Factors Associated With Attainment of Glycemic Targets Among Adults With Type 1 and Type 2 Diabetes in Canada: A Cross-sectional Study Using Primary and Specialty Care Electronic Medical Record Data.

OBJECTIVE: Using a new database combining primary and specialty care electronic medical record (EMR) data in Canada, we determined attainment of glycemic targets and associated predictors among adults with diabetes. METHODS: We conducted a cross-sectional observational study combining primary and specialty care EMR data in Canada. Adults with diabetes whose primary care provider contributed to the National Diabetes Repository or who were assessed at a diabetes specialty clinic (LMC Diabetes and Endocrinology) between July 3, 2015, and June 30, 2019, were included. Diabetes type was categorized as type 2 diabetes (T2D) not prescribed insulin, T2D prescribed insulin, and type 1 diabetes (T1D). Covariates were age, sex, income quintile, province, rural/urban location, estimated glomerular filtration rate, medications, and insulin pump use. Associations between predictors and the outcome (glycated hemoglobin [A1C] of ≤7.0%) were assessed by multivariable logistic regressions. RESULTS: Among 122,106 adults, consisting of 91,366 with T2D not prescribed insulin, 25,131 with T2D prescribed insulin, and 5,609 with T1D, attainment of an A1C of ≤7.0% was 60%, 25%, and 23%, respectively. Proportions with an A1C of ≤7.5% and ≤8.0% were 75% and 84% for those with T2D not prescribed insulin, 41% and 57% for those with T2D prescribed insulin, and 37% and 53% for those with T1D. Highest vs lowest income quintile was associated with greater odds of meeting the A1C target (adjusted odds ratio [95% confidence interval] for each diabetes category: 1.15 [1.10 to 1.21], 1.21 [1.10 to 1.33], and 1.29 [1.04 to 1.60], respectively). Individuals in Alberta and Manitoba had less antihyperglycemic medication use and attainment of A1C target than other provinces. CONCLUSIONS: Attainment of glycemic targets among adults with diabetes was poor and differed by income and geographic location, which must be addressed in national diabetes strategies.

Glucose and Psychosocial Outcomes 12 Months Following Transition from Multiple Daily Injections to Advanced Hybrid Closed Loop in Youth with Type 1 Diabetes and Suboptimal Glycemia.

Objective: To investigate 12-month glycemic and psychosocial changes following transition from multiple daily injections (MDI) to advanced hybrid closed-loop (AHCL) therapy in youth (aged 13-25 years) with type 1 diabetes and suboptimal glycemia (glycated hemoglobin [HbA1c] ≥8.5% [69 mmol/mol]). Research Design and Methods: Prospective, single arm, dual-center study in 20 participants. Extension phase outcomes reported after 12 months, including HbA1c, time in glycemic ranges, AHCL system performance, and psychosocial questionnaires assessing quality of life, diabetes treatment, and sleep. Results: After 12 months, 19 out of 20 participants continued to use AHCL. Average time-in-range 70-180 mg/dL (3.9-10.0 mmol/L) improved from 27.6% ± 13.2% to 62.5% ± 11.4%. This translated to an average 2.5 percentage-point (27.1 mmol/mol) improvement in HbA1c from 10.5% ± 2.1% (91.2 mmol/mol) at baseline to 8.0% ± 0.9% (64.1 mmol/mol) at 12 months. Psychosocial questionnaires and very high HbA1c at study entry indicated significant diabetes-associated burden for both individuals and parents. After 12 months, improvements were observed in general and diabetes-specific health-related quality of life, as well as in diabetes treatment satisfaction. Safety data were reassuring with a diabetic ketoacidosis rate of 0.15 per participant-year after 12 months of AHCL (compared to 0.25 per participant-year in the 12 months before the study). Conclusions: After 12 months of AHCL usage, this study highlights the potential for substantial and sustained glycemic and psychosocial improvements among individuals experiencing considerable diabetes burden and suboptimal glycemia, following their switch from MDI to AHCL.

Network meta-analysis of glucose-lowering drug treatment regimens with the potential risk of hypoglycemia in patients with type 2 diabetes mellitus in terms of glycemic control and severe hypoglycemia.

Insulin and its secretagogues are essential for some patients with type 2 diabetes (T2D) to maintain good glycemic control (GC), but severe hypoglycemia (SH) is a concern. This network meta-analysis aimed to find optimal glucose-lowering drug treatment regimens in terms of GC and SH in T2D patients. MEDLINE and EMBASE were used to identify trials that compared two or more treatments including insulins and/or sulfonylurea or glinides and that examined both GC and SH. Treatment hierarchy was expressed as the surface under the cumulative ranking curve (SUCRA) probabilities. We identified 137 eligible trials comprising 42 treatments. The use of insulins and non-insulin glucose-lowering agents except for sulfonylurea or glinide had a higher SUCRA than insulins only for hemoglobin A1c (A1C) (p = 0.01) changes and achievement of A1C < 7.0% (p = 0.02) or A1C ≤ 6.5% (p = 0.002). The use of sulfonylurea or glinide and other non-insulin glucose-lowering agents resulted in a lower SUCRA for SH than insulins only when trials were analyzed for A1C change (p = 0.06) and achievement of A1C < 7.0% (p = 0.004) or A1C ≤ 6.5% (p = 0.004). Cluster analysis indicated that premixed insulin plus glucagon-like peptide-1 receptor agonist (Mix-ins + GLP1) belonged to the high-efficacy category for GC and glinide plus thiazolidinedione (glinide + TZD) belonged to the relatively high-efficacy category for GC among several high-safety categories regarding SH. In T2D patients, clinicians should consider appropriate combinations of non-insulin glucose-lowering agents (especially glinide + TZD) for reducing SH risk before switching to insulin therapies. If switching, they should be willing to add non-insulin glucose-lowering agents (especially, Mix-ins + GLP1) to insulins to further improve GC.

A retrospective database study of the demographic features and glycemic control of patients with type 2 diabetes in Kinshasa, Democratic Republic of the Congo.

BACKGROUND: The Kin-Antwerp project aimed at improving the quality of care provided to patients with diabetes in Kinshasa, the Democratic Republic of the Congo in Central Africa, including the digitalisation of routine clinical data to improve patients' follow-up. We aim to analyse the data of a study population of Kin-Antwerp to characterise their demographic features, assess their achievement of glycemic target over time, and identify groups requiring prioritised attention. METHODS: We performed a secondary database analysis of routinely collected information from primary care patients with type 2 diabetes followed from 1991 to 2019. Data included demographics (age, sex), anthropometrics (weight, height), clinical parameters (blood pressure, plasma glucose), and anti-diabetic treatments. Achievement of glycemic target, defined as fasting plasma glucose < 126 mg/dL, over time was assessed using a multilevel mixed-effects logistic regression model. RESULTS: Our study population of patients with type 2 diabetes (N = 8976) comprised a higher proportion of women (67%) and patients between 40 and 65 years old (70.4%). At the first follow-up, most patients were on treatment with insulin (56.5%) and had glycemic levels under the target (79.9%). Women presented more often with obesity (27.4%) and high systolic blood pressure (41.8%) than men (8.6% and 37.0%, respectively). Patients had a median follow-up of 1.8 (interquartile range: 0.5-3.4) years. Overall, the odds of achieving glycemic target increased by 18.4% (odds ratio: 1.184, 95% CI: 1.130 to 1.239; p < 0.001) per year of follow-up. Stratified analyses suggested that the odds of achieving glycemic control over time increased among older patients (> 40 years), but not among younger patients (< 40 years). CONCLUSION: In our study population, an overall poor glycemic control was observed albeit with a modest improvement in the achievement of glycemic target throughout patients' follow-up. Younger patients may benefit from prioritised attention to achieve glycemic targets. Based on the information provided by the database, continue monitoring and improvement of the project Kin-Antwerp is recommended. Introducing further efforts to improve type 2 diabetes management should include robust glycemia-monitoring tools and haemoglobin A1c, as well as further outlining self-management strategies.

Achievement of guideline targets of glycemic and non-glycemic parameters in North Indian type 2 diabetes mellitus patients: A retrospective analysis.

BACKGROUND AND AIMS: Though, the prevalence of diabetes is increasing in the worldwide, achievement of glycemic and non-glycemic targets remain suboptimal. We conducted this retrospective cross-sectional study at two endocrine clinics of Aligarh (Uttar Pradesh) in north India. MATERIALS AND METHODS: After screening the records of 13800 patients, 12140 patients of type 2 diabetes mellitus who were attending the clinic regularly every three to four months, were included in the final analysis. The data regarding patient's height, weight, body mass index, blood pressure, blood glucose, HbA1c, lipid profile and complications were obtained. RESULTS: Mean age was 49.7 ± 11.3 years; males and females were almost equal in number. 2891 (23.8%) subjects were of age less than 40 years. 9614 (80%) patients had diabetes duration of less than 5 years. 3311 (27.3%) subjects were having an HbA1c of <7%, HbA1c 7-8% in 3711 (30.5%), HbA1c 8-9% in 2653 (21.9%) whereas HbA1c of >9% in 2465 (20.3%) subjects. The microvascular complications; diabetic nephropathy, diabetic neuropathy and diabetic retinopathy were present in 7.5%, 14.9% and 16.2% respectively. Hypertension was present in 25.8% and coronary artery disease was present in 15.5% of patients. Overall 27.3%, 41.7%, 44.1%, 45.3% and 67.7% of patients achieved their HbA1c, triglyceride, HDL, LDL and hypertension targets respectively, as per American Diabetes Association 2020 guidelines. CONCLUSION: Despite availability of multiple drugs and guidelines, the attainment rates of glycemic and non-glycemic targets remain suboptimal. A more aggressive approach in the treatment of type 2 diabetes is required.

Diabetes distress is associated with individualized glycemic control in adults with type 2 diabetes mellitus.

PURPOSE: It has been proposed that the negative emotional state of diabetes distress (DD) may exert a detrimental effect on glycemic outcomes of individuals struggling with diabetes-related challenges. Thus far, no study has investigated this association by utilizing individualized treatment targets of patients' glycemic control. Therefore, we sought to identify the potential role of DD in the achievement of individualized glycemic targets (AIGTs) among persons with type 2 diabetes mellitus (T2D). METHODS: This cross-sectional study included a well-characterized outpatient group of T2D adults cared for in an academic medical center. DD was evaluated with the Diabetes Distress Scale. The AIGTs was defined according to the American Diabetes Association guidelines. Logistic regression analyses were utilized to identify independent correlates of the AIGTs. RESULTS: A total of 123 individuals (mean [standard deviation] age: 58.0 [6.2] years, 55.3% females) were included in the final analysis. AIGTs was observed in 43.9% of the patients. Experiencing greater DD was associated with a lower likelihood of AIGTs (unadjusted odds ratio [OR]: 0.17, 95% confidence interval [CI]: 0.08-0.34, P value < 0.001), even after accounting for additional individual-level covariates (adjusted OR: 0.18, 95% CI: 0.08-0.42, P value < 0.001). Medication adherence was also a determinant of participants' AIGTs (adjusted OR: 1.91, 95% CI: 1.13-3.23, P value = 0.015). CONCLUSION: Our findings provide novel evidence that DD likely undermines glycemic status in adult outpatients with T2D, even in the context of individually tailored diabetes care, and this should be taken into account when necessary.

J-shaped association between fasting blood glucose levels and COVID-19 severity in patients without diabetes.

AIMS: Coronavirus disease 2019 (COVID-19) has become a recognized worldwide pandemic. Researchers now know that mortality from COVID-19 can be reduced through early prevention measures. This retrospective, multi-centered study of 293 COVID-19 patients without diabetes explores the association between fasting blood glucose (FBG) levels and the risk of COVID-19 disease progression, with the goal of providing clinical evidence for glycemic targets in patients. METHODS: The multivariate stepwise binary logistic regression analysis was used to test the dose-response effects of FBG levels on the risk of severe and critical condition in COVID-19 patients. RESULTS: FBG levels were plotted in quintiles with set at <4.74, 4.74-5.21, 5.21-5.78, 5.78-7.05, and ≧7.05 mmol/L. The constituent ratio of severe or critical cases in each FBG quintile was 20.7%, 1.7%, 13.8%, 27.1%, and 67.2%, respectively (P < 0.0001). When the second quintile was used as the reference, the adjusted odds ratios (AORs) (95%CI) for the risk of severe/critical condition in COVID-19 was 25.33 (2.77, 231.64), 1.00 (Reference), 3.13 (0.33, 29.67), 10.59 (1.23, 91.24), 38.93 (4.36, 347.48) per FBG quintile respectively (P < 0.001). CONCLUSIONS: We provide evidence of J-shaped associations between FBG and risk of severe and critical condition in non-diabetes patients with COVID-19, with nadir at 4.74-5.78 mmol/L.

Glycemic and lipids control in patients with diabetes and cardiovascular or renal diseases across all the government health sectors in the Emirate of Dubai, United Arab Emirates.

The guidelines suggest setting the glycemic and lipid targets according to the stage of the disease and other co -existing complications in the patients with diabetes. AIMS: We aimed to evaluate the HbA1c and lipids level in patients with high risk diabetes from 2012-2016, attending different level of care in Dubai health authority. MATERIALS AND METHODS: This is a retrospective analysis of the electronic medical records of all patients who attended the Dubai Health authority between 2012-2016. All patients with an ICD code of any type of diabetes in addition to cardiovascular or renal diseases were. Patients were categorized based on their HbA1c into control of<7.5, 7.5 - 8, and >8%. While lipids were categorized as f LDL < 70 mg/dl, and the Non-HDL <100 mg/dl. RESULTS: Out of total number of 26647 patients diagnosed with diabetes, 2015 patients did fit the criteria of this study. The desired mean of HbA1c of <7.5% achieved by 21.76% and 28.94% in T1DM and T2DM, respectively. The LDL of < 70 mg/dl was achieved by 27.8% of the patients. CONCLUSION: In patients with diabetes and multiple complications, the glycemic and lipids control is suboptimal. However, the pattern showed numerical improvement over the years.

Insulin Matters: A Practical Approach to Basal Insulin Management in Type 2 Diabetes.

It is currently estimated that 11 million Canadians are living with diabetes or prediabetes. Although hyperglycemia is associated with serious complications, it is well established that improved glycemic control reduces the risk of microvascular complications and can also reduce cardiovascular (CV) complications over the long term. The UKPDS and ADVANCE landmark trials have resulted in diabetes guidelines recommending an A1C target of ≤ 7.0% for most patients or a target of ≤ 6.5% to further reduce the risk of nephropathy and retinopathy in those with type 2 diabetes (T2D), if it can be achieved safely. However, half of the people with T2D in Canada are not achieving these glycemic targets, despite advances in diabetes pharmacological management. There are many contributing factors to account for this poor outcome; however, one of the major factors is the delay in treatment advancement, particularly a resistance to insulin initiation and intensification. To simplify the process of initiating and titrating insulin in T2D patients, a group of Canadian experts reviewed the evidence and best clinical practices with the goal of providing guidance and practical recommendations to the diabetes healthcare community at large. This expert panel included general practitioners (GPs), nurses, nurse practitioners, endocrinologists, dieticians, pharmacists, and a psychologist. This article summarizes the panel recommendations.

New glycemic targets for patients with diabetes from the Japan Diabetes Society.

In the "Evidence-based Practice Guideline for the Treatment for Diabetes in Japan 2013," a new concept of glycemic control in patients with diabetes in Japan has been declared from the Japan Diabetes Society. The main objective value of HbA1c was set to <7% from the perspective of preventing microvascular complications. On the other hand, the objective in cases where objectives can be attained by appropriate dietary or exercise therapy or during pharmacotherapy without the occurrence of side effects such as hypoglycemia was set to <6%, and the objective in cases where intensification of treatment was considered difficult because of the side effects such as hypoglycemia or for other reasons was set to <8%. Treatment objectives should be established individually, considering the age, duration of disease, organ damage, risk of hypoglycemia, support structure, etc.

Glycosylated hemoglobin level and number of oral antidiabetic drugs predict whether or not glycemic target is achieved in insulin-requiring type 2 diabetes.

AIMS: Factors predicting success (glycosylated hemoglobin (A1C)<7%) with insulin therapy in patients with insulin-requiring type 2 diabetes need to be identified. METHODS: A retrospective, multi-center, observational study was conducted for outpatients with oral antidiabetic drug (OAD)-treated type 2 diabetes whose A1C levels remained above 7%. Patients were begun on basal insulin between January 2005 and December 2006. Biochemical variables and demographic data were collected before and after 52 weeks of insulin therapy. RESULTS: A total of 565 patients (age, 60.4±11.9 years; A1C levels, 10.11 ±1.81%; duration of diabetes, 11.5±6.8 years) were studied. By study end, 63 patients (11.2%) had achieved the glycemic goal (A1C<7%). The glycemic goal attainment rate was only 9.1% in patients with A1C>8.8% and who were taking >2 OADs at baseline. The highest rate (32.7%) of successful glycemic control was observed in the group of patients with A1C ≤ 8.8% and who used ≤ 2 OADs at baseline. CONCLUSIONS: Insulin-naïve diabetic patients with A1C>8.8%, especially those who are taking >2 OADs, have small chance to achieve good glycemic control with adding only basal insulin therapy.

Glycated hemoglobin at admission in the intensive care unit: clinical implications and prognostic relevance.

OBJECTIVE: This study investigated the clinical significance of HbA1c levels on admission in the intensive care unit (ICU) as a prognostic marker for morbidity and mortality in critically ill patients. PATIENTS-METHODS: This prospective observational study included consecutive patients admitted in an 8-bed multidisciplinary ICU. Patients were prospectively followed from ICU admission until ICU outcome (death/discharge). All patients had an HbA1c measurement upon admission in the ICU. RESULTS: Five hundred fifty-five consecutive patients (376 males, 179 females) were included in the study. In patients without prior diabetes mellitus (DM) diagnosis, a cutoff of 6.5% for HbA1c (diagnostic cutoff for DM) predicted more severe disease (as described by Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores at admission) and higher ICU mortality (adjusted odds ratio, 2.33; 95% confidence interval, 1.04-5.25). In the subgroup of patients with a history of DM, a cutoff of 7% for HbA1c (glycemic target) had no predicting ability for ICU mortality. CONCLUSIONS: HbA1c is a useful tool for the diagnosis of a previously undiagnosed DM. This study showed that in critically ill patients with previously undiagnosed DM, HbA1c at admission is significantly associated with ICU mortality.

Diagnosis and Glycemic Control of Type 1 Diabetes / 임상당뇨병

Type 1 diabetes mellitus (T1DM) is characterized by an immune-mediated beta-cell destruction that causes lifelong insulin dependency. Diagnosis of diabetes is based on fasting glucose, 2-h plasma glucose value after a 75-g oral glucose tolerance test, or hemoglobin A1c (HbA1c) levels. Differentiation between type 1 and 2 diabetes is important for both education and treatment. Diabetes-associated autoantibodies, c-peptide and clinical characteristics should be considered to confirm the diagnosis of T1DM. A single HbA1c target of < 7.5% across all pediatric age groups is recommended. In nonpregnant adults, a reasonable HbA1c goal is < 7.0% to reduce the incidence of microvascular complications of T1DM. Glycemic targets should be individualized according to lifestyle, psychosocial and medical circumstances.

Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options.

The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population.

Individualizing insulin therapy in the management of type 2 diabetes.

It is recognized that reducing hyperglycemia early on in disease progression has long-term benefits for patients with diabetes. Insulin therapy has greater potential to reduce hyperglycemia than other therapies; however, there is often a significant delay in insulin initiation and intensification. Insulin replacement therapy in type 2 diabetes should no longer be viewed as the treatment of last resort. With the development of modern insulin analogs, the field has evolved. Large clinical trials have improved our understanding of the potential benefits and risks associated with intensive glycemic control in different patient populations and highlighted the need for individualization of glycemic targets and treatment strategies. Current treatment guidelines recognize the important role of insulin therapy both early on and throughout the progression of type 2 diabetes.

[Timely commencement of insulin in type 2 diabetes: benefits and risks]. / Az inzulinkezelés korai megkezdése 2-es típusú cukorbetegségben: haszon és kockázat.

The introduction of insulin in type 2 diabetes is often too late, though the immediate as well as late consequences of inadequate metabolic control are well known. That is the reason, why a special attention is given in recent therapeutic guidelines for the importance of early, at least timely insulinisation. This review article summarizes the advantages (mitigation of the beta-cell dysfunction, long lasting good metabolic control) and potential risks (hypoglycemia, weight gain, possible deteriorating patient compliance) of early or timely insulin therapy. It is pointed out that the introduction of insulin is effective and safe therapeutic option during the whole course of type 2 diabetes, the use of different regimes is suitable to reach and maintain the individual glycemic target and, with a structured patient education, it does not disturb the quality of life and the compliance of patients.

A survey on the current status of type 2 diabetic patients who failed to achieve the glycemic control target / 中华内分泌代谢杂志

Objective To investigate the current status of type 2 diabetic patients who failed to achieve the glycemic control target, and provide theoretic evidences for making corresponding strategies. Methods The 2 diabetic patients who failed to reach the glycemic target were recruited from 181 hospitals in 26 cities and received a standard questionnaire, the conditions of their blood glucose level, lifestyle intervention, blood sugar monitoring, and drug therapy were recorded. Totally 3 861 questionnaires with complete information were collected. And the causes which account for glycemic control status were analyzed. Results Among these patients, the mean HbA1c was 7.9%, the mean fasting plasma glucose was 8.2 mmol/L, and the mean postprandial plasma glucose was 11.5 mmol/L. Only 25.6% of patients take their diet control strictly as prescribed and 44. 5% of patients have little exercise. 35. 8% and 47.8% of patients did not monitor their fasting and postprandial plasma glucose,respectively. Glycemic control in the patients aged ＞ 60 years was similar to the younger patients, but the hypoglycemia incidence in the elder group reached 35.5%, which was higher than those in the other 2 groups (20.8% and 21.4%, both P＜0. 05 ). The proportion of patients with mono-therapy and combination therapy was 46. 1% and 51.7%, while the proportion with combination therapy rose in the patients aged ＞60 years (58.7%;Compared with the other age-groups, all P＜0.05 ). 75 % of patients have adjusted their drug administration regimen since initial treatment. Conclusions Inadequate or inappropriate drug therapy regimen is a major cause responsible for this poor glycemic control status. In addition, the unhealthy life styles, insufficient blood sugar monitoring, and poor compliance were also important causes. Thus, for these patients, it is necessary to further enhance patients' education, to improve life style intervention, as well as to select more effective, safer, and compliant drug therapy regimens. Finally, the glycemic control target for the elder patients should be more flexible.