American Diabetes Association Guidelines Research Articles

Screening for Diabetes Mellitus and Hypertension in Duhok Governorate, Kurdistan Region of Iraq

Objective: To determine the prevalence and significant correlates of prediabetes (pre-DM), diabetes mellitus (DM), prehypertension (pre-HT), and hypertension (HT) among adults in all districts of Duhok Governorate through a community-based screening study. Methods: This is a cross-sectional community-based screening study involving 3,000 non-fasting adults not diagnosed as prediabetes or DM and prehypertension or HT conducted in all districts of Duhok Governorate. Random glucose and blood pressure reading according to American Diabetes Association and American Heart Association Guidelines in 2023 will be used in a community-based screening. BMI will be also calculated in the present study as a screening tool. Results: Findings reveal that 18.2% had DM, 14.7% had pre-DM and 41.3% had HT and 11.5% had pre-HT. The study also revealed that nearly two third had increased BMI in which 40.1% were overweight and 24.5% were obese. Among screened subjects 32% were smokers. Around half of screened subjects reported having family history of DM and HT, DM alone (10.8%), HT alone (12.1%) and 28.9% had family history of both DM and HT together. The study also shows that screened male subjects reported higher prevalence of pre-DM, DM, pre-HT and HT than screened female subjects. Older age group of screened subjects tend to have more abnormal blood sugar and blood pressure levels than younger age group. Conclusion: This study has shown a high prevalence of pre-DM, DM, pre-HT and HT among adults in all districts of Duhok Governorate. Significant correlates of pre-DM, DM, pre-HT and HT in this study were age, gender, BMI, smoking and family history.

The 2024 American Diabetes Association guidelines on Standards of Medical Care in Diabetes: key takeaways for laboratory

The escalating prevalence of diabetes poses a significant health concern. Uncontrolled diabetes leads to a multitude of complications. A comprehensive management plan and continual adaptation of guidelines is needed. The American Diabetes Association (ADA) is a guiding force in this domain, providing diabetes care recommendations for clinicians, laboratorians, researchers, and policymakers since 1989. The latest ADA guidelines present both challenges and opportunities for laboratories. The increased emphasis on glycated hemoglobin (HbA1c) testing for early diagnosis and personalized monitoring is expected to increase testing volumes, potentially leading to a rise in point-of-care testing. Ensuring standardized testing procedures becomes paramount to maintaining consistent and reliable results across laboratories. Moreover, laboratories may need to expand their test menus to accommodate the growing demand for personalized medicine approaches and collaborate closely with healthcare providers to support informed decision-making. This commentary provides a focused analysis of the 2024 ADA guidelines for the laboratory assessment of diabetes.

Diabetic ketoacidosis resolution: From the traditional way to guideline-based management in the MICU at University Medical Center, Lubbock, Texas

Diabetes is a chronic, metabolic disease characterized by hyperglycemia which eventually can cause serious organ damage. The prevalence of diabetes has steadily increased over the past few decades, and approximately 1.4 million Americans are diagnosed with diabetes every year. Diabetes was the seventh leading cause of death in the United States in 2019. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. It occurs more frequently in the patients with type 1 diabetes but can also develop in people with type 2 diabetes. It was determined that the average cost per DKA episode was $6,444, and that the annual cost of medical treatment in a diabetic patient with a prior episode of DKA was 2.67 times higher than a diabetic patient with no history of DKA. The criteria for DKA resolution at University Medical Center (UMC) in Lubbock, Texas, are different from current American Diabetes Association (ADA) guidelines. At UMC, a plasma bicarbonate ≥18 mEq/L, a venous pH > 7.3, and anion gap ≤12 mEq/L must be recorded twice (4 hours apart) before bridging to subcutaneous long-acting insulin administration. This time requirement could contribute to a longer time for DKA resolution and longer intensive care unit and hospital stays.Keywords: Diabetic ketoacidosis, DKA resolution

Plasma Metabolomics Identifies Key Metabolites and Improves Prediction of Diabetic Retinopathy: Development and Validation across Multinational Cohorts

PurposeTo identify longitudinal metabolomic fingerprints of diabetic retinopathy (DR) and evaluate their utility in predicting DR development and progression. DesignMulticenter, multi-ethnic cohort study. ParticipantsThis study included 17,675 participants with baseline pre-diabetes/diabetes, in accordance with the 2021 American Diabetes Association guideline, and free of baseline DR from the UK Biobank (UKB); and an additional 638 diabetic participants from the Guangzhou Diabetic Eye Study (GDES) for external validation. MethodsLongitudinal DR metabolomic fingerprints were identified through nuclear magnetic resonance assay in UKB participants. The predictive value of these fingerprints for predicting DR development were assessed in a fully withheld test set. External validation and extrapolation analyses of DR progression and microvascular damage were conducted in the GDES cohort. Model assessments included the C-statistic, net classification improvement (NRI), integrated discrimination improvement (IDI), calibration, and clinical utility in both cohorts. Main Outcome MeasuresDR development, progression, and retinal microvascular damage. ResultsOf 168 metabolites, 118 were identified as candidate metabolomic fingerprints for future DR development. These fingerprints significantly improved the predictability for DR development beyond traditional indicators (C-statistic: 0.802, 95% CI, 0.760–0.843 vs. 0.751, 95% CI, 0.706–0.796; P = 5.56×10−4). Glucose, lactate, and citrate were among the fingerprints validated in the GDES cohort. Using these parsimonious and replicable fingerprints yielded similar improvements for predicting DR development (C-statistic: 0.807, 95% CI, 0.711–0.903 vs. 0.617, 95% CI, 0.494, 0.740; P = 1.68×10−4) and progression (C-statistic: 0.797, 95% CI, 0.712–0.882 vs. 0.665, 95% CI, 0.545–0.784; P = 0.003) in the external cohort. Improvements in NRIs, IDIs, and clinical utility were also evident in both cohorts (all P <0.05). In addition, lactate and citrate were associated to microvascular damage across macular and optic disc regions (all P <0.05). ConclusionsMetabolomic profiling has proven effective in identifying robust fingerprints for predicting future DR development and progression, providing novel insights into the early and advanced stages of DR pathophysiology.

Interpretation of the 2024 American Diabetes Association guidelines for the comprehensive management of non-alcoholic fatty liver disease combined with diabetes mellitus

Non-alcoholic fatty liver disease (NAFLD) is a common concomitant disease in adults with type 2 diabetes mellitus (T2DM) and prediabetes. Therefore, T2DM/NAFLD patient populations are at high risk for cardiovascular disease. The occurrence and progression of non-alcoholic fatty liver disease-related liver fibrosis and cardiovascular disease have a severe impact on the patient's prognosis and mortality rate. The American Diabetes Association's 2024 "Guidelines for the Standardized Management of Diabetes" put forward recommendations relevant to the screening, evaluation, treatment, and management of NAFLD in T2DM and prediabetic populations, as well as liver fibrosis. The important measures for decelerating liver inflammation and fibrosis progression and the risk of cardiovascular disease are based on improvements in lifestyle methods, weight loss, and blood sugar control.

Insulin resistance during androgen deprivation therapy in men with prostate cancer.

Androgen deprivation therapy (ADT) in prostate cancer (PCa) has been associated with development of insulin resistance. However, the predominant site of insulin resistance remains unclear. The ADT & Metabolism Study was a single-center, 24-week, prospective observational study that enrolled ADT-naive men without diabetes who were starting ADT for at least 24 weeks (ADT group, n=42). The control group comprised men without diabetes with prior history of PCa who were in remission after prostatectomy (non-ADT group, n=23). Prevalent diabetes mellitus was excluded in both groups using all three laboratory criteria defined in the American Diabetes Association guidelines. All participants were eugonadal at enrollment. The primary outcome was to elucidate the predominant site of insulin resistance (liver or skeletal muscle). Secondary outcomes included assessments of body composition, and hepatic and intramyocellular fat. Outcomes were assessed at baseline, 12, and 24 weeks. At 24 weeks, there was no change in hepatic (1.2; 95% confidence interval [CI], -2.10 to 4.43; p=.47) or skeletal muscle (-3.2; 95% CI, -7.07 to 0.66; p=.10) insulin resistance in the ADT group. No increase in hepatic or intramyocellular fat deposition or worsening of glucose was seen. These changes were mirrored by those observed in the non-ADT group. Men undergoing ADT gained 3.7 kg of fat mass. In men with PCa and no diabetes, 24 weeks of ADT did not change insulin resistance despite adverse body composition changes. These findings should be reassuring for treating physicians and for patients who are being considered for short-term ADT.

Updates in Chronic Kidney Disease.

Chronic kidney disease (CKD) affects approximately 14% of adults in the United States and is present in at least 10% of the population worldwide. Blood glucose and blood pressure control are imperative to adequately manage CKD as they are the only primary prevention measures for the condition. Recent changes in CKD evaluation and medication therapies that modify disease progression and aid in managing complications such as anemia of CKD have emerged, including a newly approved mineralocorticoid receptor antagonist and hypoxia-inducible factor-prolyl hydroxylase inhibitor, respectively. This focused update on CKD evaluation and management will review the most recent evidence and approved agents to support patients with CKD, including a review of glomerular filtration rate measurement methods such as CKD-EPI 2021 and utilization of cystatin C, Kidney Disease Improving Global Outcomes (KDIGO) guidelines, American Diabetes Association (ADA) guidelines, and primary literature supporting the use of newer agents in CKD. Checklists for managing blood pressure and blood glucose, CKD-mineral bone disorder, and anemia of CKD targeted for pharmacists are also provided. Additionally, a discussion of Centers for Medicare & Medicaid (CMS) coverage of agents approved for managing complications of CKD is included.

Metabolic syndrome and pharmacotherapy outcomes in patients with type 2 diabetes mellitus

BackgroundMetabolic syndrome is a group of metabolic abnormalities that increase predisposition to several diseases including ischemic heart disease and diabetes mellitus. The study aimed to investigate metabolic syndrome among patients with type-2 diabetes mellitus (DM), and its impact on pharmacotherapy outcomes.MethodsAn observational cross-sectional study was performed on 910 patients with type-2 DM between June and December 2023. Fasting blood sugar, triglycerides, high-density lipoproteins (HDL), blood pressure, and abdominal obesity were measured. Metabolic syndrome was identified according to the National Cholesterol Education Program Adult Treatment Panel III criteria. Pharmacotherapy outcomes were assessed according to American Association of Clinical Endocrinologists and American Diabetes Association guidelines using the ability to achieve adequate glycemic control and normal levels of blood pressure and fasting plasma lipoproteins.ResultsIn total, 87.5% of type-2 DM patients had metabolic syndrome; the prevalence increased with age and was higher among females. Metabolic syndrome showed the following distribution of risk factors: insulin resistance (100%), low HDL (95.3%), elevated blood pressure (83%), triglycerides dyslipidemia (80.1%), and abdominal obesity (62.5%). Majority of the patients had either 5 or 4 risk factors of metabolic syndrome. The most common comorbidities were dyslipidemia (97.7%) and hypertension (83%). Treatment outcomes were insufficient where adequate glycemic control was only achieved in 12% of type-2 DM patients, and proper management of comorbid dyslipidemia and hypertension was achieved in 29% and 40.9% of patients, respectively. Adequate blood pressure control was less achieved in patients with metabolic syndrome (34.4%) than those without metabolic syndrome (77.2%). Similarly, dyslipidemia was less controlled in patients with metabolic syndrome (26.9%) than in those without metabolic syndrome (47.3%).ConclusionPharmacotherapy outcomes were inadequate for most patients with type-2 diabetes mellitus. Adopting early preventive and therapeutic interventions for metabolic syndrome is advised to improve treatment outcomes of the comorbid dyslipidemia and hypertension.

Evaluating adherence to American Diabetes Association standards of care in diabetes and impacts of social determinants of health on patients at two nurse practitioner-owned clinics.

The COVID-19 pandemic created barriers in the management of type 2 diabetes mellitus (T2DM) and worsened social determinants of health (SDOH). A New Hampshire primary care office worked to adhere to T2DM standards of care and began screening for SDOH. This project assessed adherence to quality metrics, hemoglobin A1C, and SDOH screening as telehealth utilization decreased. A1C values have increased at the practice, especially since COVID-19. The practice also began screening for SDOH at every visit, but there was need to assess how needs were being documented and if/how they were addressed. A retrospective chart review of patients with T2DM was performed. Demographic data and T2DM metrics were collected and compared with previous years and compared new versus established patients. Charts were reviewed to evaluate documentation of SDOH and appropriate referral. The practice transitioned from an increased utliization of telehealth back to prioritizing in-office visits. The practice also began routinely screening for SDOH in 2020; however, this process had not been standardized or evaluated. Adherence to nearly all quality metrics improved. Glycemic control improved after a year of nurse practitioner (NP) care, especially in new patients. All patients were screened for SDOH, but documentation varied, and affected patients had higher A1Cs, despite receiving comparable care. Nurse practitioners at this practice are adhering to American Diabetes Association guidelines, and A1C values improve under their care. Social determinants of health continue to act as unique barriers that keep patients from improving glycemic control, highlighting the need for individualized treatment of SDOH in T2DM care.

Transforming diabetes care with continuous glucose monitoring: Rationale for expanded eligibility criteria.

Randomized trials and large retrospective database studies have shown that individuals treated with noninsulin therapies experience the same glycemic benefits from continuous glucose monitoring (CGM) use as those treated with more intensive treatment regimens. However, many policy makers and payers are reluctant to provide CGM coverage for these patients. Although the recent American Diabetes Association guidelines have taken an important first step in recommending that CGM should be offered to all adults treated with basal insulin who are capable of using it, clinicians should consider the acute and long-term consequences of persistent hyperglycemia in all of their patients with diabetes. This article describes how the use of the FreeStyle Libre 2 CGM System (Abbott Diabetes Care, Alameda, CA) improved glycemic outcomes and facilitates personalized diabetes care in two type 2 diabetes patients treated with noninsulin therapies.

Impact of American Diabetes Association 2022 Guidelines on Prescribing Rates of Sodium-Glucose Cotransporter-2 Inhibitors in Ambulatory Care Organization Patients With Type 2 Diabetes.

Background: Recent clinical trials and guideline updates have highlighted the efficacy and safety of sodium-glucose cotransporter-2 inhibitor (SGLT2i) use in patients with type 2 diabetes (T2D) and comorbidities including atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), or heart failure (HF). Objective: This study assesses the rates of guideline-based prescribing of SGLT2i in patients with T2D and one or more of the following comorbidities: ASCVD, CKD, or HF, prior to and after the 2022 American Diabetes Association (ADA) guideline publication within the Atrius Health clinical pharmacy, internal medicine, and specialty medicine departments. Methods: This is a retrospective chart review of data from the electronic medical record. Patients with the aforementioned criteria were included if they were managed by either the clinical pharmacy department, internal medicine, or specialty medicine departments. Patients were excluded if they did not have any of the comorbidities listed or a form of diabetes other than T2D. Results: Of the 10,631 patients enrolled, 354 (3.3%) were initiated on an SGLT2i during the study. The average number of SGLT2i initiations prior to the 2022 ADA guideline publication was five prescription starts per week. After the guideline publication initiation increased to seven prescription starts per week. Secondary outcomes showed the majority of SGLT2i prescriptions were started in the internal medicine department, followed by cardiology and nephrology. Conclusion: Overall utilization rates of SGLT2i are low but increased after the 2022 ADA guidelines were published. These results suggest opportunities to optimize the use of SGLT2i in this patient population.

Liraglutide versus pramlintide in protecting against cognitive function impairment through affecting PI3K/AKT/GSK-3β/TTBK1 pathway and decreasing Tau hyperphosphorylation in high-fat diet- streptozocin rat model.

The American Diabetes Association guidelines (2021) confirmed the importance of raising public awareness of diabetes-induced cognitive impairment, highlighting the links between poor glycemic control and cognitive impairment. The characteristic brain lesions of cognitive dysfunction are neurofibrillary tangles (NFT) and senile plaques formed of amyloid-β deposition, glycogen synthase kinase 3 beta (GSK3β), and highly homologous kinase tau tubulin kinase 1 (TTBK1) can phosphorylate Tau proteins at different sites, overexpression of these enzymes produces extensive phosphorylation of Tau proteins making them insoluble and enhance NFT formation, which impairs cognitive functions. The current study aimed to investigate the potential contribution of liraglutide and pramlintide in the prevention of diabetes-induced cognitive dysfunction and their effect on the PI3K/AKT/GSK-3β/TTBK1 pathway in type 2 diabetic (T2D) rat model. T2D was induced by administration of a high-fat diet for 10weeks, then injection of a single dose of streptozotocin (STZ); treatment was started with either pramlintide (200μg/kg/day sc) or liraglutide (0.6mg/kg/day sc) for 6weeks in addition to the HFD. At the end of the study, cognitive functions were assessed by novel object recognition and T-maze tests. Then, rats were sacrificed for biochemical and histological assessment of the hippocampal tissue. Both pramlintide and liraglutide treatment revealed equally adequate control of diabetes, prevented the decline in memory function, and increased PI3K/AKT expression while decreasing GSK-3β/TTBK1 expression; however, liraglutide significantly decreased the number of Tau positive cells better than pramlintide did. This study confirmed that pramlintide and liraglutide are promising antidiabetic medications that could prevent associated cognitive disorders in different mechanisms.

Physicians' Practices in Diabetic Nephropathy in Primary Healthcare Centers in Jazan City, Saudi Arabia, 2023.

Background and Objectives: Diabetes is one of the most common diseases dealt with by physicians in primary healthcare centers (PHCs). The disease is associated with macrovascular and microvascular complications, especially in those with long disease duration and uncontrolled diabetic nephropathy, which is one of the most common microvascular complications among diabetic patients. This investigation assessed the practices of physicians working at PHCs in terms of diabetic nephropathy screening, management, and referral. Materials and Methods: This study is a cross-sectional investigation targeting physicians working at PHCs in the Jazan region of Saudi Arabia between March and August of 2023. Data were collected via a self-administered questionnaire, which was distributed via online platforms. The questionnaire included sections measuring physicians' demographic data and associated factors regarding training, the availability of resources, and practices in diabetic nephropathy, including screening, management, and referral. Chi-squared tests were used to assess associations between the practices of physicians and the measured demographics. Result: A total of 234 physicians participated in the investigation. The median age of the participants was 35 years. The adherence level of practice toward diabetic nephropathy according to American Diabetes Association (ADA) guidelines ranged from 40 points (the highest adherence level of participants) to 19 points (the lowest adherence level of participants), with a median of 33 points. Higher adherence levels were noted among physicians in Saudi Arabia, physicians with higher education levels, physicians specializing as family physicians or diabetologists, physicians who reported attending online and on-site training at diabetic centers, physicians who reported continuous access to urine and serum creatinine tests, and physicians who reported continuous access to the American Diabetes Association guidelines (p < 0.05). Conclusions: There are several factors associated with the level of adherence in diabetic nephropathy practice, such as physicians' education level, specialty, training, and access to guidelines. The findings suggest the need for more training for PHC physicians in the care of patients affected by or at risk of diabetic nephropathy.

Clinical attachment loss is cross-sectionally associated with elevated glucose among adults without diabetes.

We investigated whether periodontal measures are cross-sectionally associated with prediabetes and cardiometabolic biomarkers among non-diabetic younger adults. One thousand seventy-one participants (mean age = 32.2 years [SE = 0.3]; 73% female) from the Oral Infections, Glucose Intolerance and Insulin Resistance Study were enrolled. Full-mouth clinical attachment loss (fm-CAL), probing depth (fm-PD) and bleeding on probing were ascertained. Interproximal CAL (i-CAL) and probing depths (i-PD) served as our primary exposures. Glucose, HbA1c, insulin and insulin resistance (HOMA-IR) outcomes were assessed from fasting blood. Prediabetes was defined per American Diabetes Association guidelines. Prediabetes prevalence ratios (PR [95% CI]) and mean [SE] cardiometabolic biomarkers were regressed on periodontal variables via multivariable robust variance Poisson regression or multivariable linear regression. Prevalence of prediabetes was 12.5%. Fully adjusted prediabetes PR in Tertiles 3 versus 1 of mean i-CAL was 2.42 (1.77, 3.08). Fully adjusted fasting glucose estimates across i-CAL tertiles were 83.29 [0.43], 84.31 [0.37], 86.48 [0.46]; p for trend <.01. Greater percent of sites with i-PD ≥3 mm showed elevated natural-log-HOMA-IR after adjustment (0%-12% of sites = 0.33 [0.03], 13%-26% of sites = 0.39 [0.03], ≥27% of sites = 0.42 [0.03]; p for trend = .04). i-CAL (vs. fm-CAL) was associated with elevated fasting glucose and prediabetes, whereas i-PD (vs. fm-PD) was associated with insulin resistance. Future studies are needed to examine periodontal disease and incident prediabetes.

The Impact of Time-Restricted Meal Intake on Glycemic Control and Weight Management in Type 2 Diabetes Mellitus Patients: An 18-Month Longitudinal Study.

This study aimed to investigate the impact of time-restricted meal intake (TRM) on anthropometric and biochemical parameters in patients with type 2 diabetes mellitus (T2DM). A total of 400 patients diagnosed with T2DM were selected from the Endocrinology Department at King George's Medical University (KGMU), Lucknow, based on the American Diabetes Association (ADA) guidelines and specific criteria. A total of 127 patients were lost to follow-up, resulting in 273 patients who completed the study. The patients were randomly assigned to two groups: the TRM group (consenting to have an early dinner at 7 pm) and the control group (non-TRM/late-night eater group). Baseline data were recorded, and follow-up assessments were conducted at six months, 12 months, and 18 months. Informed consent was obtained, and a diet chart was regularly maintained and updated. The TRM group experienced a significant weight loss of 3.88 kg (5.45%) and a substantial reduction in BMI by 1.5 units (5.26%). In contrast, the non-TRM/control group had smaller reductions in weight (1.36 kg, 1.77%) and BMI (0.5 units, 1.65%). TRM group showed significant reductions in fasting blood sugar levels by 33.9 mg/dl (21.17%), postprandial blood sugar levels by 94.6 mg/dl (38.88%), andglycosylated hemoglobin (HbA1c) levels by 1.37 (15.87%). These improvements were significantly greater than the reductions observed in the control group, which had decreases of 29.3 mg/dl (17.85%) in fasting blood sugar levels, 41.6 mg/dl (16.84%) in postprandial blood sugar levels, and 0.59 (6.89%) in HbA1c levels. Our findings underscore the potential of TRM as an effective strategy for weight management and glycemic control in patients with T2DM, even in a long-term context. These results supporttime-restricted eating as a sustainable lifestyle modification for managing chronic metabolic diseases.

Modern methods for assessing compensation of diabetes mellitus. Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes

Background. An integral part of diabetes mellitus (DM) management is its timely diagnosis. The reference method to study the quality of glycemic control is evaluating the level of glycated hemoglobin (HbA1c) as one of the most accessible and informative tools. However, the introduction of novel technologies, namely the use of continuous glucose monitoring (CGM), has given patients with DM, their relatives and healthcare professionals an access to new indicators of glycemic control such as time in range (TIR), time above range and time below range. These indicators are criteria for compensation of carbohydrate metabolism according to the 2023 American Diabetes Association guidelines. The purpose of the study was to compare the effectiveness of using glucometers and the FreeStyle Libre system for flash glucose monitoring in patients with DM. Materials and methods. An examination of 60 patients with type 2 DM who received insulin therapy was conducted. They were aged 45–65 years, with DM duration of 5 ± 2 years. All participants were divided into two equal groups of 30 people each. The first group consisted of patients with CGM devices, the second group used glucometers for daily glycemic control. Additional CGM parameters were used: glucose coefficient of variation, glucose management indicator, which shows the probable level of HbA1c. Results. When evaluating the data obtained from patients who used CGM, it is important to note their high adherence to the use of flash glucose monitoring. The use of CGM made it possible to achieve compensation of carbohydrate metabolism faster compared to patients who used glucometers to correct glycemia. Discontinuation of CGM resulted in poorer glycemic control. The obtained results prove that the compensation of patients depends primarily on their motivation, willingness to follow medical prescriptions, careful glycemic control, and compliance with medical recommendations. Conclusions. For better control of the DM course, patients should use CGM. In order to assess diabetes compensation, it is not enough to consider only TIR. Time below range indicating hypoglycemia, time above range indicating hyperglycemia, glucose management indicator should also be taken into account. Discontinuation of CGM resulted in a loss of approximately half of the initial TIR gain achieved while using CGM. CGM is more favored among patients than a 7-point self-monitoring of blood glucose.

Glycemic control and cardiovascular outcomes in patients with diabetes and coronary artery disease according to triglyceride-glucose index: a large-scale cohort study

BackgroundThe role of triglyceride-glucose (TyG) index, an insulin resistance indicator, in glycemic management for diabetic patients with coronary artery disease (CAD) was still unknown. Therefore, we aimed to explore the association between glycemic control and cardiovascular (CV) outcomes in patients with diabetes and CAD according to different TyG index levels.MethodsA total of 9996 diabetic patients with angiograph-proven CAD were consecutively recruited from 2017 to 2018 at Fuwai Hospital. Patients were assigned into 3 groups according to TyG index tertiles (T) (T1: <8.895; T2: 8.895-9.400; T3: ≥9.400). According to American Diabetes Association guidelines, controlled glycemia was defined as targeting glycosylated hemoglobin Alc (HbA1c) < 7%. The primary endpoint was CV events including CV death, nonfatal myocardial infarction, and nonfatal stroke.ResultsDuring a median 3-year follow-up, 381 (3.8%) CV events occurred. Overall, high TyG index (T3) was associated with increased risk of CV events (hazard ratio [HR]: 1.40; 95% confidence interval [CI]: 1.02–1.94) compared with the lowest TyG index (T1) after multivariable adjustment. Upon stratification by the TyG index, in fully adjusted models, controlled glycemia was associated with reduced risk of CV events in the high TyG index (T3) subgroup (HR: 0.64; 95%CI: 0.42–0.96) but not in the low (T1; HR: 0.79; 95%CI: 0.53–1.16) and moderate (T2; HR: 0.84; 95%CI: 0.56–1.25) TyG index subgroups.ConclusionsControlled glycemia was associated with improved CV outcomes in patients with diabetes and established CAD, especially in those with high TyG index levels. Our study, for the first time, provided valuable information that TyG index could help making risk stratification on the glycemic management in diabetic patients with CAD.

Medicare formulary restrictions for glucagon-like peptide 1 receptor agonists and sodium glucose cotransporter 2 inhibitors used in type 2 diabetes mellitus: 2019-2023.

Glucagon-like peptide 1 receptor agonists (GLP1-RAs) and sodium glucose cotransporter 2 inhibitors (SGLT2is) have proven benefits in patients with type 2 diabetes mellitus related to decreasing cardiovascular events and heart failure hospitalizations as well as preventing the progression of kidney disease. This led the American Diabetes Association (ADA) to update their guidelines in 2022 to recommend GLP1-RAs and SGLT2is as potential first-line options in patients with cardiorenal conditions. Formulary restrictions, such as step therapy and prior authorizations, can limit access to these beneficial medications. To evaluate trends in Medicare formulary restrictions of GLP1-RAs and SGLT2is following the recommendations by the ADA for first-line use. We conducted a retrospective cohort study of Quarter 1 Medicare formulary restrictions on GLP1-RAs and SGLT2is from 2019 to 2023. We analyzed changes in formulary restrictions by year, before and after the ADA first-line recommendations, single vs combination products, and products with and without other indications on a medication level (ie, each unique National Drug Code number on each unique formulary) and formulary level (ie, any prior authorization or step therapy requirements yield formulary restriction). We analyzed 12,212 unique Medicare formularies. GLP1-RAs were 12.5% less likely (relative risk [RR] = 0.87; 95% CI = 0.84-0.91; P < 0.001) and 33.2% less likely (RR = 0.67; 95% CI = 0.60-0.74; P < 0.001) to have restrictions after the ADA guideline changes on a medication and formulary level, respectively. SGLT2is were 87.8% less likely (RR = 0.12; 95% CI = 0.11-0.13; P < 0.001) and 53.0% less likely (RR = 0.47; 95% CI = 0.27-0.80; P = 0.005) to have restrictions after the ADA guideline changes on medication and formulary levels, respectively. Decreasing trends of medications and formularies with restrictions may indicate payers are recognizing GLP1-RAs and SGLT2is as potential first-line agents, aligning with ADA recommendations.

Achievement of Treatment Goals and Mortality in Individuals with Diabetes: The ELSA-Brasil Study.

To prevent diabetes complications, the American Diabetes Association (ADA) has recommended the treatment of blood glucose, blood pressure, and LDL-cholesterol (LDL-c) to target levels. Our aim is to characterize the risk of death according to the achievement of these goals in subjects with diabetes participating in the ELSA-Brasil study. ELSA-Brasil is an occupational cohort study of middle-aged and elderly adults followed from a 2008-2010 baseline to 2019 by two additional clinic visits and annual telephone interviews. We ascertained known diabetes by self-reported diagnosis or anti-diabetic medication use. We used treatment targets based on the 2022 ADA guidelines. We ascertained deaths from any cause based on the annual surveillance confirmed by death certificates. After 11 (1.8) years of follow-up, 261 subjects had died among 2423 with known diabetes. Within-target HbA1c was associated with the greatest protection (HR = 0.66; 95%CI 0.50-0.88) against all-cause mortality. Achieving both glycemic and blood pressure targets conferred substantial protection (HR = 0.54; 95%CI 0.37-0.78). Within-target LDL-c, however, was associated with increased mortality (HR = 1.44; 95%CI 1.11-1.88). Glucose and blood pressure control, especially when concomitant, reduced mortality. The increased mortality associated with achieving the LDL-c target merits further investigation.

A Novel Receivership Model for Transition of Young Adults With Diabetes: Experience From a Single-center Academic Transition Program

ObjectiveThe transition from pediatric to adult care for young adults with diabetes represents an important but often challenging time characterized by a shift from a family-centered care model of pediatrics to a patient-centered care model of adult medicine. We developed a structured transition program based on an adult receivership model at a large academic medical center to improve care coordination and patient satisfaction with the transition process. MethodsFrom 2016 to 2020, we implemented a series of quality improvement efforts for young adults aged 18 to 23 years with diabetes by incorporating best practices from the American Diabetes Association guidelines on care for emerging adults. We measured transition orientation attendance, patient satisfaction, hemoglobin A1c (HbA1c) pre- and post-transfer, and care gaps to determine the impact of the program. ResultsIn this study, 307 individuals with type 1 diabetes and 16 individuals with type 2 diabetes were taken care of by the adult endocrinology department at the University of Michigan between January 1, 2016 and October 31, 2020. We observed high attendance rates (86% among internal transfers) and favorable patient satisfaction scores for the transition orientation session. Despite the glycemic challenges posed during the transition, HbA1c modestly yet significantly improved 1-year after transfer (−0.4%, P < .01). ConclusionWe successfully established and maintained a young adult diabetes transition program using a quality improvement approach. Future work will focus on reducing care gaps at the time of transfer, assessing long-term retention rates, and enhancing care coordination for patients referred from outside the health network.