Momento Científico 22/05/2014 Renata Borges Facury Arroyo

Apresentação em tema: "Momento Científico 22/05/2014 Renata Borges Facury Arroyo"— Transcrição da apresentação:

1 Momento Científico 22/05/2014 Renata Borges Facury Arroyo
Residente de Geriatria do HCFMUSP Dra Maria Luiza de Melo Paulo (Preceptora) Dr Daniel Apolinário (Orientação Científica) Dr Jonas Gordilho Souza (Editorial)

2 Huang e cols - JAMA Intern Med 2014;174(2):251-258

3 Introdução idosos com Diabetes mellitus (DM) População heterogênea
Duração da doença Comorbidades Longa duração do DM Mais complicações Maior dificuldade de controle glicêmico Nearly half of the 24 million patients with diabetes mellitus living in the United States are older than 60 years. In the next 2 decades, their numbers are expected to double and their direct medical costs are expected to triple because of the combined effects of an aging population and high rates of overweight and obesity.1 The clinical heterogeneity of these patients, in terms of characteristics such as duration of diabetes and comorbid illnesses, greatly increases the challenge of caring for older patients.2 Many older patients with diabetes are living longer than in previous years. Longer duration of diabetes is associated with more complications and more difficulty with maintaining glycemic control.3,4 Understanding the contemporary clinical course of diabetes in older patients is the critical first step needed to individualize and prioritize care as well as target support for future research efforts. Huang e cols - JAMA Intern Med 2014;174(2):

4 Curso clínico atual x estudos prévios (década de 90)
Maior risco de complicações micro e cardiovasculares e de mortalidade Eventos cardiovasculares DAC: 181,5/1000 pessoas-ano AVC: 126,2/1000 pessoas-ano Hipoglicemia  muito menos comum 28,3/1000 pessoas-ano Rápida evolução dos cuidados do DM (UKPDS) Controle mais agressivo Mais opções de tratamento Prevenção primária e controle de fatores de risco The clinical course of diabetes in older patients today is presumably different from that reported in previous studies because of the rapid evolution of diabetes care. Most of our current understanding about the clinical course of diabetes in older patients is based on studies of populations from the 1990s.5,6 These studies found that Medicare patients with diabetes had elevated risks of complications (microvascular and cardiovascular) and mortality compared with patients without diabetes5 and that cardiovascular events (ischemic heart disease [181.5 events per 1000 person-years] and stroke [126.2 per 1000 person-years]) were by far the most common complications, with hypoglycemia being much less common (28.3 per 1000 person-years).6 After publication of the UK Prospective Diabetes Study findings in the late 1990s,7,8 clinicians have pursued more aggressive risk factor control and have more treatment options at their disposal.9 For example, clinicians dramatically increased their prescribing of angiotensin-converting enzyme inhibitors and statins after the release of evidence demonstrating the benefits of these drugs10,11 for preventing diabetes complications. Huang e cols - JAMA Intern Med 2014;174(2):

5 Idade x duração do DM 2 guias potenciais para individualizar metas e tratamentos Bertoni e cols, 2002 Taxas de complicação por faixa etária Bethel e cols, 2007 DM curta duração Descrição detalhada do curso clínico do DM necessário Taxas atuais de complicações e mortalidade por DM Apart from not reflecting the influence of recent changes in clinical practice, prior studies5,6 of older patients did not systematically examine how the course of diabetes differs by age and duration of the disease. These variables have been proposed as 2 key potential guides to the individualization of care goals and treatments.13 In a study by Bethel and colleagues,5 investigators monitored a diabetic population from a 5% sample of the Medicare population with newly diagnosed diabetes in 1994 and did not provide data on patients with longer diabetes duration. Bertoni and colleagues6 used the same Medicare sample to look at rates of complications by different age categories but did not evaluate differences in the course of the disease by duration of diabetes. A more nuanced description of the clinical course of diabetes is needed to inform medical decision making in older patients with diabetes. In this article, we describe contemporary rates of diabetes complications and mortality and contrast them across categories of age and duration of diabetes in a population of older adults with uniform access to integrated care. Huang e cols - JAMA Intern Med 2014;174(2): / Bethel e cols - Arch Intern Med. 2007;167(9): / Bertoni e cols ;25(3):

6 Critérios de inclusão Critérios de exclusão Métodos
The Diabetes and Aging Study Kaiser Foundation Research Institute University of Chicago Individuos com DM2 ≥60 anos em 01/01/2004 Associação contínua ao Kaiser Dados clínicos disponíveis Critérios de inclusão Ausência de HbA1c no ano anterior a linha de base Ausência de data do diagnóstico de DM (estimar duração) Critérios de exclusão Source Population The Kaiser Permanente Northern California (Kaiser) Diabetes Registry (Registry) is a well-characterized population maintained continuously since Registry inclusion is based ona validated algorithmincorporating multiple sources ofdata, including pharmacy records, laboratory data, and outpatient, emergency department, and hospitalization diagnoses of diabetes.17 Data from clinical information systems (electronic medical records) are downloaded annually. The Diabetes and Aging Study has been approved by the review boards of the Kaiser Foundation Research Institute and the University of Chicago. A waiver of informed patient consent was granted by both review boards. Our sampling frame included individualswith type 2 diabetes from the Registry who were aged 60 years or older on January 1, 2004 (baseline), with continuous Kaiser membership and available clinical data. Startingwith the full Registry (N = ),we excluded individuals younger than 60 years, lacking continuous Kaiser membership or pharmacy benefits in the 12 months prior to baseline, with type 1 diabetes mellitus or unknown type of diabetes,18 and 8366individualswithnohemoglobinA1c(HbA1c) test result during the year prior to baseline or no date of diabetes diagnosis (used to estimate duration).Theremaining patientswere the basis for these analyses. Huang e cols - JAMA Intern Med 2014;174(2):

7 Amostra 72.310 pacientes analisados
pacientes – Kaiser Registry Excluídos menores de 60 anos pacientes Excluídos por associação ao Kaiser não contínua no ano anterior pacientes Excluídos por DM tipo 1 ou desconhecido – pacientes Excluídos sem dosagem de HbA1c no ano anterior ou duração do DM desconhecido pacientes analisados Our sampling frame included individualswith type 2 diabetes from the Registry who were aged 60 years or older on January 1, 2004 (baseline), with continuous Kaiser membership and available clinical data. Startingwith the full Registry (N = ),we excluded individuals younger than 60 years, lacking continuous Kaiser membership or pharmacy benefits in the 12 months prior to baseline, with type 1 diabetes mellitus or unknown type of diabetes,18 and 8366individualswithnohemoglobinA1c(HbA1c) test result during the year prior to baseline or no date of diabetes diagnosis (used to estimate duration).Theremaining patientswere the basis for these analyses. Huang e cols - JAMA Intern Med 2014;174(2):

8 Análise Início em 01/01/2004 Janela de observação de 7 anos
Término do seguimento na primeira ocorrência de: Qualquer um dos desfechos não fatais Morte Descontinuação da associação ao Kaiser Final do seguimento (31/12/2010) Tempo médio de seguimento para mortalidade: 5.44 anos Time Frame for Analysis We monitored patients for a 7-year observation window, assigning person-time at risk starting on January 1, 2004, and censoring follow-up at the first occurrence of the following: any of the nonfatal outcomes of interest, death, discontinuation of Kaiser membership or pharmacy benefits (gap of at least 3 months in coverage), or the end of follow-up (December 31, 2010). The mean follow-up time for mortality was 5.44 years. Huang e cols - JAMA Intern Med 2014;174(2):

9 Exposição 6 maiores subgrupos:
Duração do diabetes (auto-relatado ou dados de prontuário) Curta duração (0-9 anos) Longa duração (≥ 10 anos) 60-69 anos Curta duração Longa duração 70-79 anos ≥ 80 anos Exposures Patients were divided into 6 major subgroups defined jointly by age (60-69, 70-79, and ≥80 years) and duration of diabetes (shorter [0-9]vs longer [≥10]years) asof the baselinedate (January 1,2004).Date of initialdiagnosisofdiabeteswasbased preferentially on self-report (38.5%) and, if that date was missing, on administrative records (61.5%). Huang e cols - JAMA Intern Med 2014;174(2):

10 Desfechos Evento hiperglicêmico agudo
hiperosmolaridade, cetoacidose ou DM descompensado Evento hipoglicêmico agudo Complicações microvasculares Doença renal em estágio terminal Retinopatia diabética grave Doença vascular periférica Amputação de membros inferiores Complicações cardiovasculares não fatais Doença arterial coronariana Doença cerebrovascular Insuficiência cardíaca congestiva Outcomes The occurrence and timing of each eventwere based on a combination of outpatient,emergencydepartment, or inpatient primary diagnostic codes (International Classification of Diseases, Ninth Revision) or procedure codes (Current Procedural Technology, Fourth Edition) (Supplement [eAppendix 1] ). Acute hyperglycemic event was defined as hospitalization for diabetes with hyperosmolarity, diabetes with ketoacidosis, or uncontrolled diabetes.Acute hypoglycemic event (hypoglycemia) was defined based on hospitalization or emergency department diagnostic codes for hypoglycemia. Microvascular complications included end-stage renal disease (ESRD), severe diabetic eye disease, peripheral vascular disease, and lower limb amputation. Incident ESRD was defined as initiation of chronic dialysis therapy or kidney transplant identified through hospitalization records or Kaiser’s reporting systems for theUSRenal Data System. Severe diabetic eye diseasewasidentified basedonoutpatient diagnostic codes forblindness, proliferative retinopathy,macular edema, or outpatient photocoagulation procedures. The presence of peripheral vascular disease was based on inpatient codes for the disease as well as lower limb angioplasty. Amputation was identified through inpatient diagnostic and procedure codes. Nonfatal cardiovascular complication was identified via hospitalization and/or emergency department records. These complications included coronary artery disease (myocardial infarction, coronary artery bypass surgery, and angioplasty), cerebrovascular disease (ischemic or hemorrhagic stroke and carotid endarterectomy), and congestive heart failure. Mortality and date of deathwere captured fromtheCalifornia State Mortality File, Social SecurityDeathRecords, or Kaiser administrative records when the death occurred within the health system. Mortalidade Registros administrativos Huang e cols - JAMA Intern Med 2014;174(2):

11 Covariáveis Dados demográficos Dados laboratoriais
Sexo Etnia Dados laboratoriais HbA1c no ano anterior LDL Taxa de filtração glomerular Complicações prévias Medicações relacionadas ao DM Other Variables Covariates ascertained at baseline included demographics (sex and race/ethnicity), most recent laboratory test resultswithin 1 year before baseline (HbA1c, low-density lipoprotein cholesterol, and glomerular filtration rate), prevalent complications (acute hyperglycemic or hypoglycemic eventwithin the previous year, or any history of ESRD, peripheral vascular disease, lower limb amputation, eye disease, coronary artery disease, cerebrovascular disease, and congestive heart failure), and diabetes-related medications the patient was receiving. Statistical Analysis Huang e cols - JAMA Intern Med 2014;174(2):

12 Análise estatística SAS versão 9.1 Significância estatística p<0.05
Significância clínica (amostra grande) Densidades de incidência Número de eventos por 1000 pessoas-ano Baseado na subpopulação em risco Ajustadas para raça e sexo Testes de tendência: aumentou ou diminuiu com a faixa etária ou duração do DM Análise de sensibilidade: subpopulação sem história dos desfechos no início do estudo All analyses were performed with SAS, version 9.1 (SAS Institute Inc) and associations were considered statistically significant at the P < .05 level. However, given the large sample size,we also considered clinical significance in addition to statistically significant contrasts. We calculated crude and sexaswell as race-adjusted incidence densities for each outcome (number of events per 1000 person-years, based on the subpopulation at risk, ie, after excluding individualswith a prevalent history of each outcome of interest).We also conducted tests of trend to determine whether the incidence significantly increased or decreased by age group or duration of diabetes. In sensitivity analyses, rather than excluding patients with a prevalent history of only the outcome of interest, we repeated the above analyses in the subpopulationwith no history of any of our outcomes of interest at baseline. Huang e cols - JAMA Intern Med 2014;174(2):

13 Resultados 14,5% Idade média: 71 anos
2,4 1,5 The mean age of the patients was 71 years, with 14.5% of the study population aged 80 years or older. For each age group, most patients had shorter duration (0-9 years) of diabetes (Table 1). Therewere 2.4 times more patientswith shorter than longer duration of diabetes for patients aged 60 to 69 years and 1.5 timesmorepatientswith shorter duration for those80years or older. There were several noteworthy baseline differences between patients with shorter vs longer duration of diabetes. Within each age category, patients with a longer duration of diabetesweremorelikely to have poorer glycemic controlcompared with those with a shorter diabetes duration. For example, 14.3% of patients aged 80 years or older with a longer duration of diabetes had a baseline HbA1c greater than 8.0% compared with only 6.4% of those in the same age group but with a shorter duration of diabetes (to convert HbA1c toaproportion of total Hb, multiply by 0.01). Compared with patientswith a shorter duration of diabetes, thosewith a longer duration also had higher baseline prevalence rates of microvascular and cardiovascular complications and were more likely to use each class of glucose-lowering medication, particularly insulin.

14 27,6 6,4 14,3 The mean age of the patients was 71 years, with 14.5% of the study population aged 80 years or older. For each age group, most patients had shorter duration (0-9 years) of diabetes (Table 1). Therewere 2.4 times more patientswith shorter than longer duration of diabetes for patients aged 60 to 69 years and 1.5 timesmorepatientswith shorter duration for those80years or older. There were several noteworthy baseline differences between patients with shorter vs longer duration of diabetes. Within each age category, patients with a longer duration of diabetesweremorelikely to have poorer glycemic controlcompared with those with a shorter diabetes duration. For example, 14.3% of patients aged 80 years or older with a longer duration of diabetes had a baseline HbA1c greater than 8.0% compared with only 6.4% of those in the same age group but with a shorter duration of diabetes (to convert HbA1c toaproportion of total Hb, multiply by 0.01). Compared with patientswith a shorter duration of diabetes, thosewith a longer duration also had higher baseline prevalence rates of microvascular and cardiovascular complications and were more likely to use each class of glucose-lowering medication, particularly insulin.

15 Compared with patientswith a shorter duration of diabetes, thosewith a longer duration also had higher baseline prevalence rates of microvascular and cardiovascular complications and were more likely to use each class of glucose-lowering medication, particularly insulin. For example, the proportion of patients aged 80 years or older with a longer duration of the disease using insulin was 34.8%compared with 5.0% for those in the same age group but with a shorter duration of diabetes. Most patients were receiving statins and angiotensin-converting enzyme inhibitors, but the prevalence varied across age and duration subgroups (range, 56.9%-70.8% for statins; 50.6%- 63.5% for angiotensin-converting enzyme inhibitors). Huang e cols - JAMA Intern Med 2014;174(2):

16 DM2 Curta Duração Huang e cols - JAMA Intern Med 2014;174(2):251-258
229% 255% Rates of Complications and MortalityWith Shorter Duration of Diabetes In general, the nonfatal complications with the highest incidence were cardiovascular (coronary artery disease, congestive heart failure, and cerebrovascular disease), followed by diabetic eye disease and acute hypoglycemic events (Table 2). Congestive heart failure and cerebrovascular disease increased most dramatically with advancing age (255% and 229% increase between ages and ≥80, respectively); the other outcomes increased less markedly. Endstage renal disease, lower limb amputation, and acute hyperglycemic events were consistently rare complications. Among individual microvascular complications, diabetic eye disease had the highest incidence in all age groups. Forexample, in patients aged 70 to 79 years, the incidence of eye disease was 6.16 per 1000 person-years and the incidences of ESRD and amputation were 2.60 per 1000 person-years and 1.28 per 1000 person-years, respectively. Not unexpectedly, the mortality rates increased steeply with advancing ageamong thosewitha shorter duration ofdiabetes (60-69, per1000person-years; 70-79, 42.69per1000 person-years; and ≥80, per 1000 person-years). In patients aged 80 years or older, the mortality rate was 4.3 times the rate of congestive heart failure, the most common nonfatal event. Huang e cols - JAMA Intern Med 2014;174(2):

17 DM2 Curta Duração Huang e cols - JAMA Intern Med 2014;174(2):251-258
Rates of Complications and MortalityWith Shorter Duration of Diabetes In general, the nonfatal complications with the highest incidence were cardiovascular (coronary artery disease, congestive heart failure, and cerebrovascular disease), followed by diabetic eye disease and acute hypoglycemic events (Table 2). Congestive heart failure and cerebrovascular disease increased most dramatically with advancing age (255% and 229% increase between ages and ≥80, respectively); the other outcomes increased less markedly. Endstage renal disease, lower limb amputation, and acute hyperglycemic events were consistently rare complications. Among individual microvascular complications, diabetic eye disease had the highest incidence in all age groups. Forexample, in patients aged 70 to 79 years, the incidence of eye disease was 6.16 per 1000 person-years and the incidences of ESRD and amputation were 2.60 per 1000 person-years and 1.28 per 1000 person-years, respectively. Not unexpectedly, the mortality rates increased steeply with advancing ageamong thosewitha shorter duration ofdiabetes (60-69, per1000person-years; 70-79, 42.69per1000 person-years; and ≥80, per 1000 person-years). In patients aged 80 years or older, the mortality rate was 4.3 times the rate of congestive heart failure, the most common nonfatal event. Huang e cols - JAMA Intern Med 2014;174(2):

18 DM2 Longa Duração Huang e cols - JAMA Intern Med 2014;174(2):251-258
3 3 Rates of Complications and MortalityWith Longer Duration of Diabetes The incidence rates in older patientswith a longer duration of diabetes (≥10 years) sharedsomesimilaritieswith ratesof those with a shorter durations, with some exceptions (Table 3). For patientswith a longer duration of diabetes, hypoglycemia had incidence rates that were similar to those of coronary artery disease and cerebrovascular disease. As a result, hypoglycemia had the fourth highest incidence of all individual nonfatal complications among patients aged 60 to 69 years and the third highest incidenceamong patients aged 70 years or older. Rates of incident coronary artery disease, cerebrovascular disease, congestive heart failure, and hypoglycemic events increased more steeply with advancing age than did the other nonfatal outcomes. Unlike thosewith a shorter duration of diabetes, patientswith a longer duration had modest declines in the rates of microvascular complications (ESRD, eye disease, and lower limb amputation)with advancing age (−27%, −27%, and −1%between ages and ≥80 years, respectively). The rarest complicationsamong all age groupswere lower limbamputation and acute hyperglycemic events. The largest difference across age groupsamong thosewith the longer duration of diabetes was in the mortality rates. The mortality rateswere significantly higher among patients aged 80 years or older in comparisonwith those in the younger patients (60-69, per1000person-years; 70-79,65.87per1000 person-years; and ≥80, per 1000 person-years). In patients aged 80 years or older, the mortality rate was almost 4.0 times the rate of congestive heart failure, the most common nonfatal event. Huang e cols - JAMA Intern Med 2014;174(2):

19 DM2 Longa Duração Huang e cols - JAMA Intern Med 2014;174(2):251-258
Rates of Complications and MortalityWith Longer Duration of Diabetes The incidence rates in older patientswith a longer duration of diabetes (≥10 years) sharedsomesimilaritieswith ratesof those with a shorter durations, with some exceptions (Table 3). For patientswith a longer duration of diabetes, hypoglycemia had incidence rates that were similar to those of coronary artery disease and cerebrovascular disease. As a result, hypoglycemia had the fourth highest incidence of all individual nonfatal complications among patients aged 60 to 69 years and the third highest incidenceamong patients aged 70 years or older. Rates of incident coronary artery disease, cerebrovascular disease, congestive heart failure, and hypoglycemic events increased more steeply with advancing age than did the other nonfatal outcomes. Unlike thosewith a shorter duration of diabetes, patientswith a longer duration had modest declines in the rates of microvascular complications (ESRD, eye disease, and lower limb amputation)with advancing age (−27%, −27%, and −1%between ages and ≥80 years, respectively). The rarest complicationsamong all age groupswere lower limbamputation and acute hyperglycemic events. The largest difference across age groupsamong thosewith the longer duration of diabetes was in the mortality rates. The mortality rateswere significantly higher among patients aged 80 years or older in comparisonwith those in the younger patients (60-69, per1000person-years; 70-79,65.87per1000 person-years; and ≥80, per 1000 person-years). In patients aged 80 years or older, the mortality rate was almost 4.0 times the rate of congestive heart failure, the most common nonfatal event. Huang e cols - JAMA Intern Med 2014;174(2):

20 Taxas de complicações e mortalidade através da duração do diabetes
Curta Duração Longa Duração 296% 248% 290% Curta Duração Longa Duração Rates of Complications and Mortality Across Duration of Diabetes For a givenage group, incidence rateswere consistently higher for all outcomes (nonfatal complications aswell as mortality) in patients with a longer compared with those with a shorter duration of diabetes. This pattern was most evident in those aged 60 to 69 years. The incidence of microvascular outcomes was much greater among patients with a longer duration of diabetes compared with those with a shorter duration. For example, ESRD, eye disease, and lower limb amputation incidences were 296%, 248%, and 290% greater, respectively, comparing longer with shorter duration among patients aged 60 to 69 years.Much smaller differences (142%, 86%, and 128%, respectively) were observed in the 80 years or older group. The other complications differed less dramatically by duration. Among patients in the 80 years or older group, the nonfatal complicationwith the greatest elevated risk with longer duration was hypoglycemia (215%). 215% 142% 86% 128% Huang e cols - JAMA Intern Med 2014;174(2):

21 Análise de sensibilidade
Taxas de complicações < coorte completa Rankings de complicações muito semelhantes Padrões semelhantes: DM de duração curta ou longa Entre as faixas etárias Findings for the Subpopulation Without Prior Complications For patients with no prevalent history of any complications, we found that, in general, complication rates were markedly lower compared with those in the overall cohort (Supplement [eAppendix2andeAppendix3]).However,wefoundvery similar rankings of individual complications as well as similar patterns between patients with shorter and longer durations of diabetes and across age groups. Huang e cols - JAMA Intern Med 2014;174(2):

22 Discussão Individualização do tratamento
Idade Duração do DM Preditores independentes do curso clínico Interação idade x duração: significativa Doença renal em fase terminal Retinopatia Amputação de membro inferior AVC e ICC Mortalidade Recent recommendations regarding diabetes care in older patients19,20 have emphasized the importance of individualization of treatment, although this remains poorly defined. Based on clinical trial results,13,21 some experts suggest the importance of considering age and duration of diabetes as criteria for risk stratification when individualizing care.13 However, the contemporary epidemiologic patterns have not been adequately documented in usual care settings. In this evaluation ofpatientswith type 2 diabetes,wefound that age and duration of diabetes were independent predictors of the clinical course of the disease. Moreover, their interaction (ie, age × duration) was significant for ESRD, eye disease, lower limb amputation, stroke, heart failure, and mortality, albeit not for hyperglycemia. The significant interactions justified evaluating effect sizes separately for each stratum. For consistency, we used the stratified approach for all outcomes. Huang e cols - JAMA Intern Med 2014;174(2):

23 Comparação com estudos prévios
Complicação (por 1000 pessoas-ano) Bertoni, 1995 Huang, ≥ 80 anos Eventos hiperglicêmicos agudos 24,3 2,35 Doença arterial coronariana 181,5 24,09 Amputação de membros inferiores 9,8 3,92 Hipoglicemia 28,3 3,03 – 19,6 These findings are based on observations in a contemporary, ethnically diversepopulation of older diabeticpatientswith uniform access to care in a large, integrated health care delivery system. The incidence rates of acutehyperglycemic events, microvascular complications, and cardiovascular complications in our study are all dramatically lower than those reported previously. Inthe study byBertoni et al6 ofMedicare recipients enrolled in 1995, the incidence density of diabetic ketoacidosis was 24.3 per 1000 person-years, the incidence of ischemic heartdiseasewas181.5 per1000person-years,andthe incidence ofamputationwas9.8per 1000 person-years.We observed much lower rates of those complications in the present study.For example,among the oldest patients (≥80 years)with a longer duration of diabetes, the rates for acute hyperglycemic events, coronary artery disease, and lower limb amputationwere only 2.35 per 1000 person-years, per 1000 person- years, and 3.92 per 1000 person-years, respectively. Our lower rates of cardiovascular events are consistentwith a general decline inthese events in the past 30 years for both the diabetic and nondiabetic populations.27 Our hypoglycemia rates varied froma lowof 3.03 per1000person-years forpatients aged 60 to 69 years with a diabetes duration of less than 10 years to 19.60per1000person-years for thoseaged80years or olderwith 10 ormoreyears of diabetes.Because these rateswere very sensitive to age and diabetes duration, it is difficult to contrast the hypoglycemia rates we observed with those reported by Bertoni et al6 (28.3 per 1000 person-years). Huang e cols - JAMA Intern Med 2014;174(2):

24 Hipoglicemia Contrarregulação deficiente Tratamentos mais intensivos
Fatores psicossociais Limitações funcionais Complicações micro e cardiovasculares prevenção primária controle dos fatores de risco Efeito adverso do tratamento x complicação não fatal Progression of diabetes complications is influenced by myriad factors, including delays in diagnosis, the natural history of type 2 diabetes, evolving diabetes care, patient selfmanagement, and genotypic variation. For example, the incidence of hypoglycemia among the elderly may increase because of defective counterregulation and hypoglycemic unawareness that occurs with aging and longer duration of diabetes,28 or itmay be the result of increased reliance on specific agents (eg, insulin, sulfonylureas) associatedwitha higher risk of hypoglycemia to achieve lower glycemic targets. Psychosocial factors and functional limitations are also likely to be important determinants of hypoglycemia risk.29 Hypoglycemiamay also occur more frequently than traditional diabetes complications because the rates ofmicrovascular and cardiovascular complications have declined from historic highs with more effective primary prevention efforts and better risk factor control. The use of more intensive diabetes treatments, which became more common from the 1990s to the 2000s,30may put patients at greater risk for hypoglycemia. As we become more successful at increasing long-term survivorshipwith type 2 diabetes,hypoglycemiamayemerge as a dominant nonfatal complication of older patients.To the extent that hypoglycemia is an adverse effect of treatment, its emergence as a dominant “complication” raises serious concerns about the acceptable limits of iatrogenesis; it has been suggested that, for some patients, preventing hypoglycemia is more important than tight glycemic control.31 Para alguns pacientes, prevenir a hipoglicemia é mais importante que o controle glicêmico rigoroso Huang e cols - JAMA Intern Med 2014;174(2):

25 Memória metabólica Pacientes mais idosos com diabetes de maior duração começaram a ser tratados na década de 90 Tratamento inicial menos intensivo (pré-UKPDS) Controle glicêmico precoce - efeitos de longa duração Taxas de complicação observadas em pacientes com longa duração do diabetes será diferente nas próximas décadas Acesso a saúde e qualidade do cuidado Bom controle glicêmico Uso de estatinas e IECA Não disponível para todos os pacientes The event rates of outcomes observed in this study are influenced not only by short-term clinical exposures and treatments but also by those received over a lifetime. For example, the older patients in our sample with a duration of diabetes of more than 10 yearsmay have received their initial treatments during the early 1990s; thus, their early treatment may have been less intensive because they predated the influence of UK Prospective Diabetes Study and Diabetes Control and Complications Trial32 findings. In accordancewith the concept that early control of glucose has long-lasting effects (legacyeffector metabolicmemory),22,33 it is likely that the rates of complications observed in patients with a longer duration of diabeteswill be quite different in the coming decade resulting from changes that have occurred in treatment patterns. The clinical course of disease among patients in the Registry is also, in part, a product of the access and quality of diabetes care deliveredwithin an integrated health care delivery system. In this population, the blood glucose levels were, on average, well controlled (which may have influenced hypoglycemia rates) and the use of statins and angiotensinconverting enzyme inhibitors was high. The patterns observed in this setting may differ from those in other clinical settings and populations, particularly the uninsured and underinsured. Although there are geriatric diabetic populations with limited access to quality diabetes care (eg, geographically isolated patients), our findings should be broadly applicable tomany older peoplewith diabetes because the vast majority receive Medicare-supported coverage. In addition, the event rates in this studywere basedona particular coding strategy that we applied systematically to all patient subgroups (Supplement [eAppendix 1]). Huang e cols - JAMA Intern Med 2014;174(2):

26 Conclusão Curso clínico do DM contemporâneo
Idade do paciente Duração da doença Necessidade de estudos para reduzir e entender a hipoglicemia Política de saúde Projetar gastos de saúde Necessidades específicas de idosos com diabetes This 4-year cohort study describes the clinical course of diabetes in older adults. These findings will be relevant and informative for clinicians, researchers, and policymakers. For clinicians, the study details how the expected course of diabetes may differ by age and duration of the disease. Although we havewitnessed great advances in the prevention of microvascular and cardiovascular disease among patientswith diabetes, our findings suggest the need for increased clinical and research focus on reducing and understanding the incidence of hypoglycemia in older adultswith diabetes. For policymakers, the study provides important data that may be used for projecting health care expenditures for a largeandgrowing segment of the Medicare population.1 More important, the data from this study may inform the design and scope of public policy interventions that meet the unique needs of elderly patients with the disease. Huang e cols - JAMA Intern Med 2014;174(2):

27 Editorial Este estudo foi realizado em uma coorte de pacientes de convênio dos Estados Unidos. Até que ponto esses resultados são transponíveis para a população brasileira? Os achados deste estudo vão ao encontro das diretrizes mais recentes, principalmente no que diz respeito ao controle intensivo da hemoglobina glicada em pacientes muito idosos? Na população estudada, nota-se também uma taxa de controle glicêmico melhor em pacientes acima de 80 anos em comparação com as faixas etárias mais jovens. Como justificar tal achado? Você acredita que os resultados deste estudo poderiam alterar o rastreio de complicações em idosos, dependendo da faixa etária e do tempo de duração do diabetes? Huang e cols - JAMA Intern Med 2014;174(2):