Approach to obesity in the elderly population: a consensus report from the Diabetes, Obesity and Nutrition Working Group of SEMI (Spanish Society of Internal Medicine).

Obesity in the elderly not only impacts morbidity and mortality but their quality of life. This phenomenon has sparked extensive research and debate regarding treatment recommendations, primarly due to the lack evidence in this specific population. When addressing possible treatment recommendations for older adults with obesity, it is crucial to assess certain essential aspects such as functional status, sarcopenia, cognitive status, and others. Intentional weight loss in this population can be both effective and safe. The best weight loss plan for the elderly revolves around adopting a healthy lifestyle, which includes following a Mediterranean diet pattern and engaging in physical exercise, particularly strength training. Additionally, the use of weight loss medications, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RA) and novel glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonists, can provide an additional stage of treatment. In selective candidates, bariatric surgery may also be considered. The objective of this document is to propose a comprehensive algorithm of recommendations for the management of obesity in the elderly (above the age of 65), based on scientific evidence and the expertise of members from the Diabetes, Obesity, and Nutrition Workgroup of the Spanish Society of Internal Medicine.

Optimization of potassium management in patients with chronic kidney disease and type 2 diabetes on finerenone.

INTRODUCTION: Patients with type 2 diabetes (T2DM) and chronic kidney disease (CKD) are at high risk of CKD progression and cardiovascular events. Despite treatment with renin-angiotensin system inhibitors and SGLT-2 inhibitors, the residual risk is substantial. There is preclinical and clinical evidence supporting a key role of mineralocorticoid receptor in cardiorenal injury in T2DM. AREAS COVERED: Finerenone is a selective and nonsteroidal mineralocorticoid receptor antagonist that reduces -on preclinical studies- heart and kidney inflammation and fibrosis. Clinical trials have demonstrated that among patients with T2DM and CKD, finerenone reduces CKD progression and the risk of cardiovascular events. The incidence of adverse events is similar than for placebo. Permanent discontinuation of study drug due to hyperkalemia was low (1.7% of finerenone and 0.6% of placebo participants) as was the risk of hyperkalemia-related severe-adverse events (1.1%). We provide an overview of risk factors for hyperkalemia and management of serum potassium in people with CKD and T2DM on finerenone. EXPERT OPINION: As finerenone increases potassium levels in a predictable way, patients at risk of hyperkalemia can be identified early in clinical practice and monitored for an easy management. This will allow people with T2DM and CKD to safely benefit from improved cardiorenal outcomes.

Effect of semaglutide on fatty liver disease biomarkers in patients with diabetes and obesity.

AIM: This work aims to assess the effect of weekly subcutaneous semaglutide on biomarkers of metabolic-associated fatty liver disease (MAFLD), namely the hepatic steatosis index (HSI) and the fibrosis-4 (FIB-4) index, at 24 weeks in outpatients attended to in internal medicine departments. METHODS: This study analyzed patients in an ongoing, multicenter, prospective, pre-post, uncontrolled cohort registry that enrolls unique, consecutive patients with type 2 diabetes treated with weekly subcutaneous semaglutide. Steatosis/fibrosis were determined by HSI (<30 ruled out, >36 steatosis) and FIB-4 (<1.3 ruled out, >2.67 fibrosis), respectively. RESULTS: The sample included 213 patients (46.9% women) with a median age of 64 (19) years. The median baseline body mass index and weight were 36.1 (8.4) kg/m2 and 98 (26.9) kg, respectively. A total of 99.9% had HSI values indicating steatosis, with a mean HSI of 47.9 (8.2). Additionally, 10.8% had fibrosis (FIB-4 > 2.67) and 42.72% had values in intermediate ranges (FIB-4 1.3-2.67). At 24 weeks, there was a significant reduction in HSI (-2.36 (95%CI 1.83-2.9) p < 0.00001) and FIB-4 (-0.075 (95%CI 0.015-0.14) p < 0.016), mainly related to declines in body weight, triglyceride levels, insulin resistance (estimated by the triglyceride-glucose index), and liver enzymes. CONCLUSION: These results show that weekly subcutaneous semaglutide had a beneficial effect on liver steatosis that went beyond glucose control. Its effects were mainly related to weight loss, a decline in biomarkers, and improvements in insulin sensitivity. For many patients, early detection is essential for improving MAFLD outcomes and may allow for selecting the most efficient treatment options.

Análisis de coste-efectividad de dapagliflozina en comparación con los inhibidores de la DPP4 y otros antidiabéticos orales en el tratamiento de la diabetes mellitus tipo 2 en España / Cost-effectiveness analysis of dapagliflozin compared to DPP4 inhibitors and other oral antidiabetic drugs in the treatment of type-2 diabetes mellitus in Spain

OBJETIVO: Evaluar la eficiencia de la terapia combinada de metformina y dapagliflozina, un nuevo antidiabético oral con un mecanismo de acción independiente de la insulina, en el tratamiento de la diabetes mellitus tipo 2 (DM2) en comparación con inhibidores de DPP4, sulfonilureas y tiazolidindionas, combinados también con metformina. DISEÑO: Análisis de coste-efectividad utilizando un modelo de simulación de eventos discretos a partir de los resultados de los ensayos clínicos disponibles y considerando un horizonte temporal de toda la vida del paciente. Emplazamiento: Perspectiva del Sistema Nacional de Salud. PARTICIPANTES: El modelo simuló la historia natural de 30.000 pacientes con DM2 para cada opción comparada. MEDICIONES PRINCIPALES: Años de vida ajustados por calidad (AVAC) y consecuencias económicas del manejo de la enfermedad y sus complicaciones. Se consideraron los costes directos (actualizados a euros de 2013) y se aplicó un descuento del 3% tanto para costes como para resultados en salud. RESULTADOS: El análisis principal comparó dapagliflozina con los inhibidores de DPP4, resultando dapagliflozina como una opción de tratamiento que aportaría una ligera mayor efectividad (0,019 AVAC) con menores costes totales asociados (−42 Euros). En los análisis adicionales, dapagliflozina fue una opción coste-efectiva en comparación con sulfonilureas y tiazolidindionas con razones de coste por AVAC ganado de 3.560 Euros y 2.007 Euros, respectivamente. Los análisis de sensibilidad univariantes y probabilístico confirmaron la solidez de los RESULTADOS: CONCLUSIONES: Los resultados del análisis realizado sugieren que dapagliflozina, en combinación con metformina, sería una alternativa coste-efectiva en el contexto español para el tratamiento de la DM2

OBJECTIVE: To assess the efficiency of the combined therapy with metformin and dapagliflozin, a new oral anti-diabetic drug with an insulin-independent mechanism of action, in the treatment of type-2 diabetes mellitus (T2DM) compared to DPP4 inhibitors, sulphonylureas and thiazolidindiones, also combined with metformin. DESIGN: Cost-effectiveness analysis using a discrete event simulation model based on the results of the available clinical trials and considering patient's entire life as time horizon. SETTING: National Health System perspective. PARTICIPANTS: The model simulated the natural history of 30,000 patients with T2DM for each of the options compared. MAIN MEASUREMENTS: Quality-adjusted life-years (QALY) and economic consequences of managing the disease and its complications. The analysis considered direct costs updated to 2013. A discount rate of 3% was applied to costs and health outcomes. RESULTS: In the main analysis comparing dapagliflozin with DPP4 inhibitors, dapagliflozin resulted in a treatment option that would provide a slightly higher effectiveness (0.019 QALY) and lower overall associated costs (- 42 Euros). In the additional analyses, dapagliflozin was a cost-effective option compared with sulphonylureas and thiazolidinediones resulting in a cost per QALY gained of 3,560 Euros and 2,007 Euros, respectively. The univariate and probabilistic sensitivity analyses confirmed the robustness of the RESULTS: CONCLUSIONS: The results of the analyses performed suggested that dapagliflozin, in combination with metformin, would be a cost-effective alternative in the Spanish context for the treatment of T2DM

[Cost-effectiveness analysis of dapagliflozin compared to DPP4 inhibitors and other oral antidiabetic drugs in the treatment of type-2 diabetes mellitus in Spain]. / Análisis de coste-efectividad de dapagliflozina en comparación con los inhibidores de la DPP4 y otros antidiabéticos orales en el tratamiento de la diabetes mellitus tipo 2 en España.

OBJECTIVE: To assess the efficiency of the combined therapy with metformin and dapagliflozin, a new oral anti-diabetic drug with an insulin-independent mechanism of action, in the treatment of type-2 diabetes mellitus (T2DM) compared to DPP4 inhibitors, sulphonylureas and thiazolidindiones, also combined with metformin. DESIGN: Cost-effectiveness analysis using a discrete event simulation model based on the results of the available clinical trials and considering patient's entire life as time horizon. SETTING: National Health System perspective. PARTICIPANTS: The model simulated the natural history of 30,000 patients with T2DM for each of the options compared. MAIN MEASUREMENTS: Quality-adjusted life-years (QALY) and economic consequences of managing the disease and its complications. The analysis considered direct costs updated to 2013. A discount rate of 3% was applied to costs and health outcomes. RESULTS: In the main analysis comparing dapagliflozin with DPP4 inhibitors, dapagliflozin resulted in a treatment option that would provide a slightly higher effectiveness (0.019 QALY) and lower overall associated costs (-€42). In the additional analyses, dapagliflozin was a cost-effective option compared with sulphonylureas and thiazolidinediones resulting in a cost per QALY gained of €3,560 and €2,007, respectively. The univariate and probabilistic sensitivity analyses confirmed the robustness of the results. CONCLUSIONS: The results of the analyses performed suggested that dapagliflozin, in combination with metformin, would be a cost-effective alternative in the Spanish context for the treatment of T2DM.