Rates, determinants and success of implementing deprescribing in people with type 2 diabetes:A scoping review

Background Individualizing goals for people with type 2 diabetes may result in deintensification of medication, but a comprehensive picture of deprescribing practices is lacking. Aims To conduct a scoping review in order to assess the rates, determinants and success of implementing deprescribing of glucose-, blood pressure- or lipid-lowering medications in people with diabetes. Methods A systematic search on MEDLINE and Embase between January 2007 and January 2019 was carried out for deprescribing studies among people with diabetes. Outcomes were rates of deprescribing related to participant characteristics, the determinants and success of deprescribing, and its implementation. Critical appraisal was conducted using predefined tools. Results Fourteen studies were included; eight reported on rates, nine on determinants and six on success and implementation. Bias was high for studies on success of deprescribing. Deprescribing rates ranged from 14% to 27% in older people with low HbA(1c)levels, and from 16% to 19% in older people with low systolic blood pressure. Rates were not much affected by age, gender, frailty or life expectancy. Rates were higher when a reminder system was used to identify people with hypoglycaemia, which led to less overtreatment and fewer hypoglycaemic events. Most healthcare professionals accepted the concept of deprescribing but differed on when to conduct it. Deprescribing glucose-lowering medications could be successfully conducted in 62% to 75% of participants with small rises in HbA(1c). Conclusions Deprescribing of glucose-lowering medications seems feasible and acceptable, but was not widely implemented in the covered period. Support systems may enhance deprescribing. More studies on deprescribing blood pressure- and lipid-lowering medications in people with diabetes are needed

M-I coupling across the auroral oval at dusk and midnight: repetitive substorm activity driven by interplanetary coronal mass ejections (CMEs)

We study substorms from two perspectives, i.e., magnetosphere–ionosphere coupling across the auroral oval at dusk and at midnight magnetic local times. By this approach we monitor the activations/expansions of basic elements of the substorm current system (Bostrøm type I centered at midnight and Bostrøm type II maximizing at dawn and dusk) during the evolution of the substorm activity. Emphasis is placed on the R1 and R2 types of field-aligned current (FAC) coupling across the Harang reversal at dusk. We distinguish between two distinct activity levels in the substorm expansion phase, i.e., an initial transient phase and a persistent phase. These activities/phases are discussed in relation to polar cap convection which is continuously monitored by the polar cap north (PCN) index. The substorm activity we selected occurred during a long interval of continuously strong solar wind forcing at the interplanetary coronal mass ejection passage on 18 August 2003. The advantage of our scientific approach lies in the combination of (i) continuous ground observations of the ionospheric signatures within wide latitude ranges across the auroral oval at dusk and midnight by meridian chain magnetometer data, (ii) snapshot satellite (DMSP F13) observations of FAC/precipitation/ion drift profiles, and (iii) observations of current disruption/near-Earth magnetic field dipolarizations at geostationary altitude. Under the prevailing fortunate circumstances we are able to discriminate between the roles of the dayside and nightside sources of polar cap convection. For the nightside source we distinguish between the roles of inductive and potential electric fields in the two substages of the substorm expansion phase. According to our estimates the observed dipolarization rate (δ Bz/δt) and the inferred large spatial scales (in radial and azimuthal dimensions) of the dipolarization process in these strong substorm expansions may lead to 50–100 kV enhancements of the cross-polar-cap potential due to inductive electric field coupling

Transitions between states of magnetotail-ionosphere coupling and the role of solar wind dynamic pressure: the 25 July 2004 interplanetary CME case

In a case study, we investigate transitions between fundamental magnetosphere–ionosphere (M-I) coupling modes during storm-time conditions (SYM-H between −100 and −160 nT) driven by an interplanetary coronal mass ejection (ICME). We combine observations from the near tail, at geostationary altitude (GOES-10), and electrojet activities across the auroral oval at postnoon-to-dusk and midnight. After an interval of strong westward electrojet (WEJ) activity, a 3 h long state of attenuated/quenched WEJ activity was initiated by abrupt drops in the solar wind density and dynamic pressure. The attenuated substorm activity consisted of brief phases of magnetic field perturbation and electron flux decrease at GOES-10 near midnight and moderately strong conjugate events of WEJ enhancements at the southern boundary of the oval, as well as a series of very strong eastward electrojet (EEJ) events at dusk, during a phase of enhanced ring current evolution, i.e., enhanced SYM-H deflection within −120 to −150 nT. Each of these M-I coupling events was preceded by poleward boundary intensifications and auroral streamers at higher oval latitudes. We identify this mode of attenuated substorm activity as being due to a magnetotail state characterized by bursty reconnection and bursty bulk flows/dipolarization fronts (multiple current wedgelets) with associated injection dynamo in the near tail, in their braking phase. The latter process is associated with activations of the Bostrøm type II (meridional) current system. A transition to the next state of M-I coupling, when a full substorm expansion took place, was triggered by an abrupt increase of the ICME dynamic pressure from 1 to 5 nPa. The brief field deflection events at GOES-10 were then replaced by a 20 min long interval of extreme field stretching (Bz approaching 5 nT and Bx ≈ 100 nT) followed by a major dipolarization (Δ Bz ≈ 100 nT). In the ionosphere the latter stage appeared as a full-size stepwise poleward expansion of the WEJ. It thus appears that the ICME passage led to fundamentally different M-I coupling states corresponding to different levels of dynamic pressure (Pdyn) under otherwise very similar ICME conditions. Full WEJ activity, covering a wide latitude range across the auroral oval in the midnight sector, was attenuated by the abrupt dynamic pressure decrease and resumed after the subsequent abrupt increase

PCV83 Cost-Effectiveness of Statins for Primary Prevention in Newly Diagnosed Type 2 Diabetes Patients in the Netherlands

Background: Patients with type 2 diabetes have an increased risk of cardiovascular events, which can be reduced by statin treatment. Objectives: The aim of this study is to determine if statin treatment for primary prevention started at the time of type 2 diabetes diagnosis is cost-effective, taking non-adherence and different age groups into account. Methods: A cost-effectiveness analysis has been performed using a Markov model with a time horizon of 10 years. The 10-years cardiovascular risk was estimated in a Dutch population of primary prevention patients with newly diagnosed diabetes from the GIANTT database (Groningen Initiative to Analyse Type 2 Diabetes Treatment) using the UKPDS risk engine. Statin adherence of a Dutch type 2 diabetes population was measured as pill days covered (PDC) in the IADB pharmacy research database. PDC of ≥ 80% and ≤ 20% were associated with full and no efficacy of the treatment. Cost-effectiveness was measured in costs per quality-adjusted life-year (QALY) from the healthcare payers perspective, also stratified for cardiovascular risk and age. A probabilistic sensitivity analysis was performed. Results: Characteristics of 4,683 primary prevention type 2 diabetes patients were inserted into the UKPDS risk engine. The mean 10-years risk of the population was 23% for coronary heart disease (CHD), 14% for fatal CHD, 10% for stroke and 2% for fatal stroke. PDC in the type 2 diabetes population was 81%, 77% and 75% in years one, two and three, respectively. In general, statin treatment was highly cost-effective at around €2,500 per QALY. Favorable cost-effectiveness was robust in sensitivity analysis. Differences in age and 10-years cardiovascular risk showed large differences in cost-effectiveness ranging from more than €800,000 per QALY to being cost saving. Conclusions: Statin treatment for primary prevention in patients newly diagnosed with type 2 diabetes is costeffective. Due to large differences in cost-effectiveness according to different risk groups, the efficiency of the treatment could be increased by focusing on patients with higher cardiovascular risk and higher ages

Prescribing patterns, adherence and LDL-cholesterol response of type 2 diabetes patients initiating statin on low-dose versus standard-dose treatment:a descriptive study

AimsThe aim of this study was to describe and compare treatment modifications and discontinuation, adherence levels and response to treatment in patients with type 2 diabetes initiating on low-dose vs. standard-dose statin treatment.MethodsA 2-year follow-up cohort study was performed using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database in patients with type 2 diabetes initiating statin treatment between January 2007 and December 2012. First, we determined whether there were differences in treatment modifications and discontinuation after statin initiation between patients starting on a low-dose vs. standard-dose. Second, we looked at differences in adherence and LDL-cholesterol response after 2 years follow-up between these groups.ResultsAround 22% of patients initiated statin treatment on a dose lower than recommended. More than half of them remained on a low dose during a 2-year follow-up period, whereas less than 15% received a dose increase. Of the patients initiating on standard-dose, also more than half remained on the same treatment during this period, whereas 8% received a dose decrease without subsequent increase. Over 25% of patients starting on low-dose or standard-dose treatment discontinued treatment, often within the first 180 days after initiation or after a first treatment change. Patients on low-dose treatment had lower adherence levels and were less likely to have adequate LDL-cholesterol response compared with patients on standard-dose after 2 years follow-up.ConclusionsCurrent patterns of statin treatment in patients with type 2 diabetes are suboptimal, with discontinuation, inadequate adherence levels and lack of treatment intensification seen in those who had inadequate LDL-cholesterol response after 2 years of follow-up. Patients starting on low-dose had more treatment modifications, discontinuation and adherence problems as compared with those starting on standard-dose treatment, which calls for a closer look at the rationale of starting patients on low-dose statin treatment.</p

Perceived barriers for treatment of chronic heart failure in general practice; are they affecting performance?

BACKGROUND: The aim of this study is to determine to what extent barriers perceived by general practitioners (GPs) for prescribing angiotensin-converting enzyme inhibitors (ACE-I) in chronic heart failure (CHF) patients are related to underuse and underdosing of these drugs in actual practice. METHODS: Barriers were assessed with a semi-structured questionnaire. Prescribing data were extracted from GPs' computerised medical records for a random sample of their CHF patients. Relations between barriers and prescribing behaviour were assessed by means of Spearman rank correlation and multivariate regression modelling. RESULTS: GPs prescribed ACE-I to 45% of their patients and had previously initiated such treatment in an additional 3.5%, in an average standardised dose of 13.5 mg. They perceived a median of four barriers in prescribing ACE-I or optimising ACE-I dose. Many GPs found it difficult to change treatment initiated by a cardiologist. Furthermore, initiating ACE-I in patients already using a diuretic or stable on their current medication was perceived as barrier. Titrating the ACE-I dose was seen as difficult by more than half of the GPs. No significant relationships could be found between the barriers perceived and actual ACE-I prescribing. Regarding ACE-I dosing, the few GPs who did not agree that the ACE-I should be as high as possible prescribed higher ACE-I doses. CONCLUSION: Variation between GPs in prescribing ACE-I for CHF cannot be explained by differences in the barriers they perceive. Tailor-made interventions targeting only those doctors that perceive a specific barrier will therefore not be an efficient approach to improve quality of car