVD risk in patients with diabetes with lasting impact. A range of observational studies have added further insight to the importance of multiple risk factor control showing an incremental association between number of risk factors controlled and reduction in CVD risk. Noteworthy, a Swedish population-based study recently showed that optimal risk factor status in patients with T2DM was associated with a CVD risk similar to the general population. Early intensive intervention to achieve optimal risk factor control reduces CVD risk and should be of principal focus in T2DM management.

Intensive Treat-to-Target Statin Therapy in High-Risk Japanese Patients With Hypercholesterolemia and Diabetic Retinopathy: Report of a Randomized Study

OBJECTIVE

Diabetes is associated with high risk of cardiovascular (CV) events, particularly in patients with dyslipidemia and diabetic complications. We investigated the incidence of CV events with intensive or standard lipid-lowering therapy in patients with hypercholesterolemia, diabetic retinopathy, and no history of coronary artery disease (treat-to-target approach).

RESEARCH DESIGN AND METHODS

In this multicenter, prospective, randomized, open-label, blinded end point study, eligible patients were randomly assigned (1:1) to intensive statin therapy targeting LDL cholesterol (LDL-C) <70 mg/dL (n = 2,518) or standard statin therapy targeting LDL-C 100-120 mg/dL (n = 2,524).

RESULTS

Mean follow-up was 37 ± 13 months. LDL-C at 36 months was 76.5 ± 21.6 mg/dL in the intensive group and 104.1 ± 22.1 mg/dL in the standard group (P < 0.001). The primary end point events occurred in 129 intensive group patients and 153 standard group patients (hazard ratio [HR] 0.84 [95% CI 0.67-1.07]; P = 0.15). The relationship between the LDL-C difference in the two groups and the event reduction rate was consistent with primary prevention studies in patients with diabetes. Exploratory findings showed significantly fewer cerebral events in the intensive group (HR 0.52 [95% CI 0.31-0.88]; P = 0.01). Safety did not differ significantly between the two groups.

CONCLUSIONS

We found no significant decrease in CV events or CV-associated deaths with intensive therapy, possibly because our between-group difference of LDL-C was lower than expected (27.7 mg/dL at 36 months of treatment). The potential benefit of achieving LDL-C <70 mg/dL in a treat-to-target strategy in high-risk patients deserves further investigation.

Legacy effect in combined diabetic-renal multifactorial intervention in patients with advanced diabetic nephropathy

AIM

Evaluate legacy effect on renal outcomes after the end of a multifactorial-multidisciplinary intervention in patients with advanced diabetic nephropathy (ADN trial) CKD 3-4.

METHODS

A retrospective electronic review was conducted of 72 patients who completed the ADN trial ESRD-free with subsequent follow-up of two years or until ESRD development.

RESULTS

At baseline, reflecting ADN trial end, 38 post-intervention and 34 post-control patients were similar except for lower HbA1c, SBP and age in the post-intervention group. In post-trial follow-up, ESRD developed in both groups at similar rates (23 vs 20%). ESRD occurred mainly in baseline CKD 4 (75%). In CKD 3, only those in post-control developed ESRD (28.6%, p = 0.067). A significant decline in eGFR occurred within both groups. In multivariate analyses, ESRD was associated with baseline yearly eGFR decline. Greater yearly eGFR decline was associated with higher albumin/creatinine ratio at follow-up, lower age, and baseline SBP not being at target (p = 0.005, with an R² of 0.197).

CONCLUSIONS

There was no significant post-intervention effect on ESRD progression in the two groups. Minimal legacy effect was observed in less advanced nephropathy (CKD 3). These renal and risk outcomes emphasize the importance and potential benefits of continuous and long-term multifactorial care.

Secondary Prevention of Cardiovascular Disease in Patients With Type 2 Diabetes Mellitus: International Insights From the TECOS Trial (Trial Evaluating Cardiovascular Outcomes With Sitagliptin)

BACKGROUND

Intensive risk factor modification significantly improves outcomes for patients with diabetes mellitus and cardiovascular disease. However, the degree to which secondary prevention treatment goals are achieved in international clinical practice is unknown.

METHODS

Attainment of 5 secondary prevention parameters-aspirin use, lipid control (low-density lipoprotein cholesterol <70 mg/dL or statin therapy), blood pressure control (<140 mm Hg systolic, <90 mm Hg diastolic), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, and nonsmoking status-was evaluated among 13 616 patients from 38 countries with diabetes mellitus and known cardiovascular disease at entry into TECOS (Trial Evaluating Cardiovascular Outcomes With Sitagliptin). Logistic regression was used to evaluate the association between individual and regional factors and secondary prevention achievement at baseline. Cox proportional hazards regression analysis was used to determine the association between baseline secondary prevention achievement and cardiovascular death, myocardial infarction, or stroke.

RESULTS

Overall, 29.9% of patients with diabetes mellitus and cardiovascular disease achieved all 5 secondary prevention parameters at baseline, although 71.8% achieved at least 4 parameters. North America had the highest proportion (41.2%), whereas Western Europe, Eastern Europe, and Latin America had proportions of ≈25%. Individually, blood pressure control (57.9%) had the lowest overall attainment, whereas nonsmoking status had the highest (89%). Over a median 3.0 years of follow-up, a higher baseline secondary prevention score was associated with improved outcomes in a step-wise graded relationship (adjusted hazard ratio, 0.60; 95% confidence interval, 0.47-0.77 for those patients achieving all 5 measures versus those achieving ≤2).

CONCLUSIONS

In an international trial population, significant opportunities exist to improve the quality of cardiovascular secondary prevention care among patients with diabetes mellitus and cardiovascular disease, which in turn could lead to reduced risk of downstream cardiovascular events.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00790205.

Long-term follow-up of a hospital-based, multi-intervention programme in type 2 diabetes mellitus: impact on cardiovascular events and death

Objective

To report the long-term impact on cardiovascular (CV) outcomes and mortality of a 2-year hospital-based multi-interventional care programme as compared with general practitioner (GP)-provided standard care.

Methods

Patients with type 2 diabetes with ≥ 1 additional CV risk factor were randomized to 2 years of specialist-based, multi-intervention comprising lifestyle modification and specific pharmacological treatment, or GP-based standard care. After the 2-year intervention period, all participants returned to pre-study care, but were followed up for CV outcomes and mortality. The primary outcome was time to any first severe CV event or death.

Results

A total of 120 patients (31 women) were enrolled in the study. During the mean ± SD observational period of 8.7 ± 2.0 years, 27 patients (16 and 11 in the multi-intervention and standard care groups, respectively) experienced at least one primary outcome event, with a hazard ratio (HR) if allocated to the multi-intervention group of 1.73 (95% confidence interval (CI) 0.80, 3.75). The HR for total mortality was 1.82 (95% CI 0.66, 5.01).

Conclusions

Hospital-based multi-intervention in patients with type 2 diabetes mellitus improved long-term glycaemic control, but failed to reduce CV outcomes and deaths.

Clinical trials.gov id: NCT00133718.

Potential Role of Serum and Urinary Biomarkers in Diagnosis and Prognosis of Diabetic Nephropathy

PURPOSE OF REVIEW

Diabetic nephropathy (DN) is a progressive kidney disease caused by alterations in kidney architecture and function, and constitutes one of the leading causes of end-stage renal disease (ESRD). The purpose of this review is to summarize the state of the art of the DN-biomarker field with a focus on the new strategies that enhance the sensitivity of biomarkers to predict patients who will develop DN or are at risk of progressing to ESRD.

OBJECTIVE

In this review, we provide a description of the pathophysiology of DN and propose a panel of novel putative biomarkers associated with DN pathophysiology that have been increasingly investigated for diagnosis, to predict disease progression or to provide efficient personal treatment.

METHODS

We performed a review of the literature with PubMed and Google Scholar to collect baseline data about the pathophysiology of DN and biomarkers associated. We focused our research on new and emerging biomarkers of DN.

KEY FINDINGS

In this review, we summarized the critical signaling pathways and biological processes involved in DN and highlighted the pathogenic mediators of this disease. We next proposed a large review of the major advances that have been made in identifying new biomarkers which are more sensitive and reliable compared with currently used biomarkers. This includes information about emergent biomarkers such as functional noncoding RNAs, microRNAs, long noncoding RNAs, exosomes, and microparticles.

LIMITATIONS

Despite intensive strategies and constant investigation, no current single treatment has been able to reverse or at least mitigate the progression of DN, or reduce the morbidity and mortality associated with this disease. Major difficulties probably come from the renal disease being heterogeneous among the patients.

IMPLICATIONS

Expanding the proteomics screening, including oxidative stress and inflammatory markers, along with metabolomics approaches may further improve the prognostic value and help in identifying the patients with diabetes who are at high risk of developing kidney diseases.

Building a Footbridge From Research to Practice in Cardiovascular Risk Reduction

As Rippe, Angelopoulos, and Zukley noted in their State-of-the-Art Review, empirically supported lifestyle modification strategies offer numerous advantages over other modalities for reducing cardiovascular risks. Yet, despite compelling evidence for their implementation, the translation of lifestyle interventions from research to practice has been challenging. Their review prompts discussion of several especially thorny barriers including the persistent tensions between (1) research and practice, (2) main effects and mediators, (3) single and multifactor approaches to risk management, and (4) primary care and communitybased systems of health delivery.

Rosuvastatin decreases testosterone levels but not sexual function in men with type 2 diabetes

OBJECTIVE

Statins may decrease serum testosterone levels via decreasing cholesterol, a precursor to testosterone. This case series studied the effects of rosuvastatin on free testosterone levels and sexual function in men with type 2 diabetes.

METHODS

We enrolled 151 men with type 2 diabetes and hypercholesterolemia. Biochemical assessments included serum total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein, triglyceride, prolactin, thyroid-stimulating hormone, luteinizing hormone, follicle stimulating hormone, total testosterone and serum sex hormone binding globulin (SHBG). All parameters were measured before statin treatment, after 6months of statin treatment, and 6months after discontinuing statin treatment. The Sexual Health Inventory for Men (SHIM) was also administered at these times.

RESULTS

Serum TC and LDL levels were high before statin therapy, decreased after six months of statin therapy, and increased significantly six months after discontinuing statin therapy (198.1±28.1mg/dl vs. 147.1±22.8mg/dl vs. 205.2±25.6mg/dl, p-value<0.001; 121.3±20.6mg/dl vs. 75.4±20.4mg/dl vs.124.9±20mg/dl, p-value<0.001). However, serum free testosterone levels calculated from total testosterone and SHBG calculated by formula were higher before statin therapy, obviously decreased after six months of statin therapy, and subsequently increased six months after discontinuing statin therapy (22.4±3.1ng/ml vs. 20.9±2.8ng/ml vs. 22.6±2.6ng/ml p value=0.006). SHIM scores did not obviously differ among the three stages (16.3±4.8 vs. 16.0±4.9 vs. 16.3±5.0 p=0.944). After adjustment for age, serum free testosterone levels correlated with SHIM scores and LDL (r=0.39, p=<0.001; r=0.26, p=0.02, respectively). SHIM scores did not correlate with TC or LDL.

CONCLUSIONS

Rosuvastatin reduces free testosterone levels but does not influence sexual function in men with type 2 diabetes.

Risk factors for cardiovascular disease and mortality events in adults with type 2 diabetes - a 10-year follow-up: Tehran Lipid and Glucose Study

BACKGROUND

To identify risk factors for cardiovascular disease (CVD) and mortality events in patients with type 2 diabetes and to calculate their population attributable fraction among a representative Iranian population.

METHODS

A total of 1198 patients with type 2 diabetes (504 men and 694 women), aged ≥30 years, without prevalent CVD, with a median follow-up of 10 years were included in current study. To examine the association between risk factors and their outcomes, multivariate sex-adjusted Cox proportional hazard regression models were used.

RESULTS

During the study, 281 and 172 participants experienced CVD and all-cause mortality events, respectively. Regarding CVD events, fasting plasma glucose (FPG) level of 7.22-<10 mmol/L [hazard ratio (HR): 1.46, 95% CI 1.12-1.96], FPG level ≥10 mmol/L (HR 2.04, 1.53-2.72), hypertension (HR 1.65, 1.28-2.13), hypercholesterolaemia (HR 1.96, 1.40-2.75) and high waist to hip ratio (HR 1.30, 0.99-1.70; p = 0.051) were significant predictors, and corresponding population attributable fractions were 9.76, 17.84, 23.26, 41.63 and 14.76%, respectively. Considering all-cause mortality events, hypertension (HR 1.70, 1.23-2.36), FPG level ≥10 mmol/L (HR 2.31, 1.55-3.20) and smoking (HR 1.45, 1.03-2.04) were significant predictors, and corresponding population attributable fractions were 25.81, 20.88 and 11.18%, respectively. Meanwhile, being overweight or obese was associated with lower all-cause and CVD mortality events.

CONCLUSIONS

Among modifiable risk factors in patients with type 2 diabetes, hypercholesterolaemia and central adiposity for CVD, smoking for mortality events and hypertension and poor glycaemic control for both outcomes need to be paid most attention by healthcare professionals. Copyright © 2016 John Wiley & Sons, Ltd.

Considerably decreased risk of cardiovascular disease with combined reductions in HbA1c, blood pressure and blood lipids in type 2 diabetes: Report from the Swedish National Diabetes Register

OBJECTIVES

Assess the effect of risk factors changes on risk for cardiovascular disease and mortality in patients with type 2 diabetes selected from the Swedish National Diabetes Register.

METHODS

Observational study of 13,477 females and males aged 30-75 years, with baseline HbA1c 41-67 mmol/mol, systolic blood pressure 122-154 mmHg and ratio non-HDL:HDL 1.7-4.1, followed for mean 6.5 years until 2012. Four groups were created: a reference group (n = 6757) with increasing final versus baseline HbA1c, systolic blood pressure and non-HDL:HDL cholesterol during the study period, and three groups with decreasing HbA1c (n = 1925), HbA1c and systolic blood pressure (n = 2050) or HbA1c and systolic blood pressure and non-HDL:HDL (n = 2745).

RESULTS

Relative risk reduction for fatal/nonfatal cardiovascular disease was 35% with decrease in HbA1c only (mean 6 to final 49 mmol/mol), 56% with decrease in HbA1c and systolic blood pressure (mean 12 to final 128 mmHg) and 75% with combined decreases in HbA1c, systolic blood pressure and non-HDL:HDL (mean 0.8 to final 2.1), all p < 0.001 adjusting for clinical characteristics, other risk factors, treatments and previous cardiovascular disease. Similar risk reductions were found for fatal/nonfatal coronary heart disease, fatal cardiovascular disease, all-cause mortality and also in a subgroup of 3038 patients with albuminuria.

CONCLUSION

Considerable risk reductions for cardiovascular disease and mortality were seen with combined long-term risk factor improvement.

Clinical Implications of Cardiovascular Outcome Trials in Type 2 Diabetes: From DCCT to EMPA-REG

Cardiovascular disease is a major threat to people with diabetes. Attempts have long been made to lower cardiovascular risk by means of glucose-lowering treatment. Initially, it seemed that was an option, but subsequent trials could not verify the original observations and there was concern that some glucose-lowering drugs can actually cause cardiovascular harm. This led medical product agencies in the United States and Europe to require major outcomes trials before accepting new glucose-lowering drugs. The least requirement was noninferiority compared with existing treatment modalities. A large number of such trials have been performed or are ongoing, including >100,000 patients. The drug classes investigated are basal insulin, glucagon-like peptide-1 agonists, dipeptidyl peptidase 4 inhibitors, and sodium-glucose cotransporter-2 (SGLT2) inhibitors. This commentary discusses these trials and their outcomes, the reasons why several of them ended with neutral results (noninferiority), and that the likelihood for showing cardiovascular benefit was minor or even nonexistent. The surprising and highly rewarding impact of the SGLT2 inhibitor empagliflozin is described and potential mechanisms for cardiovascular benefits are discussed.

Hyperglycemia-Induced Hypovolemia Is Involved in Early Cardiac Magnetic Resonance Alterations in Streptozotocin-Induced Diabetic Mice: A Comparison with Furosemide-Induced Hypovolemia

Aims

The aim of the study was to assess the early features of diabetic cardiomyopathy using cardiac magnetic resonance within the first week after streptozotocin injection in mice. We focused on the relationship between left ventricular function and hypovolemia markers in diabetic animals compared to a hypovolemic rodent model.

Methods and Results

Swiss mice were randomized into control (group C), streptozotocin-induced diabetes (group D) and furosemide-induced hypovolemia (group F) groups. Cardiac magnetic resonance, non-invasive blood pressure, urine volume, plasma markers of dehydration and cardiac histology were assessed in all groups. Mean blood glucose was higher in diabetic animals than in groups C and F (30.5±5.8 compared to 10.4±2.1 and 11.1±2.8 mmol/L, respectively; p<0.01). Diuresis was increased in animals from group D and F compared to C (14650±11499 and 1533±540 compared to 192±111 μL/24 h; p<0.05). End diastolic and end systolic volumes were lower in group D than in group C at week 1 (1.52±0.36 vs. 1.93±0.35 and 0.54±0.22 vs. 0.75±0.18 mL/kg, p<0.05). These left ventricular volume values in group D were comparable to those observed in the acute hypovolemia model (group F). Increased dehydration plasma markers and an absence of obvious intrinsic myocardial damage (evaluated by cardiac magnetic resonance and histology) suggest that a hemodynamic mechanism underlies the very early drop in left ventricular volumes in group D and provides a potential link to hyperglycemic osmotic diuresis.

Conclusions

Researchers using cardiac magnetic resonance in hyperglycemic rodent models should be aware of this hemodynamic mechanism, which may partially explain modifications in cardiac parameters in addition to diabetic myocardial damage.

Comorbidity, age, and mortality among adults treated intensively for acute myeloid leukemia (AML)

INTRODUCTION

Our goal was to characterize comorbidities among adults receiving intensive therapy for AML, and investigate their association with outcomes.

METHODS

We retrospectively analyzed 277 consecutive patients with newly diagnosed AML treated intensively at the Comprehensive Cancer Center of Wake Forest University from 2002 to 2009. Pretreatment comorbidities were identified by ICD-9 codes and chart review. Comorbidity burden (modified Charlson Comorbidity Index [CCI]) and specific conditions were analyzed individually. Outcomes were overall survival (OS), remission, and 30-day mortality. Covariates included age, gender, cytogenetic characteristics, hemoglobin, white cell count, lactate dehydrogenase, body mass index, and insurance type. Cox proportional hazards models were used to evaluate OS; logistic regression was used for remission and 30-day mortality.

RESULTS

In this series, 144 patients were ≥ 60 years old (median age 70 years, median survival 8.7 months) and 133 were <60 years (median age 47 years, median survival 23.1 months). Older patients had a higher comorbidity burden (CCI≥1 58% versus 26%, P<0.001). Prevalent comorbid conditions differed by age (diabetes 19.2% versus 7.5%; cardiovascular disease 12.5% versus 4.5%, for older versus younger patients, respectively). The CCI was not independently associated with OS or 30-day mortality in either age group. Among older patients, diabetes was associated with higher 30-day mortality (33.3% vs. 12.0% in diabetic vs. non-diabetic patients, p=0.006). Controlling for age, cytogenetic characteristics and other comorbidities, the presence of diabetes increased the odds of 30-day mortality by 4.9 (CI 1.6-15.2) times.

DISCUSSION

Diabetes is adversely associated with 30-day survival in older AML patients receiving intensive therapy.

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology

Background

In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines.

Methods

A total of 6187 patients (18–80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012–2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys.

Results

A total of 2846 (46 %) patients had no diabetes, 1158 (19 %) newly diagnosed diabetes and 2183 (35 %) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60 %, respectively. A blood pressure target of <140/90 mmHg was achieved in 68, 61, 54 % and a LDL-cholesterol target of <1.8 mmol/L in 16, 18 and 28 %. Patients with newly diagnosed and previously known diabetes reached an HbA1c <7.0 % (53 mmol/mol) in 95 and 53 % and 11 % of those with previously known diabetes had an HbA1c >9.0 % (>75 mmol/mol). Of the patients with diabetes 69 % reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40 %) and only 27 % of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets.

Conclusions

Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.

Small fiber neuropathies

PURPOSE OF REVIEW

This article reviews the clinical, neurophysiologic, and neuropathologic findings in patients presenting with small fiber neuropathies. Emphasis is placed on recent updates to the literature, but also on understanding the differential diagnosis and initial evaluation of patients with small fiber neuropathy.

RECENT FINDINGS

There have been several updates in the literature about diseases associated with small fiber neuropathy. First, treatment-induced neuropathy in diabetes mellitus is an iatrogenic small fiber neuropathy linked to overly rapid correction in blood glucose levels in the setting of chronic hyperglycemia. Second, several novel mutations to sodium channels have been identified in patients presenting with idiopathic small fiber neuropathy that may significantly alter our understanding and future treatment of small fiber neuropathy. Third, antibodies against voltage-gated potassium channels appear to be associated with a much higher incidence of pain than would be expected, although the mechanism has not been established. Fourth, the link between glucose dysregulation, metabolic syndrome, and neuropathy continues to grow. Finally, several other disorders, including postural orthostatic tachycardia syndrome, have been postulated to be associated with small fiber neuropathies.

SUMMARY

Small fiber neuropathies are a heterogeneous group of disorders that may present with a variety of sensory or autonomic symptoms. Recent reports highlight a number of new causes of small fiber neuropathy that continue to reduce the number of remaining idiopathic cases.

Pleiotropic effects of type 2 diabetes management strategies on renal risk factors

In parallel with the type 2 diabetes pandemic, diabetic kidney disease has become the leading cause of end-stage renal disease worldwide, and is associated with high cardiovascular morbidity and mortality. As established in landmark randomised trials and recommended in clinical guidelines, prevention and treatment of diabetic kidney disease focuses on control of the two main renal risk factors, hyperglycaemia and systemic hypertension. Treatment of systemic hypertension with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers is advocated because these drugs seem to exert specific renoprotective effects beyond blood pressure lowering. Emerging evidence shows that obesity, glomerular hyperfiltration, albuminuria, and dyslipidaemia might also adversely affect the kidney in diabetes. Control of these risk factors could have additional benefits on renal outcome in patients with type 2 diabetes. However, despite multifactorial treatment approaches, residual risk for the development and progression of diabetic kidney disease in patients with type 2 diabetes remains, and novel strategies or therapies to treat the disease are urgently needed. Several drugs used in the treatment of type 2 diabetes are associated with pleiotropic effects that could favourably or unfavourably change patients' renal risk profile. We review the risk factors and treatment of diabetic kidney disease, and describe the pleiotropic effects of widely used drugs in type 2 diabetes management on renal outcomes, with special emphasis on antihyperglycaemic drugs.

Lower free testosterone level is correlated with left ventricular diastolic dysfunction in asymptomatic middle-aged men with type 2 diabetes mellitus

AIMS

Low testosterone (T) level is associated with cardiovascular risk factors. However, the relationship between T level and heart function in asymptomatic men with type 2 diabetes mellitus (T2DM) is unknown.

METHODS

A total of 325 men were recruited who had no history, symptoms, or signs of heart disease.

RESULTS

T2DM had significantly lower free T (FT) levels than those with normal glucose metabolism (NGM) (428 ± 38 pmol/l vs. 444 ± 38 pmol/l, p = 0.0002), and had an increased risk of LVDD (66.1% vs. 31.8%). There was a significant difference in FT level between subjects with and without LVDD among those with T2DM (421 ± 37 pmol/l vs. 442 ± 40 pmol/l, p = 0.0007), but not among those with NGM (439 ± 37 pmol/l vs. 447 ± 39 pmol/l, p = 0.247) or in the group overall (426 ± 38 pmol/l vs. 445 ± 38 pmol/l, p = 0.156). Lower FT level was significantly associated with LVDD [univariate odds ratio (OR) = 0.63, p = 0.032; multivariate OR = 0.71, p = 0.039]. Receiver operating characteristic curve analysis of the usefulness of FT level for predicting LVDD showed an area under the curve (AUC) of 0.85 for T2DM (p < 0.001) and 0.66 for NGM (p < 0.05). FT level had a high predictive value for LVDD in T2DM (83% for FT < 414 pmol/l), but a low predictive value in NGM (61% for FT < 423 pmol/l). Comparison of the AUCs showed that FT level was more strongly correlated with LVDD in T2DM than in NGM.

CONCLUSIONS

Lower FT level is correlated with LVDD in asymptomatic middle-aged men with T2DM.

Quality of diabetes care worldwide and feasibility of implementation of the Alphabet Strategy: GAIA project (Global Alphabet Strategy Implementation Audit)

Background

The Alphabet Strategy (AS) is a diabetes care checklist ensuring “important, simple things are done right all the time.” Current audits of diabetes care in developed countries reveal wide variations in quality with performance of care processes frequently sub-optimal. This study had three components:

an audit to assess diabetes care quality worldwide,

a questionnaire study seeking opinions on the merits of the AS,

a pilot study to assess the practicality of implementation of the AS in a low socioeconomic setting.

Methods

Audit data was collected from 52 centres across 32 countries. Data from 4537 patients were converted to Quality and Outcome Framework (QOF) scores to enable inter-centre comparison. These were compared to each country’s Gross Domestic Product (GDP), and Total Health Expenditure percentage per capita (THE%). The opinions of diabetes patients and healthcare professionals from the diabetes care team at each of these centres were sought through a structured questionnaire. A retrospective audit on 100 randomly selected case notes was conducted prior to AS implementation in a diabetes outpatient clinic in India, followed by a prospective audit after four months to assess its impact on care quality.

Results

QOF scores showed wide variation across the centres (mean 49.0, range 10.2–90.1). Although there was a positive relationship between GDP and THE% to QOF scores, there were exceptions. 91% of healthcare professionals felt the AS approach was practical. Patients found the checklist to be a useful education tool. Significant improvements in several aspects of care as well as 36% improvement in QOF score were seen following implementation.

Conclusions

International centres observed large variations in care quality, with standards frequently sub-optimal. 71% of health care professionals would consider adopting the AS in their daily practice. Implementation in a low resource country resulted in significant improvements in some aspects of diabetes care. The AS checklist for diabetes care is a freely available in the public domain encompassing patient education, care plans, and educational resources for healthcare professionals including summary guidelines. The AS may provide a unique approach in delivering high quality diabetes care in countries with limited resources.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-467) contains supplementary material, which is available to authorized users.

Subclinical cardiovascular disease in type 2 diabetes mellitus: To screen or not to screen

The prevalence of type 2 diabetes mellitus (T2DM) has risen in recent decades, and cardiovascular disease remains the leading cause of death in this population. Several clinical trials have demonstrated the benefit of tight control of risk factors on the incidence and mortality of cardiovascular disease. However, in clinical practice, few patients achieve the therapeutic goals. The current diagnostic procedures for subclinical cardiovascular disease in T2DM patients have not been shown to improve prognosis or mortality, probably because they do not categorize cardiovascular risk. Thus, clinical practice guidelines do not systematically recommend screening for subclinical atherosclerosis in these patients, although it is known that patients with extra-coronary atherosclerosis, microangiopathy and poorly-controlled cardiovascular risk factors are at high risk for cardiovascular disease. Improvements in the reliability of diagnostic tests, with fewer side effects and better cost efficiency, may better help to stratify cardiovascular risk in this group of patients, and further evaluation on this topic should be considered.

Statin therapy and risk of diabetes in patients with heterozygous familial hypercholesterolemia or familial combined hyperlipidemia

OBJECTIVE

Controversial findings exist regarding potential influence of statin therapy on diabetic incidence. Aim of this study was to investigate the role of long duration statin treatment on diabetes mellitus (DM) incidence of Heterozygous Familial Hypercholesterolemia (hFH) and Familial Combined Hyperlipidemia (FCH) patients.

METHODS

Study population consisted of 212 hFH and 147 FCH patients that visited Lipid Outpatient Department (mean follow up of 11 and 10 years respectively). Several clinical data such as history of DM, cardiovascular disease, thyroid function, metabolic syndrome, glucose levels, lipid profile and lifestyle data were obtained. In order to compare the effects of different doses of different types of statins, a "statin treatment intensity product" was used.

RESULTS

14% of FCH and only 1% of hFH patients developed DM during follow up. Although univariate analysis showed a statistical trend (p = 0.06) in the association between new onset DM and statin treatment intensity (STI) in the FCH subgroup of patients with normal baseline glucose levels, this was no longer significant after adjusting for several confounders. Furthermore, the type of statins used did not seem to play a role in the development of DM either in hFH or FCH patients.

CONCLUSION

Long duration of high STI does not seem to be associated with diabetic risk in hFH patients. High STI used in the FCH population is not associated with increased risk of new onset DM compared to low STI. Further studies are required in order to clarify the potential diabetogenic effects of statins in these high risk populations.

Common polymorphisms in MIR146a, MIR128a and MIR27a genes contribute to neuropathy susceptibility in type 2 diabetes

Diabetic polyneuropathy (DPN) and cardiovascular autonomic neuropathy (CAN) are common type 2 diabetes complications with a large inter-individual variability in terms of clinical manifestations and severity. Our aim was to evaluate a possible involvement of genetic polymorphisms in miRNA regions in the susceptibility to DPN and CAN. Nine polymorphisms in miRNA genes were studied in a sample of 132 type 2 diabetes patients (T2D) analysed for DPN and 128 T2D patients analysed for CAN. A genotype-phenotype correlation analysis was performed. The T allele of rs11888095 single nucleotide polymorphism (SNP) in MIR128a was significantly associated with a higher risk (ORadj = 4.89, P adj = 0.02), whereas the C allele of rs2910164 SNP in MIR146a was associated with a lower risk to develop DPN (ORadj = 0.49, P adj = 0.09), respectively. A multivariate logistic regression analysis confirmed that both SNPs contribute to DPN (p < 0.001 and p = 0.01 for MIR128a and MIR146a, respectively). MIR128a SNP significantly contributed also to DPN score (p = 0.026). Rs895819 SNP in MIR27a was significantly associated with a higher risk to develop early CAN (P adj = 0.023 and ORadj = 3.43). The rs2910164 SNP in MIR146a showed a protective effect respect to early CAN (P adj = 0.052, ORadj = 0.32) and to confirmed CAN (P adj = 0.041, ORadj = 0.13). The same SNP resulted significantly associated with a lower CAN score and a higher E/I (p = 0.002 and p = 0.003, respectively). In conclusion, we described associations of MIR128a and MIR146a SNPs with DPN susceptibility and of MIR146a and MIR27a SNPs with CAN susceptibility. This is the first study showing that genetic variability in miRNA genes could be involved in diabetic neuropathies susceptibility.

Intensified insulin-based glycaemic control after myocardial infarction: mortality during 20 year follow-up of the randomised Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) trial

BACKGROUND

The benefits of intensified glycaemic control after acute myocardial infarction are uncertain. We report the 20 year follow-up results of the first Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) trial.

METHODS

DIGAMI 1 was a prospective, randomised, open-label trial with blinded endpoint evaluation (PROBE) done at coronary care units in 19 Swedish hospitals between Jan 1, 1990 and Dec 31, 1993. Patients with and without previously diagnosed diabetes and with blood glucose concentrations of more than 11 mmol/L who had had a suspected acute myocardial infarction in the previous 24 h were randomly assigned (1:1), with sealed envelopes, to intensified insulin-based glycaemic control for at least 3 months, or to a control group prescribed conventional glucose-lowering treatment. Masking was not considered feasible or safe on the basis of insulin use. The primary endpoint was mortality, in both the original study and the present follow-up analysis. Analysis was by intention to treat.

FINDINGS

620 patients were randomised to intensified insulin-based glycaemic control (n=306) or the control group (n=314). During a mean follow-up period of 7·3 years (SD 6·6; range 0·0-21·8) years, 271 patients (89%) died in the intensified glycaemic control group and 285 (91%) patients died in the standard glycaemic control group. Median survival time was 7·0 years (IQR 1·8-12·4) in patients in the intensified glycaemic control group and 4·7 (1·0-11·4) in those in the standard group (hazard ratio 0·83, 95% CI 0·70-0·98; p=0·027). The effect of intensified glycaemic control was apparent during 8 years after randomisation, increasing survival by 2·3 years.

INTERPRETATION

Intensified insulin-based glycaemic control after acute myocardial infarction in patients with diabetes and hyperglycaemia at admission had a long-lasting effect on longevity. Although the effect of glucose lowering might be less apparent with presently available, more effective lipid-lowering and blood-pressure-lowering drugs, improved glycaemic control might still be important for longevity after acute myocardial infarction.

FUNDING

Swedish Heart-Lung Foundation, Kronoberg County Council.

Glycemic control in patients with type 2 diabetes mellitus in Spain

OBJECTIVE

To evaluate the degree of glycemic control in patients with type 2 diabetes in Spain and identify factors associated with glycemic control.

PATIENTS AND METHODS

This was a cross-sectional, multicenter, epidemiological study that used consecutive sampling and was conducted in primary care practices in Spain. A total of 5591 patients with type 2 diabetes mellitus lasting more than 1 year and who were treated with hypoglycemic agents for more than 3 months were included in the study. At a single visit, HbA1c levels were measured (A1cNow+ system) and demographic and clinical variables related to diabetes and its treatment were recorded. During the visit, CV risk factors (CVRF), the presence of target-organ damage (TOD), the presence of hypoglycemia and body weight changes within the previous year were recorded.

RESULTS

We analyzed data from 5382 patients (mean age 66.7 [10.8] years, mean duration of the diabetes 8.8 [6.3] years). TOD was present in 43.6% of the patients and 59.1% were taking 2 or more drugs. The patients' mean HbA1c was 7.1 (1.1)%, and 48.6% had HbA1c levels <7.0%. The patients with HbA1c levels ≥7.0% had longer-standing diabetes, a higher prevalence of TOD and CVRF, used more complex therapies, experienced more hypoglycemic episodes in the previous year and had more weight gain. In the multivariate analysis, the absence of insulin treatment, the absence of abdominal obesity and atherogenic dyslipidemia, a duration of the diabetes <10 years and an age >70 years were associated with improved glycemic control.

CONCLUSIONS

Patients with poorly controlled type 2 diabetes mellitus are highly prevalent in Spain. Factors associated with poorer glycemic control include the complexity of both the disease and the hypoglycemic therapy, a history of hypoglycemia and weight gain.

Importance of cardiovascular disease risk management in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is commonly accompanied by other cardiovascular disease (CVD) risk factors, such as hypertension, obesity, and dyslipidemia. Furthermore, CVD is the most common cause of death in people with T2DM. It is therefore of critical importance to minimize the risk of macrovascular complications by carefully managing modifiable CVD risk factors in patients with T2DM. Therapeutic strategies should include lifestyle and pharmacological interventions targeting hyperglycemia, hypertension, dyslipidemia, obesity, cigarette smoking, physical inactivity, and prothrombotic factors. This article discusses the impact of modifying these CVD risk factors in the context of T2DM; the clinical evidence is summarized, and current guidelines are also discussed. The cardiovascular benefits of smoking cessation, increasing physical activity, and reducing low-density lipoprotein cholesterol and blood pressure are well established. For aspirin therapy, any cardiovascular benefits must be balanced against the associated bleeding risk, with current evidence supporting this strategy only in certain patients who are at increased CVD risk. Although overweight, obesity, and hyperglycemia are clearly associated with increased cardiovascular risk, the effect of their modification on this risk is less well defined by available clinical trial evidence. However, for glucose-lowering drugs, further evidence is expected from several ongoing cardiovascular outcome trials. Taken together, the evidence highlights the value of early intervention and targeting multiple risk factors with both lifestyle and pharmacological strategies to give the best chance of reducing macrovascular complications in the long term.

TCF7L2 gene polymorphisms and type 2 diabetes: association with diabetic retinopathy and cardiovascular autonomic neuropathy

Type 2 diabetes (T2DM) is a complex disease resulting from the contribution of both environmental and genetic factors. Recently, the list of genes implicated in the susceptibility to T2DM has substantially grown, also as a consequence of the great development of the genome-wide association studies in the last decade. Common polymorphisms in TCF7L2 gene have shown to have a strong effect with respect to many other involved genes. The aims of our study were to confirm the role of TCF7L2 in the susceptibility to T2DM in the Italian population and to investigate whether TCF7L2 genotypes also contribute to the clinical phenotypes variability and to diabetic complications development. Three TCF7L2 polymorphisms (rs7903146, rs7901695 and rs12255372) have been analyzed by allelic discrimination assays in a cohort of 154 Italian patients with T2DM and 171 healthy controls. A case-control association study and a genotype-phenotype correlation study have been carried out. Consistent with previous studies, all three SNPs showed a strong association with susceptibility to T2DM, both at genotypic (P = 0.003, P = 0.004 and P = 0.012) and at allelic level (P = 0.0004, P = 0.0004 and P = 0.003). Moreover, we observed associations between TCF7L2 variants and the following diabetic complications: diabetic retinopathy, cardiovascular disease and coronary artery disease. We also found a strong correlation between the rs7903146 and the presence of cardiovascular autonomic neuropathy (P = 0.02 with a high OR = 8.28). In conclusion, our study, in addition to confirming the involvement of TCF7L2 gene in the T2DM susceptibility, has shown that TCF7L2 genetic variability also contributes to the development of diabetic complications such as retinopathy and cardiovascular autonomic neuropathy.

Clinical and economic benefits associated with the achievement of both HbA1c and LDL cholesterol goals in veterans with type 2 diabetes

OBJECTIVE

This study compared the clinical and economic benefits associated with dual-goal achievement, glycated hemoglobin (HbA1c)<7% (53 mmol/mol) and LDL cholesterol (LDL-C)<100 mg/dL, with achievement of only the LDL-C goal or only the HbA1c goal in veterans with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

This retrospective cohort analysis evaluated electronic medical records (Veterans Integrated Service Network 16) in adult T2DM patients with two or more measurements of LDL-C and HbA1c between 1 January 2004 and 30 June 2010 (N=75,646). Cox proportional hazards models were used to compare microvascular and cardiovascular outcomes by goal achievement status; generalized linear regression models were used to assess diabetes-related resource utilization (hospitalization days and number of outpatient visits) and medical service costs.

RESULTS

Relative to achievement of only the LDL-C goal, dual-goal achievement was associated with lower risk of microvascular complications (adjusted hazard ratio [aHR] 0.79), acute coronary syndrome (0.88), percutaneous coronary intervention (0.78), and coronary artery bypass graft (CABG) (0.74); it was also associated with fewer hospitalization days (adjusted incidence rate ratio [aIRR] 0.93) and outpatient visits (0.88), as well as lower diabetes-related annual medical costs (-$130.89). Compared with achievement of only the HbA1c goal, dual-goal achievement was associated with lower risk of the composite cardiovascular-related end point (aHR 0.87) and CABG (aHR 0.62), as well as fewer outpatient visits (aIRR 0.98).

CONCLUSIONS

Achieving both HbA1c and LDL-C goals in diabetes care is associated with additional clinical and economic benefits, as compared with the achievement of either goal alone.

Diabetic cardiomyopathy: pathophysiology and clinical features

Since diabetic cardiomyopathy was first reported four decades ago, substantial information on its pathogenesis and clinical features has accumulated. In the heart, diabetes enhances fatty acid metabolism, suppresses glucose oxidation, and modifies intracellular signaling, leading to impairments in multiple steps of excitation–contraction coupling, inefficient energy production, and increased susceptibility to ischemia/reperfusion injury. Loss of normal microvessels and remodeling of the extracellular matrix are also involved in contractile dysfunction of diabetic hearts. Use of sensitive echocardiographic techniques (tissue Doppler imaging and strain rate imaging) and magnetic resonance spectroscopy enables detection of diabetic cardiomyopathy at an early stage, and a combination of the modalities allows differentiation of this type of cardiomyopathy from other organic heart diseases. Circumstantial evidence to date indicates that diabetic cardiomyopathy is a common but frequently unrecognized pathological process in asymptomatic diabetic patients. However, a strategy for prevention or treatment of diabetic cardiomyopathy to improve its prognosis has not yet been established. Here, we review both basic and clinical studies on diabetic cardiomyopathy and summarize problems remaining to be solved for improving management of this type of cardiomyopathy.

Do heat events pose a greater health risk for individuals with type 2 diabetes?

Chronic medical conditions such as type 2 diabetes may alter the body's normal response to heat. Evidence suggests that the local heat loss response of skin blood flow (SkBF) is affected by diabetes-related impairments in both endothelium-dependent and non-endothelium-dependent mechanisms, resulting in lower elevations in SkBF in response to a heat or pharmacological stimulus. Thermoregulatory sweating may also be diminished by type 2 diabetes, impairing the body's ability to transfer heat from its core to the environment. Diabetes-associated co-morbidities and the medications (particularly those affecting fluid balance) required to treat these conditions may exacerbate the risk of heat-related illness by decreasing SkBF and sweating further. Unfortunately, the majority of studies measure local heat loss responses in the hands and feet and lack measures of core temperature. Therefore, the impact of these impairments on whole-body heat loss remains unknown. This review addresses heat-related vulnerability in individuals with type 2 diabetes by examining the literature related to heat loss responses in this population. Type 2 diabetes, its associated co-morbidities, and the medications required in their treatment may cause dehydration, lower SkBF, and reduced sweating, which could consequently impair thermoregulation. This effect is most evident in individuals with poor blood glucose control. Although type 2 diabetes can be associated with impairments in SkBF and sweating, more physically active individuals requiring fewer medications and having good blood glucose control may be able to tolerate heat as well as those of similar age and body composition.