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Koto R, Nakajima A, Miwa T, Sugimoto K. Multimorbidity, Polypharmacy, Severe Hypoglycemia, and Glycemic Control in Patients Using Glucose-Lowering Drugs for Type 2 Diabetes: A Retrospective Cohort Study Using Health Insurance Claims in Japan. Diabetes Ther 2023:10.1007/s13300-023-01421-5. [PMID: 37195511 DOI: 10.1007/s13300-023-01421-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/03/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION This study aimed to understand the actual status of multimorbidity and polypharmacy among patients with type 2 diabetes using glucose-lowering drugs, and to assess the effects of patient characteristics on severe hypoglycemia and glycemic control. METHODS We designed a retrospective cohort study using health insurance claims and medical checkup data in Japan from April 2016 to February 2021 and identified patients with type 2 diabetes who were prescribed glucose-lowering drugs. We analyzed data on patient characteristics, including multimorbidity and polypharmacy, calculated the incidence rate for severe hypoglycemic events, applied a negative binomial regression model to explore factors that affected severe hypoglycemia, and analyzed the status of glycemic control in the subcohort for which HbA1c data were available. RESULTS Within the analysis population (n = 93,801), multimorbidity was present in 85.5% and mean ± standard deviation for oral drug prescriptions was 5.6 ± 3.5 per patient, while for those aged 75 years or older these numbers increased to 96.3% and 7.1 ± 3.5, respectively. The crude incidence rate for severe hypoglycemia was 5.85 (95% confidence interval 5.37, 6.37) per 1000 person-years. Risk factors for severe hypoglycemia included younger and older age, prior severe hypoglycemia, use of insulin, sulfonylurea, two-drug therapy including sulfonylurea or glinides, three-or-more-drug therapy, excessive polypharmacy, and comorbidities including end-stage renal disease (ESRD) requiring dialysis. Subcohort analysis (n = 26,746) showed that glycemic control is not always maintained according to guidelines. CONCLUSION Patients with type 2 diabetes, particularly older patients, experienced high multimorbidity and polypharmacy. Several risk factors for severe hypoglycemia were identified, most notably younger age, ESRD, history of severe hypoglycemia, and insulin therapy. TRIAL REGISTRATION The University Hospital Medical Information Network Clinical Trials Registry (UMIN000046736).
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Affiliation(s)
- Ruriko Koto
- Medical Science Department, Teijin Pharma Limited, 2-1, Kasumigaseki 3-Chome, Chiyoda-Ku, Tokyo, 100-8585, Japan.
| | - Akihiro Nakajima
- Pharmaceutical Development Administration Department, Teijin Pharma Limited, Tokyo, Japan
| | - Tetsuya Miwa
- Medical Science Department, Teijin Pharma Limited, 2-1, Kasumigaseki 3-Chome, Chiyoda-Ku, Tokyo, 100-8585, Japan
| | - Ken Sugimoto
- General and Geriatric Medicine, Kawasaki Medical School, Okayama, Japan
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2
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Ogawa W, Hirota Y, Osonoi T, Tosaki T, Kato Y, Utsunomiya K, Nishimura R, Nakamura J. Effect of the FreeStyle Libre™ flash glucose monitoring system on glycemic control in individuals with type 2 diabetes treated with basal-bolus insulin therapy: An open label, prospective, multicenter trial in Japan. J Diabetes Investig 2021; 12:82-90. [PMID: 32562376 PMCID: PMC7779269 DOI: 10.1111/jdi.13327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS/INTRODUCTION We investigated the effect of FreeStyle LibreTM on glycemic control in Japanese type 2 diabetes patients treated with basal-bolus insulin therapy. MATERIALS AND METHODS This prospective, 90-day single-arm study enrolled 94 adults with type 2 diabetes treated with insulin. A 14-day masked baseline phase was followed by an 11-week treatment phase during which participants used the device to monitor glucose levels. The primary end-point was time spent in hypoglycemia (<70 mg/dL) for baseline versus study end (days 76-90). Secondary end-points included other measures of glycemic control, along with patient satisfaction using the Japanese Diabetes Treatment and Satisfaction Questionnaire. RESULTS Time spent in hypoglycemia was low at baseline (0.51 ± 0.93 h/day) and did not significantly decrease at study end (0.47 ± 0.63 h/day, P = 0.6354). Time in range, time in hyperglycemia and estimated A1c all improved versus baseline (by +1.7 ± 3.0 h/day, -1.6 ± .4 h/day and -0.4 ± 0.8%, respectively, P < 0.0001 in each). Finger stick tests fell from 2.9 ± 1.3 to 1.9 ± 1.4/day, and mean scanning frequency during the intervention phase was 11.3/day. The mean treatment satisfaction score increased by 11.8 ± 5.3 (P < 0.0001). Two severe hypoglycemia-related adverse events were reported; one of which was possibly related to the device. Three participants reported mild device-related skin trauma, site discomfort or subcutaneous bleeding. CONCLUSIONS Use of FreeStyle Libre by Japanese type 2 patients diabetes treated with basal-bolus insulin therapy showed a low baseline of hypoglycemia, and enabled improved glycemic control and treatment satisfaction.
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Affiliation(s)
- Wataru Ogawa
- Division of Diabetes and EndocrinologyDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yushi Hirota
- Division of Diabetes and EndocrinologyDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | | | - Takahiro Tosaki
- TDE Healthcare CorporationTOSAKI Clinic for Diabetes and EndocrinologyAichiJapan
| | - Yoshiro Kato
- Division of DiabetesDepartment of Internal MedicineAichi Medical University School of MedicineAichiJapan
| | - Kazunori Utsunomiya
- Division of Diabetes, Metabolism and EndocrinologyDepartment of Internal MedicineThe Jikei University HospitalTokyoJapan
| | - Rimei Nishimura
- Division of Diabetes, Metabolism and EndocrinologyDepartment of Internal MedicineThe Jikei University HospitalTokyoJapan
| | - Jiro Nakamura
- Division of DiabetesDepartment of Internal MedicineAichi Medical University School of MedicineAichiJapan
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Alwafi H, Alsharif AA, Wei L, Langan D, Naser AY, Mongkhon P, Bell JS, Ilomaki J, Al Metwazi MS, Man KKC, Fang G, Wong ICK. Incidence and prevalence of hypoglycaemia in type 1 and type 2 diabetes individuals: A systematic review and meta-analysis. Diabetes Res Clin Pract 2020; 170:108522. [PMID: 33096187 DOI: 10.1016/j.diabres.2020.108522] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Previous meta-analysis investigating the incidence and prevalence of hypoglycaemia in both types of diabetes is limited. The purpose of this review is to conduct a systematic review and meta-analysis of the existing literature which investigates the incidence and prevalence of hypoglycaemia in individuals with diabetes. METHODS PubMed, Embase and Cochrane library databases were searched up to October 2018. Observational studies including individuals with diabetes of all ages and reporting incidence and/or prevalence of hypoglycaemia were included. Two reviewers independently screened articles, extracted data and assessed the quality of included studies. Meta-analysis was performed using a random effects model with 95% confidence interval (CI) to estimate the pooled incidence and prevalence of hypoglycaemia in individuals with diabetes. RESULTS Our search strategy generated 35,007 articles, of which 72 studies matched the inclusion criteria and were included in the meta-analysis. The prevalence of hypoglycaemia ranged from 0.074% to 73.0%, comprising a total of 2,462,810 individuals with diabetes. The incidence rate of hypoglycaemia ranged from 0.072 to 42,890 episodes per 1,000 person-years: stratified by type of diabetes, it ranged from 14.5 to 42,890 episodes per 1,000 person-years and from 0.072 to 16,360 episodes per 1,000-person years in type 1 and type 2 diabetes, respectively. CONCLUSION Hypoglycaemia is very common among individuals with diabetes. Further studies are needed to investigate hypoglycaemia-associated risk factors.
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Affiliation(s)
- Hassan Alwafi
- Research Department of Practice and Policy, School of Pharmacy, University College London (UCL), London, United Kingdom; Faculty of Medicine, Umm Al Qura University, Mecca, Saudi Arabia
| | - Alaa A Alsharif
- Department of Pharmacy Practice, Faculty of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London (UCL), London, United Kingdom
| | - Dean Langan
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Pajaree Mongkhon
- Department of Pharmacy Practice School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand; Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Mansour S Al Metwazi
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Kenneth K C Man
- Research Department of Practice and Policy, School of Pharmacy, University College London (UCL), London, United Kingdom; Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Gang Fang
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ian C K Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London (UCL), London, United Kingdom; Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong; The University of Hong Kong - Shenzhen Hospital, 1, Haiyuan 1st Road, Futian District, Shenzhen, Guangdong, China.
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Kojima T, Mizokami F, Akishita M. Geriatric management of older patients with multimorbidity. Geriatr Gerontol Int 2020; 20:1105-1111. [PMID: 33084212 DOI: 10.1111/ggi.14065] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/17/2020] [Accepted: 09/27/2020] [Indexed: 01/08/2023]
Abstract
Older patients tend to have multimorbidity represented by multiple chronic diseases or geriatric conditions due to aging changes of organs, which require a variety of medical management. Currently, there are no sufficient disease treatment guidelines for older people with multimorbidity, therefore physicians have difficulty managing multimorbidity, such as which diseases should be treated intensively or to what extent the conditions should be improved. Furthermore, there are other points to be considered when initiating the treatment of diseases. For example, physicians must assess physical function. Some people have no difficulty with ambulation, but some are bedridden and have difficulty getting up on their own. As there are differences in disease severity, comorbid conditions and life expectancy, there should be differences in deciding treatment and prescribing drugs. It may be necessary to change the option for treatment depending on cognitive function, the living environment and the care environment, using comprehensive geriatric assessments. In addition, when treating multimorbidity, patients tend to have polypharmacy, which is a risk for adverse drug events. Because of this, it is necessary to consider dose reduction and drug discontinuation in patients with polypharmacy. Because of the global increase in older patients with multimorbidity, developing an essential method for managing multimorbidity is an urgent issue. More research and practices are necessary to achieve high-quality care in patients with multimorbidity. Geriatr Gerontol Int 2020; 20: 1105-1111.
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Affiliation(s)
- Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Fumihiro Mizokami
- Department of Pharmacy, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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5
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Tsuji S, Ishikawa T, Morii Y, Zhang H, Suzuki T, Tanikawa T, Nakaya J, Ogasawara K. Cost-Effectiveness of a Continuous Glucose Monitoring Mobile App for Patients With Type 2 Diabetes Mellitus: Analysis Simulation. J Med Internet Res 2020; 22:e16053. [PMID: 32940613 PMCID: PMC7530685 DOI: 10.2196/16053] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 02/23/2020] [Accepted: 06/03/2020] [Indexed: 01/27/2023] Open
Abstract
Background Apps for real-time continuous glucose monitoring (CGM) on smartphones and other devices linked to CGM systems have recently been developed, and such CGM apps are also coming into use in Japan. In comparison with conventional retrospective CGM, the use of CGM apps improves patients’ own blood glucose control, which is expected to help slow the progression of type 2 diabetes mellitus (DM) and prevent complications, but the effect of their introduction on medical costs remains unknown. Objective Our objective in this study was to perform an economic appraisal of CGM apps from the viewpoint of assessing public medical costs associated with type 2 DM, using the probability of developing type 2 DM–associated complications, and data on medical costs and utility value to carry out a medical cost simulation using a Markov model in order to ascertain the cost-effectiveness of the apps. Methods We developed a Markov model with the transition states of insulin therapy, nephrosis, dialysis, and cardiovascular disease, all of which have a major effect on medical costs, to identify changes in medical costs and utility values resulting from the introduction of a CGM app and calculated the incremental cost-effectiveness ratio (ICER). Results The ICER for CGM app use was US $33,039/quality-adjusted life year (QALY). Conclusions Sensitivity analyses showed that, with the exception of conditions where the transition probability of insulin therapy, utility value, or increased medical costs increases, the ICER for the introduction of CGM apps was below the threshold of US $43,478/QALY used by the Central Social Insurance Medical Council. Our results provide basic data on the cost-effectiveness of introducing CGM apps, which are currently starting to come into use.
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Affiliation(s)
- Shintaro Tsuji
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Tomoki Ishikawa
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan.,Institute for Health Economics and Policy, Tokyo, Japan
| | - Yasuhiro Morii
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Hongjian Zhang
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Teppei Suzuki
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan.,Art and Sports Business, Iwamizawa Campus, Hokkaido University of Education, Hokkaido, Japan
| | - Takumi Tanikawa
- Department of Radiological Technology, Hokkaido University of Science, Sapporo, Japan
| | - Jun Nakaya
- Graduate School of Health Sciences, Hokkaido University, Sapporo, Japan
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Kojima T. The Need for Actions Against Polypharmacy in Older People With Frailty. Ann Geriatr Med Res 2018; 22:111-116. [PMID: 32743259 PMCID: PMC7387586 DOI: 10.4235/agmr.2018.22.3.111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 06/24/2018] [Accepted: 06/29/2018] [Indexed: 11/07/2022] Open
Abstract
Providing safe and effective drug therapy to older patients is challenging for physicians since there is not sufficient evidence to support the efficacy of these drugs and this population is susceptible to adverse drug reactions. Special consideration is needed when treating patients who require nursing care or who are at a stage prior to disability (i.e., frailty) because they may have limited life expectancies, complications, or organ dysfunction. Polypharmacy refers to the condition in which a patient is taking many drugs and, thus, is at an increased risk of adverse events. Although it is difficult to avoid polypharmacy in older people with frailty, the periodic review of drugs and reduction of dose or discontinuation of potentially inappropriate medications are needed to address this problem. This article reviews the association between frailty and polypharmacy and counteractions against polypharmacy in patients with frailty.
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Affiliation(s)
- Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Ikeda Y, Kubo T, Oda E, Abe M, Tokita S. Incidence rate and patient characteristics of severe hypoglycemia in treated type 2 diabetes mellitus patients in Japan: Retrospective Diagnosis Procedure Combination database analysis. J Diabetes Investig 2018; 9:925-936. [PMID: 29171937 PMCID: PMC6031502 DOI: 10.1111/jdi.12778] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/13/2017] [Accepted: 11/13/2017] [Indexed: 12/11/2022] Open
Abstract
AIMS/INTRODUCTION To evaluate the incidence rate of and identify factors associated with severe hypoglycemic episodes in patients with treated type 2 diabetes mellitus. MATERIALS AND METHODS Using Diagnosis Procedure Combination hospital-based medical database, we carried out a retrospective cohort study to assess the incidence rate of severe hypoglycemia in treated type 2 diabetes mellitus patients. We evaluated the associations between severe hypoglycemia and age, sex, complications, and current use of insulin or sulfonylurea (SU) in a nested case-control study. RESULTS Of 166,806 eligible patients, 1,242 had episodes of severe hypoglycemia during the observational period. The incidence rate of the first hypoglycemic events was 3.70/1,000 patient years. Based on the nested case-control analysis, age was associated with hypoglycemic events with adjusted odds ratios (ORs) of 1.64 or 65-74-year-old patients and 3.79 for ≥75-year-old patients in comparison with 20-64-year-old patients. Comorbidities, such as cognitive impairment, cancer, macrovascular disease and diabetic complications (retinopathy, nephropathy and neuropathy), were associated with severe hypoglycemia, with adjusted ORs ranging from 1.25 to 3.80. Severe hypoglycemic events also increased in patients with current use of both SU and insulin, either SU or insulin, with adjusted ORs of 18.36, 6.31 or 14.07, respectively, compared with patients with other antihyperglycemic agents. In patients with an SU glimepiride, adjusted ORs increased dose-dependently from 3.65 (≤1 mg) to 13.34 (>2 mg). CONCLUSIONS The incidence rate of severe hypoglycemia in this cohort was 3.70/1,000 patient years. Age, cognitive impairment, cancer, diabetic complications, current use of insulin + SU and SU dosage were identified as risk factors for severe hypoglycemia.
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Zaccardi F, Dhalwani NN, Webb DR, Davies MJ, Khunti K. Global burden of hypoglycaemia-related mortality in 109 countries, from 2000 to 2014: an analysis of death certificates. Diabetologia 2018; 61:1592-1602. [PMID: 29717336 PMCID: PMC6438613 DOI: 10.1007/s00125-018-4626-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/04/2018] [Indexed: 12/21/2022]
Abstract
AIMS/HYPOTHESIS In the context of increasing prevalence of diabetes in elderly people with multimorbidity, intensive glucose control may increase the risk of severe hypoglycaemia, potentially leading to death. While rising trends of severe hypoglycaemia rates have been reported in some European, North American and Asian countries, the global burden of hypoglycaemia-related mortality is unknown. We aimed to investigate global differences and trends of hypoglycaemia-related mortality. METHODS We used the WHO mortality database to extract information on death certificates reporting hypoglycaemia or diabetes as the underlying cause of death, and the United Nations demographic database to obtain data on mid-year population estimates from 2000 to 2014. We calculated crude and age-standardised proportions (defined as number of hypoglycaemia-related deaths divided by total number of deaths from diabetes [i.e. the sum of hypoglycaemia- and diabetes-related deaths]) and rates (hypoglycaemia-related deaths divided by mid-year population) of hypoglycaemia-related mortality and compared estimates across countries and over time. RESULTS Data for proportions were extracted from 109 countries (31 had data from all years analysed [2000-2014] available). Combining all countries, the age-standardised proportion of hypoglycaemia-related deaths was 4.49 (95% CI 4.44, 4.55) per 1000 total diabetes deaths. Compared with the overall mean, most Central American, South American and (mainly) Caribbean countries reported higher proportions (five more age-standardised hypoglycaemia-related deaths per 1000 total diabetes deaths in Chile, six in Uruguay, 11 in Belize and 22 in Aruba), as well as Japan (11 more age-standardised hypoglycaemia-related deaths per 1000 total diabetes deaths). In comparison, lower proportions were noted in most European countries, the USA, Canada, New Zealand and Australia. For countries with data available for all years analysed, trend analysis showed a 60% increase in hypoglycaemia-related deaths until 2010 and stable trends onwards. Rising trends were most evident for Argentina, Brazil, Chile, the USA and Japan. Data for rates were available for 105 countries (30 had data for all years analysed [2000-2014] available). Combining all countries, the age-standardised hypoglycaemia-related death rate was 0.79 (95% CI 0.77, 0.80) per 1 million person-years. Most Central American, South American and Caribbean countries similarly reported higher rates of hypoglycaemia-related death, whilst virtually all European countries, the USA, Canada, Japan, New Zealand and Australia reported lower rates compared with the overall mean. Age-standardised rates were very low for most countries (lower than five per 1 million person-years in 89.5% of countries), resulting in small absolute differences among countries. As noted with the proportions analysis, trend analysis showed an overall 60% increase in hypoglycaemia-related deaths until 2010 and stable rate trends onwards; rising rates were particularly evident for Brazil, Chile and the USA. CONCLUSIONS/INTERPRETATION Most countries in South America, Central America and the Caribbean showed the highest proportions of diabetes-related deaths attributable to hypoglycaemia and the highest rates of hypoglycaemia-related deaths. Between 2000 and 2014, rising trends were observed in Brazil, Chile and the USA for both rates and proportions of hypoglycaemia-related death, and in Argentina and Japan for proportions only. Further studies are required to unravel the contribution of clinical and socioeconomic factors, difference in diabetes prevalence and heterogeneity of death certification in determining lower rates and proportions of hypoglycaemia-related deaths in high-income countries in Europe, North America and Asia. DATA AVAILABILITY Data used for these analyses are available at https://doi.org/10.17632/ndp52fbz8r.1.
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Affiliation(s)
- Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK.
| | - Nafeesa N Dhalwani
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - David R Webb
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
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Bonaventura A, Gallo F, Carbone F, Liberale L, Maggi D, Sacchi G, Dallegri F, Montecucco F, Cordera R. Levels of serum uric acid at admission for hypoglycaemia predict 1-year mortality. Acta Diabetol 2018; 55:323-330. [PMID: 29327150 DOI: 10.1007/s00592-017-1094-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/21/2017] [Indexed: 11/27/2022]
Abstract
AIMS Hypoglycaemia represents a critical burden with clinical and social consequences in the management of diabetes. Serum uric acid (SUA) has been associated with cardiovascular diseases (CVD), but no conclusive findings are available nowadays in patients suffering from hypoglycaemia. We investigated whether SUA levels at the time of hypoglycaemia could predict all-cause mortality after 1-year follow-up. METHODS In total, 219 patients admitted to the Emergency Department (ED) of Ospedale Policlinico S. Martino of Genoa (Italy) have been enrolled between January 2011 and December 2014. The primary endpoint of the study consisted in determining whether SUA levels at the time of ED admission could predict the occurrence of death after 1 year. RESULTS The majority of patients were diabetic, especially type 2. CVD and chronic kidney disease were prevalent comorbidities. By a cut-off value obtained by the receiver operating characteristic curve analysis, a Kaplan-Meier analysis demonstrated that patients with SUA levels > 5.43 mg/dL were more prone to death after 1 year compared to those with lower SUA levels. The risk of death increased with high SUA levels both in the univariate and the multivariate models including estimated glomerular filtration rate, C-reactive protein, type of diabetes, and age-adjusted Charlson comorbidity index. CONCLUSIONS SUA could be useful as a predictor of 1-year mortality in hypoglycaemic patients, irrespective of severe comorbidities notably increasing the risk of death in these frail patients.
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Affiliation(s)
- Aldo Bonaventura
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy.
| | - Fiorenza Gallo
- Diabetology Unit, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
- Center for Molecular Cardiology, University of Zürich, 12 Wagistrasse, 8952, Schlieren, Switzerland
| | - Davide Maggi
- Diabetology Unit, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
| | - Giovanni Sacchi
- Emergency Department, Ospedale Policlinico San Martino, 10 Largo Benzi, 16132, Genoa, Italy
| | - Franco Dallegri
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
- Ospedale Policlinico San Martino, 10 Largo Benzi, 16132, Genoa, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
- Ospedale Policlinico San Martino, 10 Largo Benzi, 16132, Genoa, Italy
- Centre of Excellence for Biomedical Research (CEBR), University of Genoa, 9 Viale Benedetto XV, 16132, Genoa, Italy
| | - Renzo Cordera
- Diabetology Unit, Department of Internal Medicine, University of Genoa, 6 Viale Benedetto XV, 16132, Genoa, Italy
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Sako A, Yasunaga H, Matsui H, Fushimi K, Hamasaki H, Katsuyama H, Tsujimoto T, Goto A, Yanai H. Hospitalization with hypoglycemia in patients without diabetes mellitus: A retrospective study using a national inpatient database in Japan, 2008-2012. Medicine (Baltimore) 2017; 96:e7271. [PMID: 28640135 PMCID: PMC5484243 DOI: 10.1097/md.0000000000007271] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We aimed to examine prevalence, patient characteristics, etiology, and clinical outcomes of hospitalized patients who had hypoglycemia without a diagnosis of diabetes mellitus, using a Japanese nationwide database.This was a retrospective observational study using a national database of acute-care inpatients in Japan. Nondiabetic patients aged ≥15 years who were hospitalized for hypoglycemia were eligible. We estimated the annual numbers of hospitalized cases in Japan. We also investigated the patient characteristics, and risk factors of in-hospital mortality.We identified 8684 eligible patients out of 22.7 million discharge records between July 2008 and March 2013. The average age was 70.0 years and the average body mass index (BMI) was 19.9 kg/m. Most frequently recorded underlying diseases were malignancies, cerebrovascular diseases, pneumonia, renal failure, and heart failure. The estimated annual numbers of hospitalizations because of hypoglycemia in nondiabetic patients were 5000 to 7000. In-hospital mortality was 14.9%, and predictive factors for poor survival included older age, community hospital, low BMI, coma at admission, urgent admission, renal failure, heart failure, pneumonia, sepsis, chronic liver diseases, and malignancies.Patients without diabetes mellitus but with hypoglycemia had multiple comorbidities and high in-hospital mortality. Clinicians should carefully investigate the etiology of hypoglycemia in nondiabetic patients, and treat the underlying diseases.
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Affiliation(s)
- Akahito Sako
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University Graduate School of Medicine
| | - Hidetaka Hamasaki
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba
| | - Hisayuki Katsuyama
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba
| | - Tetsuro Tsujimoto
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine
| | - Atsushi Goto
- Metabolic Epidemiology Section, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Hidekatsu Yanai
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba
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11
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Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol 2017; 27:117-122. [PMID: 28142035 PMCID: PMC5350620 DOI: 10.1016/j.je.2016.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/19/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Myxedema coma is a life-threatening and emergency presentation of hypothyroidism. However, the clinical features and outcomes of this condition have been poorly defined because of its rarity. METHODS We conducted a retrospective observational study of patients diagnosed with myxedema coma from July 2010 through March 2013 using a national inpatient database in Japan. We investigated characteristics, comorbidities, treatments, and in-hospital mortality of patients with myxedema coma. RESULTS We identified 149 patients diagnosed with myxedema coma out of approximately 19 million inpatients in the database. The mean (standard deviation) age was 77 (12) years, and two-thirds of the patients were female. The overall proportion of in-hospital mortality among cases was 29.5%. The number of patients was highest in the winter season. Patients treated with steroids, catecholamines, or mechanical ventilation showed higher in-hospital mortality than those without. Variations in type and dosage of thyroid hormone replacement were not associated with in-hospital mortality. The most common comorbidity was cardiovascular diseases (40.3%). The estimated incidence of myxedema coma was 1.08 per million people per year in Japan. Multivariable logistic regression analysis revealed that higher age and use of catecholamines (with or without steroids) were significantly associated with higher in-hospital mortality. CONCLUSIONS The present study identified the clinical characteristics and outcomes of patients with myxedema coma using a large-scale database. Myxedema coma mortality was independently associated with age and severe conditions requiring treatment with catecholamines.
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Affiliation(s)
- Yosuke Ono
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan.
| | - Sachiko Ono
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Yuji Tanaka
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
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12
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Jeon JY, Kim SR, Kim HJ, Kim DJ, Lee KW, Lee JD, Han SJ. Risk factors of severe hypoglycemia requiring medical assistance and neurological sequelae in patients with diabetes: A case-control study. Medicine (Baltimore) 2016; 95:e5365. [PMID: 27893672 PMCID: PMC5134865 DOI: 10.1097/md.0000000000005365] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hypoglycemia commonly occurs in patients who are being treated for diabetes. In some cases, these patients suffer from severe hypoglycemia that requires medical assistance and which can unfortunately result in long-term disabilities. Therefore, we investigated risk factors associated with severe hypoglycemia requiring medical assistance (HMA) and the resulting neurological sequelae in patients with diabetes. This investigation was a case-control study that assessed 129 patients with diabetes and documented hypoglycemia from a single tertiary hospital between February 2013 and May 2015. They were treated with oral hypoglycemic agents alone (54%) or with insulin with/without oral hypoglycemic agents (46%). If a patient with diabetes visited the emergency department due to hypoglycemia, this was defined as HMA. The control group was composed of patients with documented, nonsevere hypoglycemia who visited the outpatient clinic during the same period. The degree of neurological disability in the HMA patients was measured using the modified Rankin Scale. A multivariate analysis revealed that independent risk factors of HMA were associated with a lack of the self-monitoring of blood glucose (SMBG) and previous episodes of severe hypoglycemia. In the HMA group, 15 patients (22%) had neurological sequelae at the time of discharge. Patients with neurological sequelae were older than those without sequelae (74.3 years vs 65.8 years, P = 0.006) and had increased psychological evidence of disorders such as insomnia, dementia, and depression (40% vs 11%, P = 0.017). Patients with sequelae were also more likely to live in rural areas (47% vs 19%, P = 0.04) and to have a longer time from last seen normal till glucose administration (5.2 hours vs 1.6 hours, P = 0.027). In the present study, absence of SMBG and previous severe hypoglycemic episodes were independent risk factors of HMA and patients with an older age, a psychological disorder, a rural residence, and a prolonged duration of hypoglycemia had higher risks of neurological sequelae. Therefore, the present findings suggest that physicians should aim to prevent hypoglycemia in patients with a history of hypoglycemia and provide education for these patients regarding regular SMBG.
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Affiliation(s)
| | | | | | | | | | - Jung-Dong Lee
- Office of Biostatistics, Ajou University School of Medicine, Suwon, Republic of Korea
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13
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Ito H, Tsugami E, Ando S, Imai A, Matsumoto S, Omoto T, Shinozaki M, Nishio S, Abe M, Antoku S, Mifune M, Togane M. Secular Trends in the Clinical Characteristics of Type 2 Diabetic Patients With Severe Hypoglycemia Between 2008 and 2013. J Clin Med Res 2016; 8:710-4. [PMID: 27635175 PMCID: PMC5012239 DOI: 10.14740/jocmr2610w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2016] [Indexed: 01/06/2023] Open
Abstract
Background We investigated the trends in the clinical characteristics and prescriptions of type 2 diabetic patients with severe hypoglycemia because the prescription rate of antidiabetic agents has significantly changed recently. Methods A total of 193 patients with type 2 diabetes with severe hypoglycemia induced by antidiabetic agents between 2008 and 2013 were divided into three groups based on the period of visit: 2008 - 2009, 2010 - 2011 and 2012 - 2013. Results While the proportion of patients with severe hypoglycemia using insulin (from 55% to 74%), biguanides (from 6% to 20%), glinides, and dipeptidyl peptidase-4 inhibitors significantly increased, those using sulfonylureas (from 45% to 20%) significantly decreased. Errors of drug use significantly increased as a trigger of hypoglycemia in recent years. The number of antidiabetic agents (from 1.9 ± 0.6 to 2.3 ± 0.7), non-diabetic agents (from 2.3 ± 2.4 to 4.3 ± 3.3), and total drugs prescribed were significantly higher in recent years among patients receiving insulin therapy. Conclusions Polypharmacy especially in patients receiving insulin therapy and errors of drug use have increased in type 2 diabetic patients with severe hypoglycemia in recent years. Intensive education in the usage rule of drugs is considered to be important in order to prevent severe hypoglycemia.
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Affiliation(s)
- Hiroyuki Ito
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
| | - Emiko Tsugami
- Department of Pharmacy, Edogawa Hospital, Tokyo, Japan
| | | | - Ayano Imai
- Department of Pharmacy, Edogawa Hospital, Tokyo, Japan
| | - Suzuko Matsumoto
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
| | - Takashi Omoto
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
| | - Masahiro Shinozaki
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
| | - Shinya Nishio
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
| | - Mariko Abe
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
| | - Shinichi Antoku
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
| | - Mizuo Mifune
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
| | - Michiko Togane
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, Japan
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14
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Goto A, Goto M, Terauchi Y, Yamaguchi N, Noda M. Association Between Severe Hypoglycemia and Cardiovascular Disease Risk in Japanese Patients With Type 2 Diabetes. J Am Heart Assoc 2016; 5:e002875. [PMID: 26961698 PMCID: PMC4943262 DOI: 10.1161/jaha.115.002875] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background It remains unclear whether severe hypoglycemia is associated with cardiovascular disease (CVD) in Asian populations with type 2 diabetes (T2D). Furthermore, no study in Japan, where the prescription patterns differ from those in other countries, has examined this association. Methods and Results We retrospectively included 58 223 patients (18–74 years old) with T2D. First, we examined the potential predictors of severe hypoglycemia. Then, we investigated the association between severe hypoglycemia and CVD risk. Finally, we performed an updated systematic review and meta‐analysis to incorporate our findings and recently published studies into the previous systematic review and meta‐analysis. During 134 597 person‐years from cumulative observation periods, 128 persons experienced severe hypoglycemia and 550 developed CVD events. In a multivariate Cox proportional hazard model, severe hypoglycemia was strongly and positively associated with the risk of CVD (multivariate‐adjusted adjusted hazard ratio, 3.39; 95% CI, 1.25–9.18). In a propensity score–matched cohort that had similar baseline characteristics for patients with severe hypoglycemia and those without, severe hypoglycemia was more strongly associated with the risk of CVD. An updated systematic review and meta‐analysis that included 10 studies found that severe hypoglycemia was associated with an ≈2‐fold increased risk of CVD (pooled relative risk, 1.91; 95% CI, 1.69–2.15). Conclusions Our results suggest that severe hypoglycemia is strongly associated with an increased risk of CVD in Japanese patients with T2D, further supporting the notion that avoiding severe hypoglycemia may be important in preventing CVD in this patient population.
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Affiliation(s)
- Atsushi Goto
- Department of Public Health, Tokyo Women's Medical University, Tokyo, Japan Department of Diabetes Research, Diabetes Research Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Maki Goto
- Department of Diabetes Research, Diabetes Research Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Naohito Yamaguchi
- Department of Public Health, Tokyo Women's Medical University, Tokyo, Japan
| | - Mitsuhiko Noda
- Department of Diabetes Research, Diabetes Research Center, National Center for Global Health and Medicine, Tokyo, Japan Department of Endocrinology and Diabetes, Saitama Medical University, Saitama, Japan
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15
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Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Factors Associated With Mortality of Thyroid Storm: Analysis Using a National Inpatient Database in Japan. Medicine (Baltimore) 2016; 95:e2848. [PMID: 26886648 PMCID: PMC4998648 DOI: 10.1097/md.0000000000002848] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Thyroid storm is a life-threatening and emergent manifestation of thyrotoxicosis. However, predictive features associated with fatal outcomes in this crisis have not been clearly defined because of its rarity. The objective of this study was to investigate the associations of patient characteristics, treatments, and comorbidities with in-hospital mortality. We conducted a retrospective observational study of patients diagnosed with thyroid storm using a national inpatient database in Japan from April 1, 2011 to March 31, 2014. Of approximately 21 million inpatients in the database, we identified 1324 patients diagnosed with thyroid storm. The mean (standard deviation) age was 47 (18) years, and 943 (71.3%) patients were female. The overall in-hospital mortality was 10.1%. The number of patients was highest in the summer season. The most common comorbidity at admission was cardiovascular diseases (46.6%). Multivariable logistic regression analyses showed that higher mortality was significantly associated with older age (≥60 years), central nervous system dysfunction at admission, nonuse of antithyroid drugs and β-blockade, and requirement for mechanical ventilation and therapeutic plasma exchange combined with hemodialysis. The present study identified clinical features associated with mortality of thyroid storm using large-scale data. Physicians should pay special attention to older patients with thyrotoxicosis and coexisting central nervous system dysfunction. Future prospective studies are needed to clarify treatment options that could improve the survival outcomes of thyroid storm.
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Affiliation(s)
- Yosuke Ono
- From the Department of General Medicine, National Defense Medical College, Saitama (YO, YT); Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo (SO, HY, HM); and Department of Health Policy and Informatics (KF), Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
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