Comparative Effectiveness of Oral Hypoglycemic Agents for Glycemic Control and Glycemic Variability in Patients with Type 2 Diabetes Mellitus: Using Flash Glucose Monitoring.

AIM: The study aimed to compare the effectiveness of oral hypoglycemic agents (OHAs) as monotherapy, dual and quadruple therapy for glycemic control (GC) and glycemic variability (GV) in patients with type-2 diabetes (T2DM) using flash glucose monitoring system (FGM). BACKGROUND: Diabetes management largely relies on HbA1c monitoring. Glycemic variability (GV) has been an evolving glycemic target for preventing complications related to type 2 diabetes mellitus (T2DM). OBJECTIVE: The purpose of the study was to compare glycemic control (GC) measures and glycemic variability (GV) measures among study groups and to study the relationships between GC and GV indices. METHODS: Retrospectively, FGM data were collected from 50 T2DM patients. The patients were classified based on prescribed number of OHAs as monotherapy [group 1: dipeptidyl peptidase- 4 (DPP-4) inhibitors (n=10), group 2: sodium-glucose co-transporter-2 (SGLT2) inhibitors (n=10), group 3: sulphonylureas (n=10), group 4: dual therapy (n=10), and group 5: quadruple therapy (n=10)]. Measures of GC and GV were evaluated. RESULTS: Significant differences between study groups were observed in GC and GV measurements. The SGLT2 inhibitors monotherapy group demonstrated optimal GC [eA1c (%): 6.5 ± 2.2; MBG: 140.80 ± 63.94; TIR: 60.60 ± 19.96] and GV (SD: 42.38 ± 34.57; CV: 27.85 ± 6.68; MAGE: 96.76 ± 52.47; MODD: 33.96 ± 22.91) in comparison to other study groups. On using Pearson correlation analysis, mean blood glucose (MBG) and mean amplitude of glycemic excursion (MAGE) showed moderate correlation (r = 0.742)(r2 = 0.551), depicting distinct glucose variabilities at the same mean blood glucose levels. CONCLUSION: The monotherapy group of SGLT2 inhibitors demonstrated glucose-lowering effects with reduced glycemic variability. Hence, optimum glycemic control is associated with decreased glycemic variability.

Expert eValuation of Efficacy and Rationality of Vildagliptin "EVER-Vilda": An Indian Perspective.

Vildagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor is effective in reducing HbA1c levels in patients with type 2 diabetes (T2DM) when administered as monotherapy, dual or triple combination therapy. In India, Vildagliptin is commonly prescribed in T2DM patients because it reduces mean amplitude of glycemic excursion (MAGE), has lower risk of hypoglycemia and is weight neutral. Early combination therapy with vildagliptin and metformin is effective and well-tolerated in patients with T2DM, regardless of age or ethnicity. In view of already existing data on vildagliptin and the latest emerging clinical evidence, a group of endocrinologists, diabetologists and cardiologists convened for an expert group meeting to discuss the role and various combinations of vildagliptin in T2DM management. This practical document aims to guide Physicians and Specialists regarding the different available strengths and formulations of vildagliptin for the initiation and intensification of T2DM therapy.

Prevalence of Diabetic Retinopathy and Use of Common Oral Hypoglycemic Agents Increase the Risk of Diabetic Nephropathy-A Cross-Sectional Study in Patients with Type 2 Diabetes.

OBJECTIVE: This study investigated the effect of amino acid metabolism on the risk of diabetic nephropathy under different conditions of the diabetic retinopathy, and the use of different oral hypoglycemic agents. METHODS: This study retrieved 1031 patients with type 2 diabetes from the First Affiliated Hospital of Liaoning Medical University in Jinzhou, which is located in Liaoning Province, China. We conducted a spearman correlation study between diabetic retinopathy and amino acids that have an impact on the prevalence of diabetic nephropathy. Logistic regression was used to analyze the changes of amino acid metabolism in different diabetic retinopathy conditions. Finally, the additive interaction between different drugs and diabetic retinopathy was explored. RESULTS: It is showed that the protective effect of some amino acids on the risk of developing diabetic nephropathy is masked in diabetic retinopathy. Additionally, the additive effect of the combination of different drugs on the risk of diabetic nephropathy was greater than that of any one drug alone. CONCLUSIONS: We found that diabetic retinopathy patients have a higher risk of developing diabetic nephropathy than the general type 2 diabetes population. Additionally, the use of oral hypoglycemic agents can also increase the risk of diabetic nephropathy.

Drug Repositioning of Pioglitazone in Management and Improving the Cognitive Function among the Patients With Mild to Moderate Alzheimer's Disease: A Systematic Review and Meta-Analysis.

Background: Disease-modifying agents like Pioglitazone have shown promising effects on neuroinflammation and homeostasis of amyloid plaques, but there is a lack of research papers providing conclusive evidence. Objectives: This study is aimed to determine the safety and efficacy of Pioglitazone in improving cognitive function in patients with mild-moderate Alzheimer's disease (AD). Materials and Methods: Trials published in the last 12 years were identified from PubMed, Scopus, Cochrane Central, and other trial registries. Five hundred twenty-five records were obtained, from which five studies were included for quantitative analysis. Studies comparing Pioglitazone with a suitable placebo or other oral hypoglycemic agent were considered for review. Data was extracted using a pretested form, which was followed by a risk of bias assessment (ROB) with Cochrane's ROB assessment tool. Results: This meta-analysis included studies where Pioglitazone (15-30 mg) was compared to other oral hypoglycemic agents, placebo, or diabetic diet for a minimum duration of 6 months. Pioglitazone did not show a statistically significant improvement in Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) scores [mean difference (MD): -1.16; 95% confidence interval (CI): -4.14-1.81]. By conducting sensitivity analysis with the removal of one study, significant efficacy was obtained [MD: -2.75; 95% CI: -4.84--0.66]. The Wechsler Memory Scale-Revised logical memory I (WMS-R) scores had a significant improvement in the Pioglitazone group [MD: 2.02; 95% CI: 0.09-3.95]. Conclusion: Pioglitazone is a safe medication that has a promising effect in slowing the advancement of AD.

Disease Progression and Associations of Microvascular Complications in Diabetic Patients: A Study From South India.

Diabetes mellitus (DM) is a chronic metabolic disease characterized by inappropriately elevated blood glucose levels. If not treated at the early stage, it can lead to complications like diabetic retinopathy (DR) and diabetic nephropathy (DN) which are often associated with severe morbidity and mortality. This study was designed to identify the prevalence of retinopathy and nephropathy in diabetic patients and also to determine the correlation between DR and DN. In this cross-sectional study, a total of 84 diabetic patients (Male: Female- 53:31) were included. The mean age at presentation was 54.06 ± 9.85 years. Among them, 28% of patients had a duration of diabetes of < 5 years. Nearly 42% and 30% of patients had diabetes between 5-10 years, and more than 10 years respectively. At the time of presentation to us, a total of 42.8% of patients had a combination of nephropathy and retinopathy, 40.4% of patients had only retinopathy, and 16.6% of patients with only nephropathy. Among patients with nephropathy and microalbuminuria, only 5.9% had DR ranging from mild to a moderate degree and none had severe DR. In patients with macroalbuminuria, 26.2% had moderate to severe DR. Microvascular complications are more prevalent in diabetics with disease progression. Microalbuminuria is a marker for retinopathy and these patients require ophthalmic evaluation at the earliest. Early recognition and management of these, can reduce the occurrence of complications as well as disease progression, thus reducing the related mortality.

Benefits of Taking Sodium-Glucose Cotransporter 2 Inhibitors in Patients With Type 2 Diabetes Mellitus and Cardiovascular Disease: A Systematic Review.

Type 2 diabetes mellitus (T2DM) is a significant cause of cardiovascular deaths worldwide. There are many oral antihyperglycemic drugs available to treat diabetic patients. Among them, sodium-glucose cotransporter 2 (SGLT2) inhibitors provide effective treatment in all stages of T2DM regardless of blood glucose levels and benefit the cardiovascular system. SGLT2 inhibitors have an additional diuretic effect that reduces blood pressure and hospitalizations and improves heart failure outcomes. This study will assess the efficacy of SGLT2 inhibitors in cardiovascular outcomes in patients with T2DM and cardiovascular disease. Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and involved a literature search utilizing PubMed and Google Scholar databases. In addition, we thoroughly searched for studies conducted in the last 10 years that corresponded with our outlined inclusion and exclusion criteria. Our search yielded 779 articles. The articles were then quality-checked before inclusion. We ultimately selected six randomized controlled trials and two meta-analyses of research articles after applying the inclusion and exclusion criteria. Our research study included 91,796 T2DM and cardiovascular disease patients. We examined cardiovascular outcomes among these T2DM patients, such as major adverse cardiac events (MACE), blood pressure, heart failure, and hospitalizations. Our study showed that SGLT2 inhibitors significantly reduce weight and blood pressure due to their natriuretic effects. In addition, they also improve heart failure symptoms and reduce hospitalizations.

Association of metformin and depression in patients with type 2 diabetes.

BACKGROUND: Emerging evidence showed metformin may have pleiotropic effects on ameliorating depression. However, whether metformin was associated with decreased risk of depression remains unclear. METHODS: A historical cohort study was conducted based on a medical claim database from 2010 to 2017 in Beijing, China. Patients newly diagnosed with T2D were classified into the metformin and non-metformin groups according to their initial antidiabetic prescription. The incidences of depression between the groups were compared using Cox proportional regression model. RESULTS: There were 193,624 (37.4 %) and 323,930 (62.6 %) T2D patients in the metformin and non-metformin groups. The mean age was 54.9 (SD: 13.1) years and 53.9% were females. With a median follow-up of 3.2 years, 64,963 patients developed depression. The adjusted incidence of depression in the metformin group (30.6, 95 % CI: 30.1, 31.0 per 1000 person-years) was significantly lower than in the non-metformin group (39.6, 95 % CI: 39.3, 40.0 per 1000 person-years, P < 0.001). The metformin group was significantly associated with a lower risk of depression compared with the overall non-metformin group (HR: 0.77, 95% CI: 0.75, 0.78), as well as compared with α-glucosidase inhibitors (HR: 0.73, 95 % CI: 0.71, 0.74), sulfonylureas (HR: 0.84, 95 % CI: 0.82, 0.86), and glinides (HR: 0.85, 95 % CI: 0.82, 0.88), except for thiazolidinediones (HR: 0.96, 95 % CI: 0.91, 1.01). The association between metformin and lower depression risk was significant in all the age and sex subgroups. CONCLUSIONS: Metformin was associated with a lower risk of depression compared with other oral hypoglycemic agents, indicating a potential pleiotropic effect on depression.

Application of Gestational Blood Glucose Control During Perinatal Period in Parturients with Diabetes Mellitus: Meta-Analysis of Controlled Clinical Studies.

Background: Gestational diabetes mellitus (GDM) is a common metabolic disorder. Hyperglycemia may cause gestational hypertension, increase the probability of infection, abnormal embryonic development, and increase the abortion rate. Oral hypoglycemic drugs may be another effective means of blood glucose control in addition to insulin injection. We included controlled clinical studies for meta-analysis to understand the effect of oral hypoglycemic drugs in gestational diabetes. Methods: The databases were searched with the keywords "Glycemic control" & "gestational diabetes": Embase (January, 2000-August, 2021), Pubmed (January, 2000-August, 2021), Web of Science (January, 2000-August, 2021), Ovid (January, 2000-August, 2021), and ClinicalTrials.org to obtain the randomized controlled trial (RCT) literatures related to the treatment of gestational diabetes with oral hypoglycemic drugs, after screening, the R language toolkit was used for the analysis. Results: A total of 10 articles with a total of 1,938 patients were included, 7 studies used metformin as an hypoglycemic agent. Meta-analysis showed that oral metformin had no significant difference in fasting blood glucose levels after the intervention compared with insulin injection [MD = -0.35, 95%CI(-0.70,1.40), Z = 0.66, P = 0.51], with no significant difference in postprandial blood glucose levels after intervention [MD = -2.20, 95%CI(-5.94,1.55), Z = -1.15, P = 0.25], and no statistical difference in glycosylated hemoglobin [MD = 0.10, 95%CI(-0.17,-0.04), Z = -0.94, P = 0.31]. Metformin was more conducive to reducing maternal weight during pregnancy than insulin [MD = -1.55, 95%CI(-2.77,-0.34), Z = -2.5, P = 0.0123], metformin reduced the abortion rate compared with insulin [RR = 0.81, 95%CI(0.63,1.05), Z = -2.61, P = 0.015], and reduced cesarean section rate [RR = 0.66, 95%CI(0.49,0.90), Z = -3.95, P = 0.0001]. Discussion: The application of oral hypoglycemic drug metformin in blood glucose control of gestational diabetes can play a hypoglycemic effect equivalent to insulin and can control the weight of pregnant women, reduce the rate of abortion and cesarean section, and improve pregnancy outcomes.

A Clinical Decision Support System for Diabetes Patients with Deep Learning: Experience of a Taiwan Medical Center.

Background: Diabetes mellitus (DM) is a major public health problem worldwide. It involves dysfunction of blood sugar regulation resulting from insulin resistance, inadequate insulin secretion, or excessive glucagon secretion. Methods: This study collated 971,401 drug usage records of 51,009 DM patients. These data include patient identification code, age, gender, outpatient visiting dates, visiting code, medication features (included items, doses, and frequencies of drugs), HbA1c results, and testing time. We apply a random forest (RF) model for feature selection and implement a regression model with the bidirectional long short-term memory (Bi-LSTM) deep learning architecture. Finally, we use the root mean square error (RMSE) as the evaluation index for the prediction model. Results: After data cleaning, the data included 8,729 male and 9,115 female cases. Metformin was the most important feature suggested by the RF model, followed by glimepiride, acarbose, pioglitazone, glibenclamide, gliclazide, repaglinide, nateglinide, sitagliptin, and vildagliptin. The model performed better with the past two seasons in the training data than with additional seasons. Further, the Bi-LSTM architecture model performed better than support vector machines (SVMs). Discussion & Conclusion: This study found that Bi-LSTM models is a well kernel in a CDSS which help physicians' decision-making, and the increasing the number of seasons will negative impact the performance. In addition, this study found that the most important drug is metformin, which is recommended as first-line treatment OHA in various situations for DM patients.

Antidiabetic effects of hydroxychloroquine in two Japanese patients with systemic lupus erythematosus.

Hydroxychloroquine (HCQ), an antimalarial drug, is recommended for all patients with systemic lupus erythematosus (SLE), and is widely used around the world. HCQ has various beneficial effects, including antidiabetic effects but was unavailable in Japan until gaining approval for SLE treatment in 2015. We present herein the cases of two Japanese women with SLE and diabetes mellitus (DM) who were treated using HCQ and achieved reductions in glycosylated hemoglobin (HbA1c). A 48 year-old Japanese woman with SLE and DM (patient 1) received oral HCQ at 200 mg/day for the treatment of lupus nephritis. HbA1c levels decreased from 7.2-6.2% after 14 months of HCQ without any loss of body weight or alterations in doses of glucocorticoid or hypoglycemic agents. A 64 year-old Japanese woman with SLE and DM (patient 2) received oral HCQ at 200 mg and 400 mg on alternate days for the treatment of erythema. She also received intensive insulin therapy. HCQ drastically reduced both HbA1c levels, from 10.3 to 7.5%, and the insulin doses required without altering the doses of glucocorticoid or hypoglycemic agents, although body weight increased slightly. No episodes of hypoglycemia were seen in either patient. HCQ can achieve antidiabetic effects in Japanese SLE patients.

The efficacy and safety of dapagliflozin combined with oral hypoglycemic agents in patients with type 2 diabetes: a systematic review and meta-analysis.

BACKGROUND: There were reports that many patients with type 2 diabetes mellitus (T2DM) could not maintain the normal level of glycemic, who were treated with the antidiabetic agents. The sodium-glucose co-transporter-2 (SGLT2) inhibitors could improve patients' blood glucose level by inducing glycosuria, improving insulin sensitivity and the function of ß-cell and decreasing glucose toxicity. Which was unlike with other agents, indicating that the SGLT2 inhibitors might be effective alone or in combination with any other drugs. As a SGLT2 inhibitor, Dapagliflozin could be used in patients with T2DM. METHODS: Studies' identification were conducted with the literature search, and we searched studies published between 1950 and 2021 in PubMed, the Cochrane Library and Embase. A meta-analysis was performed using RevMan 5.3 software. Continuous data are presented as the means and standard deviations of differences in performance before and after active or control interventions. Adverse events were also assessed. RESULTS: Fifteen studies that provided individual data were included. Treatment with dapagliflozin was compared with treatment with placebo and resulted in a significantly greater change in HbA1c levels, fasting plasma glucose (FPG) and weight. In terms of the incidence of adverse drug reactions, the incidence of hypoglycemic events was not significantly different between the experimental and control groups. However, the incidences of genital infection and urinary tract infection were higher in the experimental group than in the control group. DISCUSSION: According to the available data, dapagliflozin combined with oral hypoglycemic agents can effectively reduce the level of HbA1c and body weight; however, it does not increase the incidence of hypoglycemia but can cause urinary tract infection and genital infection. Due to the limited literature included, the above conclusions need to be verified through more high-quality studies.

"The Bitter Truth of Sugar"-Euglycemic Diabetic Ketoacidosis due to Sodium-glucose Cotransporter-2 Inhibitors: A Case Series.

Diabetic ketoacidosis (DKA) is an acute and major complication of diabetes mellitus (DM), both type I and type II. Biochemically, DKA consists of a triad of blood sugar levels greater than 250 mg/dL, ketonemia of greater than 3 mmol/L and/or significant ketonuria, and a blood pH less than 7.3 with an increased anion gap. Currently, the sodium-glucose cotransporter-2 inhibitors (SGLT-2i) are widely used in management of type II diabetes. There have been several reports of an association between euglycemic diabetic ketoacidosis (EuDKA) and SGLT-2i agents. We present three different patients who were on SGLT-2i therapy who developed recurrent EuDKA postprocedure or sepsis. We believe that prolonged treatment (5-6 days) with intravenous (IV) insulin with glucose until resolution of glycosuria can be considered as an inexpensive marker of resolution of EuDKA. Moreover, the recommended duration for discontinuation of these drugs prior to elective procedures should be longer than 3 days. How to cite this article: Shah M, Pathrose E, Bhagwat NM, Chandy D. "The Bitter Truth of Sugar"-Euglycemic Diabetic Ketoacidosis due to Sodium-glucose Cotransporter-2 Inhibitors: A Case Series. Indian J Crit Care Med 2022;26(1):123-126.

Antidiabetics Interactions with Herbs: A Compressive Review.

Diabetes mellitus is a chronic illness with a variety of causes and pathophysiology. For the management of diabetes, various synthetic antidiabetic drugs are available. Still, people prefer complementary and alternative therapies as well as traditional herbal home remedies because they are perceived to be free of side effects and generally recognized as safe due to their natural origin. Hence, worldwide, the majority of the population is consuming herbs and/or herbal products in their daily routine. It has been observed that individuals with diabetes also consume herbs/herbal products either with or without medical supervision. This co-consumption of antidiabetic medications and herb/herbal products may result in herb-drug interactions, which might be potentially beneficial or harmful or, in some cases, even fatal. Most of the times, these interactions remain unnoticed or undiagnosed due to lack of knowledge and awareness about them. In this review, the authors have summarized some important aspects related to the herb-drug interaction (HDI), which include methods for prediction and mechanism of HDI (pharmacokinetic and pharmacodynamic) and also the clinical and experimental literature on herb-drug interactions (HDI) in the treatment of diabetes. Authors have attempted to categorize the interactions between oral hypoglycemic agents and various herbs as beneficial or harmful based on the results reported in the original research work.

Prescribing pattern of anti-diabetic drugs and adherence to the American Diabetes Association's (ADA) 2021 treatment guidelines among patients of type 2 diabetes mellitus: A cross-sectional study.

Background: Glycemic control is the major therapeutic objective in diabetes. Poor glycemic control in diabetes mellitus can be prevented by using rational use of anti-diabetic medication, which needs to be evaluated for effectiveness by prescription pattern studies. The objective of this study was to assess the prescribing pattern and adherence to the American Diabetic Association's (ADA) treatment guidelines in type 2 diabetes mellitus patients in a tertiary care teaching hospital in Uttarakhand, India. Methodology: This cross-sectional study was conducted on 206 type 2 diabetic patients who were prescribed anti-diabetic therapy. Patient's demographic details and drugs prescribed, with their dosage, were recorded to study the prescription pattern. Results: Oral anti-diabetic drugs were most commonly prescribed in 149 (72.33%) type 2 diabetic mellitus patients. Five of these patients (3.35%) were on metformin monotherapy, whereas majority of patients (81, 54.36%) were on a fixed dose combination of Glimepiride (SU) + Metformin (MET). Forty-five patients (30.20%) were on MET + Dipeptidyl peptidase 4 inhibitors (DPP4I) combination; 5 (3.35%) were on MET + SU + alpha-glucosidase inhibitors (AGI) combination; 7 (4.69%) were on MET + SU + Pioglitazone (PIO) (Thiazolidinediones) combination; 6 (4.02%) were on sodium/glucose cotransporter-2 inhibitors (SGLT2I) and 57 (27.66%) were on insulin therapy. Out of 206 patients, the prescriptions of 185 patients (89.8%) were adherent and of 21 patients (10.19%) were not adhering to ADA 2021 treatment guidelines. Conclusion: Oral anti-diabetic agents predominate the prescribing pattern practices for type 2 DM but there was a shift in trend towards the use of fixed-dose combinations (FDC) in the management of type 2 DM, and majority of prescriptions were adherent to ADA treatment guidelines.

Lessons on Drug Development: A Literature Review of Challenges Faced in Nonalcoholic Fatty Liver Disease (NAFLD) Clinical Trials.

NAFLD is the most common chronic liver disease worldwide, occurring in both obese and lean patients. It can lead to life-threatening liver diseases and nonhepatic complications, such as cirrhosis and cardiovascular diseases, that burden public health and the health care system. Current care is weight loss through diet and exercise, which is a challenging goal to achieve. However, there are no FDA-approved pharmacotherapies for NAFLD. This review thoroughly examines the clinical trial findings from 22 drugs (Phase 2 and above) and evaluates the future direction that trials should take for further drug development. These trialed drugs can broadly be categorized into five groups-hypoglycemic, lipid-lowering, bile-pathway, anti-inflammatory, and others, which include nutraceuticals. The multitude of challenges faced in these yet-to-be-approved NAFLD drug trials provided insight into a few areas of improvement worth considering. These include drug repurposing, combinations, noninvasive outcomes, standardization, adverse event alleviation, and the need for precision medicine with more extensive consideration of NAFLD heterogenicity in drug trials. Understandably, every evolution of the drug development landscape lies with its own set of challenges. However, this paper believes in the importance of always learning from lessons of the past, with each potential improvement pushing clinical trials an additional step forward toward discovering appropriate drugs for effective NAFLD management.

Coadministration of sitagliptin or metformin has no major impact on the adverse metabolic outcomes induced by dexamethasone treatment in rats.

AIMS: Glucocorticoids (GC) in excess cause glucose intolerance and dyslipidemia due to their diabetogenic actions. Conceptually, antidiabetic drugs should attenuate these side effects. Thus, we evaluated whether the coadministration of metformin or sitagliptin (or both) with dexamethasone could attenuate GC-induced adverse effects on metabolism. MATERIALS AND METHODS: Adult male rats were treated for 5 consecutive days with dexamethasone (1 mg/kg, body mass (bm), intraperitoneally). Additional groups were coadministered with metformin (300 mg/kg, bm, by oral gavage (og)) or sitagliptin (20 mg/kg, bm, og) or with both compounds in combination. The day after the last treatments, rats were submitted to glucose tolerance tests, pyruvate tolerance test, and euthanized for biometric, biochemical, morphologic, and molecular analyses. KEY FINDINGS: Dexamethasone treatment resulted in reduced body mass and food intake, increased blood glucose and plasma insulin, dyslipidemia, glucose intolerance, pyruvate intolerance, and increased hepatic content of glycogen and fat. Sitagliptin coadministration improved glucose tolerance compared with the control group, an effect paralleled with higher levels of active GLP-1 during an oral GTT. Overall, sitagliptin or metformin coadministration did not prevent any of the dexamethasone-induced metabolic disturbances. SIGNIFICANCE: Coadministration of sitagliptin or metformin result in no major improvement of glucose and lipid metabolism altered by dexamethasone treatment in male adult rats.

The effects of insulin therapy on mortality in diabetic patients undergoing percutaneous coronary intervention.

BACKGROUND: A growing number of studies have reported insulin therapy to be associated with a higher incidence of major adverse cardiac events in diabetic patients with coronary artery disease. However, the relationship between insulin use and the clinical outcomes of patients with diabetes who undergoing percutaneous coronary intervention (PCI) has not been fully clarified. METHODS: A total of 1,069 consecutive patients with diabetes who underwent PCI were enrolled and divided into 2groups: oral hypoglycemic agents (OHA) group (709 patients) and insulin therapy group (360 patients). The primary and secondary endpoints of this study were all-cause death and cardiac death, respectively. RESULTS: At baseline, the maximum creatine kinase-MB (CK-MB), plasma glucose, hemoglobin A1c, high-sensitivity C-reactive protein (CRP), and creatinine levels were higher, while the left ventricular ejection fraction (LVEF) was lower, in the insulin therapy group than in the OHA group. After propensity score matching of baseline characteristics, for patients treated with insulin, the odds ratios of death from any cause in hospital, within 1 year of surgery, and within 2 years of surgery were 12.03 (95% CI: 1.486-97.33, P=0.020), 10.33 (95% CI: 1.21-88.12, P=0.033), and 2.99 (95% CI: 1.22-7.31, P=0.016), respectively, and the odds ratios of cardiac death were 10.33 (95% CI: 1.21-88.12, P=0.033), 6.49 (95% CI: 1.33-31.59, P=0.021), and 5.27 (95% CI: 1.45-19.13, P=0.011), respectively. Generalized estimating equations analysis showed the odds ratios of all-cause death and cardiac death for insulin-treated patients to be 4.77 (95% CI: 1.76-12.95, P=0.002) and 5.38 (95% CI: 1.29-22.96, P=0.023), respectively. CONCLUSIONS: Compared with OHA, insulin therapy significantly increases the risk of in-hospital all-cause and cardiac death in patients with diabetes undergoing PCI, and the risk remains significantly at least 2 years after surgery.

Evaluación de la prescripción de hipoglucemiantes orales en población adulta con Diabetes Mellitus Tipo 2 / Evaluation of the prescription of oral hypoglycemic agents in the adult population with type 2 diabetes mellitus

En el nivel primario de atención se detectan errores en la prescripción del tratamiento farmacológico de la diabetes tipo 2. El objetivo de este estudio fue evaluar la calidad de la prescripción de hipoglucemiantes orales en pacientes atendidos en consultorios del médico de la familia del Policlínico Universitario Hermanos Cruz, municipio Pinar del Río, Cuba. Se realizó un estudio de utilización de medicamentos de tipo descriptivo y transversal clasificado dentro de estos como de indicación-prescripción con elementos de esquema terapéutico y de factores que condicionan los hábitos de prescripción. El universo estuvo conformado por 1575 pacientes con diagnóstico de diabetes mellitus tipo 2 tratados con hipoglucemiantes orales que pertenecían a los 20 consultorios médicos de la familia.La muestra de estudio se obtuvo por el método de muestreo no probabilístico (por conveniencia) (n=846). La información se obtuvo de la historia clínica y tarjeta control de los pacientes para adquirir estos medicamentos. Predominó la edad de 40-49 años, el sexo femenino y entre 5-10 años de evolución de la enfermedad. No se usó la primera línea de tratamiento en el 43,6 % de los casos, ningún caso tenía estudios de laboratorio para el uso de la Metformina. La prescripción y dosis fue adecuada no así su uso racional. Las interacciones más frecuentes fueron las farmacocinéticas.El uso racional de hipoglucemiantes orales fue deficiente lo que hace necesario ampliar la divulgación de un protocolo de tratamiento para mejorar el uso de estos fármacos en el nivel primario de atención.

Errors in the prescription of drug treatment for type 2 diabetes are detected at the primary level of care. the purpose of this study was to evaluate the quality of the prescription of oral hypoglycemic agents in patients attended in the family doctor's offices of the Hermanos Cruz University Polyclinic, Pinar del Río distrit, Cuba. A descriptive and cross-sectional study of the use of medications was carried out, classified within these as indication-prescription with elements of the therapeutic scheme and factors that condition prescription habits. The universe was made up of 1575 patients diagnosed with type 2 diabetes mellitus treated with oral hypoglycemic agents who belonged to the 20 family medical offices. The study sample was carried out by the non-probabilistic sampling method (for convenience) (n = 846). The information was obtained from the clinical history and control card of the patients to acquire these medications. The age of 40-49 years, the female sex and between 5-10 years of evolution of the disease predominated. The first line of treatment was not used in 43.6% of the cases; no case had laboratory studies for the use of Metformin. The prescription and dose was adequate, but not its rational use. The most frequent interactions were pharmacokinetic ones.The rational use of oral hypoglycemic agents was deficient, which makes it necessary to expand the dissemination of a treatment protocol to improve the use of these drugs at the primary level of care.

The Use of Oral Hypoglycemic Agents during Pregnancy: An Alternative to Insulin?

OBJECTIVE: Gestational Diabetes Mellitus (GDM) and Type 2 Diabetes Mellitus (DM2) are metabolic disorders characterized by increased insulin resistance. Although insulin is the treatment of choice in pregnant patients with DM, the prescription of oral hypoglycemic agents (OHA) has been increasing among practitioners. This study aimed to evaluate the maternal and neonatal outcomes when oral hypoglycemic agents were used in diabetic pregnant women. METHODS: Medical records from the Maternal-Infant Care Unit Clinics SoM-UPR (n=149) were reviewed. Patients that were treated with metformin, sulfonylurea or insulin were included. Maternal and neonatal outcomes were compared between groups. RESULTS: Patient's mean age was 28 ± 6 years. The majority had GDM (91%). The most common comorbidity was hypertension (9.9%). Lifestyle modification was used as treatment in 77% of patients during the second trimester, but its use decreased to 33% during the third trimester. Insulin was the treatment of choice. Among the OHA, sulfonylurea was preferred. Postprandial glucose levels were lower in patients who used insulin as compared to those without medications. CONCLUSION: No significant differences were found in maternal outcomes such as C-section, induction of labor, episiotomy or preterm labor, or neonatal outcomes such as macrosomia, neonatal hypoglycemia or congenital abnormalities among treatment groups. OHA can be considered as an alternative to insulin for the treatment of DM during pregnancy in selected cases.

Global Epidemiology, Health Outcomes, and Treatment Options for Patients With Type 2 Diabetes and Kidney Failure.

The burden of type 2 diabetes and related complications has steadily increased over the last few decades and is one of the foremost global public health threats in the 21st century. Diabetes is one of the leading causes of chronic kidney disease and kidney failure and is an important contributor to the cardiovascular morbidity and mortality in this population. In addition, up to one in three patients who have received kidney transplants develop post-transplant diabetes, but the management of this common complication continues to pose a significant challenge for clinicians. In this review, we will describe the global prevalence and temporal trend of kidney failure attributed to diabetes mellitus in both developing and developed countries. We will examine the survival differences between treated kidney failure patients with and without type 2 diabetes, focusing on the survival differences in those on maintenance dialysis or have received kidney transplants. With the increased availability of novel hypoglycemic agents, we will address the potential impacts of these novel agents in patients with diabetes and kidney failure and in those who have developed post-transplant diabetes.