High levels of fasting glucose and glycosylated hemoglobin values are associated with hyperfiltration in a Spanish prediabetes cohort. The PREDAPS Study.

AIM: This study aimed to investigate whether different levels of fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) in prediabetes are associated with hyperfiltration. METHODS: A prospective cohort of 2,022 individuals aged 30-74 years took part in the PREDAPS Study. One cohort of 1,184 participants with prediabetes and another cohort of 838 participants with normal FPG and normal HbA1c were followed for 5 years. Hyperfiltration was defined as an estimated glomerular filtration rate (eGFR) above the age- and gender-specific 95th percentile for healthy control participants, while hypofiltration was defined as an eGFR below the 5th percentile. The prevalence of hyperfiltration was compared for different levels of prediabetes: level 1 of prediabetes: FPG <100 mg/dL plus HbA1c 5.7-6.0% or FPG 100-109 mg/dL plus HbA1c < 5.7%; level 2 of prediabetes: FPG <100 mg/dL plus HbA1c 6.1-6.4% or FPG 100-109 mg/dL plus HbA1c 5.7-6.0% or FPG 110-125 mg/dL plus HbA1c <5.7% and level 3 of prediabetes: FPG 100-109 mg/dL plus HbA1c 6.1-6.4% or FPG 110-125 mg/dL plus HbA1c 5.7-6.4%. RESULTS: The participants with hyperfiltration were significantly younger, had a higher percentage of active smokers, and lower levels of hemoglobin and less use of ACEIs or ARBs. Only level 3 prediabetes based on FPG 100-109 mg/dL plus HbA1c 6.1-6.4% or FPG 110-125 mg/dL plus HbA1c 5.7-6.4% had a significantly higher odds ratio (OR) of hyperfiltration (OR 1.69 (1.05-2.74); P < 0.001) compared with no prediabetes (FPG < 100 mg/dL and HbA1c < 5.7%) after adjustment for different factors. The odds ratios for different levels of HbA1c alone in prediabetes increased progressively, but not significantly. CONCLUSIONS: Level 3 of prediabetes based on FPG 100-109 mg/dL plus HbA1c 6.1-6.4% or FPG 110-125 mg/dL plus HbA1c 5.7-6.4% had a significantly higher OR of hyperfiltration compared with participants without prediabetes.

[Metabolic control or reduction of vascular risk with current treatments. What is the priority?] / Control metabólico o reducción del riesgo vascular con los tratamientos actuales: ¿qué es prioritario?

In patients with type 2 diabetes, tight glycemic control prevents or delays the develop-ment of microvascular complications. In contrast, there is continued debate on the effect of macrovascular complications and the role of early glycaemic control on the ensuing cardiovascular disease. Although large randomised clinical trials have not shown a clearly beneficial effect of intensive control in the short term, subsequent follow-up studies of participants in these trials suggest a favourable cardiovascular effect in the long term. Due to doubts about the increased risk of myocardial infarction with rosiglitazone, for the last few years regulatory agencies have required sponsors to demonstrate the cardiovascular safety of new drugs before they can be approved for the treatment of hyperglycae-mia. The cardiovascular safety trials published to date have shown that the new drugs do not increase cardiovascular risk and that some molecules may even provide some cardiovascular protection. These findings raise the following question: what is the priority when selecting lipid-low-ering drugs - metabolic control or reduced cardiovascular risk? The answer lies in the word individualisation. Treatment cannot focus solely on cardiovascular safety, without considering microvascular complications, which cause high morbidity and mortality. Patients with recent onset diabetes and long life expectancy will benefit from tight meta-bolic control. Patients with diabetes and established cardiovascular disease or at high risk are candidates for treatment that includes drugs with a demonstrated benefit in this pa-tient group.

Control metabólico o reducción del riesgo vascular con los tratamientos actuales: ¿qué es prioritario? / Metabolic control or reduction of vascular risk with current treatments. What is the priority?

En el paciente con diabetes tipo 2, el control estricto de la glucemia previene o retrasa la aparición de complicaciones microvasculares. Por el contrario, sigue siendo debatido el efecto sobre las complicaciones macrovasculares y cuál es el papel del control glucémico precoz sobre la enfermedad cardiovascular subsiguiente. Aunque grandes ensayos clínicos aleatorizados no han mostrado un efecto claramente benefcioso del control intensivo a corto plazo, estudios posteriores de seguimiento de los participantes en estos ensayos sugieren un efecto cardiovascular favorable a largo plazo. Desde hace unos años, a raíz de las dudas sobre el aumento del riesgo de infarto de miocardio provocado por la rosiglitazona, las agencias reguladoras solicitan que, previa aprobación de una nueva molécula para el tratamiento de la hiperglucemia, el patrocinador demuestre que es segura desde el punto de vista cardiovascular. Los ensayos de seguridad cardiovascular publicados hasta el momento han evidenciado que los nuevos fármacos no incrementan el riesgo e, incluso, que algunas moléculas pueden proporcionar cierta protección cardiovascular. Ante estos hallazgos, ¿qué es prioritario al elegir el tratamiento hipoglucemiante: el control metabólico o la reducción del riesgo cardiovascular?. La palabra individualización ofrece la respuesta. No se puede situar el foco terapéutico únicamente en la seguridad cardiovascular dejando al margen las complicaciones micro-vasculares, causa de elevada morbimortalidad. Las personas con diabetes poco evolucionada y larga expectativa de vida se benefciarán de un control metabólico estricto. Los pacientes con diabetes y enfermedad cardiovascular establecida o elevado riesgo serán candidatos a un tratamiento que incluya fármacos que han demostrado un benefcio en este perfl de pacientes

In patients with type 2 diabetes, tight glycemic control prevents or delays the develop-ment of microvascular complications. In contrast, there is continued debate on the effect of macrovascular complications and the role of early glycaemic control on the ensuing cardiovascular disease. Although large randomised clinical trials have not shown a clearly beneficial effect of intensive control in the short term, subsequent follow-up studies of participants in these trials suggest a favourable cardiovascular effect in the long term. Due to doubts about the increased risk of myocardial infarction with rosiglitazone, for the last few years regulatory agencies have required sponsors to demonstrate the cardiovascular safety of new drugs before they can be approved for the treatment of hyperglycae-mia. The cardiovascular safety trials published to date have shown that the new drugs do not increase cardiovascular risk and that some molecules may even provide some cardiovascular protection. These findings raise the following question: what is the priority when selecting lipid-low-ering drugs - metabolic control or reduced cardiovascular risk?. The answer lies in the word individualisation. Treatment cannot focus solely on cardiovascular safety, without considering microvascular complications, which cause high morbidity and mortality. Patients with recent onset diabetes and long life expectancy will benefit from tight meta-bolic control. Patients with diabetes and established cardiovascular disease or at high risk are candidates for treatment that includes drugs with a demonstrated benefit in this pa-tient group

Prevalence of depression in patients with type 2 diabetes attended in primary care in Spain.

OBJECTIVES: To estimate the prevalence of known and undiagnosed depression in patients with type 2 diabetes attended in primary care setting in Spain, and to determine the factors associated with the presence of depression. METHODS: This was a cross-sectional and multicenter study performed in a random sample of patients with type 2 diabetes attended in 21 primary care centers. Depressive symptoms were measured with the self-administered Patient Health Questionnaire (PHQ-9). RESULTS: A total of 411 patients were analyzed (mean age 70.8 (SD 10.3) years; 53.8% women). 29.2% of patients met the diagnostic criteria of depression, of whom 17% had known depression and 12.2% undiagnosed depression (PHQ-9 score ≥10, without a previous diagnosis of depression). Depression was more common in women (43.4%; 95% confidence interval [CI] 34.5-52.3%), widow (33.3%; 95% CI 27.9-38.7%), and hypothyroidism (12.5%; 95% CI 8.7-16.3%). Cardiovascular risk factors, the degree of control, complications related to diabetes, antidiabetic therapy and the number of drugs were not associated with the presence of depression. CONCLUSIONS: The prevalence of depression was high in patients with type 2 diabetes. However, in approximately 40% of patients depression was undiagnosed. The complications related to diabetes and antidiabetic therapy were not associated with the presence of depression.

Glycemic control and use of A1c in primary care patients with type 2 diabetes mellitus.

AIMS: To evaluate the degree of glycemic control and its relationship with disease characteristics and antidiabetic treatment in patients with type 2 diabetes mellitus (DM), as well as the frequency of A1c use. METHODS: For this purpose, an observational, cross-sectorial, and multicenter study was performed. A total of 443 patients were monitored in 17 Spanish primary healthcare centers. Demographic and clinical variables were recorded from the clinical history of patients. RESULTS: Mean age was 68.9±12.0 years. Time of evolution of DM was 9.2±6.4 years. Mean A1c was 7.38±1.34% and 45% of patients achieved A1c <7%. There was a no significant relationship between the degree of control and time of evolution of DM. In 16% of patients no A1c determination was performed in the previous twelve months. In those patients in whom A1c was determined, 95% received pharmacologic treatment, and 31% insulin therapy. 66% of patients on monotherapy attained A1C <7%, compared with 39% and 23% of those receiving double- and triple-oral therapy, respectively (p<0.001). Only 21% of patients on insulin therapy achieved A1c <7%. The worst-controlled patients were those receiving oral antidiabetic agents and insulin (24% had A1c levels ≥9%). CONCLUSIONS: A large proportion of patients are poorly controlled. Poor control increases according to complexity of treatment. A1c is underdetermined in many patients, likely related to clinical inertia.

Evaluación de la realización del cribado del pie diabético en Atención Primaria / Evaluation of diabetic foot screening in Primary Care

OBJETIVO: Conocer si se realiza el cribado del pie diabético en pacientes con diabetes tipo 2 atendidos en Atención Primaria y analizar qué factores relacionados con el paciente y el centro de salud se asocian a la cumplimentación de dicho cribado. MATERIAL Y MÉTODO: Estudio epidemiológico, transversal y multicéntrico. Se revisaron las historias clínicas de una muestra representativa (n = 443) de pacientes con diabetes tipo 2 que habían sido seguidos en Atención Primaria como mínimo en los 12 meses previos. Se registraron variables demográficas, de proceso asistencial y características del centro. RESULTADOS: El 51,2% de los pacientes recibieron educación sanitaria sobre el autocuidado del pie, al 56,4% se le realizó inspección de los pies, el 39,5% fueron explorados con monofilamento, y en el 45,8 y 10,1% se realizó palpación de pulsos periféricos e índice tobillo-brazo, respectivamente. El cribado del pie diabético (inspección, exploración de sensibilidad con monofilamento y palpación de pulsos periféricos) fue efectuado al 37% de los pacientes estudiados, y la estratificación del riesgo de úlceras se determinó en el 12,4% de los casos. Existe asociación entre realización del cribado y presencia de deformidades en el pie (p < 0,001), antecedentes de neuropatía (p = 0,005) y arteriopatía periférica (p < 0,05). También se asocia a algunas características del centro: recibir información sobre consecución de objetivos (p < 0,001), y percepción de incentivos económicos por cumplimiento de los mismos (p < 0,001). CONCLUSIONES: Se constata una deficiente atención a las personas con diabetes tipo 2 respecto a la prevención del pie diabético, pues no se realiza de forma rutinaria cribado y estratificación de riesgo

AIM: To ascertain whether patients with type 2 diabetes are screened for diabetic foot, and to analyze the factors related to patients and centers associated to performance of such screening. MATERIAL AND METHODS: A multicenter, epidemiological, cross-sectional study was conducted. The clinical records of 443 patients with type 2 diabetes monitored at Primary Care for at least 12 months were reviewed. Demographic and healthcare variables and characteristics of the primary care center were recorded. RESULTS: In the previous year, 51.2% of patients had been trained on foot self-care, 56.4% had undergone foot inspection, 39.5% had been examined with a monofilament, and palpation of peripheral pulses and measurement of the ankle-brachial index were performed in 45.8 and 10.1% of patients, respectively. Diabetic foot screening (inspection, monofilament testing, and palpation of peripheral pulses) was performed in 37% of study patients. Ulcer risk stratification was done in 12.4% of patients. A significant association was found between diabetic foot screening and presence of foot deformities (P < .001), history of neuropathy (P = .005), and history of peripheral artery disease (P < .05). Screening was also associated to some characteristics of the center, such as reception of information about goal achievement (P < .001) and economic incentives for goal attainment (P < .001). CONCLUSIONS: Compliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor

Tratamiento del anciano con diabetes / Treatment of older persons with diabetes

La prevalencia de la diabetes aumenta con la edad. En España, casi un tercio de las personas mayores de 75 años presenta esta patología y el diagnóstico es desconocido en el 10% de los casos. El abordaje en este grupo etario está condicionado por la coexistencia de comorbilidades y síndromes geriátricos, así como por la polifarmacia a la que suelen estar sometidos estos pacientes. Todas las guías de práctica clínica recomiendan que el objetivo de control sea individualizado en función de factores como el tiempo de evolución de la enfermedad, la presencia de complicaciones, el estado funcional, la expectativa de vida y el entorno del paciente, entre otros. El planteamiento terapéutico, en términos generales, no difiere del recomendado en población más joven: multifactorial, considerando cambios de estilo de vida y control de la hiperglucemia y resto de factores de riesgo cardiovascular. La hipoglucemia, más frecuente y grave en este grupo etario, es la principal limitación. Las recomendaciones terapéuticas en los ancianos con diabetes están basadas en la opinión de expertos, ya que los ensayos clínicos suelen excluir a este tipo de pacientes, por lo que se utilizará el juicio clínico para optimizar el tratamiento antidiabético en el que primarán las acciones encaminadas a evitar los síntomas de la enfermedad y mejorar la calidad de vida. Los inhibidores de la DPP-4 pueden ser utilizados por su bajo riesgo de hipoglucemias y seguridad. Se debe realizar una evaluación del estado funcional y cognitivo antes de iniciar cualquier medida terapéutica, valorando la relación riesgo/ beneficio de esta (AU)

The prevalence of diabetes increases with age. In Spain, almost a third of persons older than 75 years have diabetes, and 10% of cases are undiagnosed. The approach in this age group is influenced by the coexistence of comorbidities and geriatric syndromes, as well as by the polypharmacy found in these patients. All the clinical practice guidelines recommend that glycemic control be individually tailored according to such factors as disease duration, the presence of complications, functional status, life expectancy, and the patient's environment, among other elements. In general, the therapeutic approach in older persons does not differ from that recommended in the younger population: it should be multifactorial, considering lifestyle modifications and control of hyperglycemia and the remaining cardiovascular risk factors. The main limitation is hypoglycemia, which is the most common and severe factor in this age group. Therapeutic recommendations in elderly persons with diabetes are based on expert opinion, since these patients are usually excluded from clinical trials. Consequently, clinical judgment is required to optimize the treatment of diabetes, with an emphasis on interventions to prevent symptoms and improve quality of life. DPP-4 inhibitors can be used, due to their low risk of hypoglycemias and safety. Before any treatment is started, its risk/benefit ratio should be evaluated, along with the patient's functional and cognitive status (AU)

Evaluation of diabetic foot screening in Primary Care.

AIM: To ascertain whether patients with type 2 diabetes are screened for diabetic foot, and to analyze the factors related to patients and centers associated to performance of such screening. MATERIAL AND METHODS: A multicenter, epidemiological, cross-sectional study was conducted. The clinical records of 443 patients with type 2 diabetes monitored at Primary Care for at least 12 months were reviewed. Demographic and healthcare variables and characteristics of the primary care center were recorded. RESULTS: In the previous year, 51.2% of patients had been trained on foot self-care, 56.4% had undergone foot inspection, 39.5% had been examined with a monofilament, and palpation of peripheral pulses and measurement of the ankle-brachial index were performed in 45.8 and 10.1% of patients, respectively. Diabetic foot screening (inspection, monofilament testing, and palpation of peripheral pulses) was performed in 37% of study patients. Ulcer risk stratification was done in 12.4% of patients. A significant association was found between diabetic foot screening and presence of foot deformities (P<.001), history of neuropathy (P=.005), and history of peripheral artery disease (P<.05). Screening was also associated to some characteristics of the center, such as reception of information about goal achievement (P<.001) and economic incentives for goal attainment (P<.001). CONCLUSIONS: Compliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor.