Aims
To determine the patterns and predictors of treatment intensification in patients with type 2 diabetes on ≥2 non‐insulin antidiabetic drugs (NIADs) and inadequate glycaemic control in primary ...care in Catalonia, Spain.
Material and Methods
This was a retrospective analysis using electronic medical records from patients with HbA1c ≥ 7% and a first prescription for a new NIAD or insulin recorded from January 2010 to December 2014. Therapeutic inertia was defined as no intensification if HbA1c was ≥8% at baseline or during follow‐up. Time to first intensification was evaluated by time‐to‐event analysis, and factors predicting intensification through a competing‐risk regression model.
Results
Among 23 678 patients with HbA1c ≥ 7%, 26.2% were censored without treatment intensification after a median follow up of 4.2 years. Among the 12 730 patients in the subgroup with HbA1c ≥ 8% at baseline or during follow‐up, therapeutic inertia was present in 18.1% of cases. In the overall cohort, mean HbA1c at initiation of insulin and NIAD were 9.4% ± 1.5% and 8.7% ± 1.3%, respectively. Median time to first intensification was 17.1 months in patients with HbA1c 8.0% to 9.9%, and 10.1 months in those with HbA1c > 10%. Variables strongly associated with intensification were HbA1c values 8.0% to 9.9% (subhazard ratio SHR, 1.7; 95% CI, 1.65‐1.78) and >10% (SHR, 2.5; 95% CI, 2.37‐2.68); diabetes duration ≥20 years (SHR, 1.25; 95% CI, 1.11‐1.41) and, to a lesser extent, female gender, presence of comorbidities, chronic kidney disease and microvascular complications.
Conclusions
Intensification was not undertaken in 1 in 5 patients. Both HbA1c thresholds and time until therapy intensification exceeded current recommendations.
Aim
To evaluate the cross‐sectional association between severe periodontitis and diabetes mellitus (DM), in a representative sample of Spanish population.
Materials and Methods
The di@bet.es ...epidemiological study is a population‐based cohort study aimed to determine the prevalence and incidence of DM in the adult population of Spain. The at‐risk sample at the final examination (2016–2017) included 1751 subjects who completed an oral health questionnaire. This questionnaire, together with demographic and risk factors, had been previously validated to build an algorithm to predict severe periodontitis in the Spanish population. Logistic regression models were used to evaluate the association between severe periodontitis and DM with adjustment for confounding factors.
Results
In total, 144 subjects developed DM, which yielded 8.2% cumulative incidence. Severe periodontitis was detected in 59.0%, 54.7% or 68.8% of the subjects depending on three different selected criteria at the 2016–2017 exam. All criteria used to define severe periodontitis were associated with DM in unadjusted analysis, but the magnitude of the association decreased after adjusting for significant confounders. The criteria ‘≥50% of teeth with clinical attachment loss ≥5 mm’ presented an odds ratio of 4.9 (95% confidence interval: 2.2–10.7; p ≤ .001) for DM.
Conclusions
Severe periodontitis is associated with DM in the Spanish population.
Aims
Randomized controlled trials have demonstrated the efficacy of several dietary patterns plus physical activity to reduce diabetes onset in people with prediabetes. However, there is no evidence ...on the effect from the Mediterranean diet on the progression from prediabetes to diabetes. We aimed to evaluate the effect from high adherence to Mediterranean diet on the risk of diabetes in individuals with prediabetes.
Methods
Prospective cohort study in Spanish Primary Care setting. A total of 1184 participants with prediabetes based on levels of fasting plasma glucose and/or glycated hemoglobin were followed up for a mean of 4.2 years. A total of 210 participants developed diabetes type 2 during the follow up. Hazard ratios of diabetes onset were estimated by Cox proportional regression models associated to high versus low/medium adherence to Mediterranean diet. Different propensity score methods were used to control for potential confounders.
Results
Incidence rate of diabetes in participants with high versus low/medium adherence to Mediterranean diet was 2.9 versus 4.8 per 100 persons‐years. The hazard ratios adjusted for propensity score and by inverse probability weighting (IPW) had identical magnitude: 0.63 (95% confidence interval, 0.43–0.93). The hazard ratio in the adjusted model using propensity score matching 1:2 was 0.56 (95% confidence interval, 0.37–0.84).
Conclusions
These propensity score analyses suggest that high adherence to Mediterranean diet reduces diabetes risk in people with prediabetes.
Abstract
Aim
The INTEGRA study evaluated whether a specially designed multicomponent health care intervention improved glycaemic control in subjects with poorly controlled type 2 diabetes compared ...with standard of care practice.
Research Design and Methods
Pragmatic study in subjects from primary care centres with type 2 diabetes and glycated haemoglobin (HbA1c) >9% (75 mmol/mol). The multifaceted intervention (N = 225 subjects) included a diabetes‐focused visit encouraging therapeutic intensification by health care professionals. Retrospective data from matched controls (N = 675) were obtained from electronic medical records of a primary care database. The primary outcome was to compare the change in HbA1c values between the groups at 12 months of follow‐up.
Results
The mean HbA1c decreased substantially in both groups after 3 months, and the mean reduction was significantly greater in the intervention group than in the usual care group after 12 months mean difference −0.66% (−7 mmol/mol), 95% CI −0.4, −1.0;
p
< .001. A larger percentage of participants in the intervention group achieved HbA1c <7% and <8% goals (15.5% vs. 5.3% and 29.3% vs. 13.5%, respectively;
p
< .001). The improvement in HbA1c levels was sustained throughout the study only in the intervention arm. Glucose‐lowering therapy was more frequently intensified in patients in the intervention group at the initial and final time points of the study (between 0‐3 and 6‐12 months;
p
< .001), with a significant increase in the number of patients prescribed ≥2 antidiabetic therapies (
p
< .001).
Conclusions
A multifaceted intervention oriented at reducing therapeutic inertia by primary care physicians was associated with greater improvement in glycaemic control compared with patients treated as per usual care.
We evaluated the ability of the Fatty Liver Index (FLI), a surrogate marker of hepatic steatosis, to predict the development of type 2 diabetes (T2D) at 3 years follow-up in a Spanish cohort with ...prediabetes from a prospective observational study in primary care (PREDAPS).
FLI was calculated at baseline for 1,142 adult subjects with prediabetes attending primary care centers, and classified into three categories: FLI <30 (no steatosis), FLI 30-60 (intermediate) and FLI ≥60 (hepatic steatosis). We estimated the incidence rate of T2D in each FLI category at 3 years of follow-up. The association between FLI and incident T2D was calculated using Cox regression models adjusted for age, sex, educational level, family history of diabetes, lifestyles, hypertension, lipid profile and transaminases.
The proportion of subjects with prediabetes and hepatic steatosis (FLI ≥60) at baseline was 55.7%. The incidence rate of T2D at 3 years follow-up was 1.3, 2.9 and 6.0 per 100 person-years for FLI<30, FLI 30->60 and FLI ≥60, respectively. The most significant variables increasing the risk of developing T2D were metabolic syndrome (hazard ratio HR = 3.02; 95% confidence interval CI = 2.14-4.26) and FLI ≥60 (HR = 4.52; 95%CI = 2.10-9.72). Moreover, FLI ≥60 was independently associated with T2D incidence: the HR was 4.97 (95% CI: 2.28-10.80) in the base regression model adjusted by sex, age and educational level, and 3.21 (95%CI: 1.45-7.09) in the fully adjusted model.
FLI may be considered an easy and valuable early indicator of high risk of incident T2D in patients with prediabetes attended in primary care, which could allow the adoption of effective measures needed to prevent and reduce the progression of the disease.
Aim
To evaluate whether a specially designed multicomponent healthcare intervention improves glycaemic control in subjects with poorly controlled type 2 diabetes.
Materials and Methods
A cluster, ...non‐randomized, controlled, pragmatic trial in subjects from 11 primary care centres with type 2 diabetes and HbA1c of more than 9% (> 75 mmol/mol) was conducted. The intervention (N = 225 subjects) was professional and patient‐centred, including a dedicated monographic visit that encouraged therapeutic intensification by physicians. The sham control (N = 181) was identical to that of the intervention group except that the dedicated visit was omitted. The primary outcome was to compare the reductions in HbA1c values between the groups at 12 months of follow‐up.
Results
The mean age at baseline was 59.5 years, mean diabetes duration was 10.7 years and mean HbA1c was 10.3% (89.0 mmol/mol). Patients in the intervention arm achieved significantly greater HbA1c reduction than those in the sham control group at 12 months (mean difference −0.62%, 95% CI = −0.2%, −1.04%; P = .002). A larger percentage of intervention participants achieved an HbA1c of less than 8% (44.8% vs. 25.5%; P = .003) and were more frequently treated with more than three antidiabetic therapies (14.4% vs. 3.5%; P = .0008). Intervention was the only variable associated with higher odds of HbA1c less than 8% (odds ratio = 2.52; 95% CI = 1.54‐4.12; P < .001).
Conclusions
A multicomponent intervention including a dedicated visit oriented at reducing therapeutic inertia by primary care physicians can improve glycaemic control in poorly controlled patients with type 2 diabetes.
Aim
To assess glycaemic control after treatment intensification in patients with type 2 diabetes uncontrolled on ≥2 non‐insulin antidiabetic drugs (NIADS).
Methods
A retrospective cohort study, using ...electronic health records from the SIDIAP database (2010–2014), was conducted. Intensification was defined as the prescription of any new antidiabetic drug in patients treated with ≥2 NIADS and HbA1c >7%. The primary outcome was the absolute change in HbA1c 6–12 months after any intensification. Secondary analyses included the percentage of patients reaching HbA1c <7%, HbA1c <8%, and a reduction of HbA1c >1% after the first intensification.
Results
There were 21 241 intensifications in 15 205 patients with a mean (SD) HbA1c of 9.02% (±1.35). Insulin and dipeptidyl peptidase‐4 inhibitors (DPP4i) were the most frequently added therapies. The mean baseline‐adjusted HbA1c reduction was 0.78% (95% CI, −0.80 to −0.76), varying from −0.69% with DPP4i to −0.85% with glucagon‐like peptide‐1 receptor agonists while the addition of insulin was associated with a reduction >1%.
After the first intensification, 48.9% of patients achieved HbA1c <8%, 16.2% HbA1c <7%, and 43.1% a reduction >1%. High previous HbA1c was positively associated with the reduction of HbA1c >1% odds ratio (OR) 2.13 (95% CI: 2.05–2.21), but inversely associated with the attainment of HbA1c <7% OR 0.64 (0.61–0.67) or < 8% OR 0.63 (0.60–0.65). Older age, male gender, higher Charlson index, and short diabetes duration were associated with achievement of HbA1c <7%.
Conclusions
Despite intensification, most patients failed the glycaemic goal of HbA1c <7%. The reduction depended mainly on preintensification HbA1c values, with small differences between drugs.
To assess trends in prescribing practices of antidiabetic agents and glycaemic control in patients with type 2 diabetes mellitus (T2DM).
Cross-sectional analysis using yearly clinical data and ...antidiabetic treatments prescribed obtained from an electronic population database.
Primary healthcare centres, including the entire population attended by the Institut Català de la Salut in Catalonia, Spain, from 2007 to 2013.
Patients aged 31-90 years with a diagnosis of T2DM.
The number of registered patients with T2DM in the database was 257 072 in 2007, increasing up to 343 969 in 2013. The proportion of patients not pharmacologically treated decreased by 9.7% (95% CI -9.48% to -9.92%), while there was an increase in the percentage of patients on monotherapy (4.4% increase; 95% CI 4.16% to 4.64%), combination therapy (2.8% increase; 95% CI 2.58% to 3.02%), and insulin alone or in combination (increasing 2.5%; 95% CI 2.2% to 2.8%). The use of metformin and dipeptidyl peptidase-IV inhibitors increased gradually, while sulfonylureas, glitazones and α-glucosidase inhibitors decreased. The use of glinides remained stable, and the use of glucagon-like peptide-1 receptor agonists was still marginal. Regarding glycaemic control, there were no relevant differences across years: mean glycated haemoglobin (HbA1c) value was around 7.2%; the percentage of patients reaching an HbA1c≤7% target ranged between 52.2% and 55.6%; and those attaining their individualised target from 72.8% to 75.7%.
Although the proportion of patients under pharmacological treatment increased substantially over time and there was an increase in the use of combination therapies, there have not been relevant changes in glycaemic control during the 2007-2013 period in Catalonia.
Diabetes microangiopathy, a hallmark complication of diabetes, is characterised by structural and functional abnormalities within the intricate network of microvessels beyond well-known and ...documented target organs, i.e., the retina, kidney, and peripheral nerves. Indeed, an intact microvascular bed is crucial for preserving each organ's specific functions and achieving physiological balance to meet their respective metabolic demands. Therefore, diabetes-related microvascular dysfunction leads to widespread multiorgan consequences in still-overlooked non-traditional target organs such as the brain, the lung, the bone tissue, the skin, the arterial wall, the heart, or the musculoskeletal system. All these organs are vulnerable to the physiopathological mechanisms that cause microvascular damage in diabetes (i.e., hyperglycaemia-induced oxidative stress, inflammation, and endothelial dysfunction) and collectively contribute to abnormalities in the microvessels' structure and function, compromising blood flow and tissue perfusion. However, the microcirculatory networks differ between organs due to variations in haemodynamic, vascular architecture, and affected cells, resulting in a spectrum of clinical presentations. The aim of this review is to focus on the multifaceted nature of microvascular impairment in diabetes through available evidence of specific consequences in often overlooked organs. A better understanding of diabetes microangiopathy in non-target organs provides a broader perspective on the systemic nature of the disease, underscoring the importance of recognising the comprehensive range of complications beyond the classic target sites.
In this cross-sectional study, we assessed the possible association of vitamin D deficiency with self-reported treatment satisfaction and health-related quality of life in patients with type 2 ...diabetes.
We performed a sub-analysis of a previous study and included a total of 292 type 2 diabetic patients. We evaluated treatment satisfaction and health-related quality of life through specific tools: the Diabetes Treatment Satisfaction Questionnaire and the Audit of Diabetes-Dependent Quality of Life. Vitamin D deficiency was defined as 25 (OH) D serum levels < 15 ng/mL.
Multivariable linear regression models were used to estimate the relationship of vitamin D deficiency with both outcomes once adjusted for self-reported patient characteristics. Vitamin D deficiency was significantly associated with the final score of the Diabetes Treatment Satisfaction Questionnaire and the single "diabetes-specific quality of life" dimension of the Audit of Diabetes-Dependent Quality of Life (p = 0.0198 and p = 0.0070, respectively). However, lower concentrations of 25-OH vitamin D were not associated with the overall quality of life score or the perceived frequency of hyperglycaemia and hypoglycaemia.
Our study shows the association between vitamin D deficiency and both the self-reported diabetes treatment satisfaction and the diabetes-specific quality of life in patients with type 2 diabetes.
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