iGlarLixi versus premixed insulin initiation in adults with type 2 diabetes advancing from basal insulin therapy: The SoliComplex real-world study

Aim

To compare outcomes in adults with type 2 diabetes (T2D) suboptimally controlled with basal insulin who initiated treatment with iGlarLixi or premixed insulin.

Methods

This retrospective real-world analysis was conducted using data from adults (age ≥ 18 years) with T2D in the US Optum Clinformatics database who had previously received basal insulin and newly initiated iGlarLixi or premixed insulin. Cohorts were propensity-score matched on baseline characteristics using a greedy nearest neighbour-matching algorithm, and outcomes were assessed at 12 months. Subgroup analyses were performed for those aged 65 years or older and those with a baseline HbA1c of 9% or higher. The primary endpoint was treatment persistence in the overall population. Secondary endpoints were treatment adherence, healthcare resource utilization (HRU), costs, hypoglycaemia events and change in HbA1c from baseline.

Results

Each cohort comprised 834 participants. In the overall population, treatment persistence at 12 months was statistically significantly higher for iGlarLixi versus premixed insulin: 42.5% versus 39.1%; hazard ratio 0.88; 95% confidence interval 0.778-0.998; P = .0465. Adherence and HbA1c reduction were similar between groups, whereas hypoglycaemia events, HRU and costs were numerically lower for iGlarLixi. Outcomes in both the age 65 years or older subgroup and in those with an HbA1c of 9% or higher were consistent with those for the overall population.

Conclusions

In this observational study in people with T2D suboptimally controlled on basal insulin, once-daily iGlarLixi was an effective treatment alternative to premixed insulin with significantly higher treatment persistence, similar adherence and HbA1c reduction, and numerically lower hypoglycaemia events, HRU and costs, regardless of age or baseline HbA1c.     

Does Device Make Any Difference? A Real-world Retrospective Study of Insulin Treatment Among Elderly Patients With Type 2 Diabetes

We compared real-world clinical and economic outcomes for insulin glargine treatment administered by disposable pen and traditional vial-and-syringe injections among elderly patients with type 2 diabetes mellitus (T2DM). Using a large database of US retirees, this retrospective longitudinal study examined 1-year follow-up outcomes in patients with T2DM aged 65 years or older who were either insulin naïve and initiated insulin glargine via disposable pen (pen initiators [PI]) or vial (vial initiators [VI]) or were already insulin glargine users but either continued with a vial (vial continuers [VC]) or switched to a disposable pen (pen switchers [PS]). There were 7856 propensity-score-matched patients, including 2930 each in the PI and VI cohorts, and 998 each in the VC and PS cohorts. Compared with vial-and-syringe users, the disposable pen users had significantly greater treatment persistence (P < .0001 for both comparisons), duration of persistence (P < .0001 for both), and adherence (P < .01 for both) and lower insulin daily average consumption (P < .05 for both). Compared with the VI cohort, the PI cohort had significantly fewer hypoglycemia-related events (P = .0164). Total health care costs were comparable for the respective matched cohorts. In elderly patients with T2DM receiving insulin glargine therapy, initiating or switching to a disposable pen was associated with better treatment persistence and adherence than initiating or continuing with vial-and-syringe, without increased total health care costs. Among insulin-naïve patients, initiating insulin glargine by disposable pen was also associated with significantly reduced risk of hypoglycemia compared with vial-and-syringe patients.     

Disparities in adherence to and persistence with antihypertensive regimens: an exploratory analysis from a community-based provider network

Despite the availability of effective antihypertensive therapies, adherence to and persistence with treatment is suboptimal. As such, there is a need to better understand factors associated with adherence and persistence, such as race/ethnicity. In a retrospective, exploratory analysis of 51,772 hypertensive adult subjects identified in the electronic medical record, we examined medication possession ratio and proportion of days covered as proxies for adherence and persistence, respectively. Logistic regression analyses were performed to assess the role of race/ethnicity in adherence to and persistence with antihypertensive treatments. Relative to white subjects, Asian American/Pacific Islander, black, Hispanic, and “other” subjects were significantly less likely to be adherent to and persistent with their antihypertensive regimens. Black and Hispanic subjects had the lowest odds of adherence (0.46, 95% CI: 0.43–0.49 and 0.58, 95% CI: 0.54–0.62, respectively) and persistence (0.70, 95% CI: 0.65–0.75 and 0.70, 95% CI: 0.66–0.74, respectively) relative to white subjects. Other factors significantly associated with both lower adherence and persistence included younger age and lower chronic disease score. Disparities were found with regard to adherence to and persistence with antihypertensive regimens. Future studies should address these disparities by designing interventions to improve medication-taking behavior in high-risk populations.     

Comparison of medication adherence and persistence in type 2 diabetes: A systematic review and meta‐analysis

Limited medication adherence and persistence with treatment are barriers to successful management of type 2 diabetes (T2D). We searched MEDLINE, EMBASE, the Cochrane Library, the Register of Controlled Trials, PsychINFO and CINAHL for observational and interventional studies that compared the adherence or persistence associated with 2 or more glucose‐lowering medications in people with T2D. Where 5 or more studies provided the same comparison, a random‐effects meta‐analysis was performed, reporting mean difference (MD) or odds ratio (OR) for adherence or persistence, depending on the pooled study outcomes. We included a total of 48 studies. Compared with metformin, adherence (%) was better for sulphonylureas (5 studies; MD 10.6%, 95% confidence interval [CI] 6.5‐14.7) and thiazolidinediones (TZDs; 6 studies; MD 11.3%, 95% CI 2.7%‐20.0%). Adherence to TZDs was marginally better than adherence to sulphonylureas (5 studies; MD 1.5%, 95% CI 0.1‐2.9). Dipeptidyl peptidase‐4 inhibitors had better adherence than sulphonylureas and TZDs. Glucagon‐like peptide‐1 receptor agonists had higher rates of discontinuation than long‐acting analogue insulins (6 studies; OR 1.95; 95% CI 1.17‐3.27). Long‐acting insulin analogues had better persistence than human insulins (5 studies; MD 43.1 days; 95% CI 22.0‐64.2). The methods used to define adherence and persistence were highly variable.     

Adherence to statins, subsequent healthcare costs, and cardiovascular hospitalizations

Statins are the primary agents used to decrease low-density lipoprotein cholesterol. Although adherence to statins improves the clinical outcomes, the affect of statin adherence on healthcare costs has not been well studied. To examine the relation among statin adherence, subsequent hospitalizations, and healthcare costs, we conducted a retrospective cohort study of 381,422 patients, aged 18 to 61 years, using an integrated pharmacy and medical claims database. We measured adherence using the medication possession ratio (MPR) for 12 months and the healthcare costs and cardiovascular disease-related hospitalizations during the subsequent 18 months. Of those studied, 258,013 (67.6%) were adherent (MPR ≥80%), 65,795 (17.3%) had an MPR of 60% to 79%, and 57,614 (15.1%) had an MPR of <60%. The adjusted all-cause total healthcare costs were lowest in the adherent group at $10,198 ± $39.4 (mean ± SE) versus $10,609 ± $77.7 (p <0.001) for an MPR of 60% to 79%, and $11,102 ± $84.3 (p <0.001) for an MPR of <60%. The adherent group had greater statin costs at $838 ± $1.0 versus $664 ± $2.0 (p <0.001) and $488 ± $2.2 (p <0.001). When evaluated by 5 levels of MPR, 0% to 59% and increments of 10% >60%, the adjusted total healthcare costs were lowest for the MPR 90% to 100% group and significantly greater statistically (p <0.001) for each lower level of adherence. Compared to the statin-adherent patients, cardiovascular disease-related hospitalizations were more likely for the patients with an MPR of 60% to 79% (odds ratio 1.12, 95% confidence interval 1.08 to 1.16) and an MPR of 0% to 59% (odds ratio 1.26, 95% confidence interval 1.21 to 1.31). In conclusion, statin adherence is associated with reductions in subsequent total healthcare costs and cardiovascular disease-related hospitalizations.     

A prediction model of CKD progression among individuals with type 2 diabetes in the United States

BackgroundCKD progression among individuals with T2D is associated with poor health outcomes and high healthcare costs, which have not been fully studied. This study aimed to predict CKD progression among individuals with diabetes.MethodUsing ACCORD trial data, a time-varying Cox model was developed to predict the risk of CKD progression among patients with CKD and T2D. CKD progression was defined as a 50 % decline, or 25 mL/min/1.73 m² decline in eGFR from baseline, doubling of the serum creatinine, or onset of ESKD. A list of candidate variables included demographic characteristics, physical exam results, laboratory results, medical history, drug use, and healthcare utilization. A stepwise algorithm was used for variable selection. Model performance was evaluated by Brier score and C-statistics. Confidence intervals (CI) were calculated using a bootstrap method. Decomposition analysis was conducted to assess the predictor contribution. Generalizability was assessed on patient-level data of the Harmony Outcome trial and CRIC study.ResultsA total of 6982 diabetes patients with CKD were used for model development, with a median follow-up of 4 years and 3346 events. The predictors for CKD progression included female sex, age at T2D diagnosis, smoking status, SBP, DBP, HR, HbA1c, alanine aminotransferase (ALT), eGFR, UACR, retinopathy event, hospitalization. The model demonstrated good discrimination (C-statistics 0.745 [95 % CI 0.723–0.763]) and calibration (Brier Score 0.0923 [95 % CI 0.0873–0.0965]) performance in the ACCORD data. The most contributing predictors for CKD progression were eGFR, HbA1c, and SBP. The model demonstrated acceptable discrimination and calibration performance in the two external data.ConclusionFor high-risk patients with both diabetes and CKD, the tool as a dynamic risk prediction of CKD progression may help develop novel strategies to lower the risk of CKD progression.     

Impact of antidepressant drug adherence on comorbid medication use and resource utilization

BACKGROUND: Patients with depression are often nonadherent to therapy for depression and chronic comorbid conditions. METHODS: To determine whether improved antidepressant medication adherence is associated with an increased likelihood of chronic comorbid disease medication adherence and reduced medical costs, we conducted a retrospective study of patients initiating antidepressant drug therapy with evidence of dyslipidemia, coronary artery disease (CAD), or both; diabetes mellitus (DM); or CAD/dyslipidemia and DM identified from a claims database. Measures included antidepressant medication adherence, measured by medication possession ratio during 180 days without a 15-day gap before 90 days of therapy; comorbid medication adherence, measured by medication possession ratio during 1 year; and the association between improved antidepressant drug adherence and disease-specific and total medical costs. RESULTS: Of 8040 patients meeting the study criteria, those adherent to antidepressant medication were more likely to be adherent to comorbid therapy vs those nonadherent to antidepressant drug therapy (CAD/dyslipidemia: odds ratio [OR], 2.13; DM: OR, 1.82; and CAD/dyslipidemia/DM: OR, 1.45; P<.001 for all). Patients adherent to antidepressant drug therapy also had significantly lower disease-specific charges vs nonadherent patients (17% lower in CAD/dyslipidemia, P = .02; 8% lower in DM, P = .39; and 14% lower in CAD/dyslipidemia/DM, P = .38). These patients also incurred lower total medical charges (6.4% lower in CAD/dyslipidemia, P = .048; 11.8% lower in DM, P = .04; and 19.8% lower in CAD/dyslipidemia/DM, P = .03). CONCLUSIONS: Antidepressant drug adherence was associated with increased comorbid disease medication adherence and reduced total medical costs for CAD/dyslipidemia, DM, and CAD/dyslipidemia/DM. Future studies should investigate the relationship between increased adherence and costs beyond 1 year.     

Assessing the impact of complications on the costs of Type II diabetes

AIMS/HYPOTHESIS: 'The Cost of Diabetes in Europe - Type II (CODE-2) study' provides the first coordinated attempt to assess the total costs of managing people with Type II (non-insulin-dependent) diabetes mellitus in Europe. Type II diabetes is associated with a number of serious long-term complications, which are a major cause of morbidity, hospitalisation and mortality in diabetic patients. METHODS: Patients were divided into four broad categories defining their complication status in terms of no complications, one or more microvascular complications, one or more macrovascular complications or one or more of each microvascular and macrovascular complication. The prevalence of complications and associated costs were assessed retrospectively for 6 months. RESULTS: In total, 72% of patients in the CODE-2 study had at least one complication, with 19% having microvascular only, 10% having macrovascular only and 24% of the total having both microvascular and macrovascular complications. Of patients with microvascular complications, 28% had neuropathy, 20% renal damage, 20% retinopathy and 6.5% required treatment for eye complications. Among the patients with macrovascular complications, 18% had peripheral vascular disease, 17% angina, 12% heart failure and 9% had myocardial infarction. Percutaneous transluminal coronary angioplasty, coronary artery bypass graft or stroke occurred in 3%, 4% and 5% of the patients, respectively. In patients with both microvascular and macrovascular complications, the total cost of management was increased by up to 250% compared to those without complications. CONCLUSION/INTERPRETATION: Complications have a substantial impact on the costs of managing Type II diabetes. This study has confirmed that the prevention of diabetic complications will not only benefit patients, but potentially reduce overall healthcare expenditure.     

Interventions to enhance medication adherence in chronic medical conditions: a systematic review

BACKGROUND: Approximately 20% to 50% of patients are not adherent to medical therapy. This review was performed to summarize, categorize, and estimate the effect size (ES) of interventions to improve medication adherence in chronic medical conditions. METHODS: Randomized controlled trials published from January 1967 to September 2004 were eligible if they described 1 or more unconfounded interventions intended to enhance adherence with self-administered medications in the treatment of chronic medical conditions. Trials that reported at least 1 measure of medication adherence and 1 clinical outcome, with at least 80% follow-up during 6 months, were included. Study characteristics and results for adherence and clinical outcomes were extracted. In addition, ES was calculated for each outcome. RESULTS: Among 37 eligible trials (including 12 informational, 10 behavioral, and 15 combined informational, behavioral, and/or social investigations), 20 studies reported a significant improvement in at least 1 adherence measure. Adherence increased most consistently with behavioral interventions that reduced dosing demands (3 of 3 studies, large ES [0.89-1.20]) and those involving monitoring and feedback (3 of 4 studies, small to large ES [0.27-0.81]). Adherence also improved in 6 multisession informational trials (small to large ES [0.35-1.13]) and 8 combined interventions (small to large ES [absolute value, 0.43-1.20]). Eleven studies (4 informational, 3 behavioral, and 4 combined) demonstrated improvement in at least 1 clinical outcome, but effects were variable (very small to large ES [0.17-3.41]) and not consistently related to changes in adherence. CONCLUSION: Several types of interventions are effective in improving medication adherence in chronic medical conditions, but few significantly affected clinical outcomes.     

Single-pill vs free-equivalent combination therapies for hypertension: a meta-analysis of health care costs and adherence

This meta-analysis compares health care resource use costs, adherence, and persistence between groups of patients taking antihypertensives as single-pill combinations (SPCs) vs free-equivalent components (FEC) based on a structured review of published studies. The search yielded 12 retrospective database studies included in analyses. The mean difference in combined total annual all-cause and hypertension-related health care costs was $1357 (95% confidence interval [CI], $778-$1935) lower in favor of SPC than FEC groups. Adherence, measured as the mean difference in medication possession ratio, was estimated to be 8% higher for patients naive to prior antihypertensives and 14% higher for nonnaive SPC patients compared with corresponding FEC patients. Persistence in the SPC groups was twice as likely as the FEC groups (pooled risk ratio, 2.1; 95% CI, 1.1-4.1). Improved adherence and persistence may have contributed to the lower costs in the SPC groups via improved clinical outcomes.     

Impact of age,age at diagnosis and duration of diabetes on the risk of macrovascular and microvascular complications and death in type 2 diabetes

Aims/hypothesis

Data are inconsistent regarding the associations between age, age at diagnosis of diabetes, diabetes duration and subsequent vascular complications.

Methods

The associations between age (or age at diagnosis), diabetes duration and major macrovascular events, all-cause death and major microvascular events were examined in 11,140 patients with type 2 diabetes randomly allocated to intensive or standard glucose control in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Rates were calculated by 5 year baseline age (or age at diagnosis) and diabetes duration strata. Risks were estimated using Cox models adjusted for treatment assignment and HbA_1c.

Results

The mean age (±SD) was 65.8?±?6.4 years, age at diagnosis was 57.8?±?8.7 years and diabetes duration was 7.9?±?6.4 years. Diabetes duration was associated with the risk of macrovascular events (HR 1.13 [95% CI 1.08, 1.17]), microvascular events (1.28 [1.23, 1.33]) and death (1.15 [1.10, 1.20]) whereas age (or age at diagnosis) was only associated with the risk of macrovascular events (1.33 [1.27, 1.39]) and death (1.56 [1.48, 1.64]). No interaction was observed between diabetes duration, age and the risk of macrovascular events or death (both p?>?0.4). However, an interaction was observed between diabetes duration, age and the risk of microvascular events (p?=?0.002), such that the effects of increasing diabetes duration were greatest at younger rather than older age.

Conclusions/interpretation

In patients with type 2 diabetes, age or age at diagnosis and diabetes duration are independently associated with macrovascular events and death whereas only diabetes duration is independently associated with microvascular events and this effect is greater in the youngest patients.     

Serum glucose control in diabetic patients with cardiovascular disease: Should we be less aggressive?

Although aggressive control of hyperglycemia significantly reduces microvascular complications in patients with diabetes, there is no clear evidence that it improves macrovascular cardiovascular disease (CVD) outcomes. Data from recent studies suggest that intensive treatment of blood glucose has no significant effect on CVD outcomes and may even paradoxically increase cardiovascular and all-cause mortality, especially in older patients with longstanding type 2 diabetes and preexisting CVD. At present, it is prudent to aim for a glycated hemoglobin (HbA_1c) target of 7%, provided this can be achieved without hypoglycemia and other adverse effects of antidiabetic treatment. Treatment of patients with diabetes should begin early and include intensive efforts to promote a healthy lifestyle. Less stringent HbA_1c goals may be appropriate in older patients with advanced microvascular and macrovascular disease, other comorbid conditions, and a history of severe hypoglycemia. At all times, cholesterol, blood pressure, and other CVD risk factors should be aggressively managed.     

Impact of Mental Disorders on the Association Between Adherence to Antihypertensive Agents and All‐Cause Healthcare Costs

Depression and anxiety are factors associated with poor adherence to medications that lead to increased healthcare costs. The authors hypothesize that these conditions will moderate the association between adherence and healthcare costs. The aim was to examine the healthcare costs associated with adherence to antihypertensive agents in the elderly with and without depression and anxiety. The sample included participants with hypertension and used hypertensive agents (N=926). Medication possession ratio was used to calculate medication adherence. Mean total healthcare costs included costs for inpatient stays, emergency department visits, outpatient visits, physician fees, and outpatient medications. Mental disorders were assessed using a questionnaire based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. The total healthcare costs were significantly greater for nonadherent participants with depression/anxiety than for adherent participants without depression/anxiety (Δ$1841, P<.0001). This study suggests that treating mental disorders in elderly patients with hypertension will decrease total healthcare costs.     

Association of hypoglycaemia severity with clinical,patient‐reported and economic outcomes in US patients with type 2 diabetes using basal insulin

Aims

To evaluate the clinical and patient‐reported outcomes and healthcare utilization and costs associated with patient‐reported hypoglycaemia in US adults with type 2 diabetes (T2D) treated with basal insulin.

Materials and methods

This was an observational, cross‐sectional, survey‐based study of adults with T2D on basal insulin ± oral antidiabetes drugs (OADs) or rapid‐acting/premixed insulin, who had in the past ever experienced hypoglycaemia, using US data from the National Health and Wellness Survey. Eligible patients were categorized as having no hypoglycaemia (38.7%), non‐severe hypoglycaemia (55.1%), or severe hypoglycaemia (6.2%) in the preceding 3 months. Outcomes included health‐related quality of life (HRQoL), work productivity and activity impairment, healthcare resource utilization, and estimated direct and indirect costs. Multivariable regression models were performed to control for patient characteristics.

Results

Patients who experienced severe hypoglycaemia had significantly (P < .05) lower HRQoL scores, greater overall impairment of work productivity and activity, greater healthcare resource utilization, and higher costs compared with those who experienced non‐severe or no hypoglycaemia. Patients with non‐severe hypoglycaemia also reported an impact on the number of provider visits, indirect costs, and HRQoL.

Conclusions

Patients with T2D using basal insulin ± OADs or rapid‐acting/premixed insulin in the United States who experienced severe hypoglycaemia had greater impairment of activity and work productivity, utilized more healthcare resources, and incurred higher associated costs than those with non‐severe or no hypoglycaemia. The study also demonstrated the impact that non‐severe hypoglycaemic events have on economic and HRQoL outcomes. Reducing the incidence and severity of hypoglycaemia could lead to clinically meaningful improvements in HRQoL and may result in lower healthcare utilization and associated costs.     

Adjuvant therapy use among Appalachian breast cancer survivors

There is a paucity of literature systemically examining the effects of access to cancer care resources on adjuvant endocrine therapy (AET) use behaviors, especially in underserved regions such as the Appalachian region in the United States, where gaps in healthcare access are well documented. The objectives of this study were to explore AET adherence and persistence in Appalachia, delineate the effects of access to care cancer on adherence/persistence, and evaluate the influences of adherence and persistence on overall survival.A retrospective cohort study from 2006 to 2008 was conducted among female breast cancer survivors living in the Appalachian counties of 4 states (PA, OH, KY, and NC). We linked cancer registries to Medicare claims data and included patients with invasive, nonmetastatic, hormone-receptor-positive breast cancer who received guideline-recommended AET. Medication adherence was defined as corresponding to a Medication Possession Ratio (MPR) ≥0.8 and logistic regression was utilized to assess predictors of adherence. Medication nonpersistence was defined as the discontinuation of drugs after exceeding a 60-day medication gap, and multivariate adjusted estimates of nonpersistence were obtained using the Cox proportional hazards (PH) model.About 31% of the total 428 patients were not adherent to AET, and 30% were not persistent over an average follow-up period of 421 days. Tamoxifen, relative to aromatase inhibitors, was associated with higher odds of adherence (odds ratio = 2.82, P < 0.001) and a lower risk of nonpersistence (hazard ratio = 0.40, P < 0.001). Drug-related side effects like pain may be an important factor leading to nonadherence and early discontinuation. In addition, aromatase inhibitor (AI) adherence and persistence were significantly influenced by out-of-pocket drug costs, dual eligibility status, and coverage gaps. Nonadherence to and nonpersistence with AET were associated with higher risks of all-cause mortality.Our findings of suboptimal AET adherence/persistence in Appalachia as well as positive associations between AET adherence/persistence and overall survival outcomes further underscore the importance of ensuring appropriate AET use in this population to reduce breast cancer mortality disparities. Our findings also suggest that intervention strategies focusing on individualized treatment and medication-related factors may improve adjuvant treatment use.     

Reduced cardiovascular morbidity and mortality associated with metformin use in subjects with Type 2 diabetes.

AIM: Metformin therapy reduces microvascular complications in Type 2 diabetes; questions remain, however, regarding its impact on macrovascular events. This study examined metformin use in relation to risk of cardiovascular-related hospitalization and mortality. METHODS: We conducted a retrospective cohort analysis, using Saskatchewan Health administrative databases to identify new users of oral antidiabetic drugs. Subject groups were defined by medication use during 1991-1999: sulphonylurea monotherapy, metformin monotherapy, or combination therapy. Deaths and non-fatal hospitalizations recorded during the study period were identified as cardiovascular-related from ICD-9 codes. The main outcome was a composite of first non-fatal hospitalization or death. Standard multivariate techniques, including propensity scores, were used to adjust for potential confounding. Multivariate Cox proportional hazard models were used to examine the relationship between metformin use and the composite endpoint. RESULTS: Metformin monotherapy was associated with a lower risk of the composite endpoint (adjusted hazard ratio 0.81; 95% confidence interval 0.68, 0.97) compared with sulphonylurea monotherapy. Combination therapy with meformin and a sulphonylurea was associated with lower mortality, but had similar hospitalization rates, to sulphonylurea monotherapy. CONCLUSIONS: Metformin monotherapy was associated with a lower risk of cardiovascular-related morbidity and mortality, and combination metformin and sulphonylurea therapy was associated with a reduced risk of fatal cardiovascular events, when compared with sulphonylurea monotherapy.     

Obesity and Diabetic Complications: A Study from the Nationwide Diabetes Report of the National Program for Prevention and Control of Diabetes (NPPCD-2021) Implications for Action on Multiple Scales

BackgroundObesity plays a major role in the pathogenesis and development of macro- and microvascular complications of type 2 diabetes (T2D) and type 1 diabetes (T1D). We aimed to assess the association between obesity and macrovascular and microvascular complications of diabetes.MethodsThis study consisted of 111,830 patients (age range: 1–106) with diabetes including 10,641 T1D (3187 obese [38.2% men] and 7454 non-obese [45.5% men]) and 101,189 T2D (51,873 obese [27.5% men] and 49,316 non-obese [33.4% men]) from the National Program for Prevention and Control of Diabetes (NPPCD-2021) in Iran, who attended academic tertiary care outpatient clinics from February 2016 to April 2021. A pooled logistic regression model was used to examine the association between obesity and diabetic complications.ResultsAmong patients with T1D, a significant association was found between obesity and cardiovascular disease (CVD), neuropathy, nephropathy and retinopathy (OR= 1.75, 1.56, 1.80 and 1.92, P-value= 0.001, 0.004, 0.001 and <0.001, respectively). In T2D, a statistically significant association was found between obesity and CVD, neuropathy and nephropathy (OR= 1.63, 1.98, 1.21, respectively, P-values <0.001).ConclusionObesity was independently associated with CVD, neuropathy and nephropathy in patients with T1D and T2D and with retinopathy only in T1D, to different degrees. The association between obesity and retinopathy and neuropathy was the strongest among T1D and T2D, respectively. Findings from this study suggest that obesity affects diabetic complications differently among the two types of diabetes, in terms of epidemiology and pathophysiology. This signifies the importance of different preventive and therapeutic approaches to obesity in T1D compared to T2D, on a national and global scale.     

Tests of glycemia for the diagnosis of type 2 diabetes mellitus

This paper discusses tests of glycemia for the diagnosis of type 2 diabetes mellitus, with particular reference to the 1997 diagnostic criteria of the American Diabetes Association. The potential benefits of the lower diagnostic threshold for fasting plasma glucose are not well defined. However, the change in the diagnostic cut-off for diabetes mellitus affects as many as 1.9 million persons in the United States; therefore, the medical and social costs of the lower threshold may be considerable. Type 2 diabetes mellitus is defined by a threshold imposed on the continuous distribution of glycemic levels, typically with respect to risk for microvascular complications. However, the burden of type 2 diabetes relates more to macrovascular than microvascular complications. Because no clear threshold exists for macrovascular complications, a formal balancing of direct and indirect costs with both microvascular and macrovascular complications may be appropriate to establish glycemic thresholds. Because fasting plasma glucose, hemoglobin A1c, and the oral glucose tolerance test all predict diabetic complications yet test reliability is better for fasting plasma glucose and hemoglobin A1c than for the oral glucose tolerance test, we suggest an alternative diagnostic approach: If random plasma glucose is elevated (> or =11.1 mmol/L [200 mg/dL]) and the hemoglobin A1c level is more than 2 SDs above the laboratory mean, then diabetes mellitus should be diagnosed, and management should be based on the hemoglobin A1c level. If the result of only one of these tests is positive, then fasting plasma glucose should be tested to evaluate the patient for impaired fasting glucose and diabetes mellitus. The glycemic threshold for type 2 diabetes should be established by cost-effectiveness analysis. The clinical diagnosis of diabetes mellitus could be streamlined by incorporation of hemoglobin A1c into established criteria.     

Adherence to antidiabetic treatment in primary health care in individuals with type 2 diabetes. A survey including socio-demographic,patient related and clinical factors

BackgroundAdherence to medications is a critical element in diabetes management.ObjectiveTo investigate patient-related factors associated with adherence to antidiabetic treatment in patients with type 2 diabetes in primary health-care units.MethodsA cross-sectional study among patients receiving diabetes care in 18 primary care units in Mexico City was conducted. Data were collected from medical records and medical interviews. Adherence to antidiabetic therapy and patient-related factors associated with adherence were evaluated through a self-administered questionnaire. Socio-demographic, clinical, behavioral (self-care activities including a healthy diet, exercise or physical activity, self-monitoring of blood glucose testing, and foot care), and patients-adherence-related factors (health-care provider-patient communication; daily and social activities, and support network; alternative treatment beliefs; comorbidity, diabetes symptoms, and treatment; side effects and treatment access) were compared between the adherent and non-adherent group.ResultsOf 319 outpatients, 48.3% were adherent to their antidiabetic therapy. In the adjusted analysis, patient-related factors associated to adherence were exercise and physical activity self-care behavior (OR=1.26; 95%CI 1.09–1.46), treatment interference with daily activities (OR=0.27; 95%CI 0.14–0.52), not satisfied with resolution of questions by the physician (OR=0.42; 95%CI 0.19–0.94), independently to increased cardiovascular risk and insulin treatment.ConclusionA low proportion of outpatients with T2D with regular primary care were adherent to diabetes treatment and this was associated with patient-related factors like answering patients’ treatment-related questions by the physician. This information may be useful to identify patients at risk for low adherence, and to guide the design of quality-of-care strategies, like diabetes education programs to address suboptimal adherence in patients, and health-care professional communication skills training, particularly in primary care health systems.