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Patients with diabetes are more
likely to overuse than to underuse
acetylsalicylic acid
In large primary care settings, patients with diabetes are more likely to overuse
than to underuse acetylsalicylic acid.
T
his conclusion, based on results of an
analysis conducted as part of a primary
prevention effort to lower the risk of ath-
erosclerotic vascular disease was presented at
the EASD 2016 meeting.
Lauren Crain, PhD, of HealthPartners Insti-
tute, Minneapolis, Minnesota, explained that
acetylsalicylic acid is recommended for primary
prevention of cardiovascular disease for people
with and without diabetes when the risk re-
duction outweighs the risk of gastrointestinal
haemorrhage.
In a primary care setting, the complexity
and time required to assess acetylsalicylic acid
benefits and risks can result in inappropriate
acetylsalicylic acid use through either overuse
or underuse.
Dr Crain and colleagues set out to assess the
appropriateness of acetylsalicylic acid use for
primary prevention in diabetes and other patients
at high risk of cardiovascular disease in a large
primary care setting.
As part of a study funded by the US National
Institutes of Health to lower the risk of athero-
sclerotic cardiovascular disease, Dr Crain’s team
implemented electronic clinical decision support
algorithms to encourage appropriate acetylsali-
cylic acid use.
The algorithms recommend acetylsalicylic acid
if risk scores for atherosclerotic cardiovascular
disease are high and consistent with benefit
greater than gastrointestinal bleed risk using
criteria from the US Preventive Services Task
Force.
Coinvestigator JoAnn Sperl-Hillen, MD,
speaking from a clinician perspective, said, “The
latest aspirin guidelines highlight the need for an
individualised approach to aspirin recommenda-
tions for primary cardiovascular prevention that
balances a person’s benefits and risks.”
In the study, acetylsalicylic acid was not rec-
ommended if risk reduction was low or if major
contraindications were identified (anticoagulant
use or a history of intracerebral haemorrhage).
Providers were also alerted to the presence of
other potential acetylsalicylic acid risks including
allergy or intolerance, history of conditions indica-
tive of gastrointestinal bleed risk, and concomitant
use of nonsteroidal anti-inflammatory drugs.
Baseline study data was collected for whether
acetylsalicylic acid was algo-
rithmically recommended for
all patients at their first eligible
primary care encounter in 20
clinics from 2012 to 2014.
The analysis excluded pa-
tients with coronary heart
disease and included 3958
adults with diabetes (mean
age 54.6 years, mean 10-year
risk of cardiovascular disease
risk 29.2%) and 7000 adults
meeting prespecified criteria
for high risk of cardiovascular
disease risk without diabetes
(mean age 58.5 years, mean
10-year risk of cardiovascular
disease 25.6%).
Over- and underuse were
determined by comparing con-
cordance with acetylsalicylic
acid algorithm recommenda-
tions and documented acetyl-
salicylic acid use.
For the targeted population
at high cardiovascular disease
risk, clinical decision support algorithms recom-
mended acetylsalicylic acid for 2484 (62.7%)
patients with diabetes and 5341 (76.3%) without
diabetes.
Among patients for whom acetylsalicylic acid
was recommended, the agent was underused in
5171(20.8%) with diabetes and 5638 (74.4%)
without diabetes. Among patients for whom the
algorithms did not recommend acetylsalicylic
acid, the agent was overused in 840 (57.0%) with
diabetes and 559 (33.7%) without diabetes.
Dr Crain concluded that in this large primary
care setting, acetylsalicylic acid was more likely
to be overused than underused in patients with
diabetes. Those with diabetes who were likely to
benefit from acetylsalicylic acid use had higher
use rates than similar high cardiovascular-risk
patients without diabetes.
Those with diabetes who were unlikely to ben-
efit from acetylsalicylic acid (risks greater than
benefit), however, had higher rates of acetylsali-
cylic acid overuse than those without diabetes.
Dr Sperl-Hillen said, “Our study suggests that
in primary care practice, aspirin use is often not
concordant with an individual’s assessed risk and
benefit. This is due in part to the lack of available
practical assessment tools that can be used in the
context of busy clinician practices.”
She continued, “Care can be improved through
shared decision making facilitated by risk/benefit
assessment tools integrated with the electronic
health record. We successfully implemented a
Web-base, electronic health record – integrated
tool to help patients and clinicians quickly as-
sess and prioritise cardiovascular risk factors
and risk-lowering treatment opportunities. We
achieved high use rates for appropriate patients
in a primary care setting.”
When asked about the team’s further research,
Dr Sperl-Hillen replied, “We are studying how
well these electronic health record – integrated
tools work to improve patient outcomes. Risk
information that may be impacted by patient
characteristics, such as educational level, health
literacy, and numeracy, can be presented in nu-
merous ways. A major focus of our work will be to
evaluate how different formats of risk assessment
information presented to patients and clinicians
can influence clinical decisions and patient be-
haviours.”
Prediabetes is associated with
white matter atrophy in the
MAASTRICHT study
Prediabetes and type 2 diabetes have been associated with white
matter hyperintensities and white matter atrophy, and type 2 diabetes
with brain atrophy, as indicated by smaller white matter volumes.
T
his finding of a cross-sectional, comparative study of magnetic resonance and
fluid-attenuated inversion recovery weighted images was reported at the EASD
2016 meeting.
Marnix.J.M. van Agtmaal, MD, of Maastricht University Medical Center, The Nether-
lands, explained that type 2 diabetes mellitus associated with brain atrophy and cerebral
small vessel disease is believed to involve cerebral microvascular dysfunction.
He said, “The epidemic of type 2 diabetes is a major health problem, and prevention
of its complications is important. The brain is a major target for the effects of type 2
diabetes. Patients with type 2 diabetes are at increased risk of stroke, cognitive impair-
ment, dementia, and depression.”
“Moreover, age-related structural brain changes on MRI, such as markers of cerebral
small vessel disease and brain atrophy, are more common in patients with type 2 diabetes.
Little is known, however, about the pathophysiology of these structural brain changes.”
“In light of the growing diabetes epidemic, the identification of factors contributing to
structural brain changes is paramount. Microvascular dysfunction has been implicated in
the aetiology of cerebral small vessel disease and brain atrophy in type 2 diabetes. Little is
known about structural brain changes before the onset of type 2 diabetes, so preventing
these changes is problematic.”
“Since it has not been determined whether individuals with prediabetes harbour struc-
tural brain changes,” Dr vanAgtmaal asserted, “we hypothesised that cerebral small vessel
disease and brain atrophy are present in prediabetes. Answering this question is important
because cerebral small vessel disease and brain atrophy are preventable. After the brain
has undergone structural damage, however, the consequences are irreversible.”
Dr van Agtmaal and colleagues set out to determine whether prediabetes and type 2
diabetes are associated with white matter hyperintensities, a proxy of cerebral small vessel
disease, and brain atrophy in a general population age 40–75 years.
The Maastricht Study is a population-based cohort study with an oversampling of
participants with type 2 diabetes (the present analysis, n = 2243; mean age 59.2 ± 8.2
years; 45.6% females). A total of 1372 subjects had normal glucose metabolism, 347 had
prediabetes, and 524 had type 2 diabetes.
White matter hyperintensity, white matter, grey matter, and cerebrospinal fluid volumes
were determined relative to intracranial volume using automated segmentation of T1, T2,
and fluid-attenuated inversion recovery weighted magnetic resonance images.
The association between glucose metabolism status and tissue volumes was assessed
by linear regression analysis and adjusted for age, sex, body mass index, systolic blood
pressure, total-to-high-density lipoprotein-cholesterol ratio, triglyceride levels, and edu-
cational level.
Prediabetes and type 2 diabetes were associated with a smaller white matter volume
after full adjustment. The regression coefficient (
β
) of white matter volume was –0.305
(–0.569; –0.041), P < 0.001 and –0.628 (–0.876; –0.380(, P < 0.001.
No association was found between prediabetes and type 2 diabetes grey matter volume.
Type 2 diabetes was associated with a larger cerebrospinal fluid volume (0.723 [0.450;
0.995], P < 0.001), while prediabetes was not.
Prediabetes and type 2 diabetes were associated with a larger white matter hyperin-
tensity volume (
β
0.122 [0.15– 0.228], P = 0.05 and 0.228 [0.127; 0.328], P < 0.001).
Dr vanAgtmaal concluded that prediabetes and type 2 diabetes are associated with larger
white matter hyperintensity volumes. In addition, while type 2 diabetes is associated with
a smaller white matter volume, while type 2 diabetes is associated with a smaller white
matter volume and a larger cerebrospinal fluid volume. These data may indicate that, in
a middle-aged population, changes
in cerebral white matter occur before
onset of type 2 diabetes.
“We showed in a population-based
study, that both prediabetes and
type 2 diabetes are associated with
cerebral small vessel disease and
brain atrophy, independent of major
cardiovascular risk factors,” Dr van
Agtmaal said.
He continued, “The findings sup-
port the concept that (micro)vascular
structural brain damage precedes the
clinical diagnosis of type 2 diabetes
and may contribute to the cerebral
complications of prediabetes and type
2 diabetes, such as stroke, cognitive
decline, and depression.”
He added, “We will explore the
association of structural brain dam-
age with stroke, cognitive decline,
and depression. And we will follow
up on the participants after 5 years
to measure the effects of structural
brain damage on mortality and co-
morbidity.
Courtesy of EASD 2016
CONFERENCE COVERAGE
PRACTICEUPDATE ENDOCRINOLOGY
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