Diabetes Care in Nigeria

Background: Diabetes is a noncommunicable disease that has attained great significance in the sub-Saharan region, with Nigeria being the most affected. Many persons with the condition suffer a reduced life expectancy and quality of life. Diabetes places an extra burden on the individuals and families affected, especially for the majority of patients unable to access quality health care. Objective: To describe the elements of diabetes management in Nigeria, areas for improvement, and proposed strategies to optimize care. Methods: A systematic literature search was performed on diabetes in Nigeria. Local and nonindexed literature, PubMed, and Google Scholar were used to source information on the subject. Findings: Diabetes-related morbidity and mortality continue to increase due to population expansion, urban migration, declining physical activity, and dietary factors. The organization of diabetes care is poorly coordinated, especially at the primary and secondary tiers of the public health care system, with consequent poor outcomes. Thus life expectancy (just about 50 years), which is low in the region, is further reduced by the double jeopardy of communicable (eg, tuberculosis, HIV/AIDS, and malaria) and noncommunicable diseases, such as diabetes and its closely related comorbidity, hypertension. Conclusions: The way forward is to improve maternal and child care, promote screening of at-risk populations, and develop strategies for primary prevention and early intervention to optimize glycemic control. Greater commitment to health care by the government and nongovernmental organizations and greater awareness by Nigerians should facilitate the desired improvements in disease prevention and glycemic control in those who are already affected

Gradient of Risk and Associations With Cardiovascular Efficacy of Ertugliflozin by Measures of Kidney Function Observations From VERTIS CV

Ukraine: Olga Godlevska, Ivan Chopey, Zinaida Teliatnikova, Petro Kuskalo, Orest Abrahamovych, Borys Mankovskyi, Ivan Fushtey, Galyna Myshanych, Susanna Tykhonova, Vira Tseluyko, Olena Koval, Oleksandr Parkhomenko, Oleksandr Prokhorov, Myroslava Vayda, Larysa Martymianova, Viktoriia Zharinova, Lyudmyla Prystupa, Larysa Pererva, Oleksandr Kovalov, Lyubov Sokolova, Volodymyr Botsyurko, Vitaliy Maslyanko, Maryna Vlasenko, Tetyana Khomazyuk, Anna Kulyk, Volodymyr Synenko, Oleksandr Karpenko, Yuriy Mostovoy, Olga Gyrina, Maryna Dolzhenko, Oleksandra Donets, Inna Sorokina, Yaroslav Malynovsky, Olena Lysunets, Roman Petrovskyy, Svitlana Panina

Kidney outcomes using a sustained ≥40% decline in eGFR: A meta-analysis of SGLT2 inhibitor trials

Background: A recent meta-analysis of sodium–glucose cotransporter 2 (SGLT2) inhibitor outcome trials reported that SGLT2 inhibitors were associated with reduction in the risk of adverse composite kidney outcomes, with moderate heterogeneity across the trials; however, the endpoints were defined differently across the trials. Hypothesis: The apparent heterogeneity of the meta-analysis of kidney composite outcomes of SGLT2 inhibitor trials will be substantially reduced by using a consistent assessment of sustained ≥40% decline in eGFR/chronic kidney dialysis/transplantation/renal death across trials. Methods: We performed a meta-analysis of kidney composite outcomes from the four SGLT2 cardiovascular outcome trial programs conducted in general type 2 diabetes mellitus populations, which included, as a surrogate of progression to kidney failure, a sustained ≥40% decline in eGFR along with kidney replacement therapy and kidney death. The trials assessed were VERTIS CV (NCT01986881), CANVAS Program (NCT01032629 and NCT01989754), DECLARE-TIMI 58 (NCT01730534), and EMPA-REG OUTCOME (NCT01131676). Results: Data from the trials comprised 42 516 individual participants; overall, 998 composite kidney events occurred. SGLT2 inhibition was associated with a significant reduction in the kidney composite endpoint (HR 0.58 [95% CI 0.51–0.65]) and with a highly consistent effect across the trials (Q statistic p = .64; I 2 = 0.0%). Conclusions: Our meta-analysis highlights the value of using similarly defined endpoints across trials and supports the finding of consistent protection against kidney disease progression with SGLT2 inhibitors as a class in patients with type 2 diabetes mellitus who either have established atherosclerotic cardiovascular disease or are at high cardiovascular risk with multiple cardiovascular risk factors

Metabolite Profiles of Incident Diabetes and Heterogeneity of Treatment Effect in the Diabetes Prevention Program

Novel biomarkers of type 2 diabetes (T2D) and response to preventative treatment in individuals with similar clinical risk may highlight metabolic pathways that are important in disease development. We profiled 331 metabolites in 2,015 baseline plasma samples from the Diabetes Prevention Program (DPP). Cox models were used to determine associations between metabolites and incident T2D, as well as whether associations differed by treatment group (i.e., lifestyle [ILS], metformin [MET], or placebo [PLA]), over an average of 3.2 years of follow-up. We found 69 metabolites associated with incident T2D regardless of treatment randomization. In particular, cytosine was novel and associated with the lowest risk. In an exploratory analysis, 35 baseline metabolite associations with incident T2D differed across the treatment groups. Stratification by baseline levels of several of these metabolites, including specific phospholipids and AMP, modified the effect that ILS or MET had on diabetes development. Our findings highlight novel markers of diabetes risk and preventative treatment effect in individuals who are clinically at high risk and motivate further studies to validate these interactions

Ertugliflozin and Slope of Chronic eGFR: Prespecified Analyses from the Randomized VERTIS CV Trial

Background and objectives A reduction in the rate of eGFR decline, with preservation of $0.75 ml/min per 1.73 m2 per year, has been proposed as a surrogate for kidney disease progression. We report results from prespecified analyses assessing effects of ertugliflozin versus placebo on eGFR slope from the eValuation of ERTugliflozin effIcacy and Safety CardioVascular outcomes (VERTIS CV) trial (NCT01986881). Design, setting, participants, & measurements Patients with type 2 diabetes mellitus and established atherosclerotic cardiovascular disease were randomized to placebo, ertugliflozin 5 mg, and ertugliflozin 15 mg (1:1:1). The analyses compared the effect of ertugliflozin (pooled doses, n55499) versus placebo (n52747) on eGFR slope per week and per year by random coefficient models. Study periods (weeks 0–6 and weeks 6–52) and total and chronic slopes (week 0 or week 6 to weeks 104, 156, 208, and 260) were modeled separately and by baseline kidney status. Results In the overall population, for weeks 0–6, the least squares mean eGFR slopes (ml/min per 1.73 m2 per week [95% confidence interval (95% CI)]) were 20.07 (20.16 to 0.03) and 20.54 (20.61 to 20.48) for the placebo and ertugliflozin groups, respectively; the difference was 20.47 (20.59 to 20.36). During weeks 6–52, least squares mean eGFR slopes (ml/min per 1.73 m2 per year [95% CI]) were 20.12 (20.70 to 0.46) and 1.62 (1.21 to 2.02) for the placebo and ertugliflozin groups, respectively; the difference was 1.74 (1.03 to 2.45). For weeks 6–156, least squares mean eGFR slopes (ml/min per 1.73 m2 per year [95% CI]) were 21.51 (21.70 to 21.32) and 20.32 (20.45 to 20.19) for the placebo and ertugliflozin groups, respectively; the difference was 1.19 (0.95 to 1.42). During weeks 0–156, the placebo-adjusted difference in least squares mean slope was 1.06 (0.85 to 1.27). These findings were consistent by baseline kidney status. Conclusions Ertugliflozin has a favorable placebo-adjusted eGFR slope .0.75 ml/min per 1.73 m2 per year, documenting the kidney function preservation underlying the clinical benefits of ertugliflozin on kidney disease progression in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. Clinical Trial registry name and registration number: US National Library of Medicine, ClinicalTrials.gov NCT01986881. Date of trial registration: November 13, 2013

ROLE OF THIAZOLIDINEDIONES IN THE MANAGEMENT OF TYPE 2 DIABETES: FOCUS ON ETHNIC MINORITY POPULATIONS

Persons from ethnic minority populations in the United States suffer disproportionately more from type 2 diabetes and its complications than do Caucasians. Genetic and acquired factors likely contribute to the ethnic disparities of type 2 diabetes. The pathophysiologic hallmarks consist of insulin resistance, progressive pancreatic b-cell dysfunction, and excessive hepatic glucose production. The ideal treatment for type 2 diabetes should correct insulin resistance and b-cell dysfunction; and normalize hepatic glucose output; and prevent, delay, or reverse diabetic complications. The discovery of a new class of drugs, thiazolidinediones, has provided an effective tool to correct key underlying defects in type 2 diabetes. Thiazolidinediones improve insulin sensitivity and have beneficial effects on pancreatic b-cell function and hepatic glucose production. Furthermore, their potent insulin-sensitization effect predicts that treatment with thiazolidinediones will improve cardiovascular risk factors, including lipid profile, fibrinolysis, endothelial function, and atheroinflammatory markers. These benefits are expected to be particularly important among ethnic minority patients who tend to have greater insulin resistance than do Caucasians