Population-Based Analysis of Nonsteroidal Anti-inflammatory Drug Prescription in Subjects With Chronic Kidney Disease.

Background: Pain is a prevalent symptom experienced by patients with chronic kidney disease (CKD) and appropriate management of pain is an important element of comprehensive care. Nonsteroidal anti-inflammatory drugs (NSAID) are known to be nephrotoxic in persons with CKD. Objective: This study examined the pattern of NSAID prescribing practices in a population based-cohort of patients with CKD. Design: Retrospective cohort study using linked population-based health care data. Setting: Entire province of Alberta, Canada. Participants: All adults in Alberta with eGFR defined CKD G3 or greater between 2009 and 2017 were included. Measurements: CKD was defined using at least 2 outpatient serum creatinine (SCr) greater than 90 days apart; the date of second SCr measurement was used as index date. We determined the incidence of hyperkalemia using the peak serum potassium. Prescription drug information was obtained from the Pharmaceutical Information Network (PIN) database. Methods: All patients were followed from the index date until March 31, 2019, with a minimum follow-up of 2 years. Prescription drug information and the follow-up laboratory testing of serum creatinine and serum potassium were obtained. Patients with kidney failure defined as eGFR < 15 mL/min per 1.73 m2, receiving chronic dialysis, or prior kidney transplant at baseline were excluded. Results: A total of 170 574 adults (mean age 76.3; 44% male) with CKD were identified and followed for a median of 7 years; 27% were dispensed at least 1 NSAID prescription. While there was a trend toward fewer prescriptions in patients with more advanced CKD (P < .001), 16% of those with CKD G4 were prescribed an NSAID. Primary care providers provided 79% of the prescriptions. Among NSAID users, 21% had a follow-up serum creatinine (SCr) within 30 days of the index prescription. Limitations: Data collected were from clinical and administrative databases not created for research purposes. The study cohort is limited to subjects who sought medical care and had a serum creatinine measurement obtained. Measurement of NSAID use is limited to those who were dispensed a prescription, over-the-counter NSAIDs use is not captured. Conclusions: Despite guidelines advocating cautious use of NSAIDs in patients with CKD, this study indicates that there is a discrepancy from best practice recommendations. Effective strategies to better support and educate prescribers, as well as patients, may help reduce inappropriate prescribing and adverse events.

Contexte: La douleur est un symptôme fréquent chez les patients atteints d'insuffisance rénale chronique (IRC); sa prise en charge appropriée est un élément important des soins complets. Les anti-inflammatoires non stéroïdiens (AINS) sont connus pour être néphrotoxiques dans cette population de patients. Objectif: Cette étude a examiné les tendances de prescription d'AINS dans une cohorte de patients atteints d'IRC. Conception: Étude de cohorte rétrospective menée à partir des données couplées de santé de la population étudiée. Cadre: L'ensemble de la province de l'Alberta (Canada). Sujets: Tous les adultes de l'Alberta dont la mesure du DFGe correspondait à une IRC de stade 3 ou plus entre 2009 et 2017. Mesures: L'IRC a été définie par au moins deux mesures espacées de plus de 90 jours du taux de créatinine sérique (Crs) en consultation externe; la date de la deuxième mesure de Crs a servi de date indice. Le pic de potassium sérique a servi à déterminer l'incidence de l'hyperkaliémie. Les renseignements sur les médicaments d'ordonnance sont tirés de la base de données du réseau d'information pharmaceutique. Méthodologie: Tous les patients ont été suivis de leur date indice jusqu'au 31 mars 2019, soit pour un minimum de deux ans. Les renseignements sur les médicaments d'ordonnance et les résultats des tests de suivi pour la créatinine et le potassium sériques ont été obtenus. Les patients qui, au moment de l'inclusion, étaient atteints d'une insuffisance rénale définie par un DFGe inférieur à 15 mL/min/1.73 m2, sous dialyze chronique ou qui avaient reçu une greffe rénale ont été exclus. Résultats: En tout, 170 574 adultes atteints d'IRC (âge moyen: 76,3 ans; 44 % d'hommes) ont été répertoriés et suivis sur une période médiane de 7 ans; 27 % avaient reçu au moins une ordonnance d'AINS. Bien qu'on ait observé une tendance à réduire les prescriptions chez les patients atteints d'un stade plus avancé d'IRC (p < 0,001), 16 % des patients atteints d'IRC G4 avaient reçu une ordonnance d'AINS. Les prestataires de soins primaires étaient responsables de 79 % des ordonnances. Parmi les utilisateurs d'AINS, 21 % avaient une mesure de suivi pour la Crs dans les 30 jours suivant la prescription indice. Limites: Les données proviennent de bases de données cliniques et administratives qui ne sont pas créées à des fins de recherche. La cohorte est limitée aux sujets ayant requis des soins médicaux et pour qui on avait une mesure de créatinine sérique. La mesure de l'utilization d'AINS est limitée aux personnes ayant reçu une ordonnance, l'utilization d'AINS en vente libre n'est pas saisie. Conclusion: Bien que les lignes directrices prônent la prudence en ce qui concerne la prescription d'AINS chez les patients atteints d'IRC, cette étude indique que la pratique diverge des recommandations. Des stratégies efficaces pour soutenir et mieux éduquer les prescripteurs et les patients pourraient contribuer à réduire les prescriptions inappropriées et les effets indésirables.

Clinical Utility of Pre-Exercise Stress Testing in People With Diabetes.

BACKGROUND: Although suggested by practice guidelines, the need for pre-exercise stress testing in asymptomatic people with diabetes remains controversial. We examined the utility of screening with pre-exercise stress testing in patients with diabetes. METHODS: We completed a cohort study, evaluating patients with diabetes who attended an exercise program intake session between 2007 and 2012. The exposure of interest was referral for pre-exercise stress testing determined by an algorithm requiring sedentary patients with diabetes and ≥ 1 cardiac risk factor to undergo testing. Outcomes included cardiac catheterization, revascularization, cardiovascular-related admissions, mortality, and change in care. RESULTS: Among 1705 people with diabetes, 676 (40%) were referred for pre-exercise stress testing. In patients who were referred for stress testing compared with those who were not, there was no difference in the composite of cardiovascular outcomes (revascularization, cardiovascular-related admissions, and cardiovascular-related death) within 1 year (2.8% vs 1.9%, P = 0.250), or subsequent to the first year (3.1% vs 4.6%, P = 0.164). Within 1 year, more revascularizations were performed in patients referred for stress testing compared with those who were not (2.1% vs 0.8%, P = 0.027) but not during longer-term follow-up (mean 3.4 years). CONCLUSIONS: The rates of cardiovascular outcomes in both tested and untested patients were low. Patients undergoing stress testing had no difference in adverse cardiovascular outcomes over the follow-up periods. Referral for stress testing did not result in a change in care for most patients. Our findings suggest stress testing before beginning an exercise program is not necessary for most asymptomatic patients with diabetes.

Exercise as Medicine: Key Concepts in Discussing Physical Activity with Patients who have Type 2 Diabetes.

People with type 2 diabetes stand to benefit substantially from being physically active. Practice guidelines consistently recommend that people with diabetes obtain at least 150 minutes of moderate to vigorous aerobic exercise per week. Although the message of 150 minutes per week is important, there are several other key messages regarding physical activity that may not be communicated as often or as clearly. This article gives an overview of the importance of resistance training, the dose-response relationship between physical activity and health outcomes, and the emerging evidence concerning the role of sedentary behavior in people with type 2 diabetes. This article provides valuable content for healthcare providers that will help to inform their discussions about physical activity with patients who have type 2 diabetes.

Assessment of the MyWellness Key accelerometer in people with type 2 diabetes.

Accelerometers are designed to measure physical activity (PA) objectively. The MyWellness Key (MWK) accelerometer has been validated primarily in younger, normal-weight populations. The aims of this study were to examine the accuracy of the MWK against directly measured lab-based exercise and free-living PA in people with type 2 diabetes, many of whom are older and overweight or obese. Thirty-five participants with type 2 diabetes completed the protocol, which included a laboratory-based session and a free-living phase. In the laboratory visit, participants completed a structured treadmill protocol wearing MWKs on each hip (all subjects) and bra cup (women only). The speed where each MWK switched from recording light- to moderate-intensity activity was determined for each MWK worn. In the free-living phase, participants wore the MWK for all waking hours for 2 weeks, and recorded exercise in PA diaries immediately after each exercise session. The mean cut-points between low ("Free") and moderate ("Play") intensity for the right and left waist-worn MWKs were 4.1 ± 0.5 km/h and 5.0 ± 0.9 km/h for the bra-mounted MWK; ideal cut-point would be 4.0 km/h. In the free-living phase, the Spearman correlation between PA according to PA diary and the waist-worn MWK was 0.81 (95% confidence interval (CI): 0.76, 0.85; P < 0.001), but only 0.66 (95% CI: 0.53, 0.77; P < 0.001) when on the bra. In conclusion, the waist-worn MWK measured PA volume accurately, and was acceptably accurate at discriminating between low- and moderate-intensity PA in people with type 2 diabetes. The MWK underestimated PA volume and intensity when worn on a bra.

Behavioral Programs for Type 1 Diabetes Mellitus: A Systematic Review and Meta-analysis.

BACKGROUND: Whether behavioral approaches for self-management programs benefit individuals with type 1 diabetes mellitus is unclear. PURPOSE: To determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate effect. DATA SOURCES: 6 electronic databases (1993 to June 2015), trial registries and conference proceedings (2011 to 2014), and reference lists. STUDY SELECTION: 36 prospective, controlled studies involving participants of any age group that compared behavioral programs with usual care, active controls, or other programs. DATA EXTRACTION: One reviewer extracted and another verified data. Two reviewers assessed quality and strength of evidence (SOE). DATA SYNTHESIS: Moderate SOE showed reduction in glycated hemoglobin (HbA1c) at 6 months after the intervention compared with usual care (mean difference, -0.29 [95% CI, -0.45 to -0.13] percentage points) and compared with active controls (-0.44 [CI, -0.69 to -0.19] percentage points). At the end of the intervention and 12-month follow-up or longer, there were no statistically significant differences in HbA1c (low SOE) for comparisons with usual care or active control. Compared with usual care, generic quality of life at program completion did not differ (moderate SOE). Other outcomes had low or insufficient SOE. Adults appeared to benefit more for glycemic control at program completion (-0.28 [CI, -0.57 to 0.01] percentage points) than did youth (-0.12 [CI, -0.43 to 0.19] percentage points). Program intensity appeared not to influence effectiveness; some individual delivery appears beneficial. LIMITATIONS: All studies had medium or high risk of bias. There was scarce evidence for many outcomes. CONCLUSION: Behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up, but improvement for other outcomes has not been shown. (PROSPERO registration number: CRD42014010515). PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERD registration number: CRD42014010515).

Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis.

BACKGROUND: Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs. PURPOSE: To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes. DATA SOURCES: 6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists. STUDY SELECTION: Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs. DATA EXTRACTION: One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias. DATA SYNTHESIS: Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥ 11 contact hours) led to clinically important improvements in glycemic control (≥ 0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support-especially those offering 10 or fewer contact hours-provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥ 75% nonwhite participants). LIMITATIONS: All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions. CONCLUSION: Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515).

Cardiac rehabilitation completion is associated with reduced mortality in patients with diabetes and coronary artery disease.

AIMS: Cardiac rehabilitation (CR) reduces the risks of mortality and hospitalisation in patients with coronary artery disease and without diabetes. It is unknown whether patients with diabetes obtain the same benefits from CR. METHODS: We retrospectively examined patients referred to a 12 week CR programme between 1996 and 2010. Associations between CR completion vs non-completion and death, hospitalisation rate and cardiac hospitalisation rate were assessed by survival analysis. RESULTS: Over the study period, 13,158 participants were referred to CR (mean ± SD, age 59.9 ± 11.1 years, 28.9% female, 2,956 [22.5%] with diabetes). Patients with diabetes were less likely to complete CR than those without diabetes (41% vs 56%, p < .0001). Over a median follow-up of 6.6 years, there were 379 deaths in patients with diabetes vs 941 deaths among those without diabetes (12.8% vs 8.9%). Of the non-completers, patients with diabetes had a higher mortality rate compared with those without diabetes (17.7% vs 11.3%). In patients who completed CR, mortality was lower: 11.1% in patients with diabetes vs 7.0% in those without diabetes. In patients with diabetes, CR completion was associated with reduced mortality (HR 0.46 [95% CI 0.37, 0.56]), reduced hospitalisation (HR 0.86 [95% CI 0.76, 0.96]) and reduced cardiac hospitalisation (HR 0.67 [95% CI 0.54, 0.84]). The protective associations were similar to those of patients without diabetes. In multivariable adjusted analyses, all of these associations remained significant. CONCLUSIONS: Patients with diabetes were less likely to complete CR than those without diabetes. However, patients with diabetes who completed CR derived similar apparent reductions in mortality and hospitalisation to patients without diabetes.

Moving beyond cardio: the value of resistance training, balance training, and other forms of exercise in the management of diabetes.

IN BRIEF Traditionally, aerobic training has been a central focus of exercise promotion for diabetes management. However, people with diabetes have much to gain from other forms of exercise. This article reviews the evidence and recommendations on resistance, balance, and flexibility training, as well as other, less traditional, forms of exercise such as yoga and Tai Chi.

Effects of exercise training using resistance bands on glycaemic control and strength in type 2 diabetes mellitus: a meta-analysis of randomised controlled trials.

Resistance exercise using free weights or weight machines improves glycaemic control and strength in people with type 2 diabetes. Resistance band training is potentially less expensive and more accessible, but the effects of resistance band training on glycaemic control and strength in this population are not well understood. This paper aims to systematically review and meta-analyse the effect of resistance band training on haemoglobin A1c (HbA1c) and strength in adults with type 2 diabetes. Database searches were performed in August 2013 (MEDLINE, SPORTDiscus, EMBASE, and CINAHL). Reference lists of eligible articles were hand-searched for additional studies. Randomised trials evaluating the effects of resistance band training in adults with type 2 diabetes on HbA1c or objectively measured strength were selected. Baseline and post-intervention HbA1c and strength were extracted for the intervention and control groups. Details of the exercise interventions and methodological quality were collected. Seven trials met inclusion criteria. Post-intervention-weighted mean HbA1c was nonsignificantly lower in exercise groups compared to control groups [weighted mean difference (WMD) = -0.18 percentage points (-1.91 mmol/mol); P = 0.27]. Post-intervention strength was significantly higher in the exercise groups compared to the control groups in the lower extremities (WMD = 21.90 kg; P < 0.0001), but not in the upper extremities (WMD = 2.27 kg; P = 0.13) or handgrip (WMD = 1.98 kg; P = 0.46). All trials were small and had methodological limitations. Resistance band training did not significantly affect HbA1c, upper extremity, or handgrip strength but significantly increased the strength of the lower extremities in people with type 2 diabetes.

Effectiveness of mobile electronic devices in weight loss among overweight and obese populations: a systematic review and meta-analysis.

BACKGROUND: Mobile electronic devices, such as mobile phones and PDAs, have emerged as potentially useful tools in the facilitation and maintenance of weight loss. While RCTs have demonstrated a positive impact of mobile interventions, the extent to which mobile electronic devices are more effective than usual care methods is still being debated. RESULTS: Electronic databases were systematically searched for RCTs evaluating the effectiveness of mobile electronic device interventions among overweight and obese adults. Weighted mean difference for change in body weight was the primary outcome. The search strategy yielded 559 citations and of the 108 potentially relevant studies, six met the criteria. A total of 632 participants were included in the six studies reporting a mean change in body weight. Using a random-effects model, the WMD for the effect of using mobile electronic devices on reduction in body weight was -1.09 kg (95% CI -2.12, -0.05). When stratified by the type of mobile electronic device used, it suggests that interventions using mobile phones were effective at achieving weight loss, WMD = -1.78 kg (95% CI -2.92, -0.63). CONCLUSIONS: This systematic review and meta-analysis suggests that mobile electronic devices have the potential to facilitate weight loss in overweight and obese populations, but further work is needed to understand if these interventions have sustained benefit and how we can make these mHealth tools most effective on a large scale. As the field of healthcare increasingly utilizes novel mobile technologies, the focus must not be on any one specific device but on the best possible use of these tools to measure and understand behavior. As mobile electronic devices continue to increase in popularity and the associated technology continues to advance, the potential for the use of mobile devices in global healthcare is enormous. More RCTs with larger sample sizes need to be conducted to look at the cost-effectiveness, technical and financial feasibility of adapting such mHealth interventions in a real clinical setting.

Patients with diabetes in cardiac rehabilitation: attendance and exercise capacity.

PURPOSE: Diabetes increases mortality after myocardial infarction, but participation in cardiac rehabilitation (CR) reduces this risk. Our objectives were to examine whether attendance at CR and changes in cardiorespiratory fitness differed according to diabetic status and sex. METHODS: Retrospective cohort study of patients referred for CR in Calgary between 1996 and 2010. Cardiorespiratory fitness in metabolic equivalents (METs) was estimated by maximal exercise testing at baseline, at the end of the 12-wk CR program, and 1-yr after CR. RESULTS: Among 7036 nondiabetic and 1546 diabetic patients who started, 84.9% of nondiabetic versus 79.5% of diabetic patients completed CR (P < 0.0001). The difference between diabetic and nondiabetic patients was greater in women (81.7% vs 72.1%, P < 0.0001) than that in men (86.0% vs 82.5%, P = 0.004). Patients without diabetes were more likely to return for the 1-yr assessment (53.7% vs 42.7%, P < 0.0001), and nondiabetic women were more likely than diabetic women to attend the 1-yr follow-up (44.3% vs 31.7%, P < 0.0001). Change in cardiorespiratory fitness from baseline to 12 wk was +1.0 METs in nondiabetic men, +0.9 METS in diabetic men, +0.9 METs in nondiabetic women, and +0.7 METs in diabetic women (within-group change; P = 0.0009). Changes in cardiorespiratory fitness at 1 yr compared with baseline were +0.9, +0.6, +0.9, and +0.5 METS, respectively (within-group change, P = 0.0001). CONCLUSIONS: Patients with diabetes, especially females, were less likely than patients without diabetes to complete CR and attend follow-up. Among patients who attended 1-yr follow-up, changes in cardiorespiratory fitness were not as well maintained in diabetic patients as in nondiabetic patients. Identifying barriers and targeting CR adherence interventions to patients with diabetes may help improve outcomes.