Enfermedad renal crónica en España: prevalencia y factores relacionados en personas con diabetes mellitus mayores de 64 años / Chronic renal disease in spain: prevalence and related factors in persons with diabetes mellitus older than 64 years

INTRODUCCIÓN: La diabetes mellitus tipo 2 y la enfermedad renal crónica (ERC) son afecciones de elevada prevalencia en personas ≥ 65 años y constituyen un importante problema de salud pública. OBJETIVOS: Conocer la prevalencia de la ERC, sus categorías y su relación con diversos factores demográficos y clínicos, en pacientes ancianos con diabetes mellitus tipo 2 en España. MÉTODOS: Estudio epidemiológico, observacional, transversal, multicéntrico, ámbito nacional. Se incluyeron pacientes con diabetes mellitus tipo 2 conocida, edad ≥ 65 años atendidos en Atención Primaria. Se recogieron variables demográficas, antropométricas y analíticas de los últimos 12 meses, incluyendo el cociente albúmina-creatinina y el filtrado glomerular estimado para evaluar la función renal. RESULTADOS: La prevalencia de ERC fue del 37,2% (IC95%, 34,1-40,3%), de insuficiencia renal del 29,7% (IC95%, 26,8-32,6%) y de elevación de la albuminuria del 20,6% (IC95%, 17,3-23,9%), moderadamente elevada 17,8% (IC95%, 14,7-20,9%), severamente elevada 2,8% (IC95%, 1,4-4,2%). La prevalencia de las categorías de ERC fueron: G1 1,3% (IC95%, 0,6-2%), G2 6,2% (IC95%, 4,6-7,8%), G3a 17,2% (IC95%, 14,8-19,6%), G3b 9,8% (IC95%, 7,9-11,7%), G4 2% (IC95%, 1,1-2,9%) y G5 0,7% (IC95%, 0,2-1,2%). En el análisis multivariante, después de ajustar por el resto de variables, la ERC se asoció a mayor edad OR 5,13, (IC95%, 3,15-8,35), alta comorbilidad OR 3,36 (IC95%, 2,2-5,12) y la presencia de tratamiento antihipertensivo OR 2,43 (IC95%, 1,48-4,02). CONCLUSIONES: La ERC es frecuente en la población diabética ≥ 65 años y se asocia con mayor edad, alta comorbilidad e hipertensión tratada. No se ha encontrado asociación con el género y años de evolución de la diabetes

INTRODUCTION: Type 2 diabetes mellitus and chronic kidney disease (CKD) are conditions which have a high prevalence in individuals ≥ 65 years of age and represent a major public health problem. OBJECTIVES: To determine the prevalence of CKD, its categories and its relationship with various demographic and clinical factors in elderly patients with type 2 diabetes mellitus in Spain. METHODS: Observational, cross-sectional, multicenter, Spanish epidemiological study. Patients with known type 2 diabetes mellitus, age ≥ 65 years of age treated in Primary Care were included. We collected demographic, anthropometric and analytical variables from the previous 12 months, including the albumin-to-creatinine ratio and estimated glomerular filtration rate to evaluate renal function. RESULTS: The prevalence of CKD was 37.2% (95% CI, 34.1-40.3%), renal failure was 29.7% (95% CI, 26.8-32.6%) and increased albuminuria was 20.6% (95% CI, 17.3-23.9%), moderately increased albuminuria was 17.8% (95% CI, 14.7-20.9%) and severely increased albuminuria was 2.8% (95% CI, 1.4-4.2%). In turn, the prevalence of CKD categories were: G1 1.3% (95% CI, 0.6-2%), G2 6.2% (95% CI, 4.6-7.8%), G3a 17.2% (95% CI, 14.8-19.6%), G3b 9.8% (95% CI, 7.9-11.7%), G4 2% (95% CI, 1.1-2.9%) and G5 0.7% (95% CI, 0.2-1.2%). In the multivariate analysis, after adjusting for the remaining variables, CKD was associated with elderly age (OR 5.13, 95% CI, 3.15-8.35), high comorbidity (OR 3.36. 95% CI, 2.2-5.12) and presence of antihypertensive treatment (OR 2.43. 95% CI, 1.48-4.02). CONCLUSIONS: CKD is frequent in the diabetic population ≥ 65 years of age and is associated with elderly age, high comorbidity and with treated hypertension. No relationship has been found with gender and time in years since onset of diabetes

Chronic renal disease in spain: prevalence and related factors in persons with diabetes mellitus older than 64 years. / Enfermedad renal crónica en España: prevalencia y factores relacionados en personas con diabetes mellitus mayores de 64 años.

INTRODUCTION: Type 2 diabetes mellitus and chronic kidney disease (CKD) are conditions which have a high prevalence in individuals ≥ 65 years of age and represent a major public health problem. OBJECTIVES: To determine the prevalence of CKD, its categories and its relationship with various demographic and clinical factors in elderly patients with type 2 diabetes mellitus in Spain. METHODS: Observational, cross-sectional, multicenter, Spanish epidemiological study. Patients with known type 2 diabetes mellitus, age ≥ 65 years of age treated in Primary Care were included. We collected demographic, anthropometric and analytical variables from the previous 12 months, including the albumin-to-creatinine ratio and estimated glomerular filtration rate to evaluate renal function. RESULTS: The prevalence of CKD was 37.2% (95% CI, 34.1-40.3%), renal failure was 29.7% (95% CI, 26.8-32.6%) and increased albuminuria was 20.6% (95% CI, 17.3-23.9%), moderately increased albuminuria was 17.8% (95% CI, 14.7-20.9%) and severely increased albuminuria was 2.8% (95% CI, 1.4-4.2%). In turn, the prevalence of CKD categories were: G1 1.3% (95% CI, 0.6-2%), G2 6.2% (95% CI, 4.6-7.8%), G3a 17.2% (95% CI, 14.8-19.6%), G3b 9.8% (95% CI, 7.9-11.7%), G4 2% (95% CI, 1.1-2.9%) and G5 0.7% (95% CI, 0.2-1.2%). In the multivariate analysis, after adjusting for the remaining variables, CKD was associated with elderly age (OR 5.13, 95% CI, 3.15-8.35), high comorbidity (OR 3.36. 95% CI, 2.2-5.12) and presence of antihypertensive treatment (OR 2.43. 95% CI, 1.48-4.02). CONCLUSIONS: CKD is frequent in the diabetic population ≥ 65 years of age and is associated with elderly age, high comorbidity and with treated hypertension. No relationship has been found with gender and time in years since onset of diabetes.

Validation in daily clinical situations of Diascope®, a software developed to help healthcare professionals individualize antidiabetic treatment in type 2 diabetes. / Validación en situaciones clínicas reales del DiaScope®, un software de ayuda al profesional sanitario en la individualización del tratamiento antidiabético en la diabetes tipo 2.

INTRODUCTION: DiaScope® is a software to help in individualized prescription of antidiabetic treatment in type 2 diabetes. This study assessed its value and acceptability by different professionals. MATERIAL AND METHODS: DiaScope® was developed based on the ADA-EASD 2012 algorithm and on the recommendation of 12 international diabetes experts using the RAND/UCLA appropriateness method. The current study was performed at a single session. In the first phase, 5 clinical scenarios were evaluated, selecting the most appropriated therapeutic option among 4 possibilities (initial test). In a second phase, the same clinical cases were evaluated with DiaScope® (final test).Opinion surveys on DiaScope® were also performed (questionnaire). RESULTS: DiaScope® changed the selected option 1 or more times in 70.5% of cases. Among 275 evaluated questionnaires, 54.0% strongly agree that DiaScope® allowed finding easily a similar therapeutic scenario to the corresponding patient, and 52.5 among the obtained answers were clinically plausible. Up to 58.3% will recommend it to a colleague. In particular, primary care physicians with >20 years of professional dedication found with DiaScope® the most appropriate option for a particular situation against specialists or those with less professional dedication (p<.05). DISCUSSION: DiaScope® is an easy to use tool for antidiabetic drug prescription that provides plausible solutions and is especially useful for primary care physicians with more years of professional practice.

Validación en situaciones clínicas reales del DiaScope(R), un software de ayuda al profesional sanitario en la individualización del tratamiento antidiabético en la diabetes tipo 2 / Validation in daily clinical situations of Diascope(R), a software developed to help healthcare professionals individualize antidiabetic treatment in type 2 diabetes

Introducción: DiaScope(R) es un software de ayuda a la prescripción individualizada del tratamiento antidiabético en la diabetes tipo 2. Este estudio evalúa la utilidad y aceptabilidad de dicha aplicación entre diferentes profesionales. Material y métodos: DiaScope(R) fue desarrollado en base al algoritmo de la ADA-EASD 2012 y con las recomendaciones de 12 expertos en diabetes internacionales, usando el método RAND/UCLA Appropriateness Method. El presente estudio se llevó a cabo en una sola reunión. En una primera fase, se evaluaron de 5 escenarios clínicos, eligiendo la opción terapéutica más adecuada entre 4 posibilidades (test inicial). En una segunda fase, estos mismos casos clínicos fueron evaluados con DiaScope(R) (test final). Además, se realizaron encuestas de opinión sobre DiaScope(R) (cuestionario). Resultados: DiaScope(R) modificó la opinión una o más veces en un 70,5% de los casos. De los 276 cuestionarios evaluados, un 54,0% estuvieron muy de acuerdo en que DiaScope(R) permitía encontrar con facilidad un escenario terapéutico similar al de un paciente determinado, y un 52,5% en que las respuestas obtenidas eran clínicamente plausibles. Hasta un 58,3% se lo recomendaría a un compañero. En particular, los médicos de Atención Primaria y>20 años de ejercicio profesional encontraron con DiaScope(R) la opción terapéutica más adecuada para una situación concreta, frente a médicos de Atención Especializada o con menos años de ejercicio profesional (p<0,05). Discusión: DiaScope(R) es una herramienta de ayuda en la prescripción de antidiabéticos, de uso sencillo, con soluciones plausibles, especialmente útil en profesionales de Atención Primaria, con más años de ejercicio profesional (AU)

Introduction: DiaScope(R) is a software to help in individualized prescription of antidiabetic treatment in type 2 diabetes. This study assessed its value and acceptability by different professionals. Material and methods: DiaScope(R) was developed based on the ADA-EASD 2012 algorithm and on the recommendation of 12 international diabetes experts using the RAND/UCLA appropriateness method. The current study was performed at a single session. In the first phase, 5 clinical scenarios were evaluated, selecting the most appropriated therapeutic option among 4 possibilities (initial test). In a second phase, the same clinical cases were evaluated with DiaScope(R) (final test).Opinión surveys on DiaScope(R) were also performed (questionnaire). Results: DiaScope(R) changed the selected option 1 or more times in 70.5% of cases. Among 275 evaluated questionnaires, 54.0% strongly agree that DiaScope(R) allowed finding easily a similar therapeutic scenario to the corresponding patient, and 52.5 among the obtained answers were clinically plausible. Up to 58.3% will recommend it to a colleague. In particular, primary care physicians with >20 years of professional dedication found with DiaScope(R) the most appropriate option for a particular situation against specialists or those with less professional dedication (p<.05). Discussion: DiaScope(R) is an easy to use tool for antidiabetic drug prescription that provides plausible solutions and is especially useful for primary care physicians with more years of professional practice (AU)

Modifiable risk factors associated with prediabetes in men and women: a cross-sectional analysis of the cohort study in primary health care on the evolution of patients with prediabetes (PREDAPS-Study).

BACKGROUND: Prediabetes is a high-risk state for diabetes development, but little is known about the factors associated with this state. The aim of the study was to identify modifiable risk factors associated with the presence of prediabetes in men and women. METHODS: Cohort Study in Primary Health Care on the Evolution of Patients with Prediabetes (PREDAPS-Study) is a prospective study on a cohort of 1184 subjects with prediabetes and another cohort of 838 subjects without glucose metabolism disorders. It is being conducted by 125 general practitioners in Spain. Data for this analysis were collected during the baseline stage in 2012. The modifiable risk factors included were: smoking habit, alcohol consumption, low physical activity, inadequate diet, hypertension, dyslipidemia, and obesity. To assess independent association between each factor and prediabetes, odds ratios (ORs) were estimated using logistic regression models. RESULTS: Abdominal obesity, low plasma levels of high-density lipoprotein cholesterol (HDL-cholesterol), and hypertension were independently associated with the presence of prediabetes in both men and women. After adjusting for all factors, the respective ORs (95% Confidence Intervals) were 1.98 (1.41-2.79), 1.88 (1.23-2.88) and 1.86 (1.39-2.51) for men, and 1.89 (1.36-2.62), 1.58 (1.12-2.23) and 1.44 (1.07-1.92) for women. Also, general obesity was a risk factor in both sexes but did not reach statistical significance among men, after adjusting for all factors. Risky alcohol consumption was a risk factor for prediabetes in men, OR 1.49 (1.00-2.24). CONCLUSIONS: Obesity, low HDL-cholesterol levels, and hypertension were modifiable risk factors independently related to the presence of prediabetes in both sexes. The magnitudes of the associations were stronger for men than women. Abdominal obesity in both men and women displayed the strongest association with prediabetes. The findings suggest that there are some differences between men and women, which should be taken into account when implementing specific recommendations to prevent or delay the onset of diabetes in adult population.

Efficacy of treatment with a basal–prandial insulin regimen in patients with type 2 diabetes mellitus previously treated with premixed insulin / Eficacia del tratamiento con un régimen de insulina basal-prandial en pacientes con diabetes mellitus tipo 2 tratados previamente con insulina premezclada

INTRODUCTION: Premixed insulins are a common treatment for type 2 diabetes mellitus (DM). However, their limitations and the lack of achieving glycaemic control in some patients reinforce the need to find therapeutic alternatives. OBJECTIVES: To assess whether basal-prandial therapy (basal insulin, and additional pre-prandial rapid insulin boluses, when required) improves glycaemic control in patients with type 2 DM and glycosylated haemoglobin (HbA1c) > 53 mmol/mol (7%) treated with premixed insulin in the primary care setting. MATERIAL AND METHODS: A retrospective observational study in which 116 patients with type 2 DM switched from premixed insulin to basal-prandial therapy. Data on demographics, anthropometrics, laboratory results, and antidiabetic treatment were collected from the medical charts of the patients, prior to switching the treatment (baseline) and 4 months thereafter. RESULTS: HbA1c significantly decreased from baseline to month 4 (65.1 ± 5.7 mmol/mol [8.1 ± 0.5%] versus 51.9 ± 7.2 mmol/mol [6.9 ± 0.7%]; p < 0.005), and 70 patients (60.9%) had an HbA1c minor= 53 mmol/mol (7%). Additionally, fasting blood glucose (FBG) significantly decreased (9.7 ± 1.7 mmol/l [175.4 ± 31.2 mg/dl] versus 6.9 ± 1.4 mmol/l [124.4 ± 25.8 mg/dl]; p < 0.005), and the number of patients with FBG < 5.6 mmol/l (100 mg/dl) (2 patients [1.7%] versus 21 patients [18.3%]; p < .005), and with post-prandial blood glucose minor= 10 mmol/l (180 mg/dl) (14 patients, [12.1%] versus 87 patients [76.3%]; p < 0.05) significantly increased. There were also significant decreases in body weight (76.3 ± 12.9 kg versus 74.8 ± 12.5 kg; p < 0.001) and waist circumference (96.1 ± 16.0 cm versus 94.4±14.5cm; p < 0.005). Only 4 patients (3.5%) had hypoglycaemia. CONCLUSIONS: Basal-prandial therapy improved glycaemic control in patients with type 2 DM, with a low incidence of hypoglycaemia, and decreased body weight

INTRODUCCIÓN: Las insulinas premezcladas constituyen un tratamiento habitual de la diabetes mellitus (DM) tipo2. Sin embargo, sus limitaciones y la ausencia de control glucémico en algunos pacientes refuerzan la necesidad de encontrar alternativas terapéuticas. OBJETIVOS: Analizar si la terapia basal-prandial (insulina basal y bolos adicionales de insulina rápida preprandial cuando sea necesario) mejora el control glucémico de los pacientes con DM tipo2 y hemoglobina glucosilada (HbA1c) > 53mmol/mol (7%) pese al tratamiento con insulinas premezcladas en atención primaria. MATERIAL Y MÉTODOS: Estudio observacional retrospectivo en 116 pacientes con DM tipo 2 cuyo tratamiento cambió de insulina premezclada a terapia basal-prandial. Se recogieron datos demográficos, antropométricos, analíticos y tratamiento antidiabético de la historia clínica de los pacientes antes del cambio del tratamiento (basal) y 4 meses después. RESULTADOS: La HbA1c descendió significativamente entre el momento basal y el mes 4 (65,1 ± 5,7 mmol/mol [8,1 ± 0,5%] versus 51,9 ± 7,2 mmol/mol [6,9 ± 0,7%]; p < 0,005), y 70 pacientes (60,9%) mostraron HbA1cmenor = 53 mmol/mol (7%). Además, la glucemia en ayunas (FBG) disminuyó significativamente (9,7 ± 1,7 mmol/l [175,4 ± 31,2 mg/dl] versus 6,9 ± 1,4 mmol/l [124,4 ± 25,8 mg/dl]; p < 0,005), y aumentó significativamente el número de pacientes con FBG < 5,6 mmol/l (100mg/dl) (2 pacientes [1,7%] versus 21pacientes [18,3%]; p < 0,005) y con glucemia postprandial menor= 10 mmol/l (180 mg/dl) (14pacientes [12,1%] versus 87 pacientes [76,3%]; p < 0,05). Se observaron descensos significativos del peso corporal (76,3 ± 12,9 versus 74,8 ± 12,5 kg; p < 0,001) y del perímetro de cintura (96,1 ± 16,0 versus 94,4 ± 14,5 cm; p < 0,005). Solamente 4 pacientes (3,5%) sufrieron hipoglucemia. CONCLUSIONES: La terapia basal-prandial logró mejorar el control metabólico de los pacientes con DM tipo2, con una baja incidencia de hipoglucemias y pérdida de peso

Guías de práctica clínica en diabetes mellitus tipo 2: concordancias y discrepancias / Clinical practice guidelines in type 2 diabetes mellitus: similarities and discrepancies

Tras el análisis pormenorizado de las recomendaciones terapéuticas de las principales guías de práctica clínica (GPC) podemos observar cómo, a pesar de parecer muy diferentes tanto en su forma como en su contenido, presentan más semejanzas que discrepancias. La metformina es un fármaco recomendado de primera elección tanto en monoterapia como en doble terapia oral en las 5 GPC incluidas. También las sulfonilureas son de elección para todas las guías en la doble terapia oral, aunque también todas incluyen en este escalón, ya sea como primera o segunda elección, a las glitazonas. Además, existe unanimidad en la recomendación del uso de insulina por todas las GPC cuando fracasan las combinaciones de antidiabéticos, aconsejando inicialmente la introducción de una dosis de insulina basal junto a metformina. El resto de alternativas terapéuticas tiene menor presencia. Con relación al objetivo de buen control glucémico, también existen discrepancias entre las distintas GPC ya que una recomienda una HbA1c ≤ 6,5%, otras HbA1c < 7 %, y, por último, en una de ellas se recomienda en estadios iniciales una HbA1c 6,5% y en casos avanzados HbA1c < 7,5 (AU)

A careful analysis of the therapeutic recommendations of the main clinical practice guidelines (CPGs) reveals that, although they appear to be highly diverse both in their form and content, they share more similarities than discrepancies. Metformin is the recommended first-line drug both in monotherapy and double oral therapy in the 5 CPGs included in this study. Sulphonylureas are also the standard of care for all the guidelines on dual oral therapy, although they also include glitazones and DPP-4 inhibitors at this stage as well, as a first or a second-line drug. Moreover, there is unanimous agreement on the recommendation of the use of insulin by all the CPGs when anti-diabetes combinations prove ineffective, initially advising the application of a basal insulin dose in conjunction with metformin. Other therapeutic alternatives are given less coverage. In relation to the aim of achieving good glycemic control, there are discrepancies amongst the different CPGs, as one recommends target HbA1c ≤ 6.5% and others < 7%. Finally, one recommends target HbA1c 6.5% in the initial phases and < 7.5% in advanced cases (AU