Perfiles de hipoglicemiantes e insulinas en pacientes con diabetes mellitus tipo 2 y su efecto en control metabólico, hipoglicemia y otros efectos adversos / Profile of glucose lowering drug use in outpatients with type 2 diabetes mellitus

BACKGROUND: The use of glucose lowering agents with favorable weight profile is a growing practice in Diabetology. AIM: To characterize medication combinations in patients with type 2 Diabetes (T2D) and their effect on metabolic control. MATERIAL AND METHODS: Review of medical records of 249 outpatients with T2D with a median age of 66 years, cared for at a medical network. Clinical characteristics, glycated hemoglobin (HbA1c), details of Diabetes treatment (types of drugs or insulin), renal function, lipids and B12 vitamin levels were registered. RESULTS: The median disease duration was 16 years. The most recent HbA1c was 7.4%. No patient was using sulfonylureas, 45 were using Dipeptidyl peptidase 4 inhibitors, 113 were using Sodium-glucose Cotransporter-2 (SGLT2i) Inhibitors, 21 used Glucagon-like Peptide-1 Receptor Agonists (GLP1ra), 158 used basal insulin and 61 on basal plus bolus insulin. The use of SGLT2i or GLP1ra was associated with a metabolic control similar to those patients not using them, while patients on rapid insulin had a significantly worse metabolic control and a tendency to greater body mass index. The use of basal insulin and rapid insulin was significantly associated with more hypoglycemia events. CONCLUSIONS: The use of SGLT2i and GLP1ra in patients with T2D is associated with better metabolic control than rapid insulin with less risk of hypoglycemia. The use of these therapies should be prioritized in the future.

Adesão ao tratamento e qualidade de vida em população diabética admitida em serviço público / Adherence to treatment and quality of life in a diabetic population admitted to a public service facility

Objetivo: Avaliar a adesão ao tratamento e a qualidade de vida de pacientes diabéticos e identificar características epidemio- lógicas e da doença relacionadas. Métodos: Estudo transversal realizado com 98 pacientes diabéticos em acompanhamento. Foram aplicados: um questionário sociodemográfico; o Diabe- tes Quality of Life na versão brasileira, para avaliar qualidade de vida, e o teste Morisky-Green-Levine, para checar a adesão ao tratamento. O nível de significância adotado foi de 5%. Resul- tados: A maioria (87,8%) dos pacientes apresentou boa quali- dade de vida. O escore médio de qualidade de vida foi de 2,2. Existência de complicações, uso de insulina e má adesão ao tra- tamento foram fatores associados à pior qualidade de vida. A boa adesão ao tratamento (58,2%) foi associada à boa qualidade de vida (p<0,001). Conclusão: A boa adesão ao tratamento está relacionada à boa qualidade de vida. Deve-se enfatizar a impor- tância da adesão ao tratamento para prevenção de possíveis com- plicações e manutenção da qualidade de vida.

Objective: To evaluate adherence to treatment and quality of life of diabetic patients and to identify related epidemiological and disease characteristics. Methods: Cross-sectional study conducted with 98 diabetic patients undergoing treatment. A socio-demographic questionnaire, the Diabetes Quality of Life in the Brazilian version (to measure quality of life) and the Mo- risky-Green-Levine test (to check adherence to treatment) were applied. The level of significance was set at 5%. Results: Most patients (87.8%) showed good quality of life. The mean score of quality of life was 2.2. The existence of complications, insulin use, and poor treatment adherence were factors associated with worse quality of life. Good adherence to treatment, (58.2%) was associated with good quality of life (p<0.001). Conclusion: Satis- factory treatment adherence is associated with good quality of life. The importance of adherence to treatment to prevent possible complications and maintain quality of life shall be emphasized.

Making a case for the combined use of SGLT2 inhibitors and GLP1 receptor agonists for cardiorenal protection / Argumentando a favor do uso combinado de inibidores de SGLT2 e agonistas do receptor GLP1 para proteção cardiorrenal

ABSTRACT Sodium glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) were initially approved to improve glycemic control in the treatment of type 2 diabetes. Clinical trials have also demonstrated beneficial effects with regards to cardiovascular and renal parameters. Beyond improving glycemic control, these therapies promote weight loss and lower blood pressure when used individually, and in an additive manner when used together. Accordingly, taking advantage of complementary mechanisms of action with the combined use of these two classes of agents to further improve cardiorenal outcomes is conceptually appealing, but has yet to be explored in detail in clinical trials. In this review, we discuss proposed mechanisms for renal protection, clinical benefits, and adverse events associated with the individual and combined use of SGLT2 inhibitors and GLP-1RA. The management of type 2 diabetes has significantly changed over the last few years, moving away from solely glycemic control towards the concurrent management of associated comorbidities in a patient population at significant risk of cardiovascular disease and progression of chronic kidney disease. It is from this perspective that we seek to outline the rationale for the sequential and/or combined use of SGLT2 inhibitors and GLP-1RA in patients with type 2 diabetes.

RESUMO Inibidores do cotransporter-2 de glicose sódica (SGLT2) e agonistas do receptor peptídeo-1 do tipo glucagon (GLP-1RA) foram inicialmente aprovados para melhorar o controle glicêmico no tratamento da diabetes tipo 2. Os ensaios clínicos também demonstraram efeitos benéficos em relação aos parâmetros cardiovasculares e renais. Além de melhorar o controle glicêmico, essas terapias promovem perda de peso e redução da pressão arterial quando usadas individualmente, e de forma aditiva quando usadas em conjunto. Consequentemente, tirar proveito de mecanismos de ação complementares com o uso combinado dessas duas classes de agentes para melhorar ainda mais os resultados cardiorrenais é conceitualmente atraente, mas ainda precisa ser explorado em detalhes em ensaios clínicos. Nesta revisão, discutimos os mecanismos propostos para proteção renal, benefícios clínicos e eventos adversos associados ao uso individual e combinado de inibidores de SGLT2 e GLP-1RA. O tratamento do diabetes tipo 2 mudou significativamente nos últimos anos, passando do controle exclusivamente glicêmico para o tratamento simultâneo de comorbidades associadas em uma população de pacientes com risco significativo de doença cardiovascular e progressão da doença renal crônica. É nessa perspectiva que procuramos delinear a justificativa para o uso sequencial e/ou combinado de inibidores de SGLT2 e GLP-1RA em pacientes com diabetes tipo 2.

SGLT-2 inhibitors in diabetes: a focus on renoprotection

SUMMARY Type 2 diabetes mellitus is an important public health problem, with a significant impact on cardiovascular morbidity and mortality and an important risk factor for chronic kidney disease. Various hypoglycemic therapies have proved to be beneficial to clinical outcomes, while others have failed to provide an improvement in cardiovascular and renal failure, only reducing blood glucose levels. Recently, sodium-glucose cotransporter-2 (SGLT2) inhibitors, represented by the empagliflozin, dapagliflozin, and canagliflozin, have been showing satisfactory and strong results in several clinical trials, especially regarding the reduction of cardiovascular mortality, reduction of hospitalization due to heart failure, reduction of albuminuria, and long-term maintenance of the glomerular filtration rate. The benefit from SGLT2 inhibitors stems from its main mechanism of action, which occurs in the proximal tubule of the nephron, causing glycosuria, and a consequent increase in natriuresis. This leads to increased sodium intake by the juxtaglomerular apparatus, activating the tubule glomerular-feedback and, finally, reducing intraglomerular hypertension, a frequent physiopathological condition in kidney disease caused by diabetes. In addition, this class of medication presents an appropriate safety profile, and its most frequently reported complication is an increase in the incidence of genital infections. Thus, these hypoglycemic agents gained space in practical recommendations for the management of type 2 diabetes mellitus and should be part of the initial therapeutic approach to provide, in addition to glycemic control, cardiovascular outcomes, and the renoprotection in the long term.

Prácticas autoreferidas para controlar la hipertensión y la diabetes mellitus en adultos mayores de Campinas, Brasil, en tres períodos / Self-care management practices for arterial hypertension and diabetes mellitus among elderly people in Campinas, Brazil, in three periods

RESUMEN El objetivo fue estimar la prevalencia de las prácticas autoreferidas para controlar la hipertensión y la diabetes, con y sin medicamentos, en adultos mayores de Campinas, Brasil, en tres períodos. Se analizaron los datos de las encuestas de salud realizadas en tres períodos: 2001-2002, 2008-2009 y 2014-2015. La prevalencia de hipertensión, de diabetes, del uso de medicación continua y las prácticas comportamentales aumentaron durante el período analizado, con una caída significativa en el uso no regular de medicamentos y las consultas médicas de rutina en individuos sin plan de salud privado. Los resultados evidenciaron avances en las prácticas relacionadas con la dieta en aquellas personas sin plan de salud y en quienes declararon contar con plan de salud, destacando mejoras en el tratamiento con medicamentos y la práctica de actividad física. La adherencia al uso de medicamentos y a prácticas comportamentales para controlar las morbilidades se mostró consistente en el período evaluado. Estos indicadores refuerzan la necesidad de mantener y ampliar las políticas dirigidas a la educación sanitaria y la asistencia farmacéutica en el país.

ABSTRACT The objective of this study was to estimate the prevalence of self-care management practices - both with and without medication - in elderly hypertensive and diabetic patients in Campinas, Brazil, in three periods. Data from health surveys conducted in three periods 2001-2002, 2008-2009 and 2014-2015 were analyzed. The prevalence of hypertension, diabetes, the continuous use of medication, and all behavioral practices showed an overall increase in the period analyzed, with a significant drop in both the non-regular use of medications and routine doctor visits on the part of individuals without a private health plan. The results evidenced advances in diet-related practices among individuals without health plans as well as those who reported having healthcare coverage, highlighting improvements in drug treatment and physical activity. Adherence to medication and health behaviors for the management of morbidities was shown to be consistent in the period evaluated. These indicators reinforce the need to maintain and expand policies directed at health education and pharmaceutical assistance in the country.

Beliefs related to insulin use in people with Type 2 Diabetes Mellitus / Creencias relacionadas con el uso de insulina en personas con Diabetes Mellitus tipo 2 / Crenças relacionadas ao uso de insulina em pessoas com Diabetes Mellitus tipo 2

ABSTRACT Objectives: to identify the beliefs of people with Type 2 Diabetes Mellitus related to insulin use. Methods: a descriptive, cross-sectional, quantitative-qualitative study based on Theory of Planned Behavior and performed with 32 participants using insulin. The data were analyzed and grouped into categories by beliefs similarity, counted from the frequencies. Results: 118 behavioral, 60 normative and 97 control beliefs were issued. Among the behavioral beliefs, there was an advantage in keeping the diabetes under control and disadvantage, the pain of being pierced by the application of insulin. Regulations highlighted the children as referents who support the treatment. In control beliefs, it was observed that the application of insulin appears as easiness and difficulty to the treatment. Conclusions: the study will support the construction of a psychometric scale to measure the determinants of insulin use, revealing particularities for the structuring of educational interventions that contribute to adherence of the treatment verified in adequate glycemic control.

RESUMEN Objetivos: identificar las creencias de personas con Diabetes Mellitus tipo 2, relacionadas con el uso de insulina. Métodos: el estudio descriptivo, transversal y cuantitativo, fundamentado en la Theory of Planned Behavior y realizado con 32 participantes en uso de insulina. Los datos fueron analizados y agrupados en categorías por la similitud de las creencias, contabilizados a partir de las frecuencias. Resultados: se emitieron 118 creencias comportamentales, 60 normativas y 97 de control. Entre las creencias comportamentales, se destacó la ventaja en mantener la diabetes controlada y desventaja, dolor de la perforación por la aplicación de insulina. Las normativas destacaron a los hijos como referentes que apoyan el tratamiento. En las creencias de control, se observó que la aplicación de la insulina aparece como facilidad y dificultad al tratamiento. Conclusiones: el estudio subsidiará la construcción de escala psicométrica para medir los factores determinantes del uso de la insulina, desvelando particularidades para la estructuración de intervenciones educativas que contribuyan con adhesión del tratamiento verificado en el control glucémico adecuado.

RESUMO Objetivos: identificar as crenças de pessoas com Diabetes Mellitus tipo 2, relacionadas ao uso de insulina. Métodos: estudo descritivo, transversal e quanti-qualitativo, fundamentado na Theory of Planned Behavior e realizado com 32 participantes em uso de insulina. Os dados foram analisados e agrupados em categorias pela similitude das crenças, contabilizados a partir das frequências. Resultados: foram emitidas 118 crenças comportamentais, 60 normativas e 97 de controle. Entre as crenças comportamentais, destacou-se vantagem em manter o diabetes controlado e desvantagem, dor da furada pela aplicação de insulina. As normativas destacaram os filhos como referentes que apoiam o tratamento. Nas crenças de controle, observou-se que a aplicação da insulina aparece como facilidade e dificuldade ao tratamento. Conclusões: o estudo subsidiará a construção de escala psicométrica para mensurar os fatores determinantes do uso da insulina, desvendando particularidades para estruturação de intervenções educativas que contribuam com adesão do tratamento verificado no controle glicêmico adequado.

Polifarmácia e cognição em pacientes com idade avançada / Polypharmacy and cognition in elderly patients

Objetivo: Avaliar a prevalência da polifarmácia e da prescrição de medicações inapropriadas, bem como suas associações com a capacidade cognitiva e funcional do idoso. Métodos: Estudo observacional transversal, no qual foram analisadas as medicações prescritas em 141 prontuários para pacientes acima de 50 anos, em associação com testes que quantificaram a capacidade funcional e cognitiva deles. Resultados: Observou-se média de 4,41 medicamentos por paciente, sendo que 0,41 deles foram considerados inapropriado, segundo o critério de Beers. Verificou-se também relação estatisticamente significativa quanto ao número de medicações e testes que mediam a capacidade funcional e cognitiva dos idosos. Conclusão: O aumento da polifarmácia e da prescrição de medicações potencialmente inadequadas acarretou significativa piora da capacidade cognitiva e funcional do idoso

Objective: To evaluate the prevalence of polypharmacy and of the prescription of inappropriate medications, as well as their associations with the cognitive and functional capacity of the elderly. Methods: Cross-sectional observational study which analyzed the drugs prescribed in 141 medical records for patients over 50 years of age, associated with tests that quantified their functional and cognitive capacity. Results: An average of 4.41 medications per patient was observed, and 0.41 were considered inappropriate according to the Beers criteria. There was also a statistically significant relation regarding the number of medications and tests that measure the functional and cognitive capacity of the elderly. Conclusion: The increase in polypharmacy and in the prescription of potentially inappropriate medications led to a significant impairment of the cognitive and functional capacity of the elderly

Literacy in health and self-care in people with type 2 diabetes mellitus / Alfabetización en salud y autocuidado en individuos con diabetes mellitus tipo 2 / Alfabetização em saúde e autocuidado em pessoas com diabetes mellitus tipo 2

ABSTRACT Objective: To evaluate the effect of educational intervention in the adherence to self-care activities and functional health literacy and numeracy in people with type 2 diabetes mellitus. Methods: This was a quasi-experimental study conducted in two units of the Brazilian Family Health Strategy, involving people with diabetes. Educational interventions occurred in three meetings, weekly, lasting 60 minutes on average. Data were collected using the Questionário de Autocuidado com o Diabetes, before and after the interventions. Results: 55 people participated in the study. After the interventions, the greatest difference for a better adherence to self-care was the item "inspecting the inside of the shoes before putting them on", with 3.29 days in the week delta at analytical level. The worst was "taking insulin shots as recommended", with 0.00 days a week delta at basic level. Conclusion: Educational interventions had a positive effect on adherence to self-care and functional literacy in health.

RESUMEN Objetivo: Evaluar el resultado de una intervención educativa en la adhesión a las actividades de autocuidado y de literacidad funcional en salud en el dominio de numeración en individuos con diabetes mellitus tipo 2. Método: Estudio casi experimental realizado en dos unidades de estrategia de salud de la familia, del cual participaron individuos con diabetes. Las intervenciones educativas se realizaron durante tres encuentros semanales, con una duración media de 60 minutos cada una. Los datos fueron recolectados mediante el Cuestionario de Actividades de Autocuidado con la Diabetes, antes y después de las intervenciones. Resultados: Participaron del estudio 55 individuos. Después de las intervenciones, el ítem con mayor diferencia en la mejor adhesión al autocuidado fue "examinar el calzado antes de ponerlo", con el delta de 3,29 días a la semana, nivel analítico. El peor fue "aplicar las inyecciones de insulina según lo recomendado", con el delta de 0,00 días a la semana, nivel básico. Conclusión: Las intervenciones educativas tuvieron un efecto positivo en la adhesión al autocuidado y la literacidad en salud.

RESUMO Objetivo: Avaliar o efeito de intervenção educativa na adesão às atividades de autocuidado e letramento funcional em saúde no domínio numeramento em pessoas com diabetes mellitus tipo 2. Método: Estudo quase-experimental, conduzido em duas unidades da estratégia de saúde da família, envolvendo pessoas com diabetes. As intervenções educativas aconteceram em três encontros, semanalmente, com duração média de 60 minutos. Os dados foram coletados pelo Questionário de Atividades de Autocuidado com o Diabetes, antes e após as intervenções. Resultados: Participaram do estudo 55 pessoas. Após as intervenções, o item que obteve maior diferença para uma melhor adesão ao autocuidado foi "examinar dentro do calçado antes de calçá-los", com delta de 3,29 dias na semana, nível analítico. O pior foi "tomar as injeções de insulina conforme recomendado", com delta de 0,00 dias na semana, nível básico. Conclusão: As intervenções educativas apresentaram efeito positivo na adesão ao autocuidado e letramento funcional em saúde.

Diabetes mellitus asociada a pancreatitis autoinmune: caso clínico / Autoimmune pancreatitis associated with diabetes mellitus: report of one case

Autoimmune pancreatitis is uncommon, responds to steroids and is usually associated with diabetes mellitus. We report a 73 year-old male who, two months after a diagnosis of diabetes mellitus, presented with obstructive jaundice and weight loss. Abdominal magnetic resonance imaging was suggestive of an autoimmune pancreatitis and serum IgG4 was 339 mg/dl (normal range 3-201). The patient was treated with prednisone 40 mg/day with a good clinical and laboratory response. During outpatient care, the dose of prednisone was tapered.

Efeitos da suplementação de resveratrol sobre fatores de risco cardiovascular / Effects of resveratrol supplementation on cardiovascular risk factors

O resveratrol, ou 3,5,4-triidroxiestilbeno, é um polifenol encontrado principalmente em uvas, vinho tinto, amendoins, chocolate amargo e algumas frutas silvestres. Diversos estudos investigaram sua ação sobre doenças cardiovasculares, câncer, doenças neurodegenerativas, diabetes, hiperglicemia, bem como seus possíveis efeitos sobre a longevidade. No entanto, os resultados ainda são inconclusivos, principalmente no que se refere à dose necessária, que dificilmente é atingida só com a alimentação. Portanto, foi feita uma revisão da literatura recente quanto à suplementação de resveratrol em seres humanos e seus efeitos sobre os fatores de risco para desenvolvimento de doenças cardiovasculares. Foram incluídos 15 estudos que avaliaram a função endotelial, o perfil glicêmico, o perfil inflamatório, lipoproteínas, bem como a segurança do consumo por idosos. A suplementação de resveratrol mostrou-se segura em idosos e benéfica principalmente para a função endotelial em diferentes populações, tendo efeito positivo também sobre o perfil glicêmico de pacientes com resistência à insulina e inflamação. Além disso, verificou-se redução significativa da produção intestinal e hepática das lipoproteínas Apo B-48 e Apo B-100. Devido a todos esses aspectos, a suplementação com resveratrol pode exercer papel protetor contra o desenvolvimento de doenças cardiovasculares

Resveratrol, or 3,4,5-trihydroxystilbene, is a polyphenol found mainly in grapes, red wine, peanuts, dark chocolate and some berries. Several studies have investigated the impact of resveratrol on cardiovascular diseases, cancer, neurodegenerative diseases, diabetes and hyperglycemia, as well as its potential effects on longevity. However, the results are still inconclusive, especially regarding the necessary dosage, which is unlikely to be achieved through diet alone. Therefore, we have reviewed the recent literature on resveratrol supplementation in humans and its effects on risk factors for the development of cardiovascular diseases. We included fifteen studies that evaluated the endothelial function, glycemic profile, inflammatory profile, lipoproteins, and the safety of its consumption by the elderly. Resveratrol supplementation was proven to be safe for use in the elderly and mainly benefits endothelial function in different populations, also having a positive effect on the glycemic profile of patients with insulin resistance and inflammation. A significant reduction in the intestinal and hepatic production of lipoproteins Apo B-48 and Apo B-100 was also observed. Due to all these aspects, supplementation with resveratrol could play a protective role in the development of cardiovascular diseases

Implantação de um serviço sobre orientação de insulina na transição do cuidado: contribuições para o autocuidado / Setting up a service for insulin orientation during the transition in care: contributions to self-care

O diabetes mellitus é uma doença crônica responsável por inúmeras complicações que comprometem a qualidade de vida dos pacientes, sendo necessário para prevenção a adoção de medidas educativas que enfatize a importância do autocuidado e da adesão ao tratamento. Objetivo deste artigo é descrever as ações realizadas e os resultados alcançados com a implementação do Serviço de Orientação Sobre o Uso de Insulina (SOSUI). Trata-se de um estudo observacional, realizado no período de agosto de 2014 a fevereiro de 2015. Foram selecionados pacientes diabéticos insulinizados, sendo eles idosos e adultos frágeis submetidos à amputação devido a comprometimento de pé diabético. O SOSUI foi constituído em duas fases, sendo uma no período da internação hospitalar (pré-alta), e a segunda no período pós-alta hospitalar. No período pré-hospitalar, farmacêuticos vinculados a um programa de residência multiprofissional realizaram uma abordagem entre os pacientes, seguida de treinamentos práticos individualizados sobre a administração da insulina. Passado um período mínimo de quatro meses após a alta hospitalar, foi realizada interação mediada por telefone com o intuito de identificar mudanças nos relatos dos pacientes em relação ao uso da insulina, assim como melhora nos valores glicêmicos. Os dados foram registrados no programa Microsoft Excel, seguido de análise univariada. Foram 17 pacientes elegíveis para o estudo, com idade média de 63 anos, sendo 76,47% do sexo masculino e 23,53% do sexo feminino. O tempo médio de internação foi de 21 dias. Em relação ao perfil glicêmico dos participantes, observa-se que houve melhora nos níveis de glicemia de jejum e hemoglobina glicada dos pacientes orientados pelo serviço, e que estavam sob os cuidados da Atenção Primária. Além de melhoras nos relatos sobre técnicas de homogeneização e administração da insulina, foi evidenciada entre os pacientes uma hemoglobina glicada média de 9,97%, sendo esse valor médio reduzido para 7,0% após a alta hospitalar. Isso indica melhora do controle glicêmico pelos pacientes, o que pode ser influenciado pelas experiências de adoecimento, internação e amputação decorrente de complicações do diabetes, associadas ao fato de os pacientes terem também recebido orientações educacionais sobre o uso da insulina, favorecendo melhor entendimento sobre o uso desse medicamento. A implementação do SOSUI serviu como importante ferramenta no processo de educação em saúde sobre o diabetes para os pacientes acompanhados pelo Serviço de Farmácia Clínica, proporcionando melhora no gerenciamento da farmacoterapia com insulina; melhor conhecimento sobre o diabetes e suas complicações; e para a importância da adesão ao tratamento.

Diabetes mellitus is a chronic disease that causes numerous complications that impair the quality of life of patients, making the adoption of educational measures that emphasize the importance of self-care and adherence to treatment necessary for prevention. Objective: To describe the actions and results achieved with the implementation of the Insulin Usage Guidance Service(SOSUI). Methodology: This is a observational study conducted from August / 2014 to February / 2015. Diabetic patients treated with insulin were selected, all of them elderly and vulnerable adults subjected to amputation due to pre-diabetic impairment. SOSUI constituted of two phases, one of them being during the hospitalization period (pre-discharge), and the second one being after hospital discharge. During the hospitalization period, pharmacists part of a multidisciplinary residency program approached patients, followed by individual practical training on insulin handling. After a period of at least 4 months of hospital discharge, a post-discharge contact was performed, mediated by phone to identify changes in the accounts of patients regarding insulin handling as well as improvement on glycemic levels. The data was recorded on Microsoft Excel, followed by univariate analysis. Results: 17 of the participants qualified for the study, with average age of 67, 76.47% were male and 23.53% female. The average length of hospitalization was 21 days. Regarding the glycemic profile of the participants, it was observed that there was an improvement in fasting glucose levels and glycated hemoglobin of patients guided by the service, and under the care of Primary Care. Conclusion: The implementation of SOIRI served as an important tool in the health education process about diabetes for patients guided by the Clinical Pharmacy Service providing an improvement of the management of pharmacotherapy with insulin, a better knowledge about diabetes, its complications and the importance of adherence to treatment.

Inhibition of the sodium-glucose co-transporter 2 in the elderly: clinical and mechanistic insights into safety and efficacy

SUMMARY The prevalence of type 2 diabetes mellitus (T2DM) in the elderly grew sharply over the last decade. Reduced insulin sensitivity and secretory capacity, weight gain, sarcopenia, and elevated adiposity are all common metabolic and body changes in the aging population that favor an increased risk of hypoglycemia, frailty syndrome, falls, and cognitive dysfunction. First line antidiabetic therapy is frequently not safe in older individuals because of its high risk of hypoglycemia and prevalent co-morbid diseases, such as chronic kidney disease, osteoporosis, cardiovascular disease, and obesity. Sodium-glucose cotransporter 2 inhibitor (SGLT2i) is a new class of antidiabetic therapy that inhibits glucose and sodium reabsorption on renal proximal convoluted tubule. Its effect is well demonstrated in various clinical scenarios in the younger population. This review and metanalysis describe particularities of the SGLT2i on the elderly, with mechanistic insights of the potential benefit and remaining challenges about the use of these drugs in this important age group. Further, we will present a meta-analysis of the main effects of SGLT2i reported in post-hoc studies in which the median age of the subgroups analyzed was over 60 years. Despite the absence of specific clinical trials for this population, our findings suggest that SGLT2i therapy on older individuals is effective to lower glucose and maintain its effect on systolic blood pressure and body weight.

RESUMO A prevalência da diabetes mellitus tipo 2 em idosos cresceu muito na última década. A redução na sensibilidade à insulina e na capacidade secretora, ganho de peso, sarcopenia e adiposidade elevada são todas alterações metabólicas e corporais comuns entre a população idosa. Essas mudanças críticas favorecem o aumento no risco de hipoglicemia, síndrome de fragilidade, quedas e disfunções cognitivas. A primeira linha de tratamento contra a diabete muitas vezes não é segura para indivíduos mais velhos devido ao alto risco de hipoglicemia e a prevalência de comorbidades patogênicas, como doença renal crônica, osteoporose, doença cardiovascular e obesidade. Os inibidores do cotransportador sódio-glicose 2 (SGLT2) são uma nova classe de tratamento contra a diabete que inibe reabsorção de glicose e sódio na parte convoluta do túbulo proximal. Seu efeito é claramente demonstrado em diversos cenários clínicos em populações mais jovens. Esta revisão e meta-análise descreve as particularidades dos SGLT2 na população idosa, abordando os mecanismos dos potenciais benefícios e desafios ainda presentes do uso destes medicamentos nesse grupo etário tão importante. Além disso, apresentaremos uma meta-análise dos principais efeitos dos SGLT2 encontrados em estudos post-hoc nos quais a idade média dos subgrupos analisados foi acima de 60 anos. Apesar da ausência de ensaios clínicos que incluem essa população, os dados encontrados sugerem que o tratamento com SGLT2 em idosos é eficaz para diminuir os níveis de glicose e tem efeitos na pressão arterial sistólica e no peso corporal.

Brazilian generics market change after Farmácia Popular program

ABSTRACT OBJECTIVE To evaluate trends in the use of generic and non-generic medicines to treat hypertension and diabetes under the Farmácia Popular Program (FP) and its impact on generic medicines sales volume and market share in the Brazilian pharmaceutical market. METHODS This longitudinal, retrospective study used interrupted time series design to analyze changes in monthly sales volume and proportion of medicines sales (market share) for oral antidiabetic and antihypertensive medicines for generic versus non-generic products. Analyses were conducted in a combined dataset that aggregate monthly sales volumes from the Farmácia Popular program and from the QuintilesIMS™ (IQVIA) national market sales data from January 2007 to December 2012. The Farmácia Popular program phases analyzed included: a) 2009 reductions in medicines reference prices (AFP-II) and b) 2011 implementation of free medicines program for hypertension and diabetes, the Saúde não tem preço (SNTP - Health has no price). RESULTS Patterns of use for FP-covered antidiabetic and antihypertensive medicines were similar to their use in the market in general. After one year of the decreases in government subsidies in April 2010, market share of antidiabetic and antihypertensive medicines experienced relative declines of -54.5% and -59.9%, respectively. However, when FP-covered medicines were made free to patients, overall market volume for antidiabetic and antihypertensive generics increased dramatically, with 242.6% and 277.0% relative increases by February 2012, as well as non-generics with relative increase of 209.7% and 279% for antidiabetic and antihypertensive medicines, respectively. CONCLUSIONS Ministry of Health policies on the amount of patient cost sharing and on the choice of medicines on coverage lists have substantial impacts on overall generic sales volume in retail pharmacies.

Efficacy and safety of sitagliptin added to metformin and insulin compared with voglibose in patients with newly diagnosed type 2 diabetes

OBJECTIVE: To assess the efficacy and safety of sitagliptin compared with voglibose added to combined metformin and insulin in patients with newly diagnosed type 2 diabetes (T2DM). METHODS: In this 12-week prospective, randomized, parallel trial, 70 newly diagnosed T2DM patients with glycosylated hemoglobin (HbA1c) ≥9% and/or fasting plasma glucose (FPG) ≥11.1 mmol/L were randomized (1:1) to receive sitagliptin 100 mg per day + metformin + insulin glargine or voglibose 0.2 mg three times daily + metformin + insulin glargine. Change in HbA1c at week 12 was the primary endpoint. RESULTS: The mean baseline HbA1c was 11.0% in the patients. The changes in HbA1c from baseline were -6.00% in the sitagliptin group and -3.58% in the voglibose group, and the between-group difference was -2.42% (95% CI -1.91 to -2.93, p=0.02). The differences in FPG and homeostatic model assessment of β-cell function (HOMA-β) and the change in body weight between groups from baseline were -2.95 mmol/L (p=0.04), 43.91 (p=0.01) and -2.23 kg (p=0.01), respectively. One patient (2.9%) in the sitagliptin group and three patients (8.6%) in the voglibose group exhibited hypoglycemia. CONCLUSIONS: Sitagliptin added to combined metformin and insulin therapy showed greater efficacy and good safety regarding hypoglycemia in patients with newly diagnosed T2DM compared with voglibose.

Doenças crônicas não transmissíveis em profissionais de enfermagem de um hospital filantrópico no Sul do Brasil / Enfermedades crónicas no transmisibles en profesionales de enfermería de un hospital filantrópico en el sur de Brasil / Noncommunicable diseases among nursing professionals at a charitable hospital in Southern Brazil

Objetivo: descrever a prevalência de doenças crônicas não transmissíveis (DCNT), uso de medicamentos, valores tensionais e glicemia capilar de uma equipe de enfermagem de um hospital filantrópico de Pelotas, RS, Brasil. Métodos: estudo transversal; as perguntas foram adaptadas do questionário do sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico (Vigitel); todos tiveram pressão arterial e glicemia aferidos. Resultados: do total de 272 funcionários avaliados, 29,4% afirmaram ter DCNT, 48,9% faziam uso de medicamento contínuo e 73,9% referiram antecedentes familiares para DCNT; dos entrevistados, 20,6% usavam anti-hipertensivos, e destes, 27,7% apresentaram níveis tensionais elevados e 2,6% referiram usar hipoglicemiantes; destes últimos, 42,9% apresentaram níveis glicêmicos elevados. Conclusão: dos profissionais autodeclarados hipertensos e diabéticos, aqueles em uso de medicações apresentaram valores tensionais e glicemia mais elevados do que os que não faziam tratamento medicamentoso.

Objetivo: Describir la prevalencia de enfermedades crónicas no transmisibles (ECNT), uso de medicamentos y valores de tensión y glucemia capilar de un equipo de enfermería de un hospital filantrópico de Pelotas/RS. Métodos: Estudio transversal; las preguntas fueron adaptadas del cuestionario Vigilancia de Factores de Riesgo y Protección para Enfermedades Crónicas por Encuesta Telefónica (Vigitel). Todos tuvieron la presión arterial y la glucemia medidas. Resultados: Del total de 272 funcionarios evaluados, un 29,4% reportó tener ECNT, un 48,9% hacía uso de medicamento continuado y 73,9% refería antecedentes familiares para ECNT. Entre los entrevistados, 20,6% refirió usar antihipertensivos, de estos 27,7% presentaron niveles de tensión elevados, y un 2,6% refirieron usar hipoglucemiantes, de los cuales 42,9% presentó niveles glucémicos elevados. Conclusión: Los profesionales que se autodeclararon hipertensos y diabéticos y estaban en uso de medicamentos presentaron valores de tensión y glucemia más elevados que aquellos que no hacían tratamiento medicamentoso.

Objective: to describe the prevalence of noncommunicable diseases (NCDs), long term (current) drug therapy, blood pressure levels and capillary glycemia among a nursing team at a charitable hospital in Pelotas/RS. Methods: This was a cross-sectional study. The questions were adapted from the Vigitel system questionnaire (Telephone Surveillance of Chronic Disease Risk and Protection Factors). All participants had their blood pressure and blood glucose measured. Results: Of the 272 staff assessed, 29.4% reported having NCDs, 48.9% were on long term (current) drug therapy and 73.9% reported a family history of NCDs. Among those interviewed, 20.6% reported using antihypertensive drugs, of these 27.7% had high blood pressure levels, and 2.6% reported using antihypoglycemic agents, 42.9% of whom had high blood glucose. Conclusion: Among those professionals who stated they had high blood pressure and diabetes, those who were on medication had higher blood pressure and glucose levels than those who were not on medication.

Utilização de anti-hipertensivos e antidiabéticos no Brasil: análise das diferenças socioeconômicas. Pesquisa Nacional de Saúde 2013 / Use of antihypertensive and antidiabetic medications in Brazil: an analysis of socioeconomic differences. National Health Survey, 2013

RESUMO: Objetivos: Avaliar a magnitude de desigualdades socioeconômicas e demográficas da utilização de medicamentos para controle de hipertensão arterial e diabetes mellitus na população brasileira. Método: Foram analisados dados da Pesquisa Nacional de Saúde (PNS) conduzida no Brasil em 2013, com amostra representativa da população com idade de 18 anos ou mais. Foi estimada a utilização de medicamentos para hipertensão e diabetes segundo renda, escolaridade, raça, posse de plano de saúde e região de moradia. Também foram estimadas as razões de prevalência ajustadas por sexo e idade, por meio de regressão de Poisson. Resultados: Entre os hipertensos, 81,4% fazem uso de medicamentos para controle da doença, sendo a utilização maior entre as mulheres, os brancos e os que têm plano de saúde. No caso de diabetes mellitus, 80,2% fazem uso de medicamentos para controlar a doença e o uso foi mais elevado entre os pacientes idosos, com maior escolaridade, com plano de saúde e da Região Sudeste. As desigualdades segundo renda e plano de saúde foram de pequena magnitude mesmo nos estratos de sexo, idade e região geográfica analisados. Conclusão: Foi constatada utilização de medicamentos para controle da hipertensão e diabetes que pode ser considerada elevada, e as desigualdades socioeconômicas e regionais desse uso revelaram-se de magnitude não expressiva, em virtude da implementação de políticas farmacêuticas no Brasil, que visam promover maior e mais equânime acesso da população a medicamentos.

ABSTRACT: Objectives: To analyze the socioeconomic and demographic differences in medication use to control hypertension and diabetes mellitus in Brazil. Method: Data from the National Health Survey (Pesquisa Nacional de Saúde - PNS) performed in Brazil in 2013 with a representative sample of the population aged 18years old or older were analyzed. The use of medications for hypertension and diabetes according to income, education, race, possession of a private health insurance plan and region of household were estimated. Theprevalence ratios adjusted for sex and age were also estimated using Poisson regression. Results: 81.4% of the hypertensive population used medication to control the disease. The use was higher among females, white/Caucasian individuals and those with a private health plan. In the case of diabetes mellitus, 80.2% of the population used medication to control the disease and the use was higher in elderly patients, patients with a higher level of education, patients with a private health plan, and patients in the Southeast region. Inequalities according to income and health plan were small even in the strata of sex, age and geographic region analyzed. Conclusion: We found a high use of medication to control hypertension and diabetes. Socioeconomic inequalities in use were not expressive, probably due to medication policies that promote greater and equitable access to medicines in Brazil.

Impact of an inpatient multidisciplinary glucose control management program

ABSTRACT Objective: Glycemic control has been increasingly recognized as a critical element in inpatient care, but optimal management of blood glucose in the hospital setting remains challenging. The aims of this study were to describe and evaluate the impact of the implementation of an inpatient multidisciplinary glucose control management program on glucose control in hospitalized patients. Materials and methods: Retrospective analysis of medical records and glucose monitoring data obtained by point- of-care testing (POCT) in hospitalized patients before (May 2014) and after (June 2015 and May 2017) the implementation of the program. Results: We analyzed 6888, 7290, and 7669 POCTs from 389, 545, and 475 patients in May 2014, June 2015, and May 2017, respectively. Hyperglycemia (≥ 180 mg/ dL) occurred in 23.5%, 19.6%, and 19.3% POCTs in May 2014, June 2015, and May/2017, respectively (p < 0.001), while severe hyperglycemia (≥ 300 mg/dL) was observed in 2.5%, 2.2%, and 1.8% of them, respectively (p = 0.003). Hyperglycemia (≥ 180 mg/dL) reduced significantly from May 2014 to June 2015 (16.3%, p < 0.001) and from May 2014 to May 2017 (178%, p < 0.001). No significant changes occurred in hypoglycemic parameters. Conclusions: The implementation of an inpatient multidisciplinary glucose control management program led to significant reductions in hyperglycemic events. The key elements for this achievement were the development of institutional inpatient glycemic control protocols, establishment of a multidisciplinary team, and continuing educational programs for hospital personnel. Altogether, these actions resulted in improvements in care processes, patient safety, and clinical outcomes of hospitalized patients.

The impact of metformin use on the risk of prostate cancer after prostate biopsy in patients with high grade intraepithelial neoplasia

ABSTRACT Purpose We report our experience on metformin use in diabetic patients and its impact on prostate cancer (PCa) after a high-grade prostatic intraepithelial neoplasia (HGPIN) diagnosis. Materials and Methods We retrospectively analyzed 551 patients with a diagnosis of HGPIN without PCa in a first prostate biopsy. The cohort of the study consisted of 456 nondiabetic subjects, and 95 diabetic patients. Among the patients with diabetes 44 were treated with metformin, and 51 with other antidiabetic drugs. A transrectal ultrasound prostate biopsy scheme with 22 cores was carried out 4-6 months after the first diagnosis of HGPIN. Results Among 195 (35.4%) patients with cancer, there were statistically significant differences in terms of PCa detection (p<0.001), Gleason score distribution (p<0.001), and number of positive biopsy cores (p<0.002) between metformin users and non-users. Metformin use was associated with a decreased risk of PCa compared with neveruse (p<0.001). Moreover, increasing duration of metformin assumption (≥2 years) was associated with decreasing incidence of PCa and higher Gleason score ≥7 compared with assumption <2 years. Conclusions This preliminary experience suggests that metformin use may have some beneficial effects in patients with diabetes and HGPIN; metformin should not be overlooked in these patients because it is neither new nor expensive.

Fatores relacionados à autoaplicação de insulina em indivíduos com diabetes mellitus / Factores relacionados con la autoadministración de insulina en sujetos con diabetes mellitus / Factors related to the self-application of insulin in subjects with diabetes mellitus

Resumo OBJETIVO Identificar os fatores associados à autoaplicação de insulina em adultos com Diabetes Mellitus. MÉTODO Estudo transversal desenvolvido no município de Viçosa-MG, que avaliou 142 pacientes. A coleta de dados foi realizada entre abril e julho de 2013 mediante entrevista no domicílio do participante. Regressão logística múltipla foi utilizada. RESULTADO A prevalência de autoaplicação de insulina foi de 67,6%, apresentando associação com idade entre 57 e 68 anos (OR = 0,3; IC95%: 0,1 - 0,9), conviver com companheiro e filhos (OR = 2,5; IC95%: 1,1 - 5,0), ter 9 anos ou mais de estudo (OR = 8,4; IC95%: 1,9 - 37,9), morar em área não coberta pela Estratégia Saúde da Família (ESF) (OR = 2,8; IC95%: 1,1 - 7,0). CONCLUSÃO Autoaplicação de insulina mostrou-se associada à idade, escolaridade, situação conjugal e cobertura da ESF. O reconhecimento desses fatores pode contribuir para o desenvolvimento de estratégias para adesão à autoaplicação de insulina.

Resumen OBJETIVO Identificar los factores asociados con la autoadministración de insulina en adultos con diabetes mellitus. MÉTODOS Se trata de un estudio transversal desarrollado en el municipio de Viçosa-MG, en el que se evaluaron 142 pacientes. La recolección de datos se llevó a cabo entre abril y julio de 2013 mediante entrevistas en el hogar del participante. Se aplicó la regresión logística múltiple. RESULTADOS La prevalencia de la auto-administración de insulina fue de 67,6% y se asoció con edad entre 57 y 68 años (OR = 0,3; IC del 95%: 0,1 - 0,9), que viven con una pareja e hijos ( OR = 2,5; IC del 95%: 1.1 5,0), con 9 o más años de educación (OR = 8,4; IC del 95%: no 1,9-37,9), que viven en un área cubierta por la Estrategia de Salud de la familia (ESF) (OR = 2,8; IC del 95%: 1.1 7.0). CONCLUSIÓN La autoadministración de insulina se asoció con la edad, la educación, el estado civil y la cobertura del ESF. El reconocimiento de estos factores puede contribuir para la adhesión a la autoadministración de insulina.

ABSTRACT Objective: To identify the factors associated with the self-application of insulin in adult individuals with Diabetes Mellitus. Method: A cross-sectional study developed in the city of Viçosa-MG, which assessed 142 patients. The data collection was performed between April and July 2013 through an interview at the participant's home. Multiple logistic regression was used. Results: The prevalence of the self-administration of insulin was of 67.6%, and it was associated with ages between 57 and 68 years old (OR = 0.3, 95% CI: 0.1-0.9), living with a partner and children (OR = 2.5, 95% CI: 1.1-5.0), 9 years or more of study (OR = 8.4, 95% CI: 1.9-37.9), living in an area not covered by the Family Health Strategy (FHS) (OR = 2.8, 95% CI: 1.1 - 7.0). Conclusion: The self-application of insulin was associated with age, schooling, marital status, and the FHS coverage. The recognition of these factors may contribute to the adherence to the self-application of insulin.

Use of medications for type 2 diabetes mellitus in the Brazil's family health strategy: gender differences

Introduction: The medications are the main therapeutic inputs in the treatment of type 2 diabetes mellitus. When properly used, they allow disease control and reduction of morbidity and mortality, resulting in improvements in quality of life. Thus, the purpose of this article is to characterize the use of medications for type 2 diabetes mellitus with emphasis on gender differences. Methods: A cross-sectional study performed in Family Health Units in Ribeirão Preto, São Paulo, Brazil, with 100 men and 100 women. Sociodemographic characteristics, clinical data, lifestyle and use of medications were the variables of interest. Results: Mean number of diabetes medications referred by study participants was 1.6 (SD = 0.7) for women and 1.5 (SD = 0.6) for men (p = 0.40). The use of metformin was mentioned by 70% of women and 65% of men, and adverse reactions were reported by 15% of women and 2% of men (p < 0.01). Medications were obtained mainly from public health system pharmacies in both genders. Conclusions: Gender differences in the use of diabetes medications were found in reported adverse reactions, with more cases among women.