Multicausal analysis of mortality due to diabetes mellitus in Spain, 2016-2018.

OBJECTIVES: This study aimed to assess multicausal mortality due to diabetes from 2016-2018 in Spain. Specific objectives were to quantify the occurrence of diabetes as an underlying cause or as any registered cause on the death certificate. MATERIALS AND METHODS: A cross-sectional descriptive study taking a multicausal approach. RESULTS: Diabetes appears as an underlying cause of 2.3% of total deaths in Spain, and as any cause in 6.2%. In patients in whom Diabetes appears as an underlying cause on the death certificates, the 15 most frequent immediate causes are cardiovascular diseases in men(prevalence ratio 1,59)and women (PR1,31). In men, the causes associated with diabetes as any cause were skin diseases(prevalence ratio 1.33), followed by endocrine diseases(prevalence ratio 1.26)and genitourinary diseases (prevalence ratio1.14). In women, the causes associated with the presence of diabetes as any cause were endocrine (prevalence ratio 1.13)and genitourinary (prevalence ratio 1.04)diseases. CONCLUSIONS: In patients in whom diabetes appears as an underlying cause on the death certificates, the 15 most frequent immediate causes are cardiovascular diseases. In men, the causes associated with the presence of diabetes as any cause of death are skin, endocrine and genitourinary diseases. In women, the causes associated with diabetes as any cause are endocrine and genitourinary.

Diabetes Does Not Increase the Risk of Hospitalization Due to COVID-19 in Patients Aged 50 Years or Older in Primary Care-APHOSDIAB-COVID-19 Multicenter Study.

The purpose of this study was to identify clinical, analytical, and sociodemographic variables associated with the need for hospital admission in people over 50 years infected with SARS-CoV-2 and to assess whether diabetes mellitus conditions the risk of hospitalization. A multicenter case-control study analyzing electronic medical records in patients with COVID-19 from 1 March 2020 to 30 April 2021 was conducted. We included 790 patients: 295 cases admitted to the hospital and 495 controls. Under half (n = 386, 48.8%) were women, and 8.5% were active smokers. The main comorbidities were hypertension (50.5%), dyslipidemia, obesity, and diabetes (37.5%). Multivariable logistic regression showed that hospital admission was associated with age above 65 years (OR from 2.45 to 3.89, ascending with age group); male sex (OR 2.15, 95% CI 1.47-3.15), fever (OR 4.31, 95% CI 2.87-6.47), cough (OR 1.89, 95% CI 1.28-2.80), asthenia/malaise (OR 2.04, 95% CI 1.38-3.03), dyspnea (4.69, 95% CI 3.00-7.33), confusion (OR 8.87, 95% CI 1.68-46.78), and a history of hypertension (OR 1.61, 95% CI 1.08-2.41) or immunosuppression (OR 4.97, 95% CI 1.45-17.09). Diabetes was not associated with increased risk of hospital admission (OR 1.18, 95% CI 0.80-1.72; p = 0.38). Diabetes did not increase the risk of hospital admission in people over 50 years old, but advanced age, male sex, fever, cough, asthenia, dyspnea/confusion, and hypertension or immunosuppression did.

The influence of hemoglobin A1c levels on cardiovascular events and all-cause mortality in people with diabetes over 70 years of age. A prospective study.

AIM: Glycated hemoglobin A1c (HbA1c) is a reliable risk factor of cardiovascular diseases in diabetic patients, but information about this relationship in elderly patients is scarce. The aim of this study is to analyze, the relationship between HbA1c levels and the risk of mayor adverse cardiovascular events (MACE) in patients with diabetes over 70 years. METHODS: Prospective study of subjects with diabetes using electronic health records from the universal public health system in the Valencian Community, Spain, 2008-2012. We included men and women aged≥70 years with diabetes who underwent routine health examinations in primary care. Primary endpoint was the incidence of MACE: all-cause mortality and/or hospital admission due to coronary heart disease or stroke. A standard Cox and Cox-Aalen models were adjusted. RESULTS: 5016 subjects were included whit a mean age of 75.1 years (46.7% men). During an average follow-up of 49 months (4.1 years), 807 (16.1%) MACE were recorded. The incidence of MACE was 20.6 per 1000-person-years. Variables significantly associated to the incidence of MACE were male gender (HR: 1.61), heart failure (HR: 2.26), antiplatelet therapy (HR: 1.39), oral antidiabetic treatment (HR: 0.74), antithrombotics (HR: 1.79), while age, creatinine, HbA1c and peripheral arterial disease were time-depend associated variables. CONCLUSION: These results highlights the importance of HbA1c level in the incidence of cardiovascular events in older diabetic patients.

[Management of hyperglycaemia with non-insulin drugs in adult patients with type 2 diabetes]. / Manejo de la hiperglucemia con fármacos no insulínicos en pacientes adultos con diabetes tipo 2.

Treatment of diabetes mellitus type2 (DM2) includes healthy eating and exercise (150minutes/week) as basic pillars. For pharmacological treatment, metformin is the initial drug except contraindication or intolerance; in case of poor control, 8 therapeutic families are available (6 oral and 2 injectable) as possible combinations. An algorithm and some recommendations for the treatment of DM2 are presented. In secondary cardiovascular prevention, it is recommended to associate an inhibitor of the sodium-glucose cotransporter type 2 (iSGLT2) or a glucagon-like peptide-1 receptor agonist (arGLP1) in patients with obesity. In primary prevention if the patient is obese or overweight metformin should be combined with iSGLT2, arGLP1, or inhibitors of type4 dipeptidylpeptidase (iDPP4). If the patient does not present obesity, iDPP4, iSGLT2 or gliclazide, sulfonylurea, recommended due to its lower tendency to hypoglycaemia, may be used.

A Review of Practical Issues on the Use of Glucagon-Like Peptide-1 Receptor Agonists for the Management of Type 2 Diabetes.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are well established as effective treatments for patients with type 2 diabetes. GLP-1 RAs augment insulin secretion and suppress glucagon release via the stimulation of GLP-1 receptors. Although all GLP-1 RAs share the same underlying mechanism of action, they differ in terms of formulations, administration, injection devices and dosages. With six GLP-1 RAs currently available in Europe (namely, immediate-release exenatide, lixisenatide, liraglutide; prolonged-release exenatide, dulaglutide and semaglutide), each with its own characteristics and administration requirements, physicians caring for patients in their routine practice face the challenge of being cognizant of all this information so they are able to select the agent that is most suitable for their patient and use it in an efficient and optimal way. The objective of this review is to bring together practical information on the use of these GLP-1 RAs that reflects their approved use.Funding: Eli Lilly and Company.Plain Language Summary: Plain language summary available for this article.

Spanish Diabetes Society (SED) recommendations for the pharmacologic treatment of hyperglycemia in type 2 diabetes: 2018 Update. / Recomendaciones de la Sociedad Española de Diabetes (SED) para el tratamiento farmacológico de la hiperglucemia en la diabetes tipo 2: Actualización 2018.

Type 2 diabetes mellitus (DM2) has become a problem of global dimensions by their high and growing prevalence worldwide and the personal and economic costs associated with it. Correct treatment can reduce mortality and associated complications. New concepts have recently been included in routine clinical practice and have changed the algorithm of DM2 pharmacological therapy. Therefore, the Spanish Society of Diabetes (SED) entrusted to the Working Group of Consensus and Clinical Guidelines an update of the 2010 document Recommendations for Pharmacological Treatment of Hyperglycemia in Diabetes type2. Novel aspects include nine characteristics to describe each drug group: efficiency, the risk of hypoglycemia, effects on body weight, the demonstrated effect in cardiovascular risk, nephroprotection, limitation of use in renal insufficiency, the rate of secondary effects, complexity and costs. Additionally, the document details combination options, and develop the start and adjustment of available injectable therapies.

Calculating individualized glycaemic targets using an algorithm based on expert worldwide diabetologists: Implications in real-life clinical practice.

BACKGROUND: The aim of this study was to assess the clinical implications of calculating an individualized HbA1c target using a recently published algorithm in a real-life clinical setting. METHODS: General practitioners (GPs) from the Spanish Society of Family Medicine Diabetes Expert Group were invited to participate in the study. Each GP selected a random sample of patients with diabetes from his or her practice and submitted their demographic and clinical data for analysis. Individualized glycaemic targets were calculated according to the algorithm. Predictors of good glycaemic control were studied. The rate of patients attaining their individualized glycaemic target or the uniform target of HbA1c  < 7.0% was calculated. RESULTS: Forty GPs included 408 patients in the study. Of the 8 parameters included in the algorithm, "comorbidities," "risk of hypoglycaemia from treatment," and "diabetes duration" had the greatest impact on determining the individualized glycaemic target. Number of glucose-lowering agents and adherence were independently associated with glycaemic control. Overall, 60.5% of patients had good glycaemic control per individualized target, and 56.1% were well controlled per the uniform target of HbA1c  < 7.0% (P = .20). However, 12.8% (23 of 246) of the patients with HbA1c  ≥ 7.0% were adequately controlled per individualized target, and 2.6% (6 of 162) of the patients with HbA1c  < 7.0% were uncontrolled since their individualized target was lower. CONCLUSIONS: In a real-life clinical setting, applying individualized targets did not change the overall rate of patients with good glycaemic control yet led to reclassification of 7.1% (29 of 408) of the patients. More studies are needed to validate these results in different populations.

Prevalence of diabetic retinopathy and its relationship with glomerular filtration rate and other risk factors in patients with type 2 diabetes mellitus in Spain. DM2 HOPE study.

AIM: Diabetic retinopathy (DR) is the leading cause of blindness in working age population in developed countries. Albuminuria and estimated glomerular filtration rate (eGFR) have been considered biomarkers for DR. This study aimed to investigate the prevalence of DR and its relationship with eGFR and other risk factors in type 2 diabetic patients (T2DM) in Spain. METHODS: A cross-sectional and descriptive study has been performed in 14,266 patients. Clinical records were reviewed. Demographic data, clinical diagnoses, clinical variables, and results from laboratory tests were recorded. Prevalence rates of DR were calculated. Logistic regression analysis was applied to assess predictors of the DR presence/absence. RESULTS: DR prevalence was 14.9%, being more prevalent in women (p = 0.0087) and in older patients (p < 0.0001). Duration of disease (OR = 5.3, IC95% = 3.8-7.4; p < 0.0001), eGFR < 60 ml/min/1.73 m2 (OR = 2.0, IC95% 1.6-2.4; p < 0.0001), levels of HbA1c ≥ 7% (OR = 1.9, IC95% = 1.5-2.3; p < 0.0001) and high blood pressure (OR = 1.6, IC95% = 1.2-2.1; p = 0.0032) were associated with higher risk of DR. DR was also more frequent in patients taking insulin (32,6% vs. 10,2%; p < 0.0001). CONCLUSION: Around one in seven patients with T2DM has DR after nine years since diagnosis. Time since diagnosis, insulin therapy, cardiovascular profile, and renal dysfunction are associated with DR in patients with T2DM in Spain.

Attitudes towards insulin initiation in type 2 diabetes patients among healthcare providers: A survey research.

AIMS: To describe the views of healthcare providers about starting insulin in patients with type 2 diabetes and to determine the specific factors that contribute to delay insulin initiation. METHODS: Two-phases observational descriptive study. In the quantitative phase we conducted a cross-sectional survey of a sample of 380 healthcare professionals (general practitioners (GPs), endocrinologists, internists and nurses). In the qualitative phase, a discussion group reviewed the results of the survey to propose solutions. RESULTS: In poorly controlled patients, 46% of GPs vs. 43.2% of internists and 31.3% of endocrinologists waited 3-6months before starting insulin, and 71.4% of GPs vs. 66.7% of internists vs. 58.8% of endocrinologists need to confirm twice the HbA1c levels. The upper level of basal glucose more frequently considered as good control is 130mg/dL for GPs (35.7%), and 120mg/dL for internists (35.8%) and endocrinologists (37.5%). In patients without comorbidities, 32.5% of endocrinologists vs. 27.2% of internists vs. 17.9% of GPs initiated insulin when HbA1c was >7% while 26.3% of endocrinologists vs. 28.4% of internists vs. 38.4% of GPs initiated insulin when HbA1c was >8%. The interference of the therapy with the patient' social life and the need for time management were the most accepted barriers to initiate insulin. CONCLUSIONS: There are significant differences between GPs and endocrinologists regarding the insulin initiation and GPs and internists felt less empowered to manage patients with diabetes. Specific training for professionals and joint work with patients could improve the glycemic control.

Barriers to improved dyslipidemia control: Delphi survey of a multidisciplinary panel.

OBJECTIVE: To assess the barriers that make it difficult for the health care professionals (physicians, nurses and health care managers) to achieve a better control for dyslipidemia in Spain. METHODS: The study has an observational design and was performed using the modified Delphi technique. One hundred and forty-nine panel members from medicine, nursing and health care management fields and from different Spanish regions were selected randomly and were invited to participate. Individual and anonymous opinions were asked by answering a 42-items questionnaire via e-mail (two rounds were done). Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the three groups (Kappa index and McNemar chi-square). RESULTS: Response rate: 81%. The agreement index was 33.3 (95% CI: 18.9-47.7). Regarding the non-compliance with therapy, it improves with patient education degree in dyslipidemia, patient motivation, the agreement on decisions with the patient and with the use of cardiovascular risk measure and it gets worse with lack of information on the objectives to achieve. Clinical inertia improves with professional's motivation, cardiovascular risk calculation, training on objectives and the use of indicators and it gets worse with lack of treatment goals. CONCLUSION: Different perceptions and attitudes between medicine, nursing and health care management were found. An agreement in interventions in non-compliance and clinical inertia to improve dyslipidemia control was reached.

[Consensus document on the management after hospital discharge of patient with hyperglycaemia]. / Documento de consenso sobre el tratamiento al alta hospitalaria del paciente con hiperglucemia.

The present document intends to adapt the general recommendations set up in a consensus to elaborate the hospital discharge report in medical specialties to the specific needs of the hospitalized diabetic population. Diabetes is an illness with a very high health cost, being the global risk of death in people with diabetes almost double than in non-diabetes people, justifying the fact that diabetes constitutes one of the most frequent diagnoses in hospitalized patients and the growing interest upon hyperglycaemia management during hospitalization and at discharge. To set up an adequate treatment plan at discharge suitable for each patient, the most important elements to take into account are the etiology and prior hyperglycaemia treatment, the patient's clinical situation and the degree of glycaemia control. Due to instability of glycaemia control, it is also needed to anticipate the educational needs for each patient, as well as to set up the monitoring schedule and follow-up at discharge, and an adequate treatment plan at discharge.

[Update on the latest family of oral drugs marketed for the treatment of type 2 diabetes: DPP-4 inhibitors. Contributions with respect to other families of oral antidiabetic agents]. / Actualización sobre la última familia de fármacos orales comercializados para el tratamiento de la diabetes tipo 2: los inhibidores de la DPP-4. Aportaciones respecto a las otras familias de antidiabéticos orales.

The recent introduction of new drugs in the therapeutic arsenal for the management of hyperglycemia in type 2 diabetes has opened up new perspectives and raised hope for improved metabolic control in these patients. DPP-4 inhibitors are a family of drugs whose action is mediated by the incretin hormones, in particular GLP-1. This hormone is involved in the control of glucose homeostasis, as it stimulates insulin secretion in response to food intake and halts glucagon production. This effect, which is altered in patients with type 2 diabetes, can be improved by administering this group of drugs. The available evidence suggests that the efficacy, tolerability, safety, low drop-out rate and limited effects on weight, together with the low risk of hypoglycemic episodes, could place this group of drugs high on the treatment list in patients with type 2 diabetes. Incretin therapy provides an alternative to currently available glucose-lowering drugs for type 2 diabetes with good efficacy and a favorable profile on weight. In the studies performed to date, DPP-4 inhibitors seem safe. However, these agents must continue to be evaluated in long-term studies performed in clinical practice to ensure their effectiveness and safety profile, as well as to determine their precise role among all the currently available options in the treatment of type 2 diabetes.

Association of hypoglycemic symptoms with patients' rating of their health-related quality of life state: a cross sectional study.

BACKGROUND: To evaluate the association between patient-reported hypoglycemic symptoms with ratings of their health-related quality of life state and patient-reported adverse events in patients with type 2 diabetes mellitus (T2DM). METHODS: This observational, multicenter, cross sectional study was based on a sample of patients with T2DM from seven European countries who added sulfonylurea or thiazolidinedione to metformin monotherapy between January 2001 and January 2006. Included patients were required to have at least one hemoglobin A1c (HbA1c) measurement in the 12 months before enrollment and to not be receiving insulin. Demographic and clinical data from medical records were collected using case report forms. Questionnaires measured patient-reported hypoglycemic symptoms, health-related quality of life (EuroQol visual analogue scale, EQ-5D VAS), and treatment-related adverse events. RESULTS: A total of 1,709 patients were included in the study. Mean patient age was 63 years, 45% were female, mean HbA1c was 7.06%, and 28% were at HbA1c goal (HbA1c < 6.5%). Hypoglycemic symptoms during the 12 months before enrollment were reported by 38% of patients; among whom 68% reported their most severe symptoms were mild, 27% moderate, and 5% severe. Adjusted linear regression analyses revealed that patients reporting hypoglycemic symptoms had significantly lower EQ-5D VAS scores indicating worse patient-reported quality of life (mean difference -4.33, p < 0.0001). Relative to those not reporting symptoms, the adjusted decrement to quality of life increased with greater hypoglycemic symptom severity (mild: -2.68, p = 0.0039; moderate: -6.42, p < 0.0001; severe: -16.09, p < 0.0001). Patients with hypoglycemia reported significantly higher rates of shakiness, sweating, excessive fatigue, drowsiness, inability to concentrate, dizziness, hunger, asthenia, and headache (p < 0.0001 for each comparison). CONCLUSIONS: Hypoglycemic symptoms and symptom severity have an adverse effect on patients' rating of their health related quality of life state. Hypoglycemic symptoms are correlated with treatment-related adverse effects. Minimizing the risk and severity of hypoglycemia may improve patients' quality of life and clinical outcomes. Results are subject to limitations associated with observational studies including the potential biases due to unobserved patient heterogeneity and the use of a convenience sample of patients.