Combination blood pressure lowering therapy in patients with type 2 diabetes: messages from the ADVANCE trial

The Action in Diabetes and Vascular disease: preterAx and diamicroN Controlled Evaluation (ADVANCE) trial investigated the effects of intensive blood pressure (BP) lowering using a fixed combination of perindopril-indapamide versus placebo in type 2 diabetes (T2D). The study showed that combination perindopril-indapamide had significant benefits in reducing cardiovascular, renal, and mortality events, with consistent relative risk reductions across different patient subgroups. Secondary analyses of ADVANCE have identified novel risk markers in T2D including cessation of BP lowering therapy, absent peripheral pulses and cardiac biomarkers to name a few. ADVANCE also shed light on practical aspects of hypertension management, including the limitations of office BP, tolerability of combination BP lowering therapy across the range of BP levels and the interpretation of changes in serum creatinine after treatment initiation. This review article summarizes the findings of ADVANCE and its subsequent substudies, which have been foundational in our understanding of BP management and the use of combination BP lowering therapy in T2D.

Cost-effectiveness analysis of initial treatment with single-pill combination antihypertensive medications

Hypertension guidelines recommend initiating treatment with single pill combination (SPC) antihypertensive medications, but SPCs are used by only one-third of treated hypertensive US adults. This analysis estimated the cost-effectiveness of initial treatment with SPC dual antihypertensive medications compared with usual care monotherapy in hypertensive US adults.The validated BP Control Model-Cardiovascular Disease (CVD) Policy Model simulated initial SPC dual therapy (two half-standard doses in a single pill) compared with initial usual care monotherapy (half-standard dose when baseline systolic BP < 20 mmHg above goal and one standard dose when ≥20 mmHg above goal). Secondary analyses examined equivalent dose monotherapy (one standard dose) and equivalent dose dual therapy as separate pills (two half-standard doses). The primary outcomes were direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) over 10 years from a US healthcare sector perspective.At 10 years, initial dual drug SPC was projected to yield 0.028 (95%UI 0.008 to 0.051) more QALYs at no greater cost ($73, 95%UI -$1 983 to $1 629) than usual care monotherapy. In secondary analysis, SPC dual therapy was cost-effective vs. equivalent dose monotherapy (ICER $8 000/QALY gained) and equivalent dose dual therapy as separate pills (ICER $57 000/QALY gained). At average drug prices, initiating antihypertensive treatment with SPC dual therapy is more effective at no greater cost than usual care initial monotherapy and has the potential to improve BP control rates and reduce the burden of CVD in the US.

Contribution of single-pill combinations in the management of hypertension: perspectives from China, Europe and the USA

Uncontrolled hypertension is associated with an increased risk of adverse clinical vascular outcomes and death. Hypertension management guidelines from China and the USA recommend initiation of antihypertensive pharmacotherapy with a single drug for patients without severe hypertension at presentation. Current European hypertension guidelines take a different approach and recommend the use of combination therapy from the time of diagnosis of hypertension for most patients. This article reviews the burden of hypertension in these countries and summarises the evidence base for the use of antihypertensive combination therapy contained within a single tablet (single-pill combinations, SPC). Typically, half or less of populations from China, Europe and the USA who were found to have hypertension were aware of their condition, less than half of those receiving treatment, and fewer still achieved adequate blood pressure (BP) control. The reasons for the unaddressed burden of hypertension are complex and multifactorial, with contributions from factors related to patients, healthcare providers and healthcare systems. The use of SPCs of antihypertensive therapies helps to optimise adherence with therapy and is likely to result in superior BP control. There is a strong evidence base to support current European guideline recommendations on the initiation of antihypertensive therapy with SPCs for the majority of people with hypertension.

Is Physical Exercise in Hypoxia an Interesting Strategy to Prevent the Development of Type 2 Diabetes? A Narrative Review

Impaired metabolism is becoming one of the main causes of mortality and the identification of strategies to cure those diseases is a major public health concern. A number of therapies are being developed to treat type 2 diabetes mellitus (T2DM), but few of them focus on situations prior to diabetes. Obesity, aging and insulin resistance are all risk factors, which fortunately can be reversed to some extent. Non-drug interventions, such as exercise, are interesting strategies to prevent the onset of diabetes, but it remains to determine the optimal dose and conditions. In the search of optimizing the effects of physical exercise to prevent T2DM, hypoxic training has emerged as an interesting and original strategy. Several recent studies have chosen to look at the effects of hypoxic training in people at risk of developing T2DM. Therefore, the purpose of this narrative review is to give an overview of all original articles having tested the effects of a single exercise or exercise training in hypoxia on glucose metabolism and other health-related parameters in people at risk of developing T2DM. Taken together, the data on the effects of hypoxic training on glucose metabolism, insulin sensitivity and the health status of people at risk of T2DM are inconclusive. Some studies show that hypoxic training can improve glucose metabolism and the health status to a greater extent than normoxic training, while others do not corroborate the latter. When an additional benefit of hypoxic vs normoxic training is found, it still remains to determine which signaling pathways and molecular mechanisms are involved.

Effect of hypoxic exercise on glucose tolerance in healthy and prediabetic adults

This study aimed to investigate the mechanisms known to regulate glucose homeostasis in human skeletal muscle of healthy and prediabetic subjects exercising in normobaric hypoxia. Seventeen healthy (H; 28.8 ± 2.4 yr; maximal oxygen consumption (V̇O_2max): 45.1 ± 1.8 mL·kg^-1·min^-1) and 15 prediabetic (P; 44.6 ± 3.9 yr; V̇O_2max: 30.8 ± 2.5 mL·kg^-1·min^-1) men were randomly assigned to two groups performing an acute exercise bout (heart rate corresponding to 55% V̇O_2max) either in normoxic (NE) or in hypoxic (HE; fraction of inspired oxygen [Formula: see text] 14.0%) conditions. An oral glucose tolerance test (OGTT) was performed in a basal state and after an acute exercise bout. Muscle biopsies from m. vastus lateralis were taken before and after exercise. Venous blood samples were taken at regular intervals before, during, and after exercise. The two groups exercising in hypoxia had a larger area under the curve of blood glucose levels during the OGTT after exercise compared with baseline (H: +11%; P: +4%). Compared with pre-exercise, an increase in p-TBC1D1 Ser237 and in p-AMPK Thr172 was observed postexercise in P NE (+95%; +55%, respectively) and H HE (+91%; +43%, respectively). An increase in p-ACC Ser212 was measured after exercise in all groups (H NE: +228%; P NE: +252%; H HE: +252%; P HE: +208%). Our results show that an acute bout of exercise in hypoxia reduces glucose tolerance in healthy and prediabetic subjects. At a molecular level, some adaptations regulating glucose transport in muscle were found in all groups without associations with glucose tolerance after exercise. The results suggest that hypoxia negatively affects glucose tolerance postexercise through unidentified mechanisms.NEW & NOTEWORTHY The molecular mechanisms involved in glucose tolerance after acute exercise in hypoxia have not yet been elucidated in human. Due to the reversible character of their status, prediabetic individuals are of particular interest for preventing the development of type 2 diabetes. The present study is the first to investigate muscle molecular mechanisms during exercise and glucose metabolism after exercise in prediabetic and healthy subjects exercising in normoxia and normobaric hypoxia.

Observational analyses from ADVANCE and ADVANCE-ON

AIMS

To explain, and document, the epidemiological work associated with the action in diabetes and vascular disease: preterax and diamicron-modified release controlled evaluation (ADVANCE) clinical trial.

MATERIALS AND METHODS

ADVANCE was designed as a randomized controlled multicentre factorial trial in high-risk patients with diabetes. The two interventions were blood pressure lowering medications versus placebo, and intensive glucose control versus standard glucose control. Following termination of the trial, an observational study of surviving participants, able to join, was mounted: the ADVANCE - observational study (ADVANCE-ON). Other epidemiological analyses that were undertaken treated the trial as a cohort study, including using biomarkers from the blood samples taken from ADVANCE subjects as risk exposures.

RESULTS

More than 50 publications have reported epidemiological results from ADVANCE. The main results from ADVANCE-ON suggested attenuated benefits of ADVANCE's blood pressure lowering treatment on all-cause and cardiovascular death, but no such long-term benefits for intensive glucose control, although this did give persistent benefit for end-stage renal disease. The other epidemiological studies found, amongst other things, strong effects of NT-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T on macrovascular events, microvascular events and all-cause death.

CONCLUSIONS

Embedding post-randomization and epidemiological analyses into clinical trials is worthwhile and can be highly productive in advancing scientific knowledge.

Hypoxic Training Improves Normoxic Glucose Tolerance in Adolescents with Obesity

PURPOSE

This study aimed to test whether environmental hypoxia could potentiate the effects of exercise training on glucose metabolism and insulin sensitivity.

METHODS

Fourteen adolescents with obesity were assigned to 6 wk of exercise training either in normoxic or in hypoxic conditions (FiO2 15%). Adolescents trained three times per week for 50-60 min, including endurance and resistance exercises. Oral glucose tolerance test, blood and morphological analyses, and physical performance tests were performed before and after the training period.

RESULTS

After training, hypoxia, but not normoxia, decreased the area under the curve of plasma insulin (-49%; P = 0.001) and glucose levels (-14%; P = 0.005) during oral glucose tolerance test. Decreased plasma triglycerides levels (P = 0.03) and increased maximal aerobic power (P = 0.002), work capacity at 160 bpm (P = 0.002), and carbohydrate consumption during exercise (P = 0.03) were measured only in the hypoxic group.

CONCLUSIONS

Hypoxic exercise training was particularly efficient at improving glucose tolerance and insulin response to a glucose challenge in adolescents with obesity. These results suggest that exercise training in hypoxia could be an interesting strategy against insulin resistance and type 2 diabetes development in adolescents with obesity.

Quality of health economic evaluations for the ACC/AHA stable ischemic heart disease practice guideline: A systematic review

BACKGROUND

The American College of Cardiology/American Heart Association (ACC/AHA) recently published a rigorous framework to guide integration of economic data into clinical guidelines. We assessed the quality of economic evaluations in a major ACC/AHA clinical guidance report.

METHODS

We systematically identified cost-effectiveness analyses (CEAs) of RCTs cited in the ACC/AHA 2012 Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease. We extracted: (1) study identifiers; (2) parent RCT information; (3) economic analysis characteristics; and (4) study quality using the Quality of Health Economic Studies instrument (QHES).

RESULTS

Quality scores were categorized as high (≥75 points) or low (<75 points). Of 1,266 citations in the guideline, 219 were RCTs associated with 77 CEAs. Mean quality score was 81 (out of 100) and improved over time, though 29.9% of studies were low-quality. Cost-per-QALY was the most commonly reported primary outcome (39.0%). Low-quality studies were less likely to report study perspective, use appropriate time horizons, or address statistical and clinical uncertainty. Funding was overwhelmingly private (83%). A detailed methodological assessment of high-quality studies revealed domains of additional methodological issues not identified by the QHES.

CONCLUSIONS

Economic evaluations of RCTs in the 2012 ACC/AHA ischemic heart disease guideline largely had high QHES scores but methodological issues existed among "high-quality" studies. Because the ACC/AHA has generally been more systematic in its integration of scientific evidence compared to other professional societies, it is likely that most societies will need to proceed more cautiously in their integration of economic evidence.

Economic Evaluation alongside Multinational Studies: A Systematic Review of Empirical Studies

Purpose of the study

This study seeks to explore methods for conducting economic evaluations alongside multinational trials by conducting a systematic review of the methods used in practice and the challenges that are typically faced by the researchers who conducted the economic evaluations.

Methods

A review was conducted for the period 2002 to 2012, with potentially relevant articles identified by searching the Medline, Embase and NHS EED databases. Studies were included if they were full economic evaluations conducted alongside a multinational trial.

Results

A total of 44 studies out of a possible 2667 met the inclusion criteria. Methods used for the analyses varied between studies, indicating a lack of consensus on how economic evaluation alongside multinational studies should be carried out. The most common challenge appeared to be related to addressing differences between countries, which potentially hinders the generalisability and transferability of results. Other challenges reported included inadequate sample sizes and choosing cost-effectiveness thresholds.

Conclusions

It is recommended that additional guidelines be developed to aid researchers in this area and that these be based on an understanding of the challenges associated with multinational trials and the strengths and limitations of alternative approaches. Guidelines should focus on ensuring that results will aid decision makers in their individual countries.

Combination perindopril/indapamide for the treatment of hypertension: a review

INTRODUCTION

Hypertension is an important risk factor for cardiovascular complications and the need to treat this condition has been well established. Despite the availability of many antihypertensive drugs, it is often necessary to combine several of these drugs. The compound perindopril/indapamide offers the opportunity to start with a fixed combination of two effective agents as first-line treatment. Large outcome trials so far show that the perindopril/indapamide compound has favourable prognostic effects in elderly hypertensives as well as in patients with high cardiovascular risks, regardless of their level of blood pressure.

AREAS COVERED

This review examines the prevalence of hypertension, the major risk factors, its pharmacodynamics, pharmacokinetics and clinical efficacy, and also looks at the results of large outcome trials. This review will allow the reader to put the role of the perindopril/indapamide combination in perspective, at least from a clinical point of view.

EXPERT OPINION

Despite the positive trial results, there are still issues that deserve attention, for example safety with respect to drug levels in special patient groups. Also, in the large outcome trials placebo treatment (whether or not in addition to other medication) was taken as the comparator, and it is uncertain whether the combination of perindopril and indapamide performs better than established modes of treatment. More studies are needed to establish whether the combination drug has similar positive effects in the long run in 'ordinary' patients and those with comorbid conditions or those who are treated with other drugs as well. Nevertheless, it is fair to state that the low-dose perindopril/indapamide combination adds to our pharmaceutical arsenal and can be applied as first-line treatment by physicians who care for patients with elevated blood pressure or, more broadly, those with cardiovascular disease.

Blood pressure, lipids and glucose in type 2 diabetes: how low should we go? Re-discovering personalized care

Epidemiological studies have clearly shown a direct relationship between the levels of blood pressure, glycaemia and LDL-cholesterol, and the complications of diabetes. Although 'lower should be better', the results of recent clinical trials examining the benefits of normalizing risk factor levels have been counter-intuitive and, at times, disturbing, and have called into question this notion. This review focuses on patients with type 2 diabetes who make up 90% of patients with diabetes. It aims to provide a clear summary and interpretation of recent trials to help clinicians to set targets for cardiovascular risk factors in individual patients. It highlights areas of agreement and disagreement between current guidelines. Recent data indicate that some patient subgroups might respond differently to aggressive risk factor management. Our challenge is how to identify these patients and deliver truly personalized diabetes care that maximizes benefit, and minimizes harm. Guidelines and position statements stress the value of setting personalized targets. We explore what this means, and how this might be achieved in practice by outlining some solutions to issues that currently limit the delivery of personalized care. We call for further research assessing the overall clinical impact of cardiovascular risk factor intervention by finding appropriate ways of combining data on mortality, complications, side-effects, quality of life, and cost-effectiveness.