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Wu S, Mao Y, Chen S, Pan P, Zhang H, Chen S, Liu J, Mi D. Safety and Efficacy of Tight Versus Loose Glycemic Control in Acute Stroke Patients: A Meta-Analysis of Randomized Controlled Trials. Int J Stroke 2024:17474930241241994. [PMID: 38472157 DOI: 10.1177/17474930241241994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
BACKGROUND Hyperglycemia is associated with worse stroke outcomes but it is uncertain whether tight glycaemic control during the acute stroke period is associated with a better outcome. We conducted a meta-analysis to compare the effect of tight glycemic control versus loose glycemic control in the acute phase of stroke patients. METHODS A literature search was performed to identify randomized controlled trials (RCTs) comparing the safety and efficacy of tight glycemic control with a relatively loose control of blood glucose of acute stroke (ischemic or hemorrhagic) patients within 24 hours after stroke onset. We required that the blood glucose level of the patients should not be lower than 6.11mmol/L at the time of enrollment, and for the intensive blood glucose control range, we defined the blood glucose level as lower than that of the control group.Tight glycaemic control was defined as blood glucose ≥ 6.11 mmol/L. The primary efficacy outcome measure was deaths from any cause at 90 days. Secondary efficacy outcomes comprised the number of participants with modified Rankin score (mRS), We define mRS scores 0-2 as favorable scores, recurrent stroke, and the National Institute of Health stroke scale (NIHSS) or the European Stroke Scale (ESS) scores. We defined the number of participants with hypoglycemia as our primary safety outcome. Subgroup analysis was performed according to age, the variety of interventions, maintained glucose level, and status of hypoglycemia on NIHSS scores or ESS scores. RESULTS Fifteen RCTs with 2957 participants meeting the including criteria were identified and included in this meta-analysis, although not all included data on every outcome measure. Data on the primary efficacy endpoint, mortality at 90 days, was available in 11 RCTs a total of 2575 participants. There was no significant difference between the intervention and control groups (OR: 1.00; 95%CI: 0.81 to 1.23; P=0.99). For secondary endpoints, there was no difference between intervention and control groups for a mRS < from 0-2 (OR: 0.96; 95%CI: 0.80 to 1.15; P=0.69; data from 9 RCTs available), or recurrent stroke (OR: 1.34; 95%CI: 0.92 to 1.96; P=0.13; data from 3 RCTs available). For NIHSS scores or ESS scores, there was a small difference in favor of intensive controls (SMD: -0.29; 95%CI: -0.54 to -0.04; P=0.02) There was a marked increase in hypoglycemia with tight control: (OR of 9.46 (95%CI: 4.59 to 19.50; P<0.00001; data from 9 RCTs available). CONCLUSIONS There was no difference between tight and loose glycemic control on mortality, independence, or recurrent stroke outcome in acute stroke, but an increase in hypoglycaemia. There was a small effect improvement on neurological scales but the relevance of this needs confirming in future adequately powered studies.
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Affiliation(s)
- Shuangzhe Wu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Yuke Mao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Sijia Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Peiyan Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Huiying Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Siqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Jue Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University
| | - Donghua Mi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
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Yao M, Hao Y, Wang T, Xie M, Li H, Feng J, Feng L, Ma D. A review of stress-induced hyperglycaemia in the context of acute ischaemic stroke: Definition, underlying mechanisms, and the status of insulin therapy. Front Neurol 2023; 14:1149671. [PMID: 37025208 PMCID: PMC10070880 DOI: 10.3389/fneur.2023.1149671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/21/2023] [Indexed: 04/08/2023] Open
Abstract
The transient elevation of blood glucose produced following acute ischaemic stroke (AIS) has been described as stress-induced hyperglycaemia (SIH). SIH is common even in patients with AIS who have no previous diagnosis of diabetes mellitus. Elevated blood glucose levels during admission and hospitalization are strongly associated with enlarged infarct size and adverse prognosis in AIS patients. However, insulin-intensive glucose control therapy defined by admission blood glucose for SIH has not achieved the desired results, and new treatment ideas are urgently required. First, we explore the various definitions of SIH in the context of AIS and their predictive value in adverse outcomes. Then, we briefly discuss the mechanisms by which SIH arises, describing the dual effects of elevated glucose levels on the central nervous system. Finally, although preclinical studies support lowering blood glucose levels using insulin, the clinical outcomes of intensive glucose control are not promising. We discuss the reasons for this phenomenon.
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Affiliation(s)
- Mengyue Yao
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yulei Hao
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Tian Wang
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Meizhen Xie
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Hui Li
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jiachun Feng
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Liangshu Feng
- Stroke Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
- Liangshu Feng
| | - Di Ma
- Department of Neurology and Neuroscience Centre, The First Hospital of Jilin University, Changchun, Jilin, China
- *Correspondence: Di Ma
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Li M, Chen G, Feng Y, He X. Stress Induced Hyperglycemia in the Context of Acute Coronary Syndrome: Definitions, Interventions, and Underlying Mechanisms. Front Cardiovasc Med 2021; 8:676892. [PMID: 34055942 PMCID: PMC8149624 DOI: 10.3389/fcvm.2021.676892] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/19/2021] [Indexed: 01/08/2023] Open
Abstract
Elevation of glucose level in response to acute coronary syndrome (ACS) has been recognized as stress induced hyperglycemia (SIH). Plenty of clinical studies have documented that SIH occurs very common in patients hospitalized with ACS, even in those without previously known diabetes mellitus. The association between elevated blood glucose levels with adverse outcome in the ACS setting is well-established. Yet, the precise definition of SIH in the context of ACS remains controversial, bringing confusions about clinical management strategy. Several randomized trials aimed to evaluate the effect of insulin-based therapy on outcomes of ACS patients failed to demonstrate a consistent benefit of intensive glucose control. Mechanisms underlying detrimental effects of SIH on patients with ACS are undetermined, oxidative stress might play an important role in the upstream pathways leading to subsequent harmful effects on cardiovascular system. This review aims to discuss various definitions of SIH and their values in predicting adverse outcome in the context of ACS, as well as the effect of intensive glucose control on clinical outcome. Finally, a glimpse of the underlying mechanisms is briefly discussed.
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Affiliation(s)
- Mingmin Li
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guo Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yingqing Feng
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xuyu He
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Nguyen-Thi HY, Nguyen NTQ, Le NDT, Beillat M, Ethgen O. Cost-Effectiveness of Gliclazide-Based Intensive Glucose Control vs. Standard Glucose Control in Type 2 Diabetes Mellitus. An Economic Analysis of the ADVANCE Trial in Vietnam. Front Public Health 2020; 8:562023. [PMID: 33194963 PMCID: PMC7661634 DOI: 10.3389/fpubh.2020.562023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/02/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: ADVANCE was a large, multinational clinical study conducted over 5 years in type 2 diabetes mellitus (T2DM). In all, 11,140 patients were randomly assigned to receive gliclazide-based intensive glucose control (IGC) or standard glucose control (SGC). IGC was shown to significantly reduce the incidence of major macrovascular and microvascular events (composite endpoint) or major microvascular events compared with SGC, primarily by enhancing renal protection. We assessed the cost-effectiveness of IGC vs. SGC, based on the ADVANCE results, from a Vietnamese healthcare payer perspective. Materials and Methods: A partitioned survival times model across five health states (no complications, myocardial infarction, stroke, end-stage renal disease [ESRD], and diabetes-related eye-disease) was designed. Time-to-event curves were informed by the cumulative incidence of events and corresponding hazard ratios from the ADVANCE study. Health outcomes were expressed in terms of ESRD avoided and quality-adjusted life years (QALYs). Costs (in US $) comprised treatment costs and health state costs. Utility weights and costs were documented from literature reporting Vietnamese estimates. For sensitivity analyses, all parameters were individually varied within their 95% confidence interval bounds (when available) or within a ±30% range. Results: Over a 5-year horizon, IGC avoided 6.5 additional ESRD events per 1,000 patients treated compared with SGC (IGC, 3.5 events vs. SGC, 10.0 events) and provided 0.016 additional QALYs (IGC, 3.570 QALYs vs. SGC, 3.555 QALYs). Total costs were similar for the two strategies (IGC, $3,786 vs. SGC, $3,757). Although the total drug costs were markedly higher for IGC compared with SGC ($1,703 vs. $873), this was largely offset by the savings from better renal protection with IGC (IGC, $577 vs. SGC, $1,508). The incremental cost-effectiveness ratio (ICER) of IGC vs. SGC was $1,878/QALY gained, far below the threshold recommended by the World Health Organization (i.e., 1-3 × gross domestic product per inhabitant ≈$7,500 in Vietnam). The ICER of IGC vs. SGC per ESRD event avoided was $4,559/event. The findings were robust to sensitivity analysis. Conclusion: In Vietnam, gliclazide-based IGC was shown to be cost-effective compared with SGC from a healthcare payer perspective, as defined in the ADVANCE study.
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Affiliation(s)
- Hai-Yen Nguyen-Thi
- Department of Pharmaceutical Administration, Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nga TQ. Nguyen
- Department of Pharmaceutical Administration, Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Nguyen Dang Tu Le
- Department of Pharmaceutical Administration, Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Maud Beillat
- Servier Global Market Access & Health Economics and Outcomes Research, Suresnes, France
| | - Olivier Ethgen
- SERFAN Innovation, Namur, Belgium
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium
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Yao RQ, Ren C, Wu GS, Zhu YB, Xia ZF, Yao YM. Is intensive glucose control bad for critically ill patients? A systematic review and meta-analysis. Int J Biol Sci 2020; 16:1658-1675. [PMID: 32226310 PMCID: PMC7097913 DOI: 10.7150/ijbs.43447] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/27/2020] [Indexed: 02/07/2023] Open
Abstract
Background: The monitoring and management of blood glucose concentration are standard practices in critical settings as hyperglycaemia has been shown close association with poorer outcomes. Several meta-analyses have revealed that intensive glucose control has no benefit in decreasing short-term mortality among critically ill patients, while the studies these meta-analyses have incorporated have been largely divergent. We aim to perform a more comprehensive meta-analysis addressing this problem to provide stronger evidence. Methods: We conducted comprehensive searches for relevant randomized controlled studies in online databases, including the Cochrane Library, EMBASE, and PubMed databases, up to September 1, 2018. The clinical data, which included all-cause mortality, severe hypoglycemia, need for RRT, infection resulting in sepsis, ICU mortality, 90-day mortality, 180-day mortality, and hospital and ICU lengths of stay, were screened and analyzed after data extraction. We applied odds ratios (ORs) to analyze dichotomous outcomes and mean differences for continuous outcomes with a random effects model. Results: A total of 57 RCTs involving a total of 21840 patients were finally included. Patients admitted to the ICU who underwent intensive glucose control showed significantly reduced all-cause mortality (OR: 0.89; 95% CI: 0.80-1.00; P=0.04; I2=32%), reduced infection rate (OR: 0.65, 95% CI: 0.51-0.82, P=0.0002; I2=47%), a lower occurrence of acquired sepsis (OR: 0.80, 95% CI: 0.65-0.99, P=0.04; I2=0%) and shortened length of ICU stay (MD: -0.70, 95% CI: -1.21--0.19, P=0.007, I2=70%) when compared to the same parameters as those treated with the usual care strategy. However, patients in the intensive glucose control group presented with a significantly higher risk of severe hypoglycemia (OR: 5.63, 95% CI: 4.02-7.87, P<0.00001; I2=67%). Conclusions: Critically ill patients undergoing intensive glucose control showed significantly reduced all-cause mortality, length of ICU stay and incidence of acquired infection and sepsis compared to the same parameters in patients treated with the usual care strategy, while the intensive glucose control strategy was associated with higher occurrence of severe hypoglycemic events.
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Affiliation(s)
- Ren-qi Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Chao Ren
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
| | - Guo-sheng Wu
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Yi-bing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing 100038, People's Republic of China
| | - Zhao-fan Xia
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Yong-ming Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
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Giugliano D, Maiorino MI, Bellastella G, Chiodini P, Esposito K. Glycemic Control, Preexisting Cardiovascular Disease, and Risk of Major Cardiovascular Events in Patients with Type 2 Diabetes Mellitus: Systematic Review With Meta-Analysis of Cardiovascular Outcome Trials and Intensive Glucose Control Trials. J Am Heart Assoc 2019; 8:e012356. [PMID: 31166153 PMCID: PMC6645638 DOI: 10.1161/jaha.119.012356] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background The value of glycemic control and preexisting cardiovascular disease in determining the risk of major cardiovascular events (MACE) in type 2 diabetes mellitus is uncertain. Intensive glucose control trials suggest that the 9% lower risk of MACE associated with intensive glycemic control, as compared with conventional glycemic control, is only driven by patients with type 2 diabetes mellitus without cardiovascular disease at baseline. Methods and Results We did a meta‐analysis of cardiovascular outcome trials dividing patients with or without preexisting cardiovascular disease; we found that the lower risk of MACE is confined to patients with cardiovascular disease at baseline. Compared with placebo, the use of both glucagon‐like peptide‐1 receptor agonists and sodium‐glucose cotransporter‐2 inhibitors was associated with a significant 14% lower MACE risk in patients with preexisting cardiovascular disease and with a nonsignificant 2% higher MACE risk in those without preexisting cardiovascular disease (P for interaction=0.021). The meta‐regression analysis of all 12 trials demonstrated a significant (P=0.002) association between reductions of glycated hemoglobin in glycated hemoglobin A1C. Accordingly, the reduction of MACE expected if all cardiovascular outcome trials had achieved a 0.9% glycated hemoglobin reduction would have been 33%. Routine clinical care data complement the results of cardiovascular outcome trials but with some differences: the lower risk of MACE with sodium‐glucose cotransporter‐2 inhibitor use is evident in patients with type 2 diabetes mellitus with or without preexisting cardiovascular disease. Conclusions Sodium‐glucose cotransporter‐2 inhibitors and glucagon‐like peptide‐1 receptor agonists should be included in the therapeutic plan of patients with type 2 diabetes mellitus and overt cardiovascular disease, with due attention paid to improvement of glycemic control, which may amplify their benefit on MACE.
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Affiliation(s)
- Dario Giugliano
- 1 Division of Endocrinology and Metabolic Diseases Università della Campania Luigi Vanvitelli Naples Italy
| | | | - Giuseppe Bellastella
- 1 Division of Endocrinology and Metabolic Diseases Università della Campania Luigi Vanvitelli Naples Italy
| | - Paolo Chiodini
- 3 Medical Statistics Unit Università della Campania Luigi Vanvitelli Naples Italy
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He F, Shu Y, Wang X, Liu X, Liu G, Chen Z, Wang Z, Li L, Liu R, Zhou H, Xu H, Zhang W, Zhou G. Intensive Glucose Control Reduces the Risk Effect of TRIB3, SMARCD3, and ATF6 Genetic Variation on Diabetic Vascular Complications. Front Pharmacol 2018; 9:1422. [PMID: 30618737 PMCID: PMC6297143 DOI: 10.3389/fphar.2018.01422] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 11/19/2018] [Indexed: 02/05/2023] Open
Abstract
Type 2 diabetes mellitus is a complex disease. Our previous study revealed that TRIB3 genetic variations were strongly associated with diabetic vascular complications, although TRIB3 regulation pathways remain poorly understood. We used two extreme treatment groups from a 2 × 2 factorial randomized controlled trial to identify a positive association, which was further validated in patients receiving cross treatment to test the effect of genetic polymorphisms among the different treatment groups. A gene-centric score (GS)-weighted model including the three associated genetic variations TRIB3 rs2295490, ATF6 rs12086247, and SMARCD3 rs58125572 was used. The results of the GS model indicated a 46% reduction in the risk of primary vascular complications in patients bearing more than two risk alleles [hazard ratio (HR) 0.54, 95% confidence interval (CI) 0.38-0.76, p < 0.001], following intensive glucose control treatment when compared with patients who received standard glucose control treatment. Furthermore, these patients benefited from active blood pressure-lowering treatment (HR 0.39, 95% CI 0.24-0.64, p < 0.001). However, no significant difference was observed between the two interventions in patients with fewer than two risk alleles (HR 1.09, 95% CI 0.86-1.39, p = 0.47). These results indicate that genetic variants in these three genes may be useful biomarkers for individualized drug therapy in diabetic patients.
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Affiliation(s)
- Fazhong He
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Pharmacogenetics, Pharmacogenetics Research Institute – Institute of Clinical Pharmacology, Central South University, Changsha, China
- National Clinical Research Center for Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Yan Shu
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Maryland, Baltimore, MD, United States
| | - Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China
| | - Xin Liu
- Beijing Hypertension League Institute, Beijing, China
| | - Guojing Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Pharmacogenetics, Pharmacogenetics Research Institute – Institute of Clinical Pharmacology, Central South University, Changsha, China
- National Clinical Research Center for Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Zhangren Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Pharmacogenetics, Pharmacogenetics Research Institute – Institute of Clinical Pharmacology, Central South University, Changsha, China
- National Clinical Research Center for Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenmin Wang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Pharmacogenetics, Pharmacogenetics Research Institute – Institute of Clinical Pharmacology, Central South University, Changsha, China
- National Clinical Research Center for Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Ling Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Pharmacogenetics, Pharmacogenetics Research Institute – Institute of Clinical Pharmacology, Central South University, Changsha, China
- National Clinical Research Center for Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Rong Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Pharmacogenetics, Pharmacogenetics Research Institute – Institute of Clinical Pharmacology, Central South University, Changsha, China
- National Clinical Research Center for Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Honghao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Pharmacogenetics, Pharmacogenetics Research Institute – Institute of Clinical Pharmacology, Central South University, Changsha, China
- National Clinical Research Center for Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Heng Xu
- Department of Laboratory Medicine, Precision Medicine Center, and Precision Medicine Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, China
- Sichuan and Collaborative Innovation Center, Chengdu, China
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
- Hunan Key Laboratory of Pharmacogenetics, Pharmacogenetics Research Institute – Institute of Clinical Pharmacology, Central South University, Changsha, China
- National Clinical Research Center for Geriatrics, Xiangya Hospital, Central South University, Changsha, China
| | - Gan Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China
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Abstract
Glucose meters (GMs) are routinely used for self-monitoring of blood glucose by patients and for point-of-care glucose monitoring by health care providers in outpatient and inpatient settings. Although widely assumed to be accurate, numerous reports of inaccuracies with resulting morbidity and mortality have been noted. Insulin dosing errors based on inaccurate GMs are most critical. On October 28, 2011, the Diabetes Technology Society invited 45 diabetes technology clinicians who were attending the 2011 Diabetes Technology Meeting to participate in a closed-door meeting entitled New Criteria for Assessing the Accuracy of Blood Glucose Monitors. This report reflects the opinions of most of the attendees of that meeting. The Food and Drug Administration (FDA), the public, and several medical societies are currently in dialogue to establish a new standard for GM accuracy. This update to the FDA standard is driven by improved meter accuracy, technological advances (pumps, bolus calculators, continuous glucose monitors, and insulin pens), reports of hospital and outpatient deaths, consumer complaints about inaccuracy, and research studies showing that several approved GMs failed to meet FDA or International Organization for Standardization standards in postapproval testing. These circumstances mandate a set of new GM standards that appropriately match the GMs' analytical accuracy to the clinical accuracy required for their intended use, as well as ensuring their ongoing accuracy following approval. The attendees of the New Criteria for Assessing the Accuracy of Blood Glucose Monitors meeting proposed a graduated standard and other methods to improve GM performance, which are discussed in this meeting report.
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Affiliation(s)
- John Walsh
- Advanced Metabolic Care and Research, Escondido, California 92026, USA.
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Abstract
BACKGROUND Results from clinical trials examining the effect of intensive glucose control on cardiovascular disease have been conflicting. PURPOSE To summarize clinical benefits and harms of intensive versus conventional glucose control for adults with type-2 diabetes. DATA SOURCES Studies were retrieved by systematically searching the MEDLINE database (January 1950-April 2009) with no language restrictions. STUDY SELECTION Two independent reviewers screened abstracts or full text articles to identify randomized trials comparing clinical outcomes in type-2 diabetes patients treated with intensive compared to conventional glucose control. DATA EXTRACTION Two investigators independently abstracted data on study variables and outcomes including severe hypoglycemia, cardiovascular disease, and all-cause mortality. DATA SYNTHESIS Five trials involving 27,802 adults were included. Intensive glucose targets were lower in the three most recent trials. Summary analyses showed that, compared with conventional control, intensive glucose control reduced the risk of cardiovascular disease (relative risk (RR): 0.90, 95% confidence interval (CI): 0.83, 0.98; risk difference per 1,000 patients per 5 years (RD): -15, CI: -24, -5) but not cardiovascular death (RR: 0.97, CI: 0.76, 1.24; RD: -3, CI: -14, 7) or all-cause mortality (RR: 0.98, CI: 0.84, 1.15; RD: -4, CI: -17, 10) and increased the risk of severe hypoglycemia (RR: 2.03, CI: 1.46, 2.81; RD: 39, CI: 7, 71). Similar to overall analyses, intensive glucose control reduced risk of cardiovascular disease and increased risk of severe hypoglycemia in pooled findings from early and more recent trials. LIMITATIONS Summary rather than individual data were pooled across trials. CONCLUSIONS Intensive glucose control reduced risk for some cardiovascular disease (e.g., non-fatal myocardial infarction), but did not reduce risk for cardiovascular or all-cause mortality and increased risk of severe hypoglycemia.
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