Oral antidiabetic treatment in type-2 diabetes in the elderly: balancing the need for glucose control and the risk of hypoglycemia

BACKGROUND: We aimed at identifying variables predicting hypoglycemia in elderly type 2 diabetic patients and the relation to HbA1c values achieved. DESIGN: Prospective, observational registry in 3810 patients in primary care. Comparison of patients in different age tertiles: with an age < 60 (young, n=1,253), age 60 to < 70 (middle aged, n=1,184) to those ≥ 70 years (elderly, n=1,373). Odds Ratios (OR) with 95% confidence intervals (CI) were determined from univariable and multivariable regression analyses. RESULTS: Elderly patients had a later diabetes diagnosis, a longer diabetes duration, better glucose control and more frequent co-morbid disease conditions. Overall 10.7% of patients experienced any severity hypoglycemia within the last 12 months prior to inclusion. Higher rates of hypoglycemia were observed in the elderly than in the young after adjusting for differences in HbA1c, fasting and post-prandial blood glucose (OR 1.68; 95%CI 1.16-2.45). This was particularly true for hypoglycemic episodes without specific symptoms (OR 1.74; 95%CI 1.05-2.89). In a multivariate model stroke / transitory ischemic attack, the presence of heart failure, clinically relevant depression, sulfonylurea use and blood glucose self-measurement were associated with hypoglycemic events. CONCLUSION: Elderly patients are at an increased risk of hypoglycemia even at comparable glycemic control. Therefore identified variables associated with hypoglycemia in the elderly such as heart failure, clinically relevant depression, the use of sulfonylurea help to optimize the balance between glucose control and low levels of hypoglycemia. Asymptomatic hypoglycemia should not be disregarded as irrelevant but considered as a sign of possible hypoglycemia associated autonomic failure

Achievement of recommended glucose and blood pressure targets in patients with type 2 diabetes and hypertension in clinical practice -- study rationale and protocol of DIALOGUE

BACKGROUND: Patients with type 2 diabetes have 2–4 times greater risk for cardiovascular morbidity and mortality than those without, and this is even further aggravated if they also suffer from hypertension. Unfortunately, less than one third of hypertensive diabetic patients meet blood pressure targets, and more than half fail to achieve target HbA1c values. Thus, appropriate blood pressure and glucose control are of utmost importance. Since treatment sometimes fails in clinical practice while clinical trials generally suggest good efficacy, data from daily clinical practice, especially with regard to the use of newly developed anti-diabetic and anti-hypertensive compounds in unselected patient populations, are essential. The DIALOGUE registry aims to close this important gap by evaluating different treatment approaches in hypertensive type 2 diabetic patients with respect to their effectiveness and tolerability and their impact on outcomes. In addition, DIALOGUE is the first registry to determine treatment success based on the new individualized treatment targets recommended by the ADA and the EASD. METHODS: DIALOGUE is a prospective observational German multicentre registry and will enrol 10,000 patients with both diabetes and hypertension in up to 700 sites. After a baseline visit, further documentations are scheduled at 6, 12 and 24 months. There are two co-primary objectives referring to the most recent guidelines for the treatment of diabetes and hypertension: 1) individual HbA1c goal achievement with respect to anti-diabetic pharmacotherapy and 2) individual blood pressure goal achievement with different antihypertensive treatments. Among the secondary objectives the rate of major cardio-vascular and cerebro-vascular events (MACCE) and the rate of hospitalizations are the most important. CONCLUSION: The registry will be able to gain insights into the reasons for the obvious gap between the demonstrated efficacy and safety of anti-diabetic and anti-hypertensive drugs in clinical trials and their real world balance of effectiveness and safety

Antidiabetic pharmacotherapy and anamnestic hypoglycemia in a large cohort of type 2 diabetic patients - an analysis of the DiaRegis registry

<p>Abstract</p> <p>Background</p> <p>We aimed to identify predictors of anamnestic hypoglycaemia in type-2 diabetic patients on oral mono- or dual oral combination antidiabetic pharmacotherapy.</p> <p>Methods</p> <p>DiaRegis is a prospective registry in type-2 diabetic patients in primary care. Odds ratios (OR) with 95% confidence intervals were determined from univariate logistic regression. Using multivariate logistic regression analysis with stepwise backward selection at an alpha of 0.05 independent predictors of hypoglycaemia were determined.</p> <p>Results</p> <p>3,808 patients had data on hypoglycaemia available (median age 65.9 years, 46.6% female). 10.8% had at least one anamnestic hypoglycaemic episode within the previous 12 months. Patients with hypoglycaemia received more sulfonylureas (OR 2.16; 95%CI 1.75-2.67) and less metformin (OR 0.64; 95%CI 0.50-0.82). On top of metformin, patients with thiazolidine (OR 0.50; 95%CI 0.28-0.89) and DPP-4 inhibitor use (OR 0.34; 95%CI 0.16-0.70) had a decreased risk for hypoglycaemia while it was again increased with sulfonylureas (OR 2.08; 95%CI 1.44-2.99). Age < 65 years was an independent predictor of a reduced hypoglycaemia incidence (OR 0.76; 95%CI 0.59-0.96), low Hb_A1c(OR 1.68; 95%CI 1.31-2.14), stroke/TIA (OR 1.72; 95%CI 1.08-2.72), heart failure (OR 1.77; 95%CI 1.28-2.45), and the use of sulfonylureas (OR 2.58; 95%CI 2.03-3.29) were independent predictors of increased risk.</p> <p>Conclusions</p> <p>The results indicate that the risk of hypoglycaemia might be substantially reduced by carefully selecting antidiabetic pharmacotherapy in patients with type-2 diabets in primary care.</p

0188: Suboptimal control of low-density lipoprotein cholesterol in French patients after an acute coronary syndrome. Contemporary data from DYSIS IIACS study

AimTo document low-density lipoprotein cholesterol (LDL-C) values during hospitalization of ACS patients with/without lipid-lowering therapy (LLT) at admission, and achievement of the ESC LDL-C target (LDL-C≤70mg/dL) at 4 months following the acute event using data from the French cohort of the DYSIS IIACS study.MethodsDYSIS IIACS was a multicentre prospective observational cohort study (recruitment: Oct 2013 to Oct 2014) conducted in 24 coronary care units in France. Adults hospitalized for an ACS event and who had a lipid panel measured within 24 hours of admission were consecutively enrolled. Eligible patients had to be on LLT for≥3 months or taking no LLT. A telephone follow-up interview was carried out with patients (or their next of kin) 120±15 days after the index event.ResultsOf the 468 patients enrolled, 50.6% had ST-elevation myocardial infarction/left bundle branch block, 40.8% had non-ST-elevation myocardial infarction, and 8.5% had unstable angina. Of the 277 (59.2%) patients on LLT at admission, 25.3% had an LDL-C<70mg/dl (Table). Most patients (96.4%) were on statin therapy at discharge (mean+SD dose calculated in atorvastatin 49±28mg/day). Non-statin LLT was used in 5.6% patients at discharge (61.5% with a cholesterol-absorption inhibitor). At 120 days after admission, 50.9% of ACS patients with follow-up data had achieved the LDL-C target.ConclusionsThese observational data from contemporary French clinical practice in coronary care units indicate suboptimal LDL-C control, with a substantial proportion of very high cardiovascular risk patients presenting with elevated LDL-C despite taking LLT. Four months after the acute event, half of the patients (with data) failed to achieve the target, with a large difference between mean value and target LDL-C.Abstract 0188 – Table: Characteristics of and lipid values in ACS patients: during hospitalization and at 120 daysAll patients (n=468)LLT at admission (n=277)No LLT at admission (n=191)Age (years)65±1267±1261±12***Men80.178.083.2Diabetes type 221.827.413.6**Chronic kidney disease3.84.03.7Lipid variables (within 24 h of admission)LDL-C (mg/dL)110.6±43.493.6±36.4135.3±40.9***LDL<70mg/dL (%)16.925.34.7***Difference between mean and target values (mg/dL)52.1±38.337.0±32.169.3±37.5***Statin at hospital discharge96.497.594.8Lipid variables (120 days after admission)(n=159)(n=86)(n=73)LDL-C (mg/dL)76.1±31.179.7±31.171.9±30.7*LDL-C<70mg/dL50.941.961.6*Difference between mean and target values (mg/dL)29.7±25.828.0±26.532.6±24.7Data are mean±SD or %.*P<0.05**P?0.001**P?0.0001 (LLT vs no LLT

0191: Poor achievement of low-density lipoprotein cholesterol targets in French patients with stable coronary heart disease. Contemporary data from DYSIS II CHD study

AimWe sought to determine achievement of lipid targets according to current European guidelines (low-density lipoprotein cholesterol [LDL-C]≤70mg/dL) in patients with stable coronary heart disease (CHD) with or without lipid-lowering therapy (LLT), in the French cohort of the Dyslipidemia International Study IICHD (DYSIS IICHD).MethodsDYSIS IICHD was a multicentre observational cross-sectional study conducted from July 2013 to October 2014 in 27 centres in France. Adults with stable CHD (defined as≥1 of the following:>50% stenosis on coronary angiography or computed tomography, prior percutaneous coronary intervention, prior coronary bypass graft, history of ACS>3 months previously) and a fasting lipid profile done within the previous 12 months were consecutively enrolled. Eligible patients had to be on LLT for≥3 months or taking no LLT.ResultsA total of 436 CHD patients were enrolled. Of the 424 patients (97.2%) on LLT, 91.5% were on statin treatment at the moment of inclusion (mean±SD dose calculated in atorvastatin 27±23mg/day). Non-statin LLT was used in 17.7% patients (79.2% were on a cholesterol-absorption inhibitor). Mean±SD LDL-C was 87.4±30.5mg/dL, 28.4% achieved LDL-C<70mg/dL, and 67.7% had an LDL-C<100mg/dL (Table).Abstract 0191 – Table: Characteristics of lipid values in patients with stable CHDAll patients (n=436)LLT (n=424)No LLT (n=12)Age (years)69±1269±1274±12Men80.079.791.7ACS>3 months previously70.070.066.7Diabetes type 227.027.316.7Chronic kidney disease5.05.20Lipid variablesLDL-C (mg/dL)87.4±30.586.0±29.6135.3±24.5**LDL<70mg/dL28.429.20*Distance to target of<70mg/dL (mg/dL)31.1±24.229.7±23.265.3±24.5**LDL<100mg/dL67.769.38.3**Data are mean±SD or %.*P<0.05**P?0.0001 (LLT vs no LLT)ConclusionsThese observational data from contemporary clinical practice in France indicate suboptimal lipid control, with over two-thirds of high-risk CHD patients failing to achieve the LDL-C target despite taking LLT, and a large difference between mean value and target LDL-C. More-intensive treatment is required to optimize achievement of lipid goals in CHD