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Alsharif AA, Wong ICK, Ma T, Lau W, Alhamed M, Alwafi H, Wei L. The association between dementia and the risk of hypoglycaemia events among patients with diabetes mellitus: a propensity-score matched cohort analysis. Front Med (Lausanne) 2023; 10:1177636. [PMID: 37476614 PMCID: PMC10354255 DOI: 10.3389/fmed.2023.1177636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/02/2023] [Indexed: 07/22/2023] Open
Abstract
Background Hypoglycaemia commonly occurs in patients diagnosed with diabetes mellitus (DM) and dementia. The impact of dementia on hypoglycaemic events is controversial. Thus, we evaluated whether dementia increases the risk of hypoglycaemic events in older patients diagnosed with DM. Design A retrospective cohort study. Setting We used the IQVIA Medical Research Data (IMRD-UK) database (formerly known as the THIN database). Participants All patients aged ≥55 years and diagnosed with DM who were prescribed at least two prescriptions of antidiabetic medication between 2000 and 2017. Two groups of patients, dementia and non-dementia group, were propensity-score (PS) matched at 1:2. The risk of hypoglycaemia was assessed through a Cox regression analysis. Main outcome and measures Hypoglycaemic events were determined during the follow-up period by Read codes. Results From the database, 133,664 diabetic patients were identified, with a mean follow-up of 6.11 years. During the study period, 7,762 diabetic patients diagnosed with dementia were matched with 12,944 diabetic patients who had not been diagnosed with dementia. The PS-matched Cox regression analysis showed that patients diagnosed with dementia were at a 2-fold increased risk for hypoglycaemic events compared with those not diagnosed with dementia (hazard ratio [HR], 2.00; 95% CI, 1.63-2.66). A similar result was shown for a multivariable analysis using all patient data (adjusted HR, 2.25; 95% CI, 2.22-2.32). Conclusion Our findings suggest that diabetic patients with a diagnosis of dementia have a statistically significant higher risk of experiencing hypoglycaemia.
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Affiliation(s)
- Alaa A. Alsharif
- Department of Pharmacy Practice, Faculty of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom
| | - Ian C. K. Wong
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China
| | - Tian Ma
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom
| | - Wallis Lau
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong, China
| | - Meshari Alhamed
- Department of Emergency Medicine, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hassan Alwafi
- Faculty of Medicine, Umm Al Qura University, Mecca, Saudi Arabia
| | - Li Wei
- Research Department of Practice and Policy, University College London School of Pharmacy, London, United Kingdom
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 152] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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3
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Casagrande SS, Lee C, Stoeckel LE, Menke A, Cowie CC. Cognitive function among older adults with diabetes and prediabetes, NHANES 2011-2014. Diabetes Res Clin Pract 2021; 178:108939. [PMID: 34229005 PMCID: PMC8429258 DOI: 10.1016/j.diabres.2021.108939] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 04/06/2021] [Accepted: 06/30/2021] [Indexed: 01/02/2023]
Abstract
AIMS To determine the association between diabetes status, glycemia, and cognitive function among a national U.S. sample of older adults in the 2011-2014 National Health and Nutrition Examinations Surveys. METHODS Among 1,552 adults age ≥ 60 years, linear and multivariable logistic regressions were used to determine the association between diabetes status (diabetes, prediabetes, normoglycemia) and cognitive function [Consortium to Establish a Registry for Alzheimer's Disease-Word Learning (CERAD W-L), Animal Fluency test, Digit Symbol Substitution Test (DSST)]. RESULTS Overall, diabetes was associated with mild cognitive dysfunction. In age-adjusted models, adults with diabetes had significantly poorer performance on the delayed and total word recalls (CERAD W-L) compared to those with normoglycemia (5.8 vs. 6.8 words; p = 0.002 and 24.5 vs. 27.6 words; p < 0.001, respectively); the association was non-significant after adjusting for cardiovascular disease. Among all adults, cognitive function scores decreased with increasing HbA1c for all assessments, but remained significant in the fully adjusted model for the Animal Fluency and DSST [beta coefficient = -0.44;-1.11, p < 0.05, respectively]. As measured by the DSST, the proportion with cognitive impairment was significantly higher for older adults with HbA1c ≥ 8.0% (≥64 mmol/mol) vs. HbA1c < 7.0% (<53 mmol/mol) (14.6% vs. 6.3%, p = 0.04). CONCLUSIONS Dysglycemia, as measured by HbA1c, was associated with poorer executive function and processing speed.
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Affiliation(s)
- Sarah S Casagrande
- Social & Scientific Systems, Inc. 8757 Georgia Ave, Silver Spring, MD 20910, United States.
| | - Christine Lee
- National Institute of Diabetes and Digestive and Kidney Diseases Division of Diabetes, Endocrinology, and Metabolic Diseases, 6707 Democracy Blvd, Bethesda, MD 20892, United States
| | - Luke E Stoeckel
- National Institute of Diabetes and Digestive and Kidney Diseases Division of Diabetes, Endocrinology, and Metabolic Diseases, 6707 Democracy Blvd, Bethesda, MD 20892, United States
| | - Andy Menke
- Social & Scientific Systems, Inc. 8757 Georgia Ave, Silver Spring, MD 20910, United States
| | - Catherine C Cowie
- National Institute of Diabetes and Digestive and Kidney Diseases Division of Diabetes, Endocrinology, and Metabolic Diseases, 6707 Democracy Blvd, Bethesda, MD 20892, United States
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4
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Katsiki N, Kotsa K, Stoian AP, Mikhailidis DP. Hypoglycaemia and Cardiovascular Disease Risk in Patients with Diabetes. Curr Pharm Des 2021; 26:5637-5649. [PMID: 32912117 DOI: 10.2174/1381612826666200909142658] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/09/2020] [Indexed: 12/12/2022]
Abstract
Hypoglycaemia represents an important side effect of insulin therapy and insulin secretagogues. It can occur in both type 1 and type 2 diabetes mellitus patients. Also, some associations between hypoglycaemia and cardiovascular (CV) risk have been reported. Several mechanisms may be involved, including the sympathoadrenal system, hypokalaemia, endothelial dysfunction, coagulation, platelets, inflammation, atherothrombosis and impaired autonomic cardiac reflexes. This narrative review discusses the associations of hypoglycaemia with CV diseases, including coronary heart disease (CHD), cardiac arrhythmias, stroke, carotid disease and peripheral artery disease (PAD), as well as with dementia. Severe hypoglycaemia has been related to CHD, CV and all-cause mortality. Furthermore, there is evidence supporting an association between hypoglycaemia and cardiac arrhythmias, potentially predisposing to sudden death. The data linking hypoglycaemia with stroke, carotid disease and PAD is limited. Several factors may affect the hypoglycaemia-CV relationships, such as the definition of hypoglycaemia, patient characteristics, co-morbidities (including chronic kidney disease) and antidiabetic drug therapy. However, the association between hypoglycaemia and dementia is bilateral. Both the disorders are more common in the elderly; thus, glycaemic goals should be carefully selected in older patients. Further research is needed to elucidate the impact of hypoglycaemia on CV disease.
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Affiliation(s)
- Niki Katsiki
- Division of Endocrinology and Metabolism, Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism, Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Anca P Stoian
- Diabetes, Nutrition and Metabolic diseases Department, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
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5
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Rathmann W, Charbonnel B, Gomes MB, Hammar N, Khunti K, Kosiborod M, Kuss O, Shestakova MV, Watada H, Shimomura I, Tang F, Cid-Ruzafa J, Chen H, Fenici P, Surmont F, Ji L. Socioeconomic factors associated with hypoglycaemia in patients starting second-line glucose-lowering therapy: The DISCOVER study. Diabetes Res Clin Pract 2020; 165:108250. [PMID: 32531326 DOI: 10.1016/j.diabres.2020.108250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 05/15/2020] [Accepted: 06/04/2020] [Indexed: 11/25/2022]
Abstract
AIMS Using data from DISCOVER (NCT02322762; NCT02226822), a 3-year, global, observational study programme of patients with type 2 diabetes initiating second-line glucose-lowering therapy, we assessed socioeconomic factors associated with hypoglycaemic events and fear of hypoglycaemia. METHODS Data were collected at baseline (second-line therapy initiation) and 6, 12 and 24 months. Factors associated with experiencing a hypoglycaemic event at baseline or during follow-up were determined using a hierarchical logistic regression model and an interval-censored survival analysis, respectively. Fear of hypoglycaemia was assessed using the hypoglycaemia fear survey-II (HFS-II). RESULTS The overall proportion of patients reporting hypoglycaemic events during follow-up was 7.3%; this was higher in middle-income countries than in high-income countries (8.4% vs 5.8%, p < 0.001). Factors associated with an increased risk of hypoglycaemia during follow-up included living in a country with a low gross national income, use of glucose-monitoring equipment and second-line treatment with insulin, meglitinides or sulphonylureas (versus metformin). Experiencing hypoglycaemia was associated with increased HFS-II worry and overall scores. CONCLUSIONS Our results highlight the global inequity in the treatment of type 2 diabetes. Increased risk of hypoglycaemia in middle-income countries may be explained by limited treatment options and may be underestimated because of limited access to glucose-monitoring equipment.
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Affiliation(s)
- Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany.
| | | | | | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden; AstraZeneca Gothenburg, Mölndal, Sweden
| | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri, Kansas City, MO, USA; The George Institute for Global Health and University of New South Wales, Sydney, Australia
| | - Oliver Kuss
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | | | | | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | | | | | | | - Linong Ji
- Peking University People's Hospital, Beijing, China
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Ford E, Starlinger J, Rooney P, Oliver S, Banerjee S, van Marwijk H, Cassell J. Could dementia be detected from UK primary care patients' records by simple automated methods earlier than by the treating physician? A retrospective case-control study. Wellcome Open Res 2020; 5:120. [PMID: 32766457 PMCID: PMC7385545 DOI: 10.12688/wellcomeopenres.15903.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Timely diagnosis of dementia is a policy priority in the United Kingdom (UK). Primary care physicians receive incentives to diagnose dementia; however, 33% of patients are still not receiving a diagnosis. We explored automating early detection of dementia using data from patients' electronic health records (EHRs). We investigated: a) how early a machine-learning model could accurately identify dementia before the physician; b) if models could be tuned for dementia subtype; and c) what the best clinical features were for achieving detection. Methods: Using EHRs from Clinical Practice Research Datalink in a case-control design, we selected patients aged >65y with a diagnosis of dementia recorded 2000-2012 (cases) and matched them 1:1 to controls; we also identified subsets of Alzheimer's and vascular dementia patients. Using 77 coded concepts recorded in the 5 years before diagnosis, we trained random forest classifiers, and evaluated models using Area Under the Receiver Operating Characteristic Curve (AUC). We examined models by year prior to diagnosis, subtype, and the most important features contributing to classification. Results: 95,202 patients (median age 83y; 64.8% female) were included (50% dementia cases). Classification of dementia cases and controls was poor 2-5 years prior to physician-recorded diagnosis (AUC range 0.55-0.65) but good in the year before (AUC: 0.84). Features indicating increasing cognitive and physical frailty dominated models 2-5 years before diagnosis; in the final year, initiation of the dementia diagnostic pathway (symptoms, screening and referral) explained the sudden increase in accuracy. No substantial differences were seen between all-cause dementia and subtypes. Conclusions: Automated detection of dementia earlier than the treating physician may be problematic, if using only primary care data. Future work should investigate more complex modelling, benefits of linking multiple sources of healthcare data and monitoring devices, or contextualising the algorithm to those cases that the GP would need to investigate.
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Affiliation(s)
- Elizabeth Ford
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, UK
| | - Johannes Starlinger
- Department of Computer Science, Humboldt University of Berlin, Rudower Chaussee 25, Berlin, 12489, Germany
| | - Philip Rooney
- Department of Physics and Astronomy, University of Sussex, Brighton, BN1 9RQ, UK
| | - Seb Oliver
- Department of Physics and Astronomy, University of Sussex, Brighton, BN1 9RQ, UK
| | - Sube Banerjee
- Faculty of Health, University of Plymouth, Drake Circus, Plymouth, Devon, PL4 8AA, UK
| | - Harm van Marwijk
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, UK
| | - Jackie Cassell
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, UK
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Abusamaan MS, Marzinke MA, Ashok A, Carroll K, Lane K, Jeun R, Moseley KF, Carson KA, Mathioudakis NN. Hypoglycemic risk exposures in relation to low serum glucose values in ambulatory patients. Medicine (Baltimore) 2020; 99:e18679. [PMID: 31914062 PMCID: PMC6959883 DOI: 10.1097/md.0000000000018679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This study aimed to correlate hypoglycemic risk exposures (HREs) with low blood glucose value (BGV) in ambulatory patients to inform selection of a glucose critical action value (CAV).This was a retrospective study of ambulatory patients with at least 1 serum glucose ≤70 mg/dL obtained at 2 laboratories within the Johns Hopkins Health System over 3.8 years. Multivariable logistic regression was used to evaluate association of BGV cut-offs of <60, <54, <50, and <45 mg/dL with HREs. HREs were classified as "high hypoglycemic risk" (HHR), "moderate hypoglycemic risk" (MHR), "low hypoglycemic risk" (LHR), and "no hypoglycemic risk" (NHR).A total of 5404 patient samples of BG ≤70 mg/dL were analyzed, of which 30.3%, 23.2%, 28.5%, 18.0% occurred in NHR, LHR, MHR, and HHR groups, respectively. An inverse relationship was noted between BGV cut-offs and HHR, but no association was observed for LHR or MHR. After adjusting for age, sex, and race, there was an inverse association between BG thresholds and the odds of HHR. For classification of HHR, BGV cut-offs of <60, <54, <50, and <45 mg/dL correctly classified 71.2%, 69.8%, 68.8%, and 67.2% of BG samples, achieved false-positive rates of 13.6%, 4.7%, 1.7%, and 0.5% and positive likelihood ratios of 3.3, 6.0, 11.2, and 23.4, respectively.Nearly 70% of low BGVs occurred in patients with at least 1 HRE, but only ∼20% occurred in HHR patients. Given their high positive likelihood ratios, BGVs <54 or <50 mg/dL are reasonable candidates for CAVs that would allow sufficient clinician response time while minimizing false-positive alerts.
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Affiliation(s)
| | - Mark A. Marzinke
- Department of Pathology, Johns Hopkins University School of Medicine
| | - Aditya Ashok
- Division of Endocrinology, Diabetes, & Metabolism
| | - Karen Carroll
- Department of Pathology, Johns Hopkins University School of Medicine
| | - Kyrstin Lane
- Division of Endocrinology, Diabetes, & Metabolism
| | - Rebecca Jeun
- Division of Endocrinology, Diabetes, & Metabolism
| | | | - Kathryn A. Carson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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8
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Weiner JZ, Gopalan A, Mishra P, Lipska KJ, Huang ES, Laiteerapong N, Karter AJ, Grant RW. Use and Discontinuation of Insulin Treatment Among Adults Aged 75 to 79 Years With Type 2 Diabetes. JAMA Intern Med 2019; 179:1633-1641. [PMID: 31545376 PMCID: PMC6763990 DOI: 10.1001/jamainternmed.2019.3759] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Among older individuals with type 2 diabetes, those with poor health have greater risk and derive less benefit from tight glycemic control with insulin. OBJECTIVE To examine whether insulin treatment is used less frequently and discontinued more often among older individuals with poor health compared with those in good health. DESIGN, SETTING, AND PARTICIPANTS This longitudinal cohort study included 21 531 individuals with type 2 diabetes followed for up to 4 years starting at age 75 years. Electronic health record data from the Kaiser Permanente Northern California Diabetes Registry was collected to characterize insulin treatment and glycemic control over time. Data were collected from January 1, 2009, through December 31, 2017, and analyzed from February 2, 2018, through June 30, 2019. EXPOSURES Health status was defined as good (<2 comorbid conditions or 2 comorbidities but physically active), intermediate (>2 comorbidities or 2 comorbidities and no self-reported weekly exercise), or poor (having end-stage pulmonary, cardiac, or renal disease; diagnosis of dementia; or metastatic cancer). MAIN OUTCOMES AND MEASURES Insulin use prevalence at age 75 years and discontinuation among insulin users over the next 4 years (or 6 months prior to death if <4 years). RESULTS Of 21 531 patients, 10 396 (48.3%) were women, and the mean (SD) age was 75 (0) years. Nearly one-fifth of 75-year-olds (4076 [18.9%]) used insulin. Prevalence and adjusted risk ratios (aRRs) of insulin use at age 75 years were higher in individuals with poor health (29.4%; aRR, 2.03; 95% CI, 1.87-2.20; P < .01) and intermediate health (27.5%; aRR, 1.85; 95% CI, 1.74-1.97; P < .01) relative to good health (10.5% [reference]). One-third (1335 of 4076 [32.7%]) of insulin users at age 75 years discontinued insulin within 4 years of cohort entry (and at least 6 months prior to death). Likelihood of continued insulin use was higher among individuals in poor health (aRR, 1.47; 95% CI, 1.27-1.67; P < .01) and intermediate health (aRR, 1.16; 95% CI, 1.05-1.30; P < .01) compared with good health (reference). These same prevalence and discontinuation patterns were present in the subset with tight glycemic control (hemoglobin A1c <7.0%). CONCLUSIONS AND RELEVANCE In older individuals with type 2 diabetes, insulin use was most prevalent among those in poor health, whereas subsequent insulin discontinuation after age 75 years was most likely in healthier patients. Changes are needed in current practice to better align with guidelines that recommend reducing treatment intensity as health status declines.
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Affiliation(s)
- Jonathan Z Weiner
- Division of Research,Kaiser Permanente of Northern California, Oakland
| | - Anjali Gopalan
- Division of Research,Kaiser Permanente of Northern California, Oakland
| | - Pranita Mishra
- Division of Research,Kaiser Permanente of Northern California, Oakland
| | - Kasia J Lipska
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
| | - Neda Laiteerapong
- Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois
| | - Andrew J Karter
- Division of Research,Kaiser Permanente of Northern California, Oakland
| | - Richard W Grant
- Division of Research,Kaiser Permanente of Northern California, Oakland
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9
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Wei Y, Lin F, Lin S, Wang C. Risk of Hypoglycemia and Concomitant Use of Repaglinide and Clopidogrel: A Population‐Based Nested Case‐Control Study. Clin Pharmacol Ther 2019; 106:1346-1352. [DOI: 10.1002/cpt.1556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/25/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Yun Wei
- Graduate Institute of Clinical Pharmacy College of Medicine National Taiwan University Taipei Taiwan
| | - Fang‐Ju Lin
- Graduate Institute of Clinical Pharmacy College of Medicine National Taiwan University Taipei Taiwan
- School of Pharmacy National Taiwan University Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
| | - Shin‐Yi Lin
- School of Pharmacy National Taiwan University Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
| | - Chi‐Chuan Wang
- Graduate Institute of Clinical Pharmacy College of Medicine National Taiwan University Taipei Taiwan
- School of Pharmacy National Taiwan University Taipei Taiwan
- Department of Pharmacy National Taiwan University Hospital Taipei Taiwan
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10
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Kolesnik E, Krainer T, Wallner M, Djalinac N, Verheyen N, Ablasser K, Eaton DM, Rainer PP, Pelzmann B, von Lewinski D. Myocardial GLP-1 Receptor Activation in the Presence of Glucose: Strong Partners. Int J Pept Res Ther 2019. [DOI: 10.1007/s10989-018-9706-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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11
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Haltbakk J, Graue M, Harris J, Kirkevold M, Dunning T, Sigurdardottir AK. Integrative review: Patient safety among older people with diabetes in home care services. J Adv Nurs 2019; 75:2449-2460. [PMID: 30835874 DOI: 10.1111/jan.13993] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 11/29/2018] [Accepted: 12/21/2018] [Indexed: 12/01/2022]
Abstract
AIMS To identify diabetes specific patient safety domains that need to be addressed to improve home care of older people; to assess research from primary studies to review evidence on patient safety in home care services for older people with diabetes. DESIGN An integrative review. DATA SOURCES Domains for patient safety in diabetes home care settings were identified by conducting two searches. We performed searches in: CINAHL, Medline, Embase, and Cochrane Library for the years 2000-2017. REVIEW METHODS The first search identified frameworks or models on patient safety in home care services published up to October 2017. The second search identified primary studies about older people with diabetes in the home care setting published between 2000-2017. RESULTS Data from the 21 articles populated and refined 13 predetermined domains of patient safety in diabetes home care. These were used to explore how the domains interact to either increase or reduce risk. The domains constitute a model of associations between aspects of diabetes home care and adverse events. The results highlight a knowledge gap in safety for older persons with diabetes, influenced by e.g. hypoglycaemia, falls, pain, foot ulcers, cognitive impairment, depression, and polypharmacy. Moreover, providers' inadequate diabetes-specific knowledge and assessment skills contribute to the risk of adverse events. CONCLUSION Older persons with diabetes in home care are at risk of adverse events due to their reduced ability to self-manage their condition, adverse medication effects, the family's ability to take responsibility or home care service's suboptimal approaches to diabetes care.
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Affiliation(s)
- Johannes Haltbakk
- Department of Health- and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Marit Graue
- Department of Health- and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway.,Centre for Evidence Based Practice, Western Norway University of Applied Sciences, Bergen, Norway
| | - Janet Harris
- MPH in International Health Management & Leadership, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marit Kirkevold
- Centre for Evidence Based Practice, Western Norway University of Applied Sciences, Bergen, Norway.,Department of Nursing Science, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Trisha Dunning
- Centre for Quality and Patient Safety Research, Deakin University and Barwon Health Partnership, Geelong, Melbourne, Australia
| | - Arun K Sigurdardottir
- School of Health Sciences, University of Akureyri, Akureyri, Iceland.,Akureyri Hospital, Akureyri, Iceland
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Anyanwagu U, Mamza J, Donnelly R, Idris I. Relationship between HbA1c and all-cause mortality in older patients with insulin-treated type 2 diabetes: results of a large UK Cohort Study. Age Ageing 2019; 48:235-240. [PMID: 30615050 DOI: 10.1093/ageing/afy178] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/31/2018] [Accepted: 10/22/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND our aim was to study the relationship between HbA1c and cardiovascular morbidity and all-cause mortality among older insulin-treated patients with type 2 diabetes (T2D) after adjustment for multiple confounders. METHODS data for 4589 adults with T2D (>65 years) on insulin treatment were sourced from 532 UK General Practices via the Health Improvement Network (THIN) database. Cox proportional hazard models and Kaplan-Meier estimators were fitted to derive the hazards of all-cause mortality by HbA1c categories (<6.5, 6.5-7.4, 7.5-8.4, 8.5-9.4, 9.5-10.4, 10.5-11.4%; and 11.5% and above) after 5 years of follow-up following insulin initiation. RESULTS we observed a U-shaped relationship between all-cause mortality and HbA1c, with the lowest risk seen in the HbA1c range of 6.5-7.4% and marked increased in risk with HbA1c > 11%. The highest mortality risks of 31 and 40% were significantly associated with the lowest (<6.5%) and highest (11.5% and above) HbA1c categories: aHR: 1.31; (95%CI: 1.10-1.56; P = 0.002) and aHR: 1.40; (95%CI: 1.01-1.96; P = 0.039), respectively. CONCLUSIONS both low and high HbA1c were associated with increased all-cause mortality, among older patients with insulin-treated T2D. This cohort study supports the need for individualisation of care and suggests better outcomes with HbA1c levels around 6.5-7.4% and markedly excess risk with HbA1c > 11.
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Affiliation(s)
- Uchenna Anyanwagu
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby
| | - Jil Mamza
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby
| | - Richard Donnelly
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby
| | - Iskandar Idris
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby
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13
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Fritsche A, Anderten H, Pfohl M, Pscherer S, Borck A, Pegelow K, Bramlage P, Seufert J. HbA1c target achievement in the elderly: results of the Titration and Optimization trial for initiation of insulin glargine 100 U/mL in patients with type 2 diabetes poorly controlled on oral antidiabetic drugs. BMJ Open Diabetes Res Care 2019; 7:e000668. [PMID: 31423316 PMCID: PMC6688703 DOI: 10.1136/bmjdrc-2019-000668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/19/2019] [Accepted: 07/02/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To identify real-world, age-related trends in the use of insulin glargine 100 U/mL (Gla-100) as part of basal-supported oral therapy (BOT). RESEARCH DESIGN AND METHODS The prospective, observational Titration and Optimization registry enrolled patients with poorly controlled type 2 diabetes mellitus initiated on Gla-100 BOT. The primary outcome was the proportion of patients with capillary fasting blood glucose (FBG) ≤110 mg/dL on ≥2 occasions and/or who met their individual HbA1c target within 12 months. RESULTS 2462 patients were analyzed (<65 years: n=1122; 65-74 years: n=771; ≥75 years: n=569). Diabetes duration (6.8, 8.9, and 11.2 years, p<0.0001) and proportion of women (40.7%, 47.9%, and 55.7%, p<0.0001) increased with age. Baseline HbA1c was highest in <65-year-olds (8.6% vs 8.4% and 8.5%, p<0.0001). Gla-100 up-titration until 12 months was highest in <65-year-olds (+11.6 U/day), compared with 65-74 (+10.2 U/day) and ≥75 years (+8.8; p<0.0001) but similar by units per kilogram, as was the decrease in FBG (<65: -64.1 mg/dL; 65-74: -56.1 mg/dL; ≥75: -53.4 mg/dL) and HbA1c (<65: -1.47%; 65-74: -1.31%; ≥75: -1.22%, p<0.0001). At 12 months, 65.9% of participants met the primary endpoint, with no significant difference between age groups. The proportion achieving their individual HbA1c target was lower for <65-year-olds (46.0% vs 54.3% and 54.7%; p<0.02). Symptomatic hypoglycemia incidence was more common in the ≥75-year-old group (3.4% vs 1.4% and 1.4%; p=0.0126). CONCLUSIONS BOT with Gla-100 results in similar improvements of glycemic values with low risk of hypoglycemia across age groups. Given the link between HbA1c and long-term cardiovascular risk, ensuring appropriately stringent target-setting, intensification of basal insulin and making sure hypoglycemia is avoided is of paramount importance. TRIAL REGISTRATION NUMBER Database: https://awbdb.bfarm.de; Identifier: 1641; Date of registration: September 23, 2013.
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Affiliation(s)
| | - Helmut Anderten
- Gemeinschaftspraxis Anderten-Krok & Partner, Hildesheim, Germany
| | - Martin Pfohl
- Medizinische Klinik I, Evang. Krankenhaus Bethesda gGmbH, Duisburg, Germany
| | - Stefan Pscherer
- Klinik für Innere Medizin III, Sophien- undHufeland-Klinikum, Weimar, Germany
| | - Anja Borck
- Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | | | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Cloppenburg, Germany
| | - J Seufert
- Abteilung Endokrinologie und Diabetologie, Klinik für Innere Medizin II, Medizinische Fakultät, Albert-Ludwig-Universität Freiburg, Freiburg, Germany
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Malawana M, Hutchings A, Mathur R, Robson J. Ethnic variations in the risk of hypoglycaemia among people with Type 2 diabetes prescribed insulins and/or sulfonylureas: a historical cohort study using general practice-recorded data. Diabet Med 2018; 35:1707-1715. [PMID: 30264528 DOI: 10.1111/dme.13828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2018] [Indexed: 01/20/2023]
Abstract
AIM To identify ethnic differences in hypoglycaemic risk among people with Type 2 diabetes prescribed insulins and/or sulfonylureas in community settings. METHODS Using routine general practice-recorded data, two cohorts of adults with Type 2 diabetes from east London were studied between January 2013 and December 2015: (1) adults prescribed insulins ± other antidiabetes medications (n=7269) and (2) adults prescribed sulfonylureas ± other antidiabetes medications excluding insulins (n=12 502). Incidence rate ratios of hypoglycaemia by ethnicity, adjusting for age, sex, socio-economic status and clustering within Clinical Commissioning Groups, were estimated using random effects Poisson regression. RESULTS Compared with white British people prescribed insulins, those of black Caribbean ethnicity were at increased hypoglycaemic risk [adjusted incidence rate ratio 1.56 (95% CI 1.21,2.01)], while Bangladeshi people had a lower risk [adjusted incidence rate ratio 0.49 (95% CI, 0.38,0.64)]. In the sulfonylurea cohort, black Caribbean, black African and Indian people all had increased risks of hypoglycaemia compared with white British people [adjusted incidence rate ratios 1.63 (95% CI 1.15,2.29), 1.90 (95% CI 1.32,2.75) and 1.93 (95% CI 1.39,2.69), respectively]. CONCLUSION The differences in hypoglycaemic risk among people with Type 2 diabetes prescribed insulin and/or sulfonylureas warrant further investigation of any differing biological responses and/or cultural attitudes to antidiabetes therapy among ethnic groups, and should be considered by clinicians evaluating the treatment goals of people with Type 2 diabetes using insulins or sulfonylureas.
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Affiliation(s)
- M Malawana
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - A Hutchings
- Departments of Health Services Research and Policy, London, UK
| | - R Mathur
- Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - J Robson
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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15
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Viana ALM, Doriguetto AC, Viana OMMS, Ruela ALM, Freitas JTJ, Souto BEM, de Araújo MB, de Araújo Paula FB. Pharmacokinetics and pharmacodynamics of glimepiride polymorphs. Int J Pharm 2018; 553:272-280. [DOI: 10.1016/j.ijpharm.2018.10.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/19/2018] [Accepted: 10/22/2018] [Indexed: 10/28/2022]
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Torre C, Guerreiro JP, Romano S, Miranda A, Longo P, Alão S, Conceição J, Laires P. Real-world prevalence of mild to moderate hypoglycemic episodes in type 2 diabetes in Portugal: Results from the HIPOS-PHARMA study. Prim Care Diabetes 2018; 12:537-546. [PMID: 30017600 DOI: 10.1016/j.pcd.2018.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 12/28/2022]
Abstract
AIMS This study aimed to characterize and estimate prevalence and frequency of mild to moderate hypoglycemia and potentially associated factors in a population of type 2 diabetes mellitus (T2DM) patients treated at ambulatory care level. METHODS HIPOS-PHARMA was a nationwide observational, cross-sectional, multicenter study conducted in community pharmacies, which surveyed T2DM patients treated for at least 3 months. RESULTS Overall, 233 pharmacies recruited 1890 patients (males: 50.6%) with mean 67.1 years. On average, participants reported having diabetes for 11.8 years. A total of 86.9% had at least one chronic illness or complication of diabetes, and 76.8% were usually followed in the primary care setting. Fifty eight percent were treated without a secretagogue or insulin. Overall prevalence of mild to moderate hypoglycemic episodes in the 3 months prior to recruitment was 17.8%. A 3.13% prevalence of severe hypoglycemia was observed in the last 12 months. Results suggested that men and patients on antihyperglycemic therapies excluding secretagogues or insulin were less likely to have mild to moderate hypoglycemic episodes. CONCLUSIONS Mild to moderate hypoglycemic episodes were commonly reported, and factors like type of antihyperglycemic therapy, duration of disease and due complications may contribute. Almost half of episodes were not reported. Such factors should be considered in T2DM management.
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Affiliation(s)
- Carla Torre
- Centre for Health Evaluation & Research, National Association of Pharmacies Group, Rua Marechal Saldanha, 1, 1249-069 Lisboa, Portugal.
| | - José Pedro Guerreiro
- Centre for Health Evaluation & Research, National Association of Pharmacies Group, Rua Marechal Saldanha, 1, 1249-069 Lisboa, Portugal.
| | - Sónia Romano
- Centre for Health Evaluation & Research, National Association of Pharmacies Group, Rua Marechal Saldanha, 1, 1249-069 Lisboa, Portugal.
| | - Ana Miranda
- Centre for Health Evaluation & Research, National Association of Pharmacies Group, Rua Marechal Saldanha, 1, 1249-069 Lisboa, Portugal.
| | - Patrícia Longo
- Centre for Health Evaluation & Research, National Association of Pharmacies Group, Rua Marechal Saldanha, 1, 1249-069 Lisboa, Portugal.
| | - Sílvia Alão
- Merck Sharp & Dohme, Quinta da Fonte, 19 Edifício Vasco da Gama, 2770-192 Paço de Arcos, Portugal.
| | - João Conceição
- Merck Sharp & Dohme, Quinta da Fonte, 19 Edifício Vasco da Gama, 2770-192 Paço de Arcos, Portugal.
| | - Pedro Laires
- Merck Sharp & Dohme, Quinta da Fonte, 19 Edifício Vasco da Gama, 2770-192 Paço de Arcos, Portugal.
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Malawana M, Kerry S, Mathur R, Robson J. HbA1c and hypoglycaemia in intensively treated type 2 diabetes: a retrospective cohort study in primary care. JRSM Open 2018; 9:2054270418773669. [PMID: 30013791 PMCID: PMC6041855 DOI: 10.1177/2054270418773669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To establish whether low HbA1c is associated with clinical hypoglycaemia among people with type 2 diabetes prescribed insulins or sulphonylureas. Design Retrospective cohort study using routine electronic GP health records collected between January 2013 and December 2015. Setting Three east London Clinical Commissioning Groups. Participants Two cohorts of adults with type 2 diabetes prescribed either (i) insulins with or without other oral antidiabetic medication (n = 6788, 36.4%) or (ii) sulphonylureas with or without other oral antidiabetic medications excluding insulins (n = 11,840, 63.6%). Main outcome measures First clinically recorded hypoglycaemia and all-cause mortality. Hazard ratios (HR) adjusting for age, ethnicity, renal function and comorbidities were calculated using Cox regression models. Results Compared with an HbA1c of 53–63 mmol/mol, the adjusted HR of hypoglycaemia in those with a low HbA1c, below 53 mmol/mol, in the insulin and sulphonylurea cohorts were 1.26 (95% CI, 0.97 to 1.62) and 1.54 (95% CI, 1.27 to 1.87), respectively. Adjusted HRs of all-cause mortality from low HbA1c in the insulin and sulphonylurea cohorts were 1.54 (95% CI, 1.15 to 2.07) and 1.42 (95% CI, 1.11 to 1.81), respectively. Increasing age and renal impairment were also associated with increased hypoglycaemic risk in both cohorts. Conclusions HbA1c below 53 mmol/mol was associated with episodes of clinical hypoglycaemia among people with type 2 diabetes prescribed sulphonylureas, and all-cause mortality in those prescribed insulins and sulphonylureas. These findings support the need for reviewing glycaemic targets and the intensities of treatment in those with low HbA1c prescribed insulins or sulphonylureas to reduce the risk of hypoglycaemia.
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Affiliation(s)
- Manil Malawana
- Centre for Primary Care and Public Health, Queen Mary University of London, London E1 2AB, UK
| | - Sally Kerry
- Centre for Primary Care and Public Health, Queen Mary University of London, London E1 2AB, UK
| | - Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - John Robson
- Centre for Primary Care and Public Health, Queen Mary University of London, London E1 2AB, UK
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Maxson R, Lisenby KM. Managing the Diabetic Kidney Patient. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McCoy RG, Herrin J, Lipska KJ, Shah ND. Recurrent hospitalizations for severe hypoglycemia and hyperglycemia among U.S. adults with diabetes. J Diabetes Complications 2018; 32:693-701. [PMID: 29751961 PMCID: PMC6015781 DOI: 10.1016/j.jdiacomp.2018.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 12/17/2022]
Abstract
AIMS Examine 30-day readmissions for recurrent hypoglycemia and hyperglycemia in a national cohort of adults with diabetes. METHODS Retrospective analysis of data from OptumLabs Data Warehouse for all adults with diabetes hospitalized January 1, 2009 to December 31, 2014 with a principal diagnosis of hypoglycemia or hyperglycemia. We examined the rates and risk factors of 30-day readmissions for hypoglycemia and hyperglycemia. RESULTS After 6419 index hypoglycemia hospitalizations, 1.2% were readmitted for recurrent hypoglycemia, 0.2% for hyperglycemia, and 8.6% for other causes. Multimorbidity was the strongest predictor of recurrent hypoglycemia. After 6872 index hyperglycemia hospitalizations, 4.0% were readmitted for recurrent hyperglycemia, 0.4% for hypoglycemia, and 5.4% for other causes. Recurrent hyperglycemia was less likely in older patients (OR 0.6, 95% CI 0.5-0.9 for 45-64 vs. <45 years) and with the addition of a new glucose-lowering medication at index discharge (OR 0.40; 95% CI 0.2-0.7). New hypoglycemia readmissions were most likely among patients ≥75 years (OR 13.3, 95% CI 2.4-73.4, vs. <45 years). CONCLUSIONS Patients hospitalized for hyperglycemia are often readmitted for recurrent hyperglycemia, while patients hospitalized for hypoglycemia are generally readmitted for unrelated causes. Early recognition of high risk patients may identify opportunities to improve post-discharge management and reduce these events.
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Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States; Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN 55905, United States.
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, PO Box 208056, New Haven, CT 06520, United States
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, PO Box 208020, New Haven, CT 06520, United States
| | - Nilay D Shah
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN 55905, United States; OptumLabs, 1 Main Street, 10th Floor, Cambridge, MA 02142, United States
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20
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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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Silbert R, Salcido-Montenegro A, Rodriguez-Gutierrez R, Katabi A, McCoy RG. Hypoglycemia Among Patients with Type 2 Diabetes: Epidemiology, Risk Factors, and Prevention Strategies. Curr Diab Rep 2018; 18:53. [PMID: 29931579 PMCID: PMC6117835 DOI: 10.1007/s11892-018-1018-0] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Hypoglycemia is the most common and often treatment-limiting serious adverse effect of diabetes therapy. Despite being potentially preventable, hypoglycemia in type 2 diabetes incurs substantial personal and societal burden. We review the epidemiology of hypoglycemia in type 2 diabetes, discuss key risk factors, and introduce potential prevention strategies. RECENT FINDINGS Reported rates of hypoglycemia in type 2 diabetes vary widely as there is marked heterogeneity in how hypoglycemia is defined, measured, and reported. In randomized controlled trials, rates of severe hypoglycemia ranged from 0.7 to 12 per 100 person-years. In observational studies, hospitalizations or emergency department visits for hypoglycemia were experienced by 0.2 (patients treated without insulin or sulfonylurea) to 2.0 (insulin or sulfonylurea users) per 100 person-years. Patient-reported hypoglycemia is much more common. Over the course of 6 months, 1-4% non-insulin users reported need for medical attention for hypoglycemia; 1-17%, need for any assistance; and 46-58%, any hypoglycemia symptoms. Similarly, over a 12-month period, 4-17% of insulin-treated patients reported needing assistance and 37-64% experienced any hypoglycemic symptoms. Hypoglycemia is most common among older patients with multiple or advanced comorbidities, patients with long diabetes duration, or patients with a prior history of hypoglycemia. Insulin and sulfonylurea use, food insecurity, and fasting also increase hypoglycemia risk. Clinical decision support tools may help identify at-risk patients. Prospective trials of efforts to reduce hypoglycemia risk are needed, and there is emerging evidence supporting multidisciplinary interventions including treatment de-intensification, use of diabetes technologies, diabetes self-management, and social support. Hypoglycemia among patients with type 2 diabetes is common. Patient-centered multidisciplinary care may help proactively identify at-risk patients and address the multiplicity of factors contributing to hypoglycemia occurrence.
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Affiliation(s)
- Richard Silbert
- Department of Medicine Residency Program, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Alejandro Salcido-Montenegro
- Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Av. Francisco I. Madero y Av. Gonzalitos s/n, Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, "Dr. Jose E. González" University Hospital, Autonomous University of Nuevo Leon, 64460, Monterrey, Nuevo Leon, Mexico
| | - Rene Rodriguez-Gutierrez
- Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Av. Francisco I. Madero y Av. Gonzalitos s/n, Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, "Dr. Jose E. González" University Hospital, Autonomous University of Nuevo Leon, 64460, Monterrey, Nuevo Leon, Mexico
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Abdulrahman Katabi
- Evidence-Based Practice Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA.
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Kadowaki T, Haneda M, Ito H, Ueno M, Matsukawa M, Yamakura T, Sasaki K, Kimura M, Iijima H. Safety and efficacy of long-term treatment with teneligliptin: Interim analysis of a post-marketing surveillance of more than 10,000 Japanese patients with type 2 diabetes mellitus. Expert Opin Pharmacother 2018; 19:83-91. [PMID: 29268035 DOI: 10.1080/14656566.2017.1420165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND This post-marketing surveillance examined the safety and efficacy of long-term teneligliptin therapy in Japanese patients. RESEARCH DESIGN AND METHODS We report interim results (cut-off date: 28 June 2017) of a 3-year PMS undertaken in subjects with type 2 diabetes mellitus (T2DM). Survey items included demographics, treatments, adverse drug reactions (ADRs), and laboratory variables. A subgroup analysis was also performed across three age groups (<65 years; 65 to <75 years; ≥75 years). Main outcome measures were incidence of ADRs, laboratory variables, and change in glycated hemoglobin (HbA1c) from baseline over time. RESULTS Of 11,677 patients registered, data from 10,532 patients (6,338 males/4,194 females) were analyzed for the safety analysis set; the median administration period was 731 days. Overall, ADRs and serious ADRs were reported in 364 (3.46%) and 91 patients (0.86%), respectively. The most common ADRs were all hypoglycemia (0.32%), constipation (0.27%), and hepatic function abnormal (0.24%). No change in mean body weight occurred, and a reduction in mean HbA1c was observed until 2 years. The safety and efficacy profiles did not differ markedly among the three age groups. CONCLUSIONS These interim results show that teneligliptin was well tolerated and improved hyperglycemia in Japanese patients with T2DM in clinical practice.
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Affiliation(s)
- Takashi Kadowaki
- a Department of Diabetes and Metabolic Diseases, Graduate School of Medicine , The University of Tokyo , Tokyo , Japan
| | - Masakazu Haneda
- b Department of Medicine , Asahikawa Medical University , Hokkaido , Japan.,c Medical Corporation Kyousoukai , Osaka , Japan
| | - Hiroshi Ito
- d Department of Cardiovascular Medicine , Okayama University , Okayama , Japan
| | - Makoto Ueno
- e Ikuyaku. Integrated Value Development Division , Mitsubishi Tanabe Pharma Corporation , Osaka , Japan
| | - Miyuki Matsukawa
- e Ikuyaku. Integrated Value Development Division , Mitsubishi Tanabe Pharma Corporation , Osaka , Japan
| | - Tomoko Yamakura
- e Ikuyaku. Integrated Value Development Division , Mitsubishi Tanabe Pharma Corporation , Osaka , Japan
| | - Kazuyo Sasaki
- e Ikuyaku. Integrated Value Development Division , Mitsubishi Tanabe Pharma Corporation , Osaka , Japan
| | - Mayumi Kimura
- e Ikuyaku. Integrated Value Development Division , Mitsubishi Tanabe Pharma Corporation , Osaka , Japan
| | - Hiroaki Iijima
- f Ikuyaku. Integrated Value Development Division , Mitsubishi Tanabe Pharma Corporation , Tokyo , Japan
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Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease. Eye (Lond) 2017; 31:S1-S20. [PMID: 28490797 PMCID: PMC5437340 DOI: 10.1038/eye.2017.53] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease. The authors provide an update for ophthalmologists and allied healthcare professionals on key aspects of diabetes management, supported by a review of the pertinent literature, and recommend practice principles for optimal patient management in treating visual impairment due to diabetic eye disease. In people with diabetes, early optimal glycaemic control reduces the long-term risk of both microvascular and macrovascular complications. The authors propose more can and should be done to maximise metabolic control, promote appropriate behavioural modifications and encourage timely treatment intensification when indicated to ameliorate diabetes-related complications. All people with diabetes should be screened for sight-threatening diabetic retinopathy promptly and regularly. It is shown that attitudes towards treatment adherence in diabetic macular oedema appear to mirror patients' views and health behaviours towards the management of their own diabetes. Awareness of diabetic macular oedema remains low among people with diabetes, who need access to education early in their disease about how to manage their diabetes to delay progression and possibly avoid eye-related complications. Ophthalmologists and allied healthcare professionals play a vital role in multidisciplinary diabetes management and establishment of dedicated diabetic macular oedema clinics is proposed. A broader understanding of the role of the diabetes specialist nurse may strengthen the case for comprehensive integrated care in ophthalmic practice. The recommendations are based on round table presentations and discussions held in London, UK, September 2016.
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Zaccardi F, Webb DR, Davies MJ, Dhalwani NN, Housley G, Shaw D, Hatton JW, Khunti K. Risk factors and outcome differences in hypoglycaemia-related hospital admissions: A case-control study in England. Diabetes Obes Metab 2017; 19:1371-1378. [PMID: 28295974 DOI: 10.1111/dom.12941] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 03/03/2017] [Accepted: 03/09/2017] [Indexed: 02/06/2023]
Abstract
AIMS To evaluate risk factors for hospital admissions for hypoglycaemia and compare length of hospitalization, inpatient mortality and hospital readmission between hypoglycaemia- and non-hypoglycaemia-related admissions. MATERIALS AND METHODS We used all admissions for hypoglycaemia in individuals with diabetes to English NHS hospital trusts between 2005 and 2014 (101 475 case admissions) and 3 random admissions per case in individuals with diabetes without hypoglycaemia (304 425 control admissions). Risk factors and differences in the 3 outcomes were estimated with logistic and negative binomial regressions. RESULTS A U-shaped relationship between age and risk of admission for hypoglycaemia was observed until the age of 85 years; compared to the nadir at 60 years, the risk was progressively higher in younger and older patients and steadily declined after 85 years. Social deprivation (positively) and comorbidities (negatively) were associated with the risk of admission for hypoglycaemia. Compared to Caucasians, other ethnic groups had lower (Bangladeshi, Pakistani, Indians) or higher (Caribbean) risk of admission for hypoglycaemia. Length of hospitalization was 26% shorter while risk of rehospitalization was 65% higher in individuals admitted for hypoglycaemia. Compared to admissions for hypoglycaemia, risk of inpatient mortality was 50% lower for unstable angina but higher for acute myocardial infarction (3 times), acute renal failure (5 times) or pneumonia (8 times). CONCLUSIONS Among hospital-admitted individuals with diabetes, age, social deprivation, comorbidities and ethnicity are associated with higher frequency of hospitalization for hypoglycaemia. Admission for hypoglycaemia is associated with a greater risk of readmission, a shorter length of hospitalisation and a generally lower inpatient mortality compared to admissions for other medical conditions. These results could help in identifying at-risk groups to reduce the burden of hospitalization for hypoglycaemia.
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Affiliation(s)
| | - David R Webb
- Diabetes Research Centre, University of Leicester, Leicester, England
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, England
| | | | - Gemma Housley
- Nottingham University Hospitals and East Midlands Academic Health Science Network, Nottingham, England
| | - Dominic Shaw
- Nottingham University Hospitals and East Midlands Academic Health Science Network, Nottingham, England
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, England
| | - James W Hatton
- Nottingham University Hospitals and East Midlands Academic Health Science Network, Nottingham, England
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, England
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Bae JP, Duan R, Fu H, Hoogwerf BJ. Risk Factors for Nocturnal Hypoglycemia in Insulin-treated Patients With Type 2 Diabetes: A Secondary Analysis of Observational Data Derived From an Integrated Clinical Trial Database. Clin Ther 2017; 39:1790-1798.e7. [PMID: 28781218 DOI: 10.1016/j.clinthera.2017.07.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 07/13/2017] [Accepted: 07/18/2017] [Indexed: 01/09/2023]
Abstract
PURPOSE A trade-off exists in most diabetes therapies between the benefits of good glycemic control and the morbidity of hypoglycemia. Balancing these factors to achieve desired outcomes is a key consideration for personalized diabetes therapy. Hypoglycemia at night (nocturnal hypoglycemia [NH]) is a common but often under-reported problem in insulin-treated patients with type 2 diabetes. To better understand the risk for NH, we pooled data from multiple clinical trials of insulin treatment and specifically examined NH risk factors in relation to glycemic goals. METHODS Of 53 randomized trials involving insulin treatment, 18 trials that collected NH data were included. Risk factors associated with NH were identified by using gradient-boosting methods. A proportional hazards model was used to quantify the hazard ratio (HR) for risk factors. By modeling with individual patient data, a patient-level NH risk score distribution was created. Finally, results of the model were used to quantify an adjustment to the glycemic goal that would fully offset each risk factor, all other factors being equal. FINDINGS Data pooling resulted in the inclusion of 7341 patients with type 2 diabetes from 18 randomized clinical trials. In the mean 6-month treatment period, 43% of patients experienced at least 1 episode of NH (mean [SD], 1.1 [1.5] events/month). Reduction of glycosylated hemoglobin (HbA1c) levels during the trial was a risk factor for NH (HR, 1.40 [95% CI, 1.38-1.43] per -1% of HbA1c). Higher baseline HbA1c level was a protective factor against NH (HR, 0.76 [95% CI, 0.74-0.77] per +1% of HbA1c); and the adjustment to HbA1c goal required to offset 1% higher baseline HbA1c was -0.825%. Patient characteristics for risk of NH included older age (HR, 1.02 [95% CI, 1.01-1.02]) per 1-year increase), female sex (HR, 1.18 [95% CI, 1.15-1.22]), black or African-American race (HR, 1.41 [95% CI, 1.33-1.50] vs white race), longer diabetes duration (HR, 1.02 [95% CI, 1.01-1.02] per 1-year increase), diabetic nephropathy (HR, 1.40 [95% CI, 1.27-1.54]), and concomitant sulfonylurea use (HR, 1.10 [95% CI, 1.05-1.15]). Asian race was associated with a lower risk of NH (HR, 0.50 [95% CI, 0.48-0.53] vs white race); this finding could be offset with a 2.03% adjustment to the HbA1c goal. IMPLICATIONS Data on NH are scarce. By pooling multiple clinical trials, this study was able to evaluate patient-level data. A quantitative understanding of the trade-off between individual risk factors for NH and glycemic reduction may help clinicians to personalize patients' glycemic goals, while effectively managing NH risk. Limitations of the study include that patients were selected through inclusion/exclusion criteria and that patient compliance may be better in a trial setting. Validating the findings in the real world will be helpful.
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Affiliation(s)
- Jay P Bae
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana.
| | - Ran Duan
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
| | - Haoda Fu
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
| | - Byron J Hoogwerf
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
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Leyco T, Ryanputra D, Peh R, Ponce A, Khoo CM. Glycaemic Control after Metformin Discontinuation in Diabetic Patients with a Declining Renal Function. J Diabetes Res 2017; 2017:2769819. [PMID: 29230420 PMCID: PMC5694578 DOI: 10.1155/2017/2769819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/18/2017] [Accepted: 10/09/2017] [Indexed: 12/29/2022] Open
Abstract
Metformin is contraindicated in diabetic patients with declining renal function. This study examined the glycaemic control in diabetic patients with chronic kidney disease when metformin was discontinued. This was a retrospective study. We screened 2032 diabetic patients who attended the Diabetes Clinic at a tertiary hospital between 1 September 2014 and 30 September 2015. We analyzed the data on 69 patients whom metformin was discontinued due to declining renal function and had a complete 6-month follow-up. There was no significant difference in the HbA1c and body weight at 6-month follow-up compared to baseline after metformin discontinuation. The eGFR was significantly lower at 6-month follow-up compared to baseline. Upon metformin discontinuation, the majority of patients had their diabetes medication uptitrated (in particular insulin or sulphonylurea). Patients with an improved glycaemia at 6-month follow-up had further declined in eGFR compared to patients with worsened glycaemia. 17% of the study patients experienced hypoglycaemia. Upon metformin discontinuation, glycaemic control could be optimised with uptitration but should be balanced against the risk of hypoglycaemia. Further improvement in the glycaemic control might indicate further deterioration in the renal function.
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Affiliation(s)
- Theresa Leyco
- Department of Medicine, National University Hospital, Singapore
| | - Davin Ryanputra
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ray Peh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Alexphil Ponce
- Higher Education Department, Centre for International Education, Cebu, Philippines
| | - Chin Meng Khoo
- Department of Medicine, National University Hospital, Singapore
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Lau IT, Lee KF, So WY, Tan K, Yeung VTF. Insulin glargine 300 U/mL for basal insulin therapy in type 1 and type 2 diabetes mellitus. Diabetes Metab Syndr Obes 2017; 10:273-284. [PMID: 28721081 PMCID: PMC5501629 DOI: 10.2147/dmso.s131358] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To review published clinical studies on the efficacy and safety of new insulin glargine 300 units/mL (Gla-300), a new long-acting insulin analog, for the treatment of type 1 and type 2 diabetes mellitus (T1DM, T2DM). MATERIALS AND METHODS Data sources comprised primary research articles on Gla-300, including pharmacodynamic, pharmacokinetic, and clinical studies. RESULTS In pharmacodynamic and pharmacokinetic studies, Gla-300 showed a flatter time-action profile and longer duration of action than Gla-100. Noninferiority of Gla-300 versus Gla-100 for lowering of glycated hemoglobin was demonstrated in Phase III clinical studies covering a range of T1DM and T2DM patient populations. Over 6-12 months of follow-up, Gla-300 consistently showed comparable glycemic efficacy with less hypoglycemia vs Gla-100, even during the first 8 weeks of treatment. Although titrated insulin doses were 11%-17% higher with Gla-300 vs Gla-100, changes in body weight were similar or favored Gla-300. CONCLUSION Clinical studies provide evidence that the pharmacodynamic and pharmacokinetic properties of Gla-300 may translate into clinical benefits in both T1DM and T2DM. Gla-300 may provide a new option for people initiating basal insulin, those requiring higher basal insulin doses, those with T1DM, and those who may be at increased risk for hypoglycemia, such as people with chronic kidney disease, the elderly, and those with cardiovascular comorbidities.
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Affiliation(s)
- Ip Tim Lau
- Department of Medicine, Tseung Kwan O Hospital
- Correspondence: Ip Tim Lau, Department of Medicine, Tseung Kwan O Hospital, 2 Po Ning Lane, Hang Hau, Tseung Kwan O, Hong Kong, China, Tel +852 2208 0111, Email
| | - Ka Fai Lee
- Department of Medicine and Geriatrics, Kwong Wah Hospital
| | - Wing Yee So
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital
| | - Kathryn Tan
- Department of Medicine, Queen Mary Hospital, University of Hong Kong
| | - Vincent Tok Fai Yeung
- Department of Medicine and Geriatrics, Our Lady of Maryknoll Hospital, Hong Kong, China
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Carlson N, Hommel K, Olesen JB, Gerds TA, Soja AM, Vilsbøll T, Kamper AL, Torp-Pedersen C, Gislason G. Metformin-associated risk of acute dialysis in patients with type 2 diabetes: A nationwide cohort study. Diabetes Obes Metab 2016; 18:1283-1287. [PMID: 27534835 DOI: 10.1111/dom.12764] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/12/2016] [Accepted: 08/15/2016] [Indexed: 11/28/2022]
Abstract
Recent guidelines governing anti-diabetic medications increasingly advocate metformin as first-line therapy in all patients with type 2 diabetes. However, metformin could be associated with increased risk of acute kidney injury (AKI), acute dialysis and lactate acidosis in marginal patients. In a retrospective nationwide cohort study, a total of 168 443 drug-naïve patients with type 2 diabetes ≥50 years, initiating treatment with either metformin or sulphonyl in Denmark between 2000 and 2012 were included in this study (70.7% initiated treatment with metformin); calculation of 1-year risk of acute dialysis was based on g-standardization of cause-specific Cox regression models for acute dialysis, end-stage renal disease and death. One-year risks of acute dialysis were 92.4 per 100 000 (95% CI, 67.1-121.3) and 142.7 per 100 000 (95% CI, 118.3-168.0) for sulphonylurea and metformin, respectively. The metformin-associated 1-year risk of acute dialysis was increased by 50.3 per 100 000 (95% CI, 7.9-88.6), corresponding to a risk ratio of 1.53 (95% CI, 1.06-2.23), and a number needed to harm of 1988, thus providing evidence of potential concerns pertaining to the increasing use of metformin.
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Affiliation(s)
- Nicholas Carlson
- Department of Cardiology, Gentofte Hospital, Copenhagen University, Hellerup, Denmark
- Department of Nephrology, Herlev Hospital, Copenhagen University, Herlev, Denmark
| | - Kristine Hommel
- Department of Nephrology, Herlev Hospital, Copenhagen University, Herlev, Denmark
| | - Jonas B Olesen
- Department of Cardiology, Gentofte Hospital, Copenhagen University, Hellerup, Denmark
| | - Thomas A Gerds
- Department of Biostatistics, Copenhagen University, Copenhagen, Denmark
| | - Anne-Merete Soja
- Department of Cardiology, Hvidovre Hospital, Copenhagen University, Hvidovre, Denmark
| | - Tina Vilsbøll
- Center for Diabetes Research, Gentofte Hospital, Copenhagen University, Hellerup, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | | | - Gunnar Gislason
- Department of Cardiology, Gentofte Hospital, Copenhagen University, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
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Holstein A, Wohland T, Patzer OM, Trachte F, Kovacs P, Holstein JD. Accumulation of severe hypoglycemia at weekends and in warm seasons in patients with type 1 diabetes but not with type 2 diabetes. J Diabetes Complications 2016; 30:1308-14. [PMID: 27311787 DOI: 10.1016/j.jdiacomp.2016.05.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/29/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
AIMS To determine the influence of daytime, weekdays and seasons on the frequency of severe hypoglycemia (SH) in a German population. METHODS Prospective population-based observational study capturing all episodes of SH between 2007 and 2014 in the Lippe-Detmold area. SH was defined as a symptomatic event requiring treatment with intravenous glucose or administration of glucagon and being confirmed by a blood glucose measurement of <2.8mmol/l. RESULTS A total of 1080 episodes of SH in 747 patients were registered. 37.5% of cases (405/1080) were related to T1DM, 51.9% (561/1080) to T2DM, 3.2% (35/1080) to pancreatic diabetes and 7.3% (79/1080) to non-diabetic individuals. In cases with T1DM we observed a significantly higher event rate of SH at weekends versus the rest of the week: 2.87 events/weekend-hour versus 2.15 events/weekday-hour (p=0.004), especially on Saturdays. We found significantly increased incidences of SH in spring (31.2%) and summer (26.7%) versus autumn (20.3%) and winter (21.8%). There were no corresponding significant seasonal variations of HbA1c and insulin doses. The seasonal distribution of SH in subjects with T2DM was balanced with no peak incidence at weekends. CONCLUSIONS For the risk of SH, time factors appear to contribute more substantially in individuals with T1DM than in patients with T2DM. The enhanced frequency of SH in patients with T1DM at weekends and in warm seasons was probably caused by short-term changes in behavior. Intensification of diabetes care and education with better adjustment of insulin doses in these susceptible periods could be an appropriate approach to prevent SH.
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Affiliation(s)
- Andreas Holstein
- 1st Department of Medicine, Lippe-Detmold Hospital, Detmold, Germany.
| | - Tobias Wohland
- Leipzig University Medical Center, IFB AdiposityDiseases, University of Leipzig, Germany
| | - Olaf M Patzer
- 1st Department of Medicine, Lippe-Detmold Hospital, Detmold, Germany
| | - Florian Trachte
- 1st Department of Medicine, Lippe-Detmold Hospital, Detmold, Germany
| | - Peter Kovacs
- Leipzig University Medical Center, IFB AdiposityDiseases, University of Leipzig, Germany
| | - Judith D Holstein
- Medical Department, Division of Nephrology and Internal Intensive Care Medicine, Charité University Medicine Berlin, Germany
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van Dalem J, Brouwers MCGJ, Stehouwer CDA, Krings A, Leufkens HGM, Driessen JHM, de Vries F, Burden AM. Risk of hypoglycaemia in users of sulphonylureas compared with metformin in relation to renal function and sulphonylurea metabolite group: population based cohort study. BMJ 2016; 354:i3625. [PMID: 27413017 PMCID: PMC4948031 DOI: 10.1136/bmj.i3625] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the association between use of sulphonylureas and risk of hypoglycaemia in relation to renal function and sulphonylurea metabolic group compared with use of metformin. DESIGN Population based cohort study using routinely collected data from general practices in England. SETTING Clinical Practice Research Datalink (CPRD) database, 2004-12. PARTICIPANTS 120 803 new users of a non-insulin antidiabetic agent with at least one prescription and aged 18 years or more. The first prescription defined start of follow-up. Patients were followed until the end of data collection, a record for hypoglycaemia, or a blood glucose level of less than 3.0 mmol/L. MAIN OUTCOME MEASURES Associations between sulphonylurea dose, renal impairment, type of sulphonylurea used, and risk of hypoglycaemia, were determined using Cox proportional hazard models. Adjustments were made for age, sex, lifestyle, comorbidity, and drug use. RESULTS The risk of hypoglycaemia in current users of sulphonylureas only was significantly increased compared with current users of metformin only (adjusted hazard ratio 2.50, 95% confidence interval 2.23 to 2.82). The higher risk in current users of sulphonylureas only was further increased in patients with an estimated glomerular filtration rate of less than 30 mL/min/1.73 m(2) (4.96, 3.76 to 6.55). The risk of hypoglycaemia was also significantly higher in patients with a high sulphonylurea dose (3.12, 2.68 to 3.62) and in current users of glibenclamide (7.48, 4.89 to 11.44). Gliclazide, the sulphonylurea of first choice, showed a similar risk of hypoglycaemia compared with other sulphonylureas. CONCLUSIONS Sulphonylurea treatment in patients with a renal function of less than 30 mL/min/1.73 m(2) should be considered with caution. Moreover, an increased risk of hypoglycaemic events was observed among all users of sulphonylureas. This contrasts with several guidelines that recommend gliclazide as first choice sulphonylurea, and therefore requires further investigation.
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Affiliation(s)
- Judith van Dalem
- Department of Clinical Pharmacy, Maastricht University Medical Centre, Maastricht, Netherlands Department of Clinical Pharmacy, Zuyderland MC, Heerlen, Netherlands Care and Public Health Research Institute (CAPHRI), Maastricht, Netherlands
| | - Martijn C G J Brouwers
- Department of Internal Medicine, Division of Endocrinology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
| | - Coen D A Stehouwer
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
| | - André Krings
- Department of Clinical Pharmacy, Zuyderland MC, Heerlen, Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University, PO Box 80082, 3508 TB Utrecht, Netherlands
| | - Johanna H M Driessen
- Department of Clinical Pharmacy, Maastricht University Medical Centre, Maastricht, Netherlands Care and Public Health Research Institute (CAPHRI), Maastricht, Netherlands Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University, PO Box 80082, 3508 TB Utrecht, Netherlands
| | - Frank de Vries
- Department of Clinical Pharmacy, Maastricht University Medical Centre, Maastricht, Netherlands Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University, PO Box 80082, 3508 TB Utrecht, Netherlands
| | - Andrea M Burden
- Department of Clinical Pharmacy, Maastricht University Medical Centre, Maastricht, Netherlands Care and Public Health Research Institute (CAPHRI), Maastricht, Netherlands Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University, PO Box 80082, 3508 TB Utrecht, Netherlands
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Paul SK, Agbeve J, Maggs D, Best JH. Comparison of trajectories of self-monitored glucose levels by hypoglycemia status over 52 weeks of treatment with insulin glargine or exenatide once weekly. J Diabetes 2016; 8:148-57. [PMID: 25586464 DOI: 10.1111/1753-0407.12269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 12/26/2014] [Accepted: 01/06/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Self-monitoring of blood glucose (SMBG) is used as a means to detect and prevent hypoglycemia in patients with diabetes. However, information on the longitudinal measures (trajectory) of SMBG-based pre- and postprandial glucose fluctuations over time in relation to hypoglycemia is limited. Among patients treated with exenatide once weekly (EQW) or insulin glargine (IG), this study compared SMBG profiles over 52 weeks between patients who did and did not experience hypoglycemia. METHODS Pooled patient-level 52-week longitudinal data of treatment with EQW (n = 531) or IG (n = 219) from three controlled trials were analyzed. RESULTS The proportion of patients with at least one episode of hypoglycemia in the EQW and IG groups was 23% and 54%, respectively. The preprandial glucose measures from SMBG were significantly lower among patients who experienced hypoglycemia in both treatment groups compared with those who did not. In patients who experienced hypoglycemia, the average preprandial glucose levels over 52 weeks were lower by 0.64 and 0.66 mmol/L in the EQW and IG groups, respectively (P < 0.01 in both cases) compared with those without hypoglycemia. The average postprandial levels were not significantly different between patients who did and did not experience hypoglycemia in both treatment groups. Among patients with hypoglycemia, the average prebreakfast glucose trajectory was higher by 0.48 mmol/L in the EQW compared with the IG group. CONCLUSIONS This study has revealed differential trajectories of pre- and postprandial glucose profiles between patients with and without hypoglycemia. However, the SMBG trajectories were similar between patients treated with EQW and IG.
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Affiliation(s)
- Sanjoy K Paul
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Julius Agbeve
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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Hypoglycaemia, Abnormal Lipids, and Cardiovascular Disease among Chinese with Type 2 Diabetes. BIOMED RESEARCH INTERNATIONAL 2015; 2015:862896. [PMID: 26504840 PMCID: PMC4609392 DOI: 10.1155/2015/862896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/17/2015] [Accepted: 03/19/2015] [Indexed: 12/22/2022]
Abstract
We recruited a group of 6713 consecutive Chinese patients with T2D but normal renal and liver function who were admitted to one of 81 top tertiary care hospitals in China. Mild hypoglycaemia was defined as having symptomatic hypoglycaemia in one month before hospitalization. Severe hypoglycaemia was defined as having hypoglycaemia that needed assistance from other people in three months before hospitalization. Prior cardiovascular disease (CVD) was defined as having coronary heart disease, stroke, or peripheral arterial disease. Of 6713 patients, 80 and 304 had severe and mild hypoglycaemia episodes, respectively, and 561 had CVD. Patients with severe and mild hypoglycaemia episodes were more likely to have prior CVD (32.5% versus 16.5% versus 7.7%, P < 0.0001). Both mild and severe hypoglycaemia were associated with increased risk of CVD (adjusted odds ratios (ORs): 2.64, 95% CI: 1.85–3.76 for mild hypoglycaemia; 6.59, 95% CI: 3.79–11.45 for sever hypoglycaemia) than those patients free of hypoglycaemia. Further adjustment for lipid profile did not change these two ORs. In the same way, the ORs of lipid profile for CVD were similar before and after adjustment for hypoglycaemia. We concluded that hypoglycaemia and lipid profile were independently associated with increased risk of CVD.
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Jenssen T, Hartmann A. Emerging treatments for post-transplantation diabetes mellitus. Nat Rev Nephrol 2015; 11:465-77. [PMID: 25917553 DOI: 10.1038/nrneph.2015.59] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Post-transplantation diabetes mellitus (PTDM), also known as new-onset diabetes mellitus (NODM), occurs in 10-15% of renal transplant recipients and is associated with cardiovascular disease and reduced lifespan. In the majority of cases, PTDM is characterized by β-cell dysfunction, as well as reduced insulin sensitivity in liver, muscle and adipose tissue. Glucose-lowering therapy must be compatible with immunosuppressant agents, reduced glomerular filtration rate (GFR) and severe arteriosclerosis. Such therapy should not place the patient at risk by inducing hypoglycaemic episodes or exacerbating renal function owing to adverse gastrointestinal effects with hypovolaemia. First-generation and second-generation sulphonylureas are generally avoided, and caution is currently advocated for the use of metformin in patients with GFR <60 ml/min/1.73 m(2). DPP-4 inhibitors do not interact with immunosuppressant drugs and have demonstrated safety in small clinical trials. Other therapeutic options include glinides and glitazones. Evidence-based treatment regimens used in patients with type 2 diabetes mellitus cannot be directly implemented in patients with PTDM. Studies investigating the latest drugs are required to direct the development of improved treatment strategies for patients with PTDM. This Review outlines the modern principles of glucose-lowering treatment in PTDM with specific reference to renal transplant recipients.
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Affiliation(s)
- Trond Jenssen
- Research Group of Nephrology and Metabolism, Department of Clinical Medicine, UIT Arctic University of Norway, Hansine Hansens Veg 18, PO Box 6050 Langnes, 9037 Tromsø, Norway
| | - Anders Hartmann
- Department of Transplant Medicine, Section of Nephrology, Oslo University Hospital Rikshospitalet, Sognsvannvegen 20, PO Box 4950, Nydalen, Oslo 0424, Norway
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Iatrogenic hypoglycemia and quality of life in patients with type 2 diabetes mellitus. Rev Clin Esp 2015; 215:104-6. [DOI: 10.1016/j.rce.2014.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 11/23/2014] [Indexed: 11/22/2022]
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Predictors of nonsevere and severe hypoglycemia during glucose-lowering treatment with insulin glargine or standard drugs in the ORIGIN trial. Diabetes Care 2015; 38:22-8. [PMID: 25352653 DOI: 10.2337/dc14-1329] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hypoglycemia is a leading risk of glucose-lowering therapy. Treatment with insulin glargine compared with standard care early in the course of dysglycemia in the Outcome Reduction with an Initial Glargine Intervention (ORIGIN) trial provides information on the frequency and predictors of hypoglycemia in this setting. RESEARCH DESIGN AND METHODS A total of 12,537 people with high cardiovascular risk and dysglycemia treated with one or no oral glucose-lowering agents were randomized to add glargine titrated to a fasting glucose level of ≤5.3 mmol/L (≤95 mg/dL) or to use standard therapies. Independent associations of both nonsevere hypoglycemia (symptomatic and confirmed with a glucose level of ≤3 mmol/L [≤54 mg/dL]) and severe hypoglycemia with characteristics at baseline, treatment allocation, and average HbA1c were assessed by Cox proportional hazards models. RESULTS During a median follow-up period of 6.2 years, 28% of participants reported nonsevere hypoglycemia, and 3.8% reported severe hypoglycemia. Prior use of a sulfonylurea and allocation to glargine independently predicted a higher risk for both categories of participants. Nonsevere events were independently associated with younger age, lower BMI, the presence of diabetes, and higher baseline HbA1c level. Severe events were associated with older age, hypertension, higher serum creatinine level, and lower cognitive function, but not baseline glycemic status. Progressively higher on-treatment HbA1c level was associated with a lower risk of nonsevere events in both treatment groups; a lower risk of severe events in the glargine group, and a higher risk of severe events with standard care. CONCLUSIONS Hypoglycemia was relatively uncommon in the ORIGIN trial, but was more frequent with sulfonylurea use at baseline and allocation to glargine. Nonsevere and severe events were associated with different clinical characteristics, awareness of which may guide individualized therapy.
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Yun JS, Ko SH. Avoiding or coping with severe hypoglycemia in patients with type 2 diabetes. Korean J Intern Med 2015; 30:6-16. [PMID: 25589828 PMCID: PMC4293565 DOI: 10.3904/kjim.2015.30.1.6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 12/11/2014] [Indexed: 12/30/2022] Open
Abstract
Hypoglycemia is a major barrier to achieving the glycemic goal in patients with type 2 diabetes. In particular, severe hypoglycemia, which is defined as an event that requires the assistance of another person to actively administer carbohydrates, glucagon, or take other corrective actions, is a serious clinical concern in patients with diabetes. If severe hypoglycemia is not managed promptly, it can be life threatening. Hypoglycemia-associated autonomic failure (HAAF) is the main pathogenic mechanism behind severe hypoglycemia. Defective glucose counter-regulation (altered insulin secretion, glucagon secretion, and an attenuated increase in epinephrine during hypoglycemia) and a lack of awareness regarding hypoglycemia (attenuated sympathoadrenal activity) are common components of HAAF in patients with diabetes. There is considerable evidence that hypoglycemia is an independent risk factor for cardiovascular disease. In addition, hypoglycemia has a significant influence on the quality of life of patients with diabetes. To prevent hypoglycemic events, the setting of glycemic goals should be individualized, particularly in elderly individuals or patients with complicated or advanced type 2 diabetes. Patients at high-risk for the future development of severe hypoglycemia should be selected carefully, and intensive education with reinforcement should be implemented.
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Affiliation(s)
- Jae-Seung Yun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung-Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Paul SK, Maggs D, Klein K, Best JH. Dynamic risk factors associated with non-severe hypoglycemia in patients treated with insulin glargine or exenatide once weekly. J Diabetes 2015; 7:60-7. [PMID: 25168883 DOI: 10.1111/1753-0407.12208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 08/11/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Glycemic control in patients with type 2 diabetes is a dynamic process, and changes in risk factors affecting the incidence of hypoglycemia are not well understood. This study explored the association of longitudinal interactive effects of clinical risk factors and concomitant medications on hypoglycemia risk in patients treated with insulin glargine (IG) or exenatide once weekly (EQW). METHODS Pooled patient-level 52-week longitudinal data of treatment with EQW (n = 541) or IG (n = 223) from three controlled trials were analyzed. RESULTS Proportions of patients with at least one episode of hypoglycemia in the EQW and IG groups were 23% and 54%, respectively. Compared with patients with HbA1c ≥7% (53 mmol/mol) over time, patients with HbA1c <7% had significantly higher hypoglycemia risk in both groups (95% confidence intervals [CI] of odds ratios [OR]: EQW-1.21, 2.81; IG- 6.26, 9.84). The patterns of interaction effect of changing body mass index (BMI) and HbA1c on hypoglycemia risk differed in the two treatment groups: patients with with BMI >35 kg/m(2) had a 119% increased hypoglycemia risk in the EQW group, but a 57% reduced risk in the IG group. Sulfonylurea-treated patients in the EQW and IG groups had 4.7- and 3-fold additional hypoglycemia risk, respectively, versus non-sulfonylurea-treated patients. CONCLUSION This study revealed differential effects of tight glycemic control and itsinteraction with treatment-induced changes in BMI on hypoglycemia risk its interaction in patients treated with EQW and IG. The residual adverse effect of sulfonylurea was higher in EQW-treated patients.
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Affiliation(s)
- Sanjoy K Paul
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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Frequency and predictors of confirmed hypoglycaemia in type 1 and insulin-treated type 2 diabetes mellitus patients in a real-life setting: results from the DIALOG study. DIABETES & METABOLISM 2014; 41:116-25. [PMID: 25465273 DOI: 10.1016/j.diabet.2014.10.007] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 12/16/2022]
Abstract
AIM DIALOG assessed the prevalence and predictors of hypoglycaemia in patients with type 1 (T1DM) or insulin-treated type 2 diabetes mellitus (T2DM) in a real-life setting. METHODS In this observational study, insulin-treated patients (n=3048) completed prospective daily questionnaires reporting the frequency and consequences of severe/confirmed non-severe hypoglycaemia over 30 days. Patients (n=3743) also retrospectively reported severe hypoglycaemia over the preceding year. RESULTS In this prospective survey, 85.3% and 43.6% of patients with T1DM and T2DM, respectively, reported experiencing at least one confirmed hypoglycaemic event over 30 days, while 13.4% and 6.4%, respectively, reported at least one severe event. Hypoglycaemia frequency increased with longer duration of diabetes and insulin therapy. Strongly predictive factors for hypoglycaemia were previous hypoglycaemia, >2 injections/day, BMI<30kg/m(2) and duration of insulin therapy>10 years. HbA1c level was not predictive of hypoglycaemia in either T1DM or T2DM. The confirmed hypoglycaemia rate was increased in the lowest compared with the highest tertile of HbA1c in T1DM, but not T2DM. At the time of enrolment, physicians reported severe hypoglycaemia in 23.6% and 11.9% of T1DM and T2DM patients, respectively, during the preceding year; the retrospective survey yielded frequencies of 31.5% and 21.7%, respectively. Also, severe hypoglycaemia led to medical complications in 10.7% and 7.8% of events in T1DM and T2DM patients, respectively, over 30 days. CONCLUSION Using a unique combined prospective and retrospective approach, the DIALOG study found a relatively high frequency of hypoglycaemia among insulin-treated patients. These findings emphasize the importance of a patient-centred approach for managing diabetes in which hypoglycaemia risk evaluation is critical. TRIAL REGISTRATION ClinicalTrials.gov: NCT01628341.
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