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Abstract
Introduction: Macroalbuminuria in people with type 2 diabetes is common among Pasifika peoples and is associated with end-stage kidney disease and major cardiovascular disease.
Aim: In a primary care practice catering for Pasifika people, to determine the time after first recognition of macroalbuminuria to the occurrence of major cardiovascular and renal events, and to examine the relationship with retinopathy status.
Methods: In a retrospective observational cohort study, we documented the occurrence of major cardiovascular events and amputations, end-stage kidney disease and death in 115 people with type 2 diabetes reviewed by a specialist diabetes physician at the Langimalie Tongan Health practice between 2005 and 2018. The follow up was 1–19 (median 9.5) years from the first recognition of macroalbuminuria (albumin:creatinine ratio of.30 g/mol). Survival was described by using Kaplan–Meier analysis.
Results: Macroalbuminuria was detected a mean of 9 years after the diagnosis of diabetes, at a mean age of 52 (standard deviation 12) years. Within 6 years of macroalbuminuria detection, 4% of people had died, 15% had reached end-stage kidney disease, 15% had cardiovascular events or amputations and 30% had the composite outcome of any of these. Within 12 years, the respective proportions were: 24%, 29%, 20% and 48%. The composite outcome was less frequent (P , 0.002) in patients without retinopathy at the time macroalbuminuria was recognised. Compared to patients with retinopathy, this group were younger (P ¼ 0.025), more obese (P , 0.0001), had better baseline renal function (P ¼ 0.018) and a shorter interval between the diagnosis of diabetes and recognition of macroalbuminuria (P , 0.0001).
Discussion: In this Pasifika population, macroalbuminuria was a marker for serious adverse cardiovascular and renal disease, and mortality, but in the 29%of patients without retinopathy at the time of recognition of macroalbuminuria, the natural history was more benign. The management of such comorbid patients is a substantial challenge for primary health-care services.
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Abstract
The Tongan Health Society is working on an innovative approach to underpin best practice models for patients with diabetes who are on maximum oral hypoglycaemic medication to start insulin therapy when they are hesitant to do so. Dr Glenn Doherty, CEO and Medical Director for the Tongan Health Society Inc. initially developed the project and related research with assistance from the Ministry of Health Pacific Innovation Fund which ran concurrently with the Whakakotahi initiative.
An initial patient management system data query identified 254 diabetics on maximum oral doses of hypoglycaemic medications who were needing to start insulin. After screening for eligibility and data cleansing, a cohort of 43 people remained. We started by inviting the eligible people to participate in the trial and conducting a screening questionnaire to identify barriers to insulin initiation. Many of these patients work odd hours, which makes it difficult for them to access health care. Our diabetes nurse reached out to these patients by visiting their workplaces and homes, either very early in the morning or late at night. In this way, we were able to get these patients started on insulin. Additionally, we organised group diabetes self-management education (DSME) sessions with patients and their whānau. Specialists from the district health board were involved in these sessions to raise awareness about diabetes, and patient enablers also took part.1 Various other methods we included in this project also proved helpful. As of December 2020, the total cohort is now 49 and we have commenced 70 percent of clients on insulin, organised 10 DSME sessions and identified several barriers to starting insulin.
We continue to refine our methods based on learnings and work towards starting more patients with diabetes on insulin when that is needed.
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Abstract
Introduction: There is emerging evidence for stratified glucose-lowering responses to certain oral medications for type 2 diabetes (T2D) by individual characteristics. The objective of this study was to test whether glycaemic response to representative treatments of dipeptidyl peptidase-4 inhibitors (vildagliptin) and thiazolidinediones (pioglitazone) varies according to ethnicity, gender, baseline obesity, triglyceride level or genetic variation.
Methods: This is a multicentre, two-period, two-treatment, open-label, randomised cross-over trial of vildagliptin and pioglitazone as second-line or third-line therapy in patients with T2D who have suboptimal glycaemic control on metformin and/or sulfonylurea therapy. It is conducted in New Zealand with a target of 300 patients (40% with Māori or Pacific ancestry) eligible if aged ≥18 and ≤80 years, with T2D for more than 1 year, on stable doses of metformin and/or sulfonylurea for at least 3 months, with HbA1c between 59 and 110 mmol/mol inclusive. Participants are assigned to complete 4 months of vildagliptin 50 mg per day or pioglitazone 30 mg per day, followed by 4 months of the other medications in randomly allocated sequences. Participant characteristics, including ethnicity, obesity, lipid profile and candidate genotypes are collected at baseline. Primary outcome variable is on treatment HbA1c. Secondary outcomes include weight change, frequency of side effects and patient preference.
Ethics and dissemination: Ethical approval of the trial has been obtained from the New Zealand Health and Disability Ethics Committee (18/STH/242). The trial commenced in February 2019 and recruitment is expected to be completed by March 2020. Results will be reported in articles submitted to peer-reviewed journals, as well as in presentations at national and international meetings.
Trial registration number: ACTRN12618001907235.