[Important alteration of the Dutch treatment algorithm in patients with type 2 diabetes mellitus]. / Belangrijke wijziging van behandelrichtlijn 'Diabetes mellitus type 2'.

Recent trials of two classes of glucose-lowering drugs (SGLT2 inhibitors and GLP1RAs) have shown consistent cardiovascular and renal benefits that appear independent of glycaemic control. These results have prompted the Dutch College of General Practitioners (NHG) together with the Dutch Society of Internal Medicine (NIV) to update the treatment algorithm in patients with type 2 diabetes mellitus (T2D) at very high CVD risk. The use of SGLT2 inhibitors or GLP1RAs is now recommended in 3 groups of people with T2D. 1. patients with established CVD; 2. Patients with chronic kidney disease and a moderately to high CVD risk according to KDIGO; 3. patients with heart failure with reduced ejection fraction (HFrEF). Treatment algorithms differ for drug-naïve and drug-treated patients with T2D. In both drug-naïve and drug-treated patients the use of a SGLT2 inhibitor respectively as monotherapy or add-on is recommended as first step. If HbA1c is above the individual target, metformin will be added in drug-naive patients whereas GLP1-RAs could be considered in drug-treated patients. GLP1-RAs should also be considered when SGLT2-inhibitors are contraindicated.

Three years follow-up of screen-detected diabetic and non-diabetic subjects: who is better off? The ADDITION Netherlands study.

BACKGROUND: People with non-diabetic hyperglycaemia might be at risk of lacking adequate control for cardiovascular risk factors. Our aim was to determine the extent of health care utilization and provision in primary care and to evaluate the risk of cardiovascular disease in persons with an elevated risk score in a stepwise diabetes screening programme. METHODS: A total of 56,978 non-diabetic patients, aged 50-70 years, from 79 practices in the Netherlands were invited to participate in a screening programme starting with a questionnaire. Those with an elevated score, underwent further glucose testing. Screened participants with type 2 diabetes (n = 64), impaired glucose tolerance (IGT) (n = 62), impaired fasting glucose (IFG) (n = 86), and normal glucose tolerance (NGT) (n = 142) were compared after three years regarding use of medication, care provider encounters and occurrence of CVD. RESULTS: In all glucose regulation categories cardiovascular medication was prescribed more frequently during follow-up with the strongest increase in diabetic patients. Number of practice visits was higher in diabetic patients compared to those in the other categories. Glucose, lipids, and blood pressure were measured most frequently in diabetic patients. Numbers of cardiovascular events in participants with NGT, IFG, IGT and diabetes were 16.7, 32.6, 17.3 and 15.7 per 1,000 person-years (non significant), respectively. CONCLUSION: After three years of follow-up, screened non-diabetic participants with an elevated risk score had cardiovascular event rates comparable with diabetic patients. Screened non-diabetic persons are at risk of lacking optimal control for cardiovascular risk factors while screen-detected diabetic patients were controlled adequately.

Do characteristics of practices and general practitioners influence the yield of diabetes screening in primary care? The ADDITION Netherlands study.

OBJECTIVE: To investigate whether the yield of population-based diabetes screening is influenced by characteristics of the general practitioner (GP) and the practice. DESIGN: Cross-sectional study. SETTING: Seventy-nine general practices in the south-western region of the Netherlands. SUBJECTS: From 2002 to 2004, 56 978 people were screened for diabetes. GPs completed a questionnaire containing items on the GP (age, gender, employment, special interest in diabetes, providing insulin therapy) and the practice (setting, location, number of patients from ethnic minority groups, specific diabetes clinic, involvement of practice assistant, practice nurse or diabetes nurse in diabetes care). MAIN OUTCOME MEASURES: The ratio screen-detected diabetic patients/known diabetic patients per practice (SDM/KDM) and the number of detected diabetic patients per practice adjusted for practice size and age distribution (SDM per standardized practice). RESULTS: The yield of screening per practice varied widely. Higher age of the GP (regression coefficient 0.20; 95% confidence interval, CI 0.07-0.34), urban location (-4.60; 95% CI -6.41 to -2.78) and involvement of the practice assistant (2.27; 95% CI 0.49-4.06) were independently associated with SDM/KDM. Using the other outcome variable, results were similar. Additionally, cooperation with a diabetes nurse was associated with a lower yield. CONCLUSION: A lower yield of screening, reflecting a lower prevalence of undiagnosed diabetes, was found in practices of younger GPs and in urban practices. A lower yield was not associated with an appropriate practice organization regarding diabetes care nor with a specialty of the GP in diabetes. The wide variation in the yield of screening stresses the importance of a screening programme in each general practice.

Diabetes: glycaemic control in type 2 (drug treatments).

INTRODUCTION: Diabetes mellitus is a progressive disorder of glucose metabolism. It is estimated that about 285 million people between the ages of 20 and 79 years had diabetes worldwide in 2010, or 5% of the adult population. Type 2 diabetes may occur with obesity, hypertension, and dyslipidaemia (the metabolic syndrome), which are powerful predictors of cardiovascular disease. Without adequate blood-glucose-lowering treatment, blood glucose levels may rise progressively over time in people with type 2 diabetes. Microvascular and macrovascular complications may develop. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of blood-glucose-lowering medications in adults with type 2 diabetes? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 194 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: alpha-glucosidase inhibitors (AGIs), combination treatment (single, double, and triple), dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) analogues, insulins (including conventional [human] and analogue, different regimens, different length of action), meglitinides, metformin, sulphonylureas, and thiazolidinediones.

[Summary of the practice guideline 'The Prevention Visit' from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Het preventieconsult' van het Nederlands Huisartsen Genootschap.

The aim of the practice guideline 'The Prevention Visit' is the prevention of cardiovascular diseases, type 2 diabetes and chronic kidney injury in adults not previously diagnosed with hypertension, hypercholesterolaemia, or the above-mentioned cardiometabolic disorders. This is done by actively offering risk assessment combined with relevant treatment and advice (if indicated), integrated into primary health care. A self-report questionnaire is used to identify persons at high risk of developing cardiometabolic disease. Individuals with a risk score above the established threshold are advised to visit their general practitioner for measurement of height, weight, waist circumference, blood pressure, fasting glucose, cholesterol, and HDL cholesterol. At a subsequent practice visit, a risk assessment is performed according to the Dutch College of General Practitioners' practice guideline 'Cardiovascular Risk Management', at which time the patient's lifestyle is evaluated. If indicated, the general practitioner will initiate support and treatment according to relevant practice guidelines established by the Dutch College of General Practitioners.

[Summary of the practice guideline 'Prevention and early diagnosis of cervical cancer' of the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Preventie en vroegdiagnostiek van cervixcarcinoom' van het Nederlands Huisartsen Genootschap.

A persistent infection with human papillomavirus (HPV) underlies all cases of cervical cancer. HPV testing is repeated 6 months after initial Pap smears 2 or 3a1. As vaccination against HPV is now included in the National Immunisation Programme of the Netherlands, yearly cervical cancer morbidity and mortality rates are expected to be cut by half. After vaccination against HPV, women still need to participate in the cervical cancer screening programme. Breastfeeding is no longer a contraindication for making Pap smears, provided that breastfeeding is indicated on the cytology application form. Liquid-based cervical cytology is an equivalent to conventional cervical cytology and offers the possibility of testing for HPV. General practitioners are responsible for communicating results from the cervical cancer screening programme to the participating women.

Screen detected subjects with type 2 diabetes and impaired glucose tolerance have more adverse cardiovascular risk than subjects with impaired fasting glucose especially when they are obese: the ADDITION Netherlands study.

AIMS: To determine cardiovascular risk of screen detected subjects with type 2 diabetes (T2DM), impaired glucose tolerance (IGT) and impaired fasting glucose (IFG). To examine whether BMI is an effect modifier regarding the relation between level of glucose regulation and cardiovascular risk factors. METHODS: From 2002 to 2003, 29,251 persons, aged 50-70 years, participated in a population-based diabetes screening programme. Diagnosis was based on the 1999 WHO criteria. Characteristics were assessed of 285 subjects with T2DM, 175 with IGT and 218 with IFG. RESULTS: IFG did not resemble IGT and T2DM regarding weight and blood pressure. BMI (kg/m2) was 27.3+/-4.4, 29.5+/-5.7, 30.7+/-5.6 in IFG, IGT, DM, respectively; systolic blood pressure (mmHg) 150+/-25, 161+/-24, 162+/-23; diastolic blood pressure (mmHg) 84+/-12, 89+/-12, 90+/-11. The poorer the glycaemic control, the worse levels of BMI, blood pressure and lipids. When BMI was higher, cardiovascular risk factors were more adverse, especially in subjects with diabetes. CONCLUSIONS: Subjects with IFG had lower blood pressure and weight than subjects with IGT and T2DM suggesting IFG is a condition with less risk to develop cardiovascular diseases. Effect modification by BMI was found.