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Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update From the American College of Physicians.

Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update From the American College of Physicians.

Ann Intern Med. 2017 Jan 03;:

Authors: Qaseem A, Barry MJ, Humphrey LL, Forciea MA, Clinical Guidelines Committee of the American College of Physicians

Abstract
Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on oral pharmacologic treatment of type 2 diabetes in adults. This guideline serves as an update to the 2012 ACP guideline on the same topic. This guideline is endorsed by the American Academy of Family Physicians.
Methods: This guideline is based on a systematic review of randomized, controlled trials and observational studies published through December 2015 on the comparative effectiveness of oral medications for type 2 diabetes. Evaluated interventions included metformin, thiazolidinediones, sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Study quality was assessed, data were extracted, and results were summarized qualitatively on the basis of the totality of evidence identified by using several databases. Evaluated outcomes included intermediate outcomes of hemoglobin A1c, weight, systolic blood pressure, and heart rate; all-cause mortality; cardiovascular and cerebrovascular morbidity and mortality; retinopathy, nephropathy, and neuropathy; and harms. This guideline grades the recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.
Target Audience and Patient Population: The target audience for this guideline includes all clinicians, and the target patient population includes adults with type 2 diabetes.
Recommendation 1: ACP recommends that clinicians prescribe metformin to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. (Grade: strong recommendation; moderate-quality evidence).
Recommendation 2: ACP recommends that clinicians consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin to improve glycemic control when a second oral therapy is considered. (Grade: weak recommendation; moderate-quality evidence.) ACP recommends that clinicians and patients select among medications after discussing benefits, adverse effects, and costs.

PMID: 28055075 [PubMed - as supplied by publisher]




Annals for Educators - 3 January 2017.

Annals for Educators - 3 January 2017.

Ann Intern Med. 2017 Jan 03;166(1):ED1

Authors: Taichman DB

PMID: 28055057 [PubMed - in process]




Metformin Use in Patients With Historical Contraindications.

Metformin Use in Patients With Historical Contraindications.

Ann Intern Med. 2017 Jan 03;:

Authors: Lipska KJ

PMID: 28055052 [PubMed - as supplied by publisher]




At Last, a Good Estimate of the Magnitude of the Private-Sale Loophole for Firearms.

At Last, a Good Estimate of the Magnitude of the Private-Sale Loophole for Firearms.

Ann Intern Med. 2017 Jan 03;:

Authors: Cook PJ

PMID: 28055051 [PubMed - as supplied by publisher]




Firearm Acquisition Without Background Checks: Results of a National Survey.

Firearm Acquisition Without Background Checks: Results of a National Survey.

Ann Intern Med. 2017 Jan 03;:

Authors: Miller M, Hepburn L, Azrael D

Abstract
Background: In 1994, 40% of U.S. gun owners who had recently acquired a firearm did so without a background check. No contemporary estimates exist.
Objective: To estimate the proportion of current U.S. gun owners who acquired their most recent firearm without a background check, by time since and manner of acquisition, for the nation as a whole and separately in states with and without legislation regulating private sales.
Design: Probability-based online survey.
Setting: United States, 2015.
Participants: 1613 adult gun owners.
Measurements: Current gun owners were asked where and when they acquired their last firearm; if they purchased the firearm; and whether, as part of that acquisition, they had a background check (or were asked to show a firearm license or permit).
Results: 22% (95% CI, 16% to 27%) of gun owners who reported obtaining their most recent firearm within the previous 2 years reported doing so without a background check. For firearms purchased privately within the previous 2 years (that is, other than from a store or pawnshop, including sales between individuals in person, online, or at gun shows), 50% (CI, 35% to 65%) were obtained without a background check. This percentage was 26% (CI, 5% to 47%) for owners residing in states regulating private firearm sales and 57% (CI, 40% to 75%) for those living in states without regulations on private firearm sales.
Limitation: Potential inaccuracies due to recall and social desirability bias.
Conclusion: 22% of current U.S. gun owners who acquired a firearm within the past 2 years did so without a background check. Although this represents a smaller proportion of gun owners obtaining firearms without background checks than in the past, millions of U.S. adults continue to acquire guns without background checks, especially in states that do not regulate private firearm sales.
Primary Funding Source: Fund for a Safer Future and the Joyce Foundation.

PMID: 28055050 [PubMed - as supplied by publisher]




Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease: A Systematic Review.

Clinical Outcomes of Metformin Use in Populations With Chronic Kidney Disease, Congestive Heart Failure, or Chronic Liver Disease: A Systematic Review.

Ann Intern Med. 2017 Jan 03;:

Authors: Crowley MJ, Diamantidis CJ, McDuffie JR, Cameron CB, Stanifer JW, Mock CK, Wang X, Tang S, Nagi A, Kosinski AS, Williams JW

Abstract
Background: Recent changes to the U.S. Food and Drug Administration boxed warning for metformin will increase its use in persons with historical contraindications or precautions. Prescribers must understand the clinical outcomes of metformin use in these populations.
Purpose: To synthesize data addressing outcomes of metformin use in populations with type 2 diabetes and moderate to severe chronic kidney disease (CKD), congestive heart failure (CHF), or chronic liver disease (CLD) with hepatic impairment.
Data Sources: MEDLINE (via PubMed) from January 1994 to September 2016, and Cochrane Library, EMBASE, and International Pharmaceutical Abstracts from January 1994 to November 2015.
Study Selection: English-language studies that: 1) examined adults with type 2 diabetes and CKD (with estimated glomerular filtration rate less than 60 mL/min/1.73 m2), CHF, or CLD with hepatic impairment; 2) compared diabetes regimens that included metformin with those that did not; and 3) reported all-cause mortality, major adverse cardiovascular events, and other outcomes of interest.
Data Extraction: 2 reviewers abstracted data and independently rated study quality and strength of evidence.
Data Synthesis: On the basis of quantitative and qualitative syntheses involving 17 observational studies, metformin use is associated with reduced all-cause mortality in patients with CKD, CHF, or CLD with hepatic impairment, and with fewer heart failure readmissions in patients with CKD or CHF.
Limitations: Strength of evidence was low, and data on multiple outcomes of interest were sparse. Available studies were observational and varied in follow-up duration.
Conclusion: Metformin use in patients with moderate CKD, CHF, or CLD with hepatic impairment is associated with improvements in key clinical outcomes. Our findings support the recent changes in metformin labeling.
Primary Funding Source: U.S. Department of Veterans Affairs. (PROSPERO: CRD42016027708).

PMID: 28055049 [PubMed - as supplied by publisher]




Detecting Heterogeneous Treatment Effects to Guide Personalized Blood Pressure Treatment: A Modeling Study of Randomized Clinical Trials.

Detecting Heterogeneous Treatment Effects to Guide Personalized Blood Pressure Treatment: A Modeling Study of Randomized Clinical Trials.

Ann Intern Med. 2017 Jan 03;:

Authors: Basu S, Sussman JB, Hayward RA

Abstract
Background: Two recent randomized trials produced discordant results when testing the benefits and harms of treatment to reduce blood pressure (BP) in patients with cardiovascular disease (CVD).
Objective: To perform a theoretical modeling study to identify whether large, clinically important differences in benefit and harm among patients (heterogeneous treatment effects [HTEs]) can be hidden in, and explain discordant results between, treat-to-target BP trials.
Design: Microsimulation.
Data Sources: Results of 2 trials comparing standard (systolic BP target <140 mm Hg) with intensive (systolic BP target <120 mm Hg) BP treatment and data from the National Health and Nutrition Examination Survey (2013 to 2014).
Target Population: U.S. adults.
Time Horizon: 5 years.
Perspective: Societal.
Intervention: BP treatment.
Outcome Measures: CVD events and mortality.
Results of Base-Case Analysis: Clinically important HTEs could explain differences in outcomes between 2 trials of intensive BP treatment, particularly diminishing benefit with each additional BP agent (for example, adding a second agent reduces CVD risk [hazard ratio, 0.61], but adding a fourth agent to a third has no benefit) and increasing harm at low diastolic BP.
Results of Sensitivity Analysis: Conventional treat-to-target trial designs had poor (<5%) statistical power to detect the HTEs, despite large samples (n > 20 000), and produced biased effect estimates. In contrast, a trial with sequential randomization to more intensive therapy achieved greater than 80% power and unbiased HTE estimates, despite small samples (n = 3500).
Limitations: The HTEs as a function of the number of BP agents only were explored. Simulated aggregate data from the trials were used as model inputs because individual-participant data were not available.
Conclusion: Clinically important heterogeneity in intensive BP treatment effects remains undetectable in conventional trial designs but can be detected in sequential randomization trial designs.
Primary Funding Source: National Institutes of Health and U.S. Department of Veterans Affairs.

PMID: 28055048 [PubMed - as supplied by publisher]




Oral Pharmacologic Treatment of Type 2 Diabetes.

Oral Pharmacologic Treatment of Type 2 Diabetes.

Ann Intern Med. 2017 Jan 03;:

Authors:

PMID: 28055047 [PubMed - as supplied by publisher]




Glycemic Therapy for Type 2 Diabetes: Choices Expand, Data Lag Behind.

Glycemic Therapy for Type 2 Diabetes: Choices Expand, Data Lag Behind.

Ann Intern Med. 2017 Jan 03;:

Authors: Fradkin JE, Rodgers GP

PMID: 28055042 [PubMed - as supplied by publisher]




A Tale of Two Trials: Reconciling Differences in Results by Exploring Heterogeneous Treatment Effects.

A Tale of Two Trials: Reconciling Differences in Results by Exploring Heterogeneous Treatment Effects.

Ann Intern Med. 2017 Jan 03;:

Authors: Kaul S

PMID: 28055041 [PubMed - as supplied by publisher]