Beatriz D'Agord Schaan

Effect of Antihyperglycemic Agents Added to Metformin and a Sulfonylurea on Glycemic Control and Weight Gain in Type 2 Diabetes: A Network Meta-analysis

BACKGROUND Few studies have examined the effect of adding a third antihyperglycemic drug when blood glucose control is not achieved by using metformin and a sulfonylurea. PURPOSE To compare the efficacy of add-on antihyperglycemic drugs in patients with type 2 diabetes that is not controlled with metformin and a sulfonylurea. DATA SOURCES MEDLINE, EMBASE, Cochrane Library, LILACS, and ClinicalTrials.gov electronic databases. STUDY SELECTION Randomized trials at least 24 weeks in duration. Studies evaluated the effects of adding a third antihyperglycemic drug to treatment of adults aged 18 years or older with type 2 diabetes and a hemoglobin A(1c) (HbA(1c)) level greater than 7.0% who were already receiving a combination of metformin and a sulfonylurea. DATA EXTRACTION Primary end points were change in HbA(1c) level, change in weight, and frequency of severe hypoglycemia. DATA SYNTHESIS Eighteen trials involving 4535 participants that lasted a mean of 31.3 weeks (24 to 52 weeks) were included. Compared with placebo, drug classes did not differ in effect on HbA(1c) level (reduction ranging from -0.70% [95% credible interval {CrI}, -1.33% to -0.08%] for acarbose to -1.08% [CrI, -1.41% to -0.77%] for insulin). Weight increase was seen with insulins (2.84 kg [CrI, 1.76 to 3.90 kg]) and thiazolidinediones (4.25 kg [CrI, 2.76 to 5.66 kg]), and weight loss was seen with glucagon-like peptide-1 agonists (-1.63 kg [CrI, -2.71 to -0.60 kg]). Insulins caused twice the absolute number of severe hypoglycemic episodes than noninsulin antihyperglycemic agents. LIMITATIONS Most of the trials were short term, and trial quality varied. With so few trials relative to antihyperglycemic agents, investigators relied on indirect comparisons, which increased the uncertainty of the findings and conclusions. CONCLUSION There is no clear difference in benefit between drug classes when adding a third agent to treatment of patients with type 2 diabetes who are already receiving metformin and a sulfonylurea. The most appropriate option should depend on each patients clinical characteristics. PRIMARY FUNDING SOURCE Conselho Nacional de Desenvolvimento Científico e Tecnológico and Coordenacăo de Aperfeicoamento de Pessoal de Nível Superior.

Perfil de risco cardíaco no diabetes mellitus e na glicemia de jejum alterada

OBJECTIVE Mortality of diabetic patients is higher than that of the population at large, and mainly results from cardiovascular diseases. The purpose of the present study was to identify the prevalence of cardiovascular risk factors in subjects with diabetes mellitus (DM) or abnormal fasting glucose (FG) in order to guide health actions. METHODS A population-based cross-sectional study was carried out in a representative random cluster sampling of 1,066 adult urban population (> or =20 years) in the state of Rio Grande do Sul between 1999 and 2000. A structured questionnaire on coronary risk factors was applied and sociodemographic characteristics of all adults older than 20 years living in the same dwelling were collected. Subjects were clinically evaluated and blood samples were obtained for measuring total cholesterol and fasting glycemia. Statistical analysis was performed using Stata 7 and a 5% significance level was set. Categorical variables were compared by Pearsons chi-square and continuous variables were compared using Students t-test or Anova and multivariate analysis, all controlled for the cluster effect. RESULTS Of 992 subjects, 12.4% were diabetic and 7.4% had impaired fasting glucose. Among the risk factors evaluated, subjects who presented any kind of glucose homeostasis abnormality were at a higher prevalence of obesity (17.8, 29.2 and 35.3% in healthy subjects, impaired fasting glucose and DM respectively, p<0.001), hypertension (30.1, 56.3 and 50.5% in healthy subjects, impaired fasting glucose and DM, respectively, p<0.001), and hypercholesterolemia (23.2, 35.1 and 39.5 in healthy subjects, impaired fasting glucose and DM respectively, p=0.01). CONCLUSION Subjects with any kind of glucose homeostasis abnormality represent a group, which preventive individual and population health policies should target since they have higher prevalence of coronary artery disease risk factors.OBJETIVO: A mortalidade dos pacientes diabeticos e maior do que a da populacao em geral e decorre especialmente das doencas cardiovasculares. O objetivo do estudo foi identificar a prevalencia dos fatores de risco cardiovasculares em individuos com diabetes mellitus (DM) ou glicemia de jejum alterada, a fim de direcionar as acoes em saude. METODOS: Estudo transversal de base populacional, com amostragem aleatoria por conglomerado, constituida de 1.066 individuos, representativa da populacao urbana adulta (>20 anos) do Estado do Rio Grande do Sul, realizado entre 1999 e 2000. Foi aplicado um questionario estruturado sobre os fatores de risco coronariano e as caracteristicas sociodemograficas a todos os adultos maiores de 20 anos residentes no domicilio selecionado. Apos.os pacientes foram submetidos a avaliacao clinica e coleta de sangue para determinacao de colesterol total e glicemia de jejum. Para a analise dos dados foi utilizado o pacote estatistico Stata 7. Foi estabelecido nivel previo de significância de 5%. As variaveis categoricas foram comparadas utilizando-se qui-quadrado de Pearson, enquanto que as continuas mediante teste t de Student ou Anova, alem de analise multivariavel, todas controladas para efeito de conglomerado. RESULTADOS: De 992 individuos, 12,4% eram diabeticos e 7,4% apresentavam glicemia de jejum alterada. Dos fatores de risco estudados, os individuos com algum grau de alteracao da homeostase glicemica apresentaram maior prevalencia de obesidade (17,8, 29,2 e 35,3% em normais, glicemia de jejum alterada e DM, respectivamente, p<0,001), hipertensao (30,1, 56,3 e 50,5% em normais, glicemia de jejum alterada e DM, respectivamente, p<0,001) e hipercolesterolemia (23,2, 35,1 e 39,5% em normais, glicemia de jejum alterada e DM, respectivamente, p=0,01). CONCLUSOES: Individuos com alteracao da homeostase glicemica representam um grupo-alvo para a definicao de acoes preventivas em nivel individual e populacional devido a maior prevalencia de fatores de risco para doenca arterial coronariana.

The Costs of Type 2 Diabetes Mellitus Outpatient Care in the Brazilian Public Health System

OBJECTIVE The prevalence of type 2 diabetes has shown a significant increase in parallel with health care costs. The objective of the Brazilian Study on Diabetes Costs (ESCUDI study) was to estimate direct and indirect costs of type 2 diabetes outpatient care in the Brazilian Public Health Care System. METHODS Data were collected from different levels of health care in eight Brazilian cities in 2007. A total of 1000 outpatients were interviewed and had their medical records data analyzed. Direct medical costs included expenses with medications, diagnostic tests, procedures, blood glucose test strips, and office visits. Nonmedical direct costs included expenses with diet products, transportation, and caregivers. Absenteeism, sick leave, and early retirement were classified as indirect costs. RESULTS Total annual cost for outpatient care was US

Cardiovascular control in experimental diabetes

2108 per patient, out of which US

Educational interventions in childhood obesity: a systematic review with meta-analysis of randomized clinical trials.

1335 per patient of direct costs (63.3%) and US

GLUT4 content decreases along with insulin resistance and high levels of inflammatory markers in rats with metabolic syndrome

773 per patient of indirect costs (36.7%). Costs escalated as duration of diabetes and level of health care increased. Patients with both microvascular and macrovascular complications had higher costs (US

Relationship between cardiovascular dysfunction and hyperglycemia in streptozotocin-induced diabetes in rats

3199 per patient) compared to those with either microvascular (US

Functional electrical stimulation in the treatment of patients with chronic heart failure: a meta-analysis of randomized controlled trials.

2062 per patient) or macrovascular (US

In situ delivery of bone marrow cells and mesenchymal stem cells improves cardiovascular function in hypertensive rats submitted to myocardial infarction.

2517 per patient) complications only. The greatest portion of direct costs was attributed to medication (48.2%). CONCLUSIONS Diabetes treatment leads to elevated costs both to Brazilian Public Health Care System and society. Costs increased along with duration of disease, level of care and presence of chronic complications, which suggested a need to reallocate health resources focusing on primary prevention of diabetes and its complications.

Transportadores de glicose na síndrome metabólica

Several studies have reported impairment in cardiovascular function and control in diabetes. The studies cited in this review were carried out from a few days up to 3 months after streptozotocin administration and were concerned with the control of the circulation. We observed that early changes (5 days) in blood pressure control by different peripheral receptors were maintained for several months. Moreover, the impairment of reflex responses observed after baroreceptor and chemoreceptor stimulation was probably related to changes in the efferent limb of the reflex arc (sympathetic and parasympathetic), but changes also in the central nervous system could not be excluded. Changes in renal sympathetic nerve activity during volume expansion were blunted in streptozotocin-treated rats, indicating an adaptive natriuretic and diuretic response in the diabetic state. The improvement of diabetic cardiovascular dysfunction induced by exercise training seems to be related to changes in the autonomic nervous system. Complementary studies about the complex interaction between circulation control systems are clearly needed to adequately address the management of pathophysiological changes associated with diabetes.