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Wen WL, Lee YJ, Hwu DW, Chang YH. Age- and gender-adjusted estimated glomerular filtration rate definition reveals hyperfiltration as a risk factor for renal function deterioration in type 2 diabetes. Diabetes Obes Metab 2024; 26:1636-1643. [PMID: 38303103 DOI: 10.1111/dom.15465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 02/03/2024]
Abstract
AIM To assess the role of hyperfiltration for diabetic kidney disease (DKD) progression. MATERIALS AND METHODS A retrospective observational cohort study enrolled type 2 diabetes (T2D) patients with an initial estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73m2 or higher. Patients were categorized into two groups: hyperfiltration (eGFR exceeding the age- and gender-specific 95th percentile values from a prior national cohort study) and normofiltration. Rapid DKD progression was defined as an eGFR decline of more than 5 mL/min/1.73m2/year. We used a linear mixed effect model and Cox regression with time-varying covariate model to compare eGFR changes and identify factors associated with rapid DKD progression. RESULTS Of the enrolled 7563 T2D patients, 7.2% had hyperfiltration. The hyperfiltration group exhibited a higher rate of eGFR decline compared with the normofiltration group (-2.0 ± 0.9 vs. -1.1 ± 0.9 mL/min/1.73m2/year; P < .001). During an average follow-up period of 4.65 ± 3.86 years, 24.7% of patients with hyperfiltration experienced rapid DKD progression, compared with 15.7% of patients with normofiltration (P < .001). Cox regression analyses identified that initial hyperfiltration was a significant determinant of rapid DKD progression, with a hazard ratio of 1.66 (95% confidence interval: 1.41-1.95; P < .001). When combined with albuminuria, the risk of progression was further compounded (hazard ratio 1.76-3.11, all P < .001). CONCLUSIONS In addition to using the current Kidney Disease: Improving Global Outcomes CGA classification system, considering glomerular hyperfiltration status can improve the accuracy of predicting DKD progression.
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Affiliation(s)
- Wei-Lun Wen
- Department of Internal Medicine, Lee's Endocrinology Clinic, Pingtung City, Taiwan
| | - Yau-Jiunn Lee
- Department of Internal Medicine, Lee's Endocrinology Clinic, Pingtung City, Taiwan
| | - Der-Wei Hwu
- Department of Internal Medicine, Lee's Endocrinology Clinic, Pingtung City, Taiwan
| | - Yu-Hung Chang
- Department of Internal Medicine, Lee's Endocrinology Clinic, Pingtung City, Taiwan
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García-Villarino M, Lambert C, De la Hera JM, Torre ELM, Rodríguez-Lacín JMF, Delgado-Álvarez E. Use of electronic health records for the management of diabetes and its risk factors in the Principality of Asturias from 2014 to 2018. ENDOCRINOL DIAB NUTR 2024; 71:208-215. [PMID: 38897704 DOI: 10.1016/j.endien.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND In recent years, the implementation of electronic health records across all hospitals and primary care centres within the National Health System has significantly enhanced access to patients' clinical data. This study aims to estimate the prevalence of type 2 diabetes (T2DM) in primary care settings and to outline its associated cardiovascular risk factors (CVRF) and epidemiological characteristics. METHODS An observational cross-sectional study was conducted including 89,679 patients diagnosed with T2DM who attended the primary health care system from 2014 to 2018. Data was provided by the Primary Health Care System of the Principality of Asturias (SESPA). RESULTS The estimated prevalence of diagnosed T2DM was 8.01% (95% Confidence Interval [CI]: 7.96-8.06) of the total population. Additionally, it was more prevalent in males compared to females (9.90% [95% CI: 9.81-9.99] vs. 6.50% [95% CI: 6.44-6.57]) and increased with age in both sexes. People with T2DM had an average age of 74 years, 52.3% were male, and the most frequently associated CVRF were: dyslipidaemia (47.90%) and hypertension (62.20%). Glycaemic control improved during the 2014-2018 period (31.69%), as did lipid control (23.66%). However, the improvement in blood pressure control (9.34%) was less pronounced for the same period. Regarding the multifactorial control of diabetes (measured by LDL-cholesterol, HbA1C and blood pressure) the overall degree of control improved by 11.55% between 2014 and 2018. CONCLUSION In this 5-year retrospective population-based study, the utilisation of data from electronic medical records provides insights into the prevalence of T2DM in a large population, as well as real-time CVRFs. Leveraging this data facilitates the development of targeted health policies.
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Affiliation(s)
- Miguel García-Villarino
- Grupo de Endocrinología, Nutrición, Diabetes y Obesidad (ENDO), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA) and University of Oviedo, Oviedo, Spain.
| | - Carmen Lambert
- Grupo de Endocrinología, Nutrición, Diabetes y Obesidad (ENDO), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA) and University of Oviedo, Oviedo, Spain
| | - Jesús M De la Hera
- Grupo de Endocrinología, Nutrición, Diabetes y Obesidad (ENDO), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA) and University of Oviedo, Oviedo, Spain; Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Edelmiro Luis Menéndez Torre
- Grupo de Endocrinología, Nutrición, Diabetes y Obesidad (ENDO), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA) and University of Oviedo, Oviedo, Spain; Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - José María Fernández Rodríguez-Lacín
- Grupo de Cronicidad, Envejecimiento, Fragilidad y Continuidad Asistencial, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Elías Delgado-Álvarez
- Grupo de Endocrinología, Nutrición, Diabetes y Obesidad (ENDO), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA) and University of Oviedo, Oviedo, Spain; Servicio de Endocrinología y Nutrición, Hospital Universitario Central de Asturias, Oviedo, Spain
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Arvanitakis K, Koufakis T, Kalopitas G, Papadakos SP, Kotsa K, Germanidis G. Management of type 2 diabetes in patients with compensated liver cirrhosis: Short of evidence, plenty of potential. Diabetes Metab Syndr 2024; 18:102935. [PMID: 38163417 DOI: 10.1016/j.dsx.2023.102935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 12/16/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND AIMS Treatment of type 2 diabetes (T2D) in patients with compensated cirrhosis is challenging due to hypoglycemic risk, altered pharmacokinetics, and the lack of robust evidence on the risk/benefit ratio of various drugs. Suboptimal glycemic control accelerates the progression of cirrhosis, while the frequent coexistence of nonalcoholic fatty liver disease (NAFLD) with T2D highlights the need for a multifactorial therapeutic approach. METHODS A literature search was performed in Medline, Google Scholar and Scopus databases till July 2023, using relevant keywords to extract studies regarding the management of T2D in patients with compensated cirrhosis. RESULTS Metformin, sodium-glucose co-transporter-2 inhibitors (SGLT2i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA) are promising treatment options for patients with T2D and compensated liver cirrhosis, offering good glycemic control with minimal risk of hypoglycemia, while their pleiotropic actions confer benefits on NAFLD and body weight, and decrease cardiorenal risk. Sulfonylureas cause hypoglycemia, thus should be avoided, while in specific studies, dipeptidyl peptidase-4 inhibitors have been correlated with increased risk of decompensation and variceal bleeding. Despite the benefits of thiazolidinediones in nonalcoholic steatohepatitis, concerns about edema and weight gain limit their use in compensated cirrhosis. Insulin does not exert hepatotoxic effects and can be administered safely in combination with other drugs; however, the risk of hypoglycemia should be considered. CONCLUSIONS The introduction of new hepatoprotective diabetes drugs into clinical practice, including tirzepatide, SGLT2i, and GLP-1 RA, sets the stage for future trials to investigate the ideal therapeutic regimen for people with T2D and compensated cirrhosis.
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Affiliation(s)
- Konstantinos Arvanitakis
- Division of Gastroenterology and Hepatology, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece; Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece
| | - Theocharis Koufakis
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, 54642, Thessaloniki, Greece
| | - Georgios Kalopitas
- Division of Gastroenterology and Hepatology, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece; Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece
| | - Stavros P Papadakos
- First Department of Pathology, Medical School, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 54636, Thessaloniki, Greece
| | - Georgios Germanidis
- Division of Gastroenterology and Hepatology, First Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece; Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54636, Thessaloniki, Greece.
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Palanca A, Ampudia-Blasco FJ, Calderón JM, Sauri I, Martinez-Hervás S, Trillo JL, Redón J, Real JT. Comparison of GLP-1 receptor agonists and other Glucose-Lowering agents on cardiovascular outcomes in individuals with type 2 diabetes and Obesity: A Spanish Real-World Population-Based study. Diabetes Res Clin Pract 2024; 207:111071. [PMID: 38142748 DOI: 10.1016/j.diabres.2023.111071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/10/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
AIMS Assess the impact of glucagon-like peptide receptor agonists (GLP-1RA) compared to other glucose-lowering agents on cardiovascular outcomes in individuals with type 2 diabetes and obesity in a Spanish metropolitan area. METHODS A retrospective population-based type 2 diabetes cohort was identified from the Valencia Clinic-Malvarrosa Department electronic databases (2014-2019). Study groups included GLP-1RA, sodium-glucose co-transporter-2 inhibitors (SGLT2i), Insulin, and Miscellany (other glucose-lowering agents). 1:1:1:1 propensity score matching was conducted. The primary outcome was a composite of major adverse cardiovascular events (4-point MACE) comprising myocardial infarction, stroke, all-cause mortality, and heart failure. Secondary outcomes included individual 4-point MACE components. Hazard ratios were estimated using Cox regression analyses against the Miscellany group. RESULTS From 26,944 subjects, 1,848 adults were selected per group. GLP-1RA did not show a significant reduction in 4-point MACE risk (HR 1.05 [95%CI 0.82-1.34]). SGLT2i significantly reduced the risk of heart failure (HR 0.16 [95%CI 0.05-0.54]) and atrial fibrillation (HR 0.58, [95%CI 0.35-0.95]). The Insulin group exhibited a higher risk for 4-point MACE and most individual outcomes compared to GLP-1RA and SGLT2i. CONCLUSIONS Our findings do not provide evidence of a reduced cardiovascular risk, as assessed by 4-point MACE, with GLP-1RA. In contrast, SGLT2i demonstrated protective effects against heart failure and atrial fibrillation.
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Affiliation(s)
- Ana Palanca
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain.
| | - F Javier Ampudia-Blasco
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain.
| | | | | | - Sergio Martinez-Hervás
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain
| | - José Luis Trillo
- Department of Health of Valencia Clínico-Malvarrosa, Valencia, Spain
| | - Josep Redón
- INCLIVA Biomedical Research Institute, Valencia, Spain
| | - José T Real
- INCLIVA Biomedical Research Institute, Valencia, Spain; CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases, Madrid, Spain; Department of Endocrinology & Nutrition, Clinic University Hospital of Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Spain
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Choi Y, Ko S, Chang K, Yoo KD, Ihm S. Effect of dipeptidyl peptidase-4 inhibitor on the progression of coronary artery disease evaluated by computed tomography in patients receiving insulin therapy for type 2 diabetes mellitus. J Diabetes 2023; 15:944-954. [PMID: 37528628 PMCID: PMC10667629 DOI: 10.1111/1753-0407.13449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/23/2023] [Accepted: 07/14/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND We evaluated the effect of a dipeptidyl peptidase-4 inhibitor (DPP-4i) on the progression of obstructive coronary artery disease (OCAD) in patients with type 2 diabetes mellitus (T2DM) receiving insulin therapy. METHODS Using a multicenter clinical data warehouse, we analyzed the patients receiving insulin therapy for T2DM who underwent coronary computed tomography angiography (CCTA) for ≥2 times. The patients were divided into two groups according to the presence of DPP-4i prescription between the two CCTA examinations. The prevalence of OCAD (>50% stenosis on CCTA), new revascularization rates, and changes in the coronary calcium score (CCS) were analyzed. RESULTS A total of 623 patients were included, and a DPP-4i was prescribed to 380 (60.9%) patients. The median time difference between the two CCTAs was 39.0 (17.0-61.4) months. Newly developed OCAD at the follow-up CCTA was detected in 62 (16.3%) patients in the DPP-4i group and 76 (31.3%) patients in the no DPP-4i group (p < 0.001). The risk of new OCAD or new revascularization was lower in the DPP-4i group (19.7% vs. 38.7%; p < 0.001). After propensity score matching, the prevalence of new OCAD (15.9% vs. 29.5%; p = 0.001) and the composite rate of new OCAD or new revascularization (18.7% vs. 37.3%; p < 0.001) were lower in the DPP-4i group. The change in CCS per year did not differ significantly between the two groups (9.1 [0.1-56.8] vs. 13.5 [0.0-78.6]; p = 0.715). CONCLUSIONS Add-on DPP-4i therapy would be beneficial in preventing coronary artery disease progression in patients with T2DM receiving insulin therapy.
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Affiliation(s)
- Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
- Cardiovascular Research Institute for Intractable Disease, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
| | - Seung‐Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
- Cardiovascular Research Institute for Intractable Disease, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
| | - Ki Dong Yoo
- Cardiovascular Research Institute for Intractable Disease, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
| | - Sang‐Hyun Ihm
- Cardiovascular Research Institute for Intractable Disease, College of MedicineThe Catholic University of KoreaSeoulSouth Korea
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's HospitalThe Catholic University of KoreaSeoulSouth Korea
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Wang H, He S, Wang J, An Y, Wang X, Li G, Gong Q. Hyperinsulinemia and plasma glucose level independently associated with all-cause and cardiovascular mortality in Chinese people without diabetes-A post-hoc analysis of the 30-year follow-up of Da Qing diabetes and IGT study. Diabetes Res Clin Pract 2023; 195:110199. [PMID: 36481224 DOI: 10.1016/j.diabres.2022.110199] [Citation(s) in RCA: 2] [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: 07/07/2022] [Revised: 10/31/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
AIMS We aimed to characterize the effect of insulin resistance and plasma glucose on all-cause and cardiovascular disease (CVD) death. METHODS A total of 462 individuals without diabetes in the original Da Qing Diabetes and IGT Study were enrolled in the present analysis, and further divided into G1 (low insulin low glucose), G2 (high insulin low glucose), G3 (low insulin high glucose) and G4 (high insulin high glucose) groups according to medians of glucose and insulin level at baseline. The all-cause and CVD death were assessed from 1986 to 2016. RESULTS During the 30-year follow-up, compared with G1, G2, G3, and G4 groups were all at increased death risk after adjusting covariates. G2 and G3 were associated with similar risks in both all-cause (G2: HR 1.65, 95%CI 1.02-2.67; G3: HR 1.76, 95%CI 1.11-2.81) and CVD death (G2: HR 2.03, 95%CI 1.01-4.05; G3: HR 1.85, 95%CI 0.93-3.68). The highest risk was observed in G4 (all-cause death: HR 2.32, 95%CI 1.45-3.69; CVD death: HR 2.68, 95%CI 1.35-5.29). CONCLUSIONS In this post-hoc study, participants with either high glucose or high insulin were related to increased risk of mortality, implying that strategies targeting eliminating both hyperglycemia and hyperinsulinemia may favor the long-term outcomes.
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Affiliation(s)
- Haixu Wang
- Center of Endocrinology, National Center of Cardiology &Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siyao He
- Center of Endocrinology, National Center of Cardiology &Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Wang
- Department of Cardiology, Da Qing First Hospital, Da Qing, China
| | - Yali An
- Center of Endocrinology, National Center of Cardiology &Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuan Wang
- Center of Endocrinology, National Center of Cardiology &Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guangwei Li
- Center of Endocrinology, National Center of Cardiology &Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; China-Japan Friendship Hospital, Beijing, China
| | - Qiuhong Gong
- Center of Endocrinology, National Center of Cardiology &Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Yagyu H, Shimano H. Treatment of diabetes mellitus has borne much fruit in the prevention of cardiovascular disease. J Diabetes Investig 2022; 13:1472-1488. [PMID: 35638331 PMCID: PMC9434581 DOI: 10.1111/jdi.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 05/27/2022] [Indexed: 11/28/2022] Open
Abstract
Cardiovascular (CV) disease is the most alarming complication of diabetes mellitus (DM), and a strategy aiming at cardiovascular event prevention in diabetes mellitus has long been debated. Large landmark clinical trials have shown cardiovascular benefits of intensive glycemic control as a ‘legacy effect’ in newly diagnosed type 2 diabetes mellitus. In contrast, we have learned that excessive intervention aimed at strong glycemic control could cause unexpected cardiovascular death in patients who are resistant to treatments against hyperglycemia. It has also been shown that the comprehensive multifactorial intervention for cardiovascular risk factors that was advocated in the current guideline provided substantial cardiovascular event reduction. The impact of classical antidiabetic agents launched before 1990s on cardiovascular events is controversial. Although there are many clinical or observational studies assessing the impact of those agents on cardiovascular events, the conclusions are inconsistent owing to variable patient backgrounds and concomitant antidiabetic agents among the studies. Moreover, most of them were not large‐scale, randomized, cardiovascular outcome trials. In contrast, GLP‐1RA (glucagon‐like peptide‐1 receptor agonist) and SGLT2 (sodium‐glucose cotransporter 2) inhibitors have demonstrated undeniable cardiovascular benefits in large‐scale, randomized, controlled trials. Whereas GLP‐1RAs decrease atherosclerotic disease, especially stroke, SGLT2 inhibitors mainly prevent heart failure. SGLT2 inhibitors are superior to GLP‐1RAs with respect to hard renal outcomes. Therefore, it can be said that drugs such as GLP‐1RAs and SGLT2 inhibitors that prevent cardiovascular events, in addition to their glucose‐lowering effect, are incredible novel tools that we have gained for use in diabetic treatment.
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Affiliation(s)
- Hiroaki Yagyu
- Department of Endocrinology and Metabolism, Tsukuba University Hospital Mito Clinical Education and Training Center, Mito Kyodo General Hospital, Mito, Japan
| | - Hitoshi Shimano
- Department of Endocrinology and Metabolism, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Secnik J, Xu H, Schwertner E, Hammar N, Alvarsson M, Winblad B, Eriksdotter M, Garcia-Ptacek S, Religa D. Glucose-Lowering Medications and Post-Dementia Survival in Patients with Diabetes and Dementia. J Alzheimers Dis 2022; 86:245-257. [PMID: 35034902 PMCID: PMC9028644 DOI: 10.3233/jad-215337] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background: The effectiveness of glucose-lowering drugs (GLDs) is unknown among patients with dementia. Objective: To analyze all-cause mortality among users of six GLDs in dementia and dementia-free subjects, respectively. Methods: This was a longitudinal open-cohort registry-based study using data from the Swedish Dementia Registry, Total Population Register, and four supplemental registers providing data on dementia status, drug usage, confounders, and mortality. The cohort comprised 132,402 subjects with diabetes at baseline, of which 11,401 (8.6%) had dementia and 121,001 (91.4%) were dementia-free. Subsequently, comparable dementia – dementia-free pairs were sampled. Then, as-treated and intention-to-treat exposures to metformin, insulin, sulfonylurea, dipeptidyl-peptidase-4 inhibitors, glucagon-like peptide-1 analogues (GLP-1a), and sodium-glucose cotransporter-2 inhibitors (SGLT-2i) were analyzed in the parallel dementia and dementia-free cohorts. Confounding was addressed using inverse-probability weighting and propensity-score matching, and flexible parametric survival models were used to produce hazard ratios (HR) and 95% confidence intervals (CI) of the association between GLDs and all-cause mortality. Results: In the as-treated models, increased mortality was observed among insulin users with dementia (HR 1.34 [95%CI 1.24–1.45]) as well as in dementia-free subjects (1.54 [1.10–1.55]). Conversely, sulfonylurea was associated with higher mortality only in dementia subjects (1.19 [1.01–1.42]). GLP-1a (0.44 [0.25–0.78]) and SGLT-2i users with dementia (0.43 [0.23–0.80]) experienced lower mortality compared to non-users. Conclusion: Insulin and sulfonylurea carried higher mortality risk among dementia patients, while GLP-1a and SGLT-2i were associated with lower risk. GLD-associated mortality varied between dementia and comparable dementia-free subjects. Further studies are needed to optimize GLD use in dementia patients.
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Affiliation(s)
- Juraj Secnik
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Department of Neurology, Charles University, Second Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| | - Hong Xu
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Emilia Schwertner
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Michael Alvarsson
- Growth and Metabolism, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Winblad
- Division of Neurogeriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Theme Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Maria Eriksdotter
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Theme Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Sara Garcia-Ptacek
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Theme Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Dorota Religa
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Theme Aging, Karolinska University Hospital, Huddinge, Sweden
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Fan R, Xie L, Peng X, Yu B, Zou H, Huang J, Yu X, Wang D, Yang Y. Preadmission Insulin-Treated Type 2 Diabetes Mellitus Patients Had Increased Mortality in Intensive Care Units. Diabetes Metab Syndr Obes 2022; 15:2135-2148. [PMID: 35911502 PMCID: PMC9325876 DOI: 10.2147/dmso.s369152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/09/2022] [Indexed: 11/23/2022] Open
Abstract
AIM To explore the clinical outcomes among preadmission insulin-treated type 2 diabetes mellitus (T2DM) in intensive care units (ICU). PATIENTS AND METHODS In this retrospective observational study, 578 T2DM patients admitted to ICU were recruited from March 2011 to February 2021, which were composed of 528 patients treated with insulin after ICU admission (including 300 preadmission non-insulin-treated and 228 preadmission insulin-treated patients) and 50 patients treated without insulin before and after ICU admission. Clinical outcomes were compared between the groups. Variables of age (± 10 years), gender, blood glucose >10 mmol/l on ICU admission, and original comorbidities were used for matching to get the 1:1 matched cohort. The Kaplan-Meier survival curves were graphed to describe the survival trend and Cox regression analysis was performed to get adjusted hazard ratio (HR). RESULTS Compared with the preadmission non-insulin-treated T2DM patients, preadmission insulin-treated T2DM patients had higher incidence of hypoglycemia [14.5% (33/228) vs 8.7% (26/300); p = 0.036]. In the 1:1 matched cohort, the preadmission insulin-treated T2DM patients had significantly increased mortality rate [30.0% (45/150) vs (16.0% (24/150)); adjusted HR, 1.68 (1.01-2.80)] than preadmission non-insulin-treated T2DM patients. Compared with T2DM patients treated without insulin before and after ICU admission, preadmission insulin-treated T2DM patients had higher mortality and longer length of ICU stay (all p < 0.05). CONCLUSION Preadmission insulin treatment was associated with increased mortality rate and longer length of ICU stay among T2DM patients in ICU. Preadmission insulin-treated T2DM patients might have worse clinical outcomes when they are critically ill.
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Affiliation(s)
- Rongping Fan
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Lei Xie
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Xuemin Peng
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Bo Yu
- Division of Cardiology, Department of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Huajie Zou
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
- Division of Endocrinology, Department of Internal Medicine, The Affiliated Hospital of Qinghai University, Xining, Qinghai, 810001, People’s Republic of China
| | - Jiaojiao Huang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Xuefeng Yu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
| | - Daowen Wang
- Division of Cardiology, Department of Internal Medicine and Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
| | - Yan Yang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, People’s Republic of China
- Correspondence: Yan Yang; Daowen Wang, Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, People’s Republic of China, Tel +86-27-83665513, Fax +86-27-83662883, Email ;
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10
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Jung I, Kwon H, Park SE, Han KD, Park YG, Rhee EJ, Lee WY. The Effects of Glucose Lowering Agents on the Secondary Prevention of Coronary Artery Disease in Patients with Type 2 Diabetes. Endocrinol Metab (Seoul) 2021; 36:977-987. [PMID: 34645126 PMCID: PMC8566121 DOI: 10.3803/enm.2021.1046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with diabetes have a higher risk of requiring repeated percutaneous coronary intervention (PCI) than non-diabetic patients. We aimed to evaluate and compare the effects of anti-diabetic drugs on the secondary prevention of myocardial infarction among type 2 diabetes mellitus patients. METHODS We analyzed the general health check-up dataset and claims data of the Korean National Health Insurance Service of 199,714 participants (age ≥30 years) who underwent PCIs between 2010 and 2013. Those who underwent additional PCI within 1 year of their first PCI (n=3,325) and those who died within 1 year (n=1,312) were excluded. Patients were classified according to their prescription records for glucose-lowering agents. The primary endpoint was the incidence rate of coronary revascularization. RESULTS A total of 35,348 patients were included in the study. Metformin significantly decreased the risk of requiring repeat PCI in all patients (adjusted hazard ratio [aHR], 0.77). In obese patients with body mass index (BMI) ≥25 kg/m2, patients treated with thiazolidinedione (TZD) exhibited a decreased risk of requiring repeat revascularization than those who were not treated with TZD (aHR, 0.77; 95% confidence interval, 0.63 to 0.95). Patients treated with metformin showed a decreased risk of requiring revascularization regardless of their BMI. Insulin, meglitinide, and alpha-glucosidase inhibitor were associated with increased risk of repeated PCI. CONCLUSION The risk of requiring repeat revascularization was lower in diabetic patients treated with metformin and in obese patients treated with TZD. These results suggest that physicians should choose appropriate glucose-lowering agents for the secondary prevention of coronary artery disease.
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Affiliation(s)
- Inha Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Hyemi Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Se Eun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul,
Korea
| | - Yong-Gyu Park
- Department of Biostatistics, Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Eun-Jung Rhee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Won-Young Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
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11
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Xu S, Wang B, Liu W, Wu C, Huang J. The effects of insulin therapy on mortality in diabetic patients undergoing percutaneous coronary intervention. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1294. [PMID: 34532431 PMCID: PMC8422120 DOI: 10.21037/atm-21-1911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/16/2021] [Indexed: 01/19/2023]
Abstract
Background A growing number of studies have reported insulin therapy to be associated with a higher incidence of major adverse cardiac events in diabetic patients with coronary artery disease. However, the relationship between insulin use and the clinical outcomes of patients with diabetes who undergoing percutaneous coronary intervention (PCI) has not been fully clarified. Methods A total of 1,069 consecutive patients with diabetes who underwent PCI were enrolled and divided into 2groups: oral hypoglycemic agents (OHA) group (709 patients) and insulin therapy group (360 patients). The primary and secondary endpoints of this study were all-cause death and cardiac death, respectively. Results At baseline, the maximum creatine kinase-MB (CK-MB), plasma glucose, hemoglobin A1c, high-sensitivity C-reactive protein (CRP), and creatinine levels were higher, while the left ventricular ejection fraction (LVEF) was lower, in the insulin therapy group than in the OHA group. After propensity score matching of baseline characteristics, for patients treated with insulin, the odds ratios of death from any cause in hospital, within 1 year of surgery, and within 2 years of surgery were 12.03 (95% CI: 1.486–97.33, P=0.020), 10.33 (95% CI: 1.21–88.12, P=0.033), and 2.99 (95% CI: 1.22–7.31, P=0.016), respectively, and the odds ratios of cardiac death were 10.33 (95% CI: 1.21-88.12, P=0.033), 6.49 (95% CI: 1.33–31.59, P=0.021), and 5.27 (95% CI: 1.45–19.13, P=0.011), respectively. Generalized estimating equations analysis showed the odds ratios of all-cause death and cardiac death for insulin-treated patients to be 4.77 (95% CI: 1.76–12.95, P=0.002) and 5.38 (95% CI: 1.29–22.96, P=0.023), respectively. Conclusions Compared with OHA, insulin therapy significantly increases the risk of in-hospital all-cause and cardiac death in patients with diabetes undergoing PCI, and the risk remains significantly at least 2 years after surgery.
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Affiliation(s)
- Shaopeng Xu
- Cardiovascular Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Bei Wang
- Cardiovascular Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Wennan Liu
- Cardiovascular Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Chengcheng Wu
- Cardiovascular Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinyong Huang
- Cardiovascular Department, Tianjin Medical University General Hospital, Tianjin, China
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12
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Jeon JY, Ha KH, Kim DJ. Cardiovascular Safety of Sodium Glucose Cotransporter 2 Inhibitors as Add-on to Metformin Monotherapy in Patients with Type 2 Diabetes Mellitus. Diabetes Metab J 2021; 45:505-514. [PMID: 33120439 PMCID: PMC8369208 DOI: 10.4093/dmj.2020.0057] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Using real-world data, cardiovascular safety was investigated in metformin users newly starting sodium glucose cotransporter 2 (SGLT2) inhibitors compared with other glucose-lowering drugs in Korea. METHODS This was a retrospective observational study using the National Health Insurance Service claims database in Korea. The study period was from September 2014 to December 2016. The study included subjects who were newly prescribed SGLT2 inhibitors or other glucose-lowering drugs while on metformin monotherapy; cohort 1 was composed of new users of SGLT2 inhibitors versus dipeptidyl peptidase-4 (DPP-4) inhibitors and cohort 2 included new users of SGLT2 inhibitors versus sulfonylureas. To balance the patient characteristics, propensity score matching was performed at a 1:1 ratio. Cardiovascular outcomes included hospitalization for heart failure (HHF), all-cause mortality, HHF plus all-cause mortality, myocardial infarction (MI), stroke, and modified major adverse cardiovascular events (MACEs). RESULTS After propensity score matching, each cohort group was well balanced at baseline (21,688 pairs in cohort 1 and 20,120 pairs in cohort 2). As the second-line treatment, use of SGLT2 inhibitors was associated with a lower risk of HHF and HHF plus all-cause mortality compared with DPP-4 inhibitors. In addition, use of SGLT2 inhibitors versus sulfonylurea as add-on therapy to metformin was associated with decreased risks of HHF, all-cause mortality, HHF plus all-cause mortality, MI, stroke, and modified MACEs. CONCLUSION SGLT2 inhibitors can be a good second-line drug to reduce the incidence of cardiovascular diseases compared with DPP-4 inhibitors or sulfonylureas in people with type 2 diabetes mellitus.
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Affiliation(s)
- Ja Young Jeon
- Department of Endocrinology and Metabolism, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Kyoung Hwa Ha
- Department of Endocrinology and Metabolism, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Dae Jung Kim
- Department of Endocrinology and Metabolism, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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13
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Schwartz GG, Nicholls SJ, Toth PP, Sweeney M, Halliday C, Johansson JO, Wong NCW, Kulikowski E, Kalantar-Zadeh K, Ginsberg HN, Ray KK. Relation of insulin treatment for type 2 diabetes to the risk of major adverse cardiovascular events after acute coronary syndrome: an analysis of the BETonMACE randomized clinical trial. Cardiovasc Diabetol 2021; 20:125. [PMID: 34158057 PMCID: PMC8218391 DOI: 10.1186/s12933-021-01311-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
Background In stable patients with type 2 diabetes (T2D), insulin treatment is associated with elevated risk for major adverse cardiovascular events (MACE). Patients with acute coronary syndrome (ACS) and T2D are at particularly high risk for recurrent MACE despite evidence-based therapies. It is uncertain to what extent this risk is further magnified in patients with recent ACS who are treated with insulin. We examined the relationship of insulin use to risk of MACE and modification of that risk by apabetalone, a bromodomain and extra-terminal (BET) protein inhibitor. Methods The analysis utilized data from the BETonMACE phase 3 trial that compared apabetalone to placebo in patients with T2D, low HDL cholesterol, andACS. The primary MACE outcome (cardiovascular death, myocardial infarction, or stroke) was examined according to insulin treatment and assigned study treatment. Multivariable Cox regression was used to determine whether insulin use was independently associated with the risk of MACE. Results Among 2418 patients followed for median 26.5 months, 829 (34.2%) were treated with insulin. Despite high utilization of evidence-based treatments including coronary revascularization, intensive statin treatment, and dual antiplatelet therapy, the 3-year incidence of MACE in the placebo group was elevated among insulin-treated patients (20.4%) compared to those not-treated with insulin (12.8%, P = 0.0001). Insulin treatment remained strongly associated with the risk of MACE (HR 2.10, 95% CI 1.42–3.10, P = 0.0002) after adjustment for demographic, clinical, and treatment variables. Apabetalone had a consistent, favorable effect on MACE in insulin-treated and not insulin-treated patients. Conclusion Insulin-treated patients with T2D, low HDL cholesterol, and ACS are at high risk for recurrent MACE despite the use of evidence-based, contemporary therapies. A strong association of insulin treatment with risk of MACE persists after adjustment for other characteristics associated with MACE. There is unmet need for additional treatments to mitigate this risk. Trial registration ClinicalTrials.gov NCT02586155, registered October 26, 2015
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Affiliation(s)
- Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, 1700 N. Wheeling St. (Cardiology 111B), Aurora, CO, 80045, USA.
| | | | - Peter P Toth
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,CGH Medical Center Sterling, Sterling, IL, USA
| | | | | | | | | | | | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA
| | - Henry N Ginsberg
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, Imperial College, London, UK
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14
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Is insulin the preferred treatment in persons with type 2 diabetes and liver cirrhosis? BMC Gastroenterol 2021; 21:263. [PMID: 34118892 PMCID: PMC8199810 DOI: 10.1186/s12876-021-01773-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/22/2021] [Indexed: 12/30/2022] Open
Abstract
Background Insulin is highly recommended for diabetes management in persons with liver cirrhosis. However, few studies have evaluated its long-term effects in these persons. We conducted this study to compare the risks of mortality, liver-related complications, and cardiovascular events in persons with type 2 diabetes mellitus (T2DM) and compensated liver cirrhosis. Methods From January 1, 2000, to December 31, 2012, we selected 2047 insulin users and 4094 propensity score-matched nonusers from Taiwan’s National Health Insurance Research Database. Cox proportional hazard models were used to assess the risks of outcomes. Results The mean follow-up time was 5.84 years. The death rate during the follow-up period was 5.28 and 4.07 per 100 person-years for insulin users and nonusers, respectively. In insulin users, the hazard ratios and 95% confidence intervals (CIs) of all-cause mortality, hepatocellular carcinoma, decompensated cirrhosis, hepatic failure, major cardiovascular events, and hypoglycemia were 1.31 (1.18–1.45), 1.18 (1.05–1.34), 1.53 (1.35–1.72), 1.26 (1.42–1.86), 1.41 (1.23–1.62), and 3.33 (2.45–4.53), respectively. Conclusions This retrospective cohort study indicated that among persons with T2DM and compensated liver cirrhosis, insulin users were associated with higher risks of death, liver-related complications, cardiovascular events, and hypoglycemia compared with insulin nonusers.
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15
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Hosio M, Urpilainen E, Hautakoski A, Marttila M, Arffman M, Sund R, Ahtikoski A, Puistola U, Läärä E, Karihtala P, Jukkola A. Association of antidiabetic medication and statins with survival from ductal and lobular breast carcinoma in women with type 2 diabetes. Sci Rep 2021; 11:10445. [PMID: 34001921 PMCID: PMC8129135 DOI: 10.1038/s41598-021-88488-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
We investigated the survival of female patients with pre-existing type 2 diabetes (T2D) diagnosed with invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) of breast, in relation to the use of metformin, other antidiabetic medication (ADM) and statins. The study cohort consisted of 3,165 women (2,604 with IDC and 561 with ILC). The cumulative mortality from breast cancer (BC) and from other causes was calculated using the Aalen-Johansen estimator. The cause-specific mortality rates were analysed by Cox models, and adjusted hazard ratios (HRs) were estimated for the use of different medications. No evidence of an association of metformin use with BC mortality was observed in either IDC (HR 0.92, 95% confidence interval [CI] 0.64–1.31) or ILC (HR 0.68, 95% CI 0.32–1.46) patients, when compared to other oral ADMs. The mortality from other causes was found to be lower amongst the IDC patients using metformin (HR 0.64, 95% CI 0.45–0.89), but amongst ILC patients the evidence was inconclusive (HR 1.22, 95% CI 0.64–2.32). Statin use was consistently associated with reduced mortality from BC in IDC patients (HR 0.77, 95% CI 0.62–0.96) and ILC patients (HR 0.59, 95% CI 0.37–0.96), and also mortality from other causes in IDC patients (HR 0.81, 95% CI 0.67–0.96) and in ILC patients (HR 0.66, 95% CI 0.43–1.01). We found no sufficient evidence for the possible effects of metformin and statins on the prognosis of BC being different in the two histological subtypes.
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Affiliation(s)
- Mayu Hosio
- Department of Oncology and Radiotherapy, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PO Box 22, 90029, Oulu, Finland.
| | - Elina Urpilainen
- Department of Obstetrics and Gynaecology, PEDEGO Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PO Box 23, 90029, Oulu, Finland
| | - Ari Hautakoski
- Research Unit of Mathematical Sciences, University of Oulu, PO Box 3000, 90014, Oulu, Finland
| | - Mikko Marttila
- Orion Corporation, Orionintie 1, PO Box 65, 02101, Espoo, Finland
| | - Martti Arffman
- Service System Research Unit, Finnish Institute for Health and Welfare, PO Box 30, 00271, Helsinki, Finland
| | - Reijo Sund
- Institute of Clinical Medicine, University of Eastern Finland, PO Box 1627, 70211, Kuopio, Finland
| | - Anne Ahtikoski
- Cancer and Translational Medicine Research Unit, Department of Pathology, Oulu University Hospital and University of Oulu, PO Box 50, 90029, Oulu, Finland
| | - Ulla Puistola
- Department of Obstetrics and Gynaecology, PEDEGO Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PO Box 23, 90029, Oulu, Finland
| | - Esa Läärä
- Research Unit of Mathematical Sciences, University of Oulu, PO Box 3000, 90014, Oulu, Finland
| | - Peeter Karihtala
- Department of Oncology and Radiotherapy, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, PO Box 22, 90029, Oulu, Finland.,Department of Oncology, Helsinki University Comprehensive Cancer Center, P.O.Box 180, 00029, Helsinki, Finland.,University of Helsinki, Helsinki, Finland
| | - Arja Jukkola
- Department of Oncology and Radiotherapy, Cancer Center Tampere, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Box 2000, 33521, Tampere, Finland
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Yen FS, Hsu CC, Su YC, Wei JCC, Hwu CM. Impacts of early insulin treatment vs glimepiride in diabetic patients with background metformin therapy: A nationwide retrospective cohort study. Medicine (Baltimore) 2021; 100:e25085. [PMID: 33655987 PMCID: PMC7939219 DOI: 10.1097/md.0000000000025085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Type 2 diabetes mellitus (T2DM) is a progressive disease. After metformin failure, the addition of insulin or sulfonylureas might increase the risk of hypoglycemia and cardiovascular (CV) morbidity. Here, the risk of all-cause mortality was compared between early insulin treatment and glimepiride use in T2DM patients with background metformin therapy.We conducted a 9-year retrospective cohort study from the population-based National Health Insurance Research Database in Taiwan. A total of 2054 patients with T2DM under insulin or glimepiride treatment were enrolled during 2004 to 2012. Overall event rates of all-cause mortality were compared between 1027 insulin users and 1027 matched glimepiride users.After the propensity score matching, the mortality rates were 72.5 and 4.42 per 1000 person-years for insulin users and glimepiride users. The adjusted hazard ratio of mortality was 14.47 (95% CI: 8.64-24.24; P value <.001) as insulin compared with glimepiride users. The insulin users had significantly higher risk of CV death (adjusted hazard ratio 7.95, 95% CI 1.65-38.3, P = .01) and noncardiovascular death (adjusted hazard ratio 14.9, 95% CI 8.4-26.3, P < .001).The nationwide study demonstrated that metformin plus insulin therapy was associated with higher risk of all-cause mortality.
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Affiliation(s)
- Fu-Shun Yen
- Dr. Yen's Clinic, No. 15, Shanying Road, Gueishan District, Taoyuan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan
- Department of Health Services Administration, China Medical University, Taichung
- Department of Family Medicine, Min-Sheng General Hospital, Taoyuan
| | - Yuan-Chih Su
- Management Office for Health Data, China Medical University Hospital
- College of Medicine, China Medical University, Taichung
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University
- Department of Medicine, Chung Shan Medical University Hospital
- Graduate Institute of Integrated Medicine, China Medical University, Taichung
| | - Chii-Min Hwu
- Department of Medicine, National Yang-Ming University School of Medicine
- Section of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Yen FS, Wei JCC, Lin MC, Hsu CC, Hwu CM. Long-term outcomes of adding alpha-glucosidase inhibitors in insulin-treated patients with type 2 diabetes. BMC Endocr Disord 2021; 21:25. [PMID: 33602190 PMCID: PMC7890630 DOI: 10.1186/s12902-021-00690-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/08/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND In insulin-treated patients with type 2 diabetes mellitus (T2DM), glycemic control is usually suboptimal. METHODS This study compared the risks of mortality and cardiovascular events in insulin-treated patients adding or not adding alpha-glucosidase inhibitors (AGIs). RESULTS This cohort study included data from the Taiwan National Health Insurance Research Database. In total, 17,417 patients newly diagnosed as having T2DM and undergoing insulin therapy during 2000-2012 were enrolled. Overall incidence rates of all-cause mortality, hospitalized coronary artery disease (CAD), stroke, and heart failure were compared between 4165 AGI users and 4165 matched nonusers. The incidence rates of all-cause mortality were 17.10 and 19.61 per 1000 person-years in AGI nonusers and users, respectively. Compared with nonusers, AGI users had a higher mortality risk [adjusted hazard ratio (aHR) = 1.21, 95% confidence interval (CI) = 1.05-1.40; p = 0.01]. Regarding AGI use, aHRs (95% CI) for cardiovascular death, non-cardiovascular death, hospitalized CAD, stroke, and heart failure were 1.20 (0.83-1.74), 1.27 (1.07-1.50), 1.12 (0.95-1.31), 0.98 (0.85-1.14), and 1.03 (0.87-1.22) respectively. CONCLUSION AGI use was associated with higher risks of all-cause mortality and non-cardiovascular death in insulin-treated patients with T2DM. Therefore, adding AGIs in insulin-treated patients may not be appropriate.
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Affiliation(s)
- Fu-Shun Yen
- Dr. Yen's Clinic, No. 15, Shanying Road, Gueishan District, Taoyuan, 33354, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Rd., South District, Taichung City, 40201, Taiwan
- Department of Medicine, Chung Shan Medical University Hospital, No. 110, Sec. 1, Jianguo N. Rd., South District, Taichung City, 40201, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, No.91, Hsueh-Shih Road, Taichung, 40402, Taiwan
| | - Mei-Chen Lin
- Management Office for Health Data, China Medical University Hospital, 3F., No.373-2, Jianxing Road, Taichung, 40459, Taiwan
- College of Medicine, China Medical University, No. 110, Sec. 1, Jianguo N. Rd., South District, Taichung City, 40201, Taiwan
| | - Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, No.35, Keyan Rd., Zhunan Township, Miaoli, 35053, Taiwan.
- Department of Health Services Administration, China Medical University, No.91, Hsueh-Shih Road, Taichung, 40402, Taiwan.
- Department of Family Medicine, Min-Sheng General Hospital, 168 ChingKuo Road, Taoyuan, 33044, Taiwan.
| | - Chii-Min Hwu
- Faculty of Medicine, National Yang-Ming University School of Medicine, No. 201, Sec. 2 Shi-Pai Rd., Chung-Cheng Build. 11F Room 522, Taipei, 112, Taiwan.
- Section of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2 Shi-Pai Rd., Chung-Cheng Build. 11F Room 522, Taipei, 112, Taiwan.
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18
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Ke JF, Wang JW, Zhang ZH, Chen MY, Lu JX, Li LX. Insulin Therapy Is Associated With an Increased Risk of Carotid Plaque in Type 2 Diabetes: A Real-World Study. Front Cardiovasc Med 2021; 8:599545. [PMID: 33598483 PMCID: PMC7882504 DOI: 10.3389/fcvm.2021.599545] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/07/2021] [Indexed: 01/29/2023] Open
Abstract
Background: Controversies concerning the association between insulin therapy and atherosclerotic lesions in type 2 diabetes mellitus (T2DM) remain to exist. The purpose of this study was to investigate whether insulin therapy in T2DM patients is linked with the increased risk of carotid atherosclerosis in real-world settings. Methods: We retrospectively enrolled 2,356 hospitalized patients with T2DM, including 1,716 subjects receiving insulin therapy and 640 subjects without receiving insulin therapy. Carotid atherosclerotic lesions including carotid intima-media thickness (CIMT), carotid plaque and carotid stenosis were assessed by Doppler ultrasonography and were compared between T2DM patients treated with and without insulin. Results: After adjusting for age and duration of diabetes, there was a significant increase in the prevalence of carotid plaque in both men (52.0 vs. 41.7%, p = 0.007) and women (49.6 vs. 39.7%, p = 0.003) receiving insulin therapy than in those without receiving insulin therapy. After further controlling for other confounding factors, compared with the patients without receiving insulin therapy, the risk of carotid plaque was still significantly increased not only in women treated with insulin (OR: 1.810; 95% CI: 1.155-2.837, p = 0.010), but also in men treated with insulin (OR: 1.867; 95% CI: 1.307-2.666; p = 0.001). Additionally, HOMA2-B% was higher in both women and men without receiving insulin therapy compared with those receiving insulin therapy (p < 0.001 in both men and women), but HOMA-IR was significantly higher in patients treated with insulin than in those without receiving insulin therapy (p < 0.001 in both men and women). Conclusions: Insulin therapy is associated with markedly increased risk of carotid atherosclerotic lesions in type 2 diabetes, which partly attribute to the more serious insulin resistance in T2DM patients receiving insulin therapy.
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Affiliation(s)
- Jiang-Feng Ke
- Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Diseases, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jun-Wei Wang
- Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Diseases, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zhi-Hui Zhang
- Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Diseases, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ming-Yun Chen
- Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Diseases, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jun-Xi Lu
- Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Diseases, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lian-Xi Li
- Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Diseases, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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19
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Abstract
Diabetes mellitus (DM) has already affected one in every eleven person in the global population, and the dis-ease prevalence continues to increase because of the obesity pandemic. Even with the availability of a multitude of antidi-abetic medications for optimal glycaemic control, cardiovascular morbidity and mortality were not largely altered until re-cently when newer antidiabetic drugs such as glucagon-like peptide-1 receptor analogues (GLP-1RAs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors were introduced. Cardiovascular safety of antidiabetic drugs has also been a hot topic for global scientific debate after the US Food and Drug Administration (FDA) enforced restrictions on Rosiglita-zone in 2010 with the suspicion of increased mortality and myocardial events (with subsequent uplift of the ban on the drug in 2013 following the emergence of additional evidence on safety). After this debate, all antidiabetic should go through rigorous safety checks with cardiovascular outcome trials (CVOTs). Recent CVOTs with GLP-1RAs and SGLT2 inhibitors have revealed markedly positive outcomes that have changed the landscape of diabetes management across the world. Thus, the therapeutic algorithm for optimal management of DM should consider not only the glycaemic control ef-ficacy of the individual antidiabetic agent but also the cardiovascular safety and modifications in other anticipated long-term DM complication profiles. Therefore, it is imperative to critically appraise the efficacy and cardiovascular safety of all antidiabetic drugs to improve the scientific practice of our diabetes care globally. This issue, "Efficacy and cardiovas-cular safety of antidiabetic medications," provides readers the back-up of up to date evidence.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology & Metabolism, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, United Kingdom
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20
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Sohrabi C, Saberwal B, Lim WY, Tousoulis D, Ahsan S, Papageorgiou N. Heart Failure in Diabetes Mellitus: An Updated Review. Curr Pharm Des 2020; 26:5933-5952. [PMID: 33213313 DOI: 10.2174/1381612826666201118091659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus (DM) and heart failure (HF) are comorbid conditions associated with significant morbidity and mortality worldwide. Despite the availability of novel and effective therapeutic options and intensive glycaemic control strategies, mortality and hospitalisation rates continue to remain high and the incidence of HF persists. In this review, we described the impact of currently available glucose-lowering therapies in DM with a focus on HF clinical outcomes. Non-conventional modes of management and alternative pathophysiological mechanisms with the potential for therapeutic targeting are also discussed.
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Affiliation(s)
- Catrin Sohrabi
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Bunny Saberwal
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Wei-Yao Lim
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Dimitris Tousoulis
- First Cardiology Department, Hippokration Hospital, Athens University Medical School, Athens, Greece
| | - Syed Ahsan
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London, United Kingdom
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21
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Bondy SC, Wu M, Prasad KN. Alternatives to Insulin for the Regulation of Blood Sugar Levels in Type 2 Diabetes. Int J Mol Sci 2020; 21:E8302. [PMID: 33167495 PMCID: PMC7663956 DOI: 10.3390/ijms21218302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 12/29/2022] Open
Abstract
This short overview focuses on the causation and treatment of type 2 diabetes (T2D). Emphasis is given to the historical basis of understanding this disease and the background leading to emergence of the central role of insulin. The strengths of insulin administration in the treatment of diabetes are profound, but these need to be balanced against several serious shortcomings of its extended use. Some alternative approaches to T2D management are considered. Insulin is no longer considered as the first choice for type 2 diabetes, and an expanding range of new therapeutic possibilities is emerging. While these may lack the potency of insulin, at a minimum, they allow a major reduction in the intensity of insulin use. In view of the rising worldwide incidence of this disease, it is imperative to develop safe and inexpensive means of limiting its potential for impairment of normal functioning.
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Affiliation(s)
- Stephen C. Bondy
- Center for Occupational and Environmental Health, Department of Medicine, University of California, Irvine, CA 92697, USA
| | - Meixia Wu
- Evergreen World Healthcare Center, Garden Grove, CA 92844, USA;
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22
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Abstract
BACKGROUND Insulin shares a limited physiological concentration range with other endocrine hormones. Not only too low, but also too high systemic insulin levels are detrimental for body functions. MAIN BODY The physiological function and clinical relevance of insulin are usually seen in association with its role in maintaining glucose homeostasis. However, insulin is an anabolic hormone which stimulates a large number of cellular responses. Not only too low, but also excess insulin concentrations are detrimental to the physiological balance. Although the glucoregulatory activity of insulin is mitigated during hyperinsulinemia by dampening the efficiency of insulin signaling ("insulin resistance"), this is not the case for most other hormonal actions of insulin, including the promotion of protein synthesis, de novo lipogenesis, and cell proliferation; the inhibition of lipolysis, of autophagy-dependent cellular turnover, and of nuclear factor E2-related factor-2 (Nrf2)-dependent antioxidative; and other defense mechanisms. Hence, there is no general insulin resistance but selective impairment of insulin signaling which causes less glucose uptake from the blood and reduced activation of endothelial NO synthase (eNOS). Because of the largely unrestricted insulin signaling, hyperinsulinemia increases the risk of obesity, type 2 diabetes, and cardiovascular disease and decreases health span and life expectancy. In epidemiological studies, high-dose insulin therapy is associated with an increased risk of cardiovascular disease. Randomized controlled trials of insulin treatment did not observe any effect on disease risk, but these trials only studied low insulin doses up to 40 IU/day. Proof for a causal link between elevated insulin levels and cardiovascular disease risk comes from Mendelian randomization studies comparing individuals with genetically controlled low or high insulin production. CONCLUSIONS The detrimental actions of prolonged high insulin concentrations, seen also in cell culture, argue in favor of a lifestyle that limits circadian insulin levels. The health risks associated with hyperinsulinemia may have implications for treatment regimens used in type 2 diabetes.
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Rigato M, Avogaro A, Vigili de Kreutzenberg S, Fadini GP. Effects of Basal Insulin on Lipid Profile Compared to Other Classes of Antihyperglycemic Agents in Type 2 Diabetic Patients. J Clin Endocrinol Metab 2020; 105:5818381. [PMID: 32271381 DOI: 10.1210/clinem/dgaa178] [Citation(s) in RCA: 3] [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: 01/27/2020] [Accepted: 04/08/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The lipid profile represents a driver of cardiovascular risk in type 2 diabetes. The effect of chronic insulin therapy on cholesterol levels is unclear. We aim to evaluate the effect of basal insulin on lipid profile compared to other classes of antihyperglycemic agents in type 2 diabetic patients. DESIGN We performed a meta-analysis of randomized controlled trials reporting changes of lipid parameters in type 2 diabetic patients randomly assigned to basal insulin or other classes of anti-hyperglycemic agents. RESULTS The levels of total (TC) and low-density lipoprotein cholesterol (LDL-C) appeared to be significantly reduced by therapies with glucagon-like peptide-1 receptor agonists (GLP-1RA) in comparison to basal insulin (mean difference [MD] -3.80; 95% CI [-6.30 to -1.30] mg/dL, P < .001 and -4.17; 95% CI [-6.04 to -2.30] mg/dL, P < .0001), whereas no difference was detected between basal insulin and dipeptidyl peptidase-4 inhibitors (DPP4-I) or standard therapy (sulfonylurea ± metformin). Thiazolidinediones (TZD) produced a significant improvement in high-density lipoprotein cholesterol (HDL-C) (MD 3.55; 95% CI: 0.55 to 6.56 mg/dL, P = .02) but were associated with an increase in TC and LDL-C (MD 16.20; 95% CI: 9.09 to 23.31 mg/dL, P < .001 and 5.19: 95% CI: -3.00 to 13.39 mg/dL, P = .21). Basal insulin was superior to standard therapy in triglyceride reduction (MD 3.8; 95% CI: 0.99 to 6.63 mg/dL, P = .008). CONCLUSIONS GLP-1RA were superior to basal insulin in the control of TC and LDL-C. Basal insulin effectively reduced serum triglycerides. TZD led to improvement in HDL-C. DPP4-I and standard therapy did not have any significant effect on lipid levels.
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Affiliation(s)
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
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24
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Zhang J, Xian TZ, Wu MX, Li C, Pan Q, Guo LX. Comparison of the effects of twice-daily exenatide and insulin on carotid intima-media thickness in type 2 diabetes mellitus patients: a 52-week randomized, open-label, controlled trial. Cardiovasc Diabetol 2020; 19:48. [PMID: 32334592 PMCID: PMC7183674 DOI: 10.1186/s12933-020-01014-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 03/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Exenatide, a glucagon like peptide 1 analog, has been suggested to reduce the cardiovascular disease risk factors, such as body weight, blood pressure and subclinical atherosclerosis in patients with type 2 diabetes mellitus (T2DM). This was the first randomized, open-label, controlled trial to compare the effects of exenatide versus insulin on subclinical atherosclerosis, as assessed by carotid-intima media thickness (CIMT), in patients with T2DM. Methods A total of 66 patients with T2DM admitted from March 10, 2015 to June 20, 2017 in the Department of Endocrinology, Beijing Hospital were randomized to receive twice-daily exenatide or aspartate 70/30 insulin for 52 weeks. The primary endpoint was change from baseline in CIMT, and secondary endpoints included changes at week 52 from baseline in body weight, glycemic markers, lipid metabolism markers, blood pressure, C-reactive protein, fibrinogen, 8-hydroxydeoxyguanosine, irisin, and brain natriuretic peptide. Results Exenatide more significantly reduced the CIMT from baseline compared with insulin after 52 weeks, with a mean difference of − 0.14 mm (95% interval confidence: − 0.25, − 0.02; P = 0.016). Weight and body mass index were both significantly reduced in the exenatide group over 52 weeks. Exenatide reduced total lipoprotein and low-density lipoprotein cholesterol levels more significantly than insulin at weeks 16 and 40. Correlation analyses showed that CIMT was positively correlated with low-density lipoprotein cholesterol. Conclusions Twice-daily exenatide could prevent atherosclerosis progression in patients with T2DM over a 52-week treatment period compared with insulin therapy. Trial registration Chinese Clinical Trial Registry ChiCTR-1800015658
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Affiliation(s)
- Jie Zhang
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, No. 1 Dahua Road, Dong Dan, Beijing, 100730, P. R. China
| | - Tong-Zhang Xian
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, Dong Dan, Beijing, 100730, P. R. China
| | - Ming-Xiao Wu
- Department of Ultrasound, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, Dong Dan, Beijing, 100730, P. R. China
| | - Chen Li
- Department of Ultrasound, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, Dong Dan, Beijing, 100730, P. R. China
| | - Qi Pan
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No. 1 Dahua Road, Dong Dan, Beijing, 100730, P. R. China.
| | - Li-Xin Guo
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, No. 1 Dahua Road, Dong Dan, Beijing, 100730, P. R. China.
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25
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Baik SH, McDonald CJ. Independent effects of 15 commonly prescribed drugs on all-cause mortality among US elderly patients with type 2 diabetes mellitus. BMJ Open Diabetes Res Care 2020; 8:8/1/e000940. [PMID: 32341050 PMCID: PMC7202731 DOI: 10.1136/bmjdrc-2019-000940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/28/2020] [Accepted: 03/21/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Most patients with type 2 diabetes mellitus (T2DM) also have hypertension and hyperlipidemia. Consequently, they are taking medications for all three conditions concurrently and the effect of one drug could be confounded with that of another. This study aimed to determine the independent effects of 15 commonly prescribed medications for three conditions on the risk of all-cause mortality among elderly patients with T2DM. RESEARCH DESIGN AND METHODS A cohort of 360 437 elderly patients with T2DM from 2007 to 2016 US Medicare data was traced along with cumulative uses of 8 diabetes, 6 hypertension and 1 hyperlipidemia drugs. The relative risk of all-cause mortality for each study drug was estimated using an extended Cox regression analysis adjusting for the concurrent use of other study drugs. RESULTS Compared with the no use of each study medication, mortality risk declined with use of 3 diabetes drugs, sodium-glucose cotransporter-2 inhibitors (HR=0.73; 95% CI 0.64 to 0.84), glucagon-like peptide-1 receptor agonists (HR=0.75; 95% CI 0.70 to 0.80) and dipeptidyl peptidase-4 inhibitors (HR=0.94; 95% CI 0.91 to 0.98), the use of 3 blood pressure medications, diuretics (HR=0.89; 95% CI 0.87 to 0.92), angiotensin receptor blockers (HR=0.86; 95% CI 0.84 to 0.89), ACE inhibitors (HR=0.98; 95% CI 0.95 to 1.01) as well as statins (HR=0.83; 95% CI 0.80 to 0.85). It increased moderately with insulin (HR=1.55; 95% CI 1.51 to 1.59), sulfonylureas (HR=1.16; 95% CI 1.13 to 1.20), a small inconsistent amount with metformin (HR=1.05), beta-blockers (HR=1.07), dihydropyridine calcium-channel blockers (HR=0.99) and non-dihydropyridine calcium-channel blockers (HR=1.05). The use of thiazolidinedione had no effect. CONCLUSION Among older patients with diabetes, mortality risk decreased importantly with three new diabetes drugs, 3 blood pressure drugs and statins. It increased moderately with sulfonylurea and insulin. Studies of aggressive use of new T2DM drugs instead of sulfonylureas and insulin are needed. Our statin results empirically validate two national guidelines for using statins in older patients with diabetes. However, 23% of study patients never took a statin, suggesting missed opportunities for prevention.
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Affiliation(s)
- Seo H Baik
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, Bethesda, Maryland, USA
| | - Clement J McDonald
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, Bethesda, Maryland, USA
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Ahmed SR, Bellamkonda S, Zilbermint M, Wang J, Kalyani RR. Effects of the low carbohydrate, high fat diet on glycemic control and body weight in patients with type 2 diabetes: experience from a community-based cohort. BMJ Open Diabetes Res Care 2020; 8:8/1/e000980. [PMID: 32193200 PMCID: PMC7103851 DOI: 10.1136/bmjdrc-2019-000980] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/11/2019] [Accepted: 01/28/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The optimal diet to improve glycemia in patients with type 2 diabetes remains unclear. Low carbohydrate, high fat (LCHF) diets can improve glycemic control, but have not been investigated in real-world settings. RESEARCH DESIGN AND METHODS We investigated effects of the LCHF diet compared with usual care in a community-based cohort of patients with type 2 diabetes by performing a retrospective study of 49 patients who followed the LCHF diet for ≥3 months, and compared glycemic outcomes with age-matched and body mass index (BMI)-matched controls who received usual care (n=75). The primary outcome was change in A1C from baseline to the end of follow-up. RESULTS Compared with the usual care group, the LCHF group showed a significantly greater reduction in A1C (-1.29% (95% CI -1.75 to -0.82; p<0.001)) and body weight (-12.8 kg (95% CI -14.7 to -10.8; p<0.001) at the end of follow-up after adjusting for age, sex, baseline A1C, BMI, baseline insulin dose. Of the patients initially taking insulin therapy in the LCHF group, 100% discontinued it or had a reduction in dose, compared with 23.1% in the usual care group (p<0.001). The LCHF group also had significantly greater reduction in fasting plasma glucose (-43.5 vs -8.5 mg/mL; p=0.03) compared with usual care. CONCLUSIONS In a community-based cohort of type 2 diabetes, the LCHF diet was associated with superior A1C reduction, greater weight loss and significantly more patients discontinuing or reducing antihyperglycemic therapies suggesting that the LCHF diet may be a metabolically favorable option in the dietary management of type 2 diabetes.
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Affiliation(s)
- Shabina Roohi Ahmed
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Endocrinology, Johns Hopkins Community Physicians, Bethesda, Maryland, USA
| | - Sridevi Bellamkonda
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Internal Medicine, Johns Hopkins Community Physicians, Germantown, Maryland, USA
| | - Mihail Zilbermint
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians Suburban Hospital, Suburban Hospital, Bethesda, Maryland, USA
| | - Jiangxia Wang
- Biostatistics Consulting Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rita Rastogi Kalyani
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Kung FP, Tsai CF, Lu CL, Huang LC, Lu CH. Diabetes pay-for-performance program can reduce all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus. Medicine (Baltimore) 2020; 99:e19139. [PMID: 32049836 PMCID: PMC7035087 DOI: 10.1097/md.0000000000019139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
This study aimed to examine the effect of a diabetes pay-for-performance (P4P) program on all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus. Using a Taiwanese representative nationwide cohort, we recruited 5478 patients with newly diagnosed type 2 diabetes enrolled in the P4P program within 5 years after a diagnosis of diabetes between January 1, 2002 and December 31, 2010 and individuals not enrolled in the P4P program were recruited as the control group matched 1:1 with the study group. We used multivariate Cox proportional hazard models analysis to investigate the effect of the P4P program and adherence on all-cause mortality. A total of 250 patients died in the P4P group compared to 395 in the control group (mortality rate 104 vs 169 per 10,000 person-years, respectively, P < .0001). The control group also had more comorbidities. Patients enrolled in the P4P program demonstrated significant long-term survival benefits, of which the adjusted hazard ratio (aHR) for all-cause mortality was 0.58 [95% CI (0.48-0.69)]. In the study group, better adherence to the P4P program resulted in a greater reduction in mortality, with aHRs [95% CI] of 0.48 [0.38-0.62] and 0.36 [0.26-0.49] in subjects with a minimum 1-year and 2-year good P4P adherence, respectively. Participating in the P4P program within 5 years after the diagnosis of diabetes resulted in a significant reduction in all-cause mortality, and this effect was particularly pronounced in the patients with better adherence to the P4P program.
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Affiliation(s)
- Fang-Ping Kung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
| | - Ching-Fang Tsai
- Department of Medical Research, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
| | - Chin-Li Lu
- Department of Medical Research, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung-Hsing University, Taichung
| | - Li-Chung Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
- Division of Psychiatry, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
| | - Chieh-Hsiang Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
- Kaohsiung Christian Hospital, Kaohsiung City, Taiwan
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Forbes A. Reducing the Burden of Mortality in Older People With Diabetes: A Review of Current Research. Front Endocrinol (Lausanne) 2020; 11:133. [PMID: 32256448 PMCID: PMC7089919 DOI: 10.3389/fendo.2020.00133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 02/27/2020] [Indexed: 01/09/2023] Open
Abstract
This review considers the burden of mortality observed in the older population of people with diabetes and identifies the risk factors associated with mortality hazard in this population. The mortality gap between older people with and without diabetes is enduring, with excess mortality being 10% greater than in the general population. While early mortality in men with diabetes is significantly greater than females with diabetes, the relative mortality risk in females is much higher compared to women without diabetes. Older people who have developed diabetes in middle age have significantly higher mortality hazard compared to those who develop it in old age, emphasizing the continued importance of optimizing diabetes care in all ages. To minimize mortality hazard in older age it is important to address some of the factors that convey risk, these include: comorbidity; polypharmacy; physical and mental frailty; safe glycemic targets for older people; hypoglycemia; glycemic targets; and the hypoglycemic agents. While the data to determine optimal management approaches are limited, the overall need is for a more diligent approach in assessing the needs of older people with diabetes to inform individualized care strategies and therapy goals that minimize potential hazards.
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Min JY, Hackstadt AJ, Griffin MR, Greevy RA, Chipman J, Grijalva CG, Hung AM, Roumie CL. Evaluation of weight change and hypoglycaemia as mediators in the association between insulin use and death. Diabetes Obes Metab 2019; 21:2626-2634. [PMID: 31373104 PMCID: PMC7055153 DOI: 10.1111/dom.13846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/16/2019] [Accepted: 07/29/2019] [Indexed: 12/01/2022]
Abstract
AIM To evaluate whether weight change or hypoglycaemia mediates the association between insulin use and death. MATERIALS AND METHODS In a retrospective cohort of veterans who filled a new prescription for metformin and added insulin or sulphonylurea (2001-2012), we assessed change in body mass index (BMI) and hypoglycaemia during the first 12 months of treatment intensification. Cox proportional hazards models compared the risk of death between treatment groups. Using the difference method, we estimated the indirect effect and proportion mediated through each mediator. A sensitivity analysis assessed mediators in the first 6 months of intensified therapy. RESULTS Among 28 892 patients surviving 12 months, deaths per 1000 person-years were 15.4 for insulin users and 12.9 for sulphonylurea users (HR 1.20, 95% CI 0.87, 1.64). Change in BMI and hypoglycaemia mediated 13% (-98, 98) and -1% (-37, 71) of this association, respectively. Among 30 214 patients surviving 6 months, deaths per 1000 person-years were 34.8 for insulin users and 21.3 for sulphonylurea users (HR 1.66, 95% CI 1.28, 2.15). Change in BMI and hypoglycaemia mediated 9% (1, 23) and 0% (-9, 4) of this association, respectively. CONCLUSIONS We observed an increased risk of death among metformin users intensifying treatment with insulin versus sulphonylurea and surviving 6 months of intensified therapy, but not among those surviving 12 months. This association was mediated in part by weight change.
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Affiliation(s)
- Jea Young Min
- Veterans Health Administration (VHA) Tennessee Valley
Healthcare System, Geriatric Research and Education Clinical Center (GRECC),
HSR&D Center, Nashville, Tennessee, USA
- Department of Health Policy, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
| | - Amber. J. Hackstadt
- Veterans Health Administration (VHA) Tennessee Valley
Healthcare System, Geriatric Research and Education Clinical Center (GRECC),
HSR&D Center, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
| | - Marie R. Griffin
- Veterans Health Administration (VHA) Tennessee Valley
Healthcare System, Geriatric Research and Education Clinical Center (GRECC),
HSR&D Center, Nashville, Tennessee, USA
- Department of Health Policy, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
| | - Robert A. Greevy
- Veterans Health Administration (VHA) Tennessee Valley
Healthcare System, Geriatric Research and Education Clinical Center (GRECC),
HSR&D Center, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
| | - Jonathan Chipman
- Veterans Health Administration (VHA) Tennessee Valley
Healthcare System, Geriatric Research and Education Clinical Center (GRECC),
HSR&D Center, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
| | - Carlos G. Grijalva
- Veterans Health Administration (VHA) Tennessee Valley
Healthcare System, Geriatric Research and Education Clinical Center (GRECC),
HSR&D Center, Nashville, Tennessee, USA
- Department of Health Policy, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
| | - Adriana M. Hung
- Veterans Health Administration (VHA) Tennessee Valley
Healthcare System, Geriatric Research and Education Clinical Center (GRECC),
HSR&D Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
| | - Christianne L. Roumie
- Veterans Health Administration (VHA) Tennessee Valley
Healthcare System, Geriatric Research and Education Clinical Center (GRECC),
HSR&D Center, Nashville, Tennessee, USA
- Department of Medicine, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
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Lysy Z, Fung K, Giannakeas V, Fischer HD, Bell CM, Lipscombe LL. The Association Between Insulin Initiation and Adverse Outcomes After Hospital Discharge in Older Adults: a Population-Based Cohort Study. J Gen Intern Med 2019; 34:575-582. [PMID: 30756304 PMCID: PMC6445910 DOI: 10.1007/s11606-019-04849-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 10/10/2018] [Accepted: 12/27/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Starting insulin therapy in hospitalized patients may be associated with an increase in serious adverse events after discharge. OBJECTIVE Determine whether post-discharge risks of death and rehospitalization are higher for older hospitalized patients prescribed new insulin therapy compared with oral hypoglycemic agents (OHAs). DESIGN Retrospective population-based cohort study including hospital admissions in Ontario, Canada, between April 1, 2004, and Nov 30, 2013. PATIENTS Persons aged 66 and over discharged after a hospitalization and dispensed a prescription for insulin and/or an OHA within 7 days of discharge. We included 104,525 individuals, subcategorized into four mutually exclusive exposure groups based on anti-hyperglycemic drug use in the 7 days post-discharge and the 365 days prior to the index admission. MAIN MEASURES Prescriptions at discharge were categorized as new insulin (no insulin before admission), prevalent insulin (prescribed insulin before admission), new OHA(s) (no OHA or insulin before admission), and prevalent OHA (prescribed OHA only before admission) as the referent category. The primary and secondary outcomes were 30-day deaths and emergency department (ED) visits or readmissions respectively. KEY RESULTS Of 104,525 patients, 9.2% were initiated on insulin, 4.1% died, and 26.2% had an ED visit or readmission within 30 days of discharge. Deaths occurred in 7.14% of new insulin users, 4.86% of prevalent insulin users, 3.25% of new OHA users, and 3.45% of prevalent OHA users. After adjustment for covariates, new insulin users had a significantly higher risk of death (adjusted hazard ratio (aHR) 1.59, 95% confidence interval (CI) 1.46 to 1.74) and ED visit/readmissions (aHR 1.17, 95% CI 1.12 to 1.22) than prevalent OHA users. CONCLUSIONS Initiation of insulin therapy in older hospitalized patients is associated with a higher risk of death and ED visits/readmissions after discharge, highlighting a need for better transitional care of insulin-treated patients.
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Affiliation(s)
- Zoe Lysy
- Women's College Hospital, Women's College Research Institute, 76 Grenville St, Toronto, ON, M5S 1B2, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Kinwah Fung
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Vasily Giannakeas
- Women's College Hospital, Women's College Research Institute, 76 Grenville St, Toronto, ON, M5S 1B2, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
| | | | - Chaim M Bell
- Department of Medicine, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Sinai Health System, Toronto, Canada
| | - Lorraine L Lipscombe
- Women's College Hospital, Women's College Research Institute, 76 Grenville St, Toronto, ON, M5S 1B2, Canada. .,Department of Medicine, University of Toronto, Toronto, Canada. .,Institute for Clinical Evaluative Sciences, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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31
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Kim MT, Kim KB, Nguyen TH, Ko J, Zabora J, Jacobs E, Levine D. Motivating people to sustain healthy lifestyles using persuasive technology: A pilot study of Korean Americans with prediabetes and type 2 diabetes. PATIENT EDUCATION AND COUNSELING 2019; 102:709-717. [PMID: 30391298 PMCID: PMC6440831 DOI: 10.1016/j.pec.2018.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/15/2018] [Accepted: 10/26/2018] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To test the efficacy of a hybrid model of the self-help intervention program (hSHIP), which combines a mobile version of SHIP (mSHIP) and personal coaching, to address unique cultural and motivational factors for optimal self-management of type 2 diabetes and prediabetes among Korean Americans (KAs). METHODS A single-group feasibility study design was used. The hSHIP utilizes texts and motivational counseling based on well-tested intervention content for KAs. To facilitate the dissemination of hSHIP, we developed a web application adopting the principles of persuasive technology to motivate behavior changes. RESULTS Feasibility assessment found that hSHIP was well accepted by both participants and community health workers who delivered the intervention. An average of 1.3% A1C reduction (from 7.8% to 6.5%) was achieved by KAs with diabetes (n = 165), 51.5% of whom lowered their A1C below 6.5% in 6-months. No one with prediabetes (n = 50) progressed to diabetes. Other clinical outcomes (e.g., weight, depression, and blood pressure) also improved significantly; 41.2% were able to reduce or discontinue antidiabetic drugs. CONCLUSION The feasibility and initial efficacy of hSHIP were demonstrated. PRACTICE IMPLICATION This hybrid diabetes self-management model is a viable tool for traditionally underserved groups with diabetes or prediabetes.
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Affiliation(s)
- Miyong T Kim
- School of Nursing, University of Texas at Austin, Austin, TX, United States
| | - Kim Byeng Kim
- Korean Resource Center, 3454 Ellicott Center Dr. Suite 104, Ellicott City, MD 21043, United States.
| | - Tam H Nguyen
- Connell School of Nursing, Boston College, Chestnut Hill, MA, United States
| | - Jisook Ko
- School of Nursing, University of Texas at Austin, Austin, TX, United States
| | - Jim Zabora
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States
| | - Elizabeth Jacobs
- Department of Medicine, Dell Medical School, University of Texas at Austin, TX, United States
| | - David Levine
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
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32
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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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van Steen SC, Rijkenberg S, van der Voort PHJ, DeVries JH. The association of intravenous insulin and glucose infusion with intensive care unit and hospital mortality: a retrospective study. Ann Intensive Care 2019; 9:29. [PMID: 30742240 PMCID: PMC6370891 DOI: 10.1186/s13613-019-0507-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 02/04/2019] [Indexed: 12/12/2022] Open
Abstract
Background We assessed the association of intravenous insulin and glucose infusion with intensive care unit (ICU) and hospital mortality. Methods For this retrospective association study, we used data from all patients admitted to a medical-surgical ICU between January 2012 and September 2017. We excluded patients admitted < 24 h, patients with a diabetic ketoacidosis, patients with a therapy restriction upon ICU admission and readmissions. Using multivariate logistic regression, we examined the relation between intravenous insulin and glucose infusion and ICU and hospital mortality for all patients. Additionally, we used the same model to analyze the outcomes for patients admitted > 72 h. Results Of 9507 eligible patients, 3966 were included. After correction for potential confounders, intravenous insulin was associated with ICU and hospital mortality in patients admitted > 24 h (n = 3966) (odds ratio (OR) 1.09 [95% CI 1.05–1.13] and 1.09 [95% CI 1.06–1.13] per 0.1 IU/kg added, respectively). Likewise, intravenous glucose was associated with ICU mortality (OR 1.01 [95% CI 1.00–1.01]) but not with hospital mortality and (OR 1.00 [95% CI 1.00–1.01]) per g/day added, respectively. In patients admitted > 72 h (n = 1550), insulin dose was associated with both ICU and hospital mortality (p = 0.002 and p < 0.001, respectively), but glucose infusion was not (p = 0.08 and p = 0.2, respectively). Conclusions Intravenous insulin administration is associated with an increased risk of ICU and hospital mortality, after correction for potential confounders. Parenteral glucose administration was limited in amount but was still associated with ICU mortality. However, based on these results, it is unknown whether this association is an epiphenomenon, or represents a true harm of insulin and glucose administration. Electronic supplementary material The online version of this article (10.1186/s13613-019-0507-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sigrid C van Steen
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - Saskia Rijkenberg
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - Peter H J van der Voort
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands. .,TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Skelin M, Javor E, Lucijanić M, Lucijanić T, Jakupović L, Rahelić D. The role of glucagon in the possible mechanism of cardiovascular mortality reduction in type 2 diabetes patients. Int J Clin Pract 2018; 72:e13274. [PMID: 30295381 DOI: 10.1111/ijcp.13274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/15/2018] [Indexed: 01/10/2023] Open
Abstract
AIM Type 2 diabetes (T2D) is one of the major public health issues worldwide. The main cause of mortality and morbidity among T2D patients are cardiovascular (CV) causes. Various antidiabetics are used in T2D treatment, but until recently they lacked clear evidence of the reduction in CV mortality and all-cause mortality as independent study end-points. The aim of this article was to present and critically evaluate potential mechanisms behind the remarkable results documented in trials with new antidiabetics for the treatment of T2D. METHODS Relevant data were collected using the MEDLINE, PubMed, EMBASE, Web of Science, Science Direct, and Scopus databases with the key words: "type 2 diabetes," "mortality," "glucagon," "empagliflozin," "liraglutide," "insulin" and "QTc." Searches were not limited to specific publication types or study designs. RESULTS The EMPA-REG OUTCOME trial with empagliflozin and LEADER trial with liraglutide presented remarkable results regarding the reduction in mortality in T2D treatment. However, the potential mechanism for those beneficial effects is difficult to determine. It is not likely that improvements in classic CV risk factors are responsible for the observed effect. A potential mechanism may be caused by the elevation of postprandial (PP) glucagon concentrations that can be seen with an empagliflozin and liraglutide therapy, which could have beneficial effects considering the myocardial electrical stability in T2D patients. CONCLUSION This hypothesis throws new light upon possible mechanisms of reduction in mortality in T2D patients.
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Affiliation(s)
- Marko Skelin
- Department of Pharmacy, General Hospital Šibenik, Šibenik, Croatia
| | - Eugen Javor
- Department of Pharmacy, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Marko Lucijanić
- Department of Hematology, Dubrava University Hospital, Zagreb, Croatia
| | - Tomo Lucijanić
- Department of Endocrinology, Diabetes and Clinical Pharmacology, Dubrava University Hospital, Zagreb, Croatia
| | - Lejsa Jakupović
- Healthcare Institution of Community Pharmacy Slavonski Brod, Slavonski Brod, Croatia
| | - Dario Rahelić
- Department of Endocrinology, Diabetes and Clinical Pharmacology, Dubrava University Hospital, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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35
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Leung CS, Yang KY, Li X, Chan VW, Ku M, Waldmann H, Hori S, Tsang JCH, Lo YMD, Lui KO. Single-cell transcriptomics reveal that PD-1 mediates immune tolerance by regulating proliferation of regulatory T cells. Genome Med 2018; 10:71. [PMID: 30236153 PMCID: PMC6148788 DOI: 10.1186/s13073-018-0581-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 09/07/2018] [Indexed: 12/31/2022] Open
Abstract
Background We have previously reported an antigen-specific protocol to induce transplant tolerance and linked suppression to human embryonic stem cell (hESC)-derived tissues in immunocompetent mice through coreceptor and costimulation blockade. However, the exact mechanisms of acquired immune tolerance in this model have remained unclear. Methods We utilize the NOD.Foxp3hCD2 reporter mouse line and an ablative anti-hCD2 antibody to ask if CD4+FOXP3+ regulatory T cells (Treg) are required for coreceptor and costimulation blockade-induced immune tolerance. We also perform genome-wide single-cell RNA-sequencing to interrogate Treg during immune rejection and tolerance and to indicate possible mechanisms involved in sustaining Treg function. Results We show that Treg are indispensable for tolerance induced by coreceptor and costimulation blockade as depletion of which with an anti-hCD2 antibody resulted in rejection of hESC-derived pancreatic islets in NOD.Foxp3hCD2 mice. Single-cell transcriptomic profiling of 12,964 intragraft CD4+ T cells derived from rejecting and tolerated grafts reveals that Treg are heterogeneous and functionally distinct in the two outcomes of transplant rejection and tolerance. Treg appear to mainly promote chemotactic and ubiquitin-dependent protein catabolism during transplant rejection while seeming to harness proliferative and immunosuppressive function during tolerance. We also demonstrate that this form of acquired transplant tolerance is associated with increased proliferation and PD-1 expression by Treg. Blocking PD-1 signaling with a neutralizing anti-PD-1 antibody leads to reduced Treg proliferation and graft rejection. Conclusions Our results suggest that short-term coreceptor and costimulation blockade mediates immune tolerance to hESC-derived pancreatic islets by promoting Treg proliferation through engagement of PD-1. Our findings could give new insights into clinical development of hESC-derived pancreatic tissues, combined with immunotherapies that expand intragraft Treg, as a potentially sustainable alternative treatment for T1D. Electronic supplementary material The online version of this article (10.1186/s13073-018-0581-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cherry S Leung
- Department of Chemical Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Kevin Y Yang
- Department of Chemical Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Xisheng Li
- Department of Chemical Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Vicken W Chan
- Department of Chemical Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Manching Ku
- Department of Paediatrics and Adolescent Medicine, Division of Paediatric Hematology and Oncology, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Herman Waldmann
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | - Shohei Hori
- Laboratory of Immunology and Microbiology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Jason C H Tsang
- Department of Chemical Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.,Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Yuk Ming Dennis Lo
- Department of Chemical Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.,Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Kathy O Lui
- Department of Chemical Pathology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China. .,Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
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36
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Affiliation(s)
| | | | - Eugen Javor
- Sestre milosrdnice University Hospital Center, Zagreb, Croatia
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37
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Traunmüller F. Atherosclerosis is a vascular stem cell disease caused by insulin. Med Hypotheses 2018; 116:22-27. [PMID: 29857902 DOI: 10.1016/j.mehy.2018.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
Abstract
The present article proposes the hypothesis that when multipotent vascular stem cells are exposed to excessive insulin in a rhythmic pattern of sharply rising and falling concentrations, their differentiation is misdirected toward adipogenic and osteogenic cell lineages. This results in plaque-like accumulation of adipocytes with fat and cholesterol deposition from adipocyte debris, and osteogenic (progenitor) cells with a calcified matrix in advanced lesions. The ingrowth of capillaries and infiltration with macrophages, which upon uptake of lipids turn into foam cells, are unspecific pro-resolving reactions. Epidemiological, histopathological, pharmacological, and experimental evidence in favour of this hypothesis is summarised.
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38
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Bala C, Rusu A, Ciobanu DM, Craciun AE, Roman G. The association study of high-sensitivity C-reactive protein, pentraxin 3, nitrotyrosine, and insulin dose in patients with insulin-treated type 2 diabetes mellitus. Ther Clin Risk Manag 2018; 14:955-963. [PMID: 29881277 PMCID: PMC5978465 DOI: 10.2147/tcrm.s162086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE The objective of this study was to examine the association between insulin dose and high-sensitivity C-reactive protein (hsCRP), nitrotyrosine, and pentraxin 3 in patients with insulin-treated type 2 diabetes. PATIENTS AND METHODS Eighty patients with type 2 diabetes treated with insulin for >6 months and with stable insulin doses (±10%) within 3 months before inclusion were enrolled in this study. Medical history, including use of insulin and insulin doses, concomitant diseases and medication, and anthropometric and routine biochemical parameters were collected for each patient. hsCRP, nitrotyrosine, and pentraxin 3 were measured in fasting conditions. Comparison analysis was performed according to the distribution in tertiles of insulin dose/kg of body weight, and linear regression adjusted for confounding factors was used to examine the associations between markers of inflammation, oxidative stress, and insulin dose. RESULTS In the comparison analysis, no statistically significant difference was found between hsCRP, nitrotyrosine, and pentraxin 3 levels across tertiles of insulin dose expressed as IU/kg of body weight (p for trend >0.05 for all comparisons) except a significantly higher hsCRP level in tertile 3 compared to tertile 1 (3.9±3.6 vs 6.1±3.8 mg/dL, p=0.035). In regression analysis, after adjustment for age, gender, smoking, body mass index, glycated hemoglobin, C-peptide, metformin, antiplatelet, and statin use, only hsCRP levels were statistically significant associated with insulin dose/kg of body weight (β=0.237, p=0.043). CONCLUSION In this sample of patients with type 2 diabetes treated with insulin for >6 months, hsCRP was positively associated with insulin doses. No such association was found for pentraxin 3, a more specific marker of vascular inflammation, and for nitrotyrosine as a marker of oxidative stress.
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Affiliation(s)
- Cornelia Bala
- Department of Diabetes and Nutrition, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Adriana Rusu
- Department of Diabetes and Nutrition, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dana Mihaela Ciobanu
- Department of Diabetes and Nutrition, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Anca Elena Craciun
- Department of Diabetes and Nutrition, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Gabriela Roman
- Department of Diabetes and Nutrition, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Anagnostis P, Siolos P, Christou K, Gkekas NK, Kosmidou N, Athyros VG, Karagiannis A. The effect of antidiabetic medications on the cardiovascular system: a critical appraisal of current data. Hormones (Athens) 2018; 17:83-95. [PMID: 29858866 DOI: 10.1007/s42000-018-0017-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/23/2018] [Indexed: 02/07/2023]
Abstract
Both type 1 and type 2 diabetes are associated with increased risk for cardiovascular disease (CVD) events. This risk seems to be reduced by achievement of euglycemia. However, after the withdrawal of rosiglitazone from the market, the question arose as to whether this risk concerns simply a matter of euglycemia or the distinct role played by each antidiabetic drug with respect to its effect on CVD risk. To address this issue, many studies have been published during the last decade involving old and new antidiabetic agents, which however yielded contradictory results. Briefly, metformin is still considered safe and confers a beneficial effect on CVD risk. Conflicting data exist as concerns sulfonylureas, although the second and third generation representatives are regarded as relatively safe. Pioglitazone use seems to be associated with a reduction in CVD risk, whereas the dipeptidyl-dipeptidase-4 inhibitors (DPP-4i), lixisenatide and exenatide-LAR [from the category of glucagon-like-peptide-1 receptor (GLP-1R) agonists], confer a neutral effect. Two other GLP-1R agonists, liraglutide and semaglutide, as well as the sodium-glucose transporter-2 (SGLT2)-inhibitors, empagliflozin and cangliflozin, have shown an additional effect on CVD risk reduction, although their safety is in doubt. Insulin analogues and newer long-acting compounds are also safe for the cadiovascular system. The aim of this narrative review is to present and critically analyse the current data for each antidiabetic drug category with regard to their effect on CVD risk.
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Affiliation(s)
- Panagiotis Anagnostis
- Police Medical Center of Thessaloniki, Thessaloniki, Greece.
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Sarantaporou 10, 546 40, Thessaloniki, Greece.
| | - Pavlos Siolos
- Police Medical Center of Thessaloniki, Thessaloniki, Greece
| | | | - Nifon K Gkekas
- Police Medical Center of Thessaloniki, Thessaloniki, Greece
| | | | - Vasilios G Athyros
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Sarantaporou 10, 546 40, Thessaloniki, Greece
| | - Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Sarantaporou 10, 546 40, Thessaloniki, Greece
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40
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Alemi H, Khaloo P, Mansournia MA, Rabizadeh S, Salehi SS, Mirmiranpour H, Meftah N, Esteghamati A, Nakhjavani M. Pulse pressure and diabetes treatments: Blood pressure and pulse pressure difference among glucose lowering modality groups in type 2 diabetes. Medicine (Baltimore) 2018; 97:e9791. [PMID: 29419672 PMCID: PMC5944681 DOI: 10.1097/md.0000000000009791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Type 2 diabetes is associated with higher pulse pressure. In this study, we assessed and compared effects of classic diabetes treatments on pulse pressure (PP), systolic blood pressure (SBP), and diastolic blood pressure (DBP) in patients with type 2 diabetes.In a retrospective cohort study, 718 non-hypertensive patients with type 2 diabetes were selected and divided into 4 groups including metformin, insulin, glibenclamide+metformin, and metformin+insulin. They were followed for 4 consecutive visits lasting about 45.5 months. Effects of drug regimens on pulse and blood pressure over time were assessed separately and compared in regression models with generalized estimating equation method and were adjusted for age, duration of diabetes, sex, smoking, and body mass index (BMI).Studied groups had no significant change in PP, SBP, and DBP over time. No significant difference in PP and DBP among studied groups was observed (PP:P = 0.090; DBP:P = 0.063). Pairwise comparisons of PP, SBP, and DBP showed no statistically significant contrast between any 2 studied groups. Interactions of time and treatment were not different among groups.Our results demonstrate patients using metformin got higher PP and SBP over time. Averagely, pulse and blood pressure among groups were not different. Trends of variation in pulse and blood pressure were not different among studied diabetes treatments.
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Affiliation(s)
- Hamid Alemi
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine
| | - Pegah Khaloo
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Soghra Rabizadeh
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine
| | - Salome Sadat Salehi
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine
| | - Hossein Mirmiranpour
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine
| | - Neda Meftah
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine
| | - Manouchehr Nakhjavani
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine
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41
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Suissa S. Mortality Reduction in EMPA-REG OUTCOME Trial: Beyond the Antidiabetes Effect. Diabetes Care 2018; 41:219-223. [PMID: 29358464 DOI: 10.2337/dc17-1059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/22/2017] [Indexed: 02/03/2023]
Abstract
Two recent large-scale cardiovascular outcome trials, a now common tool in assessing the safety of pharmacological treatments for type 2 diabetes, reported significant reductions in all-cause mortality. In EMPA-REG OUTCOME [BI 10773 (Empagliflozin) Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients], patients who received the SGLT2 inhibitor empagliflozin had a notable reduction of 9.2 deaths per 1,000 per year, while LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results-A Long Term Evaluation) found that the patients receiving the GLP-1 receptor agonist liraglutide had a reduction of 3.7 deaths per 1,000 per year. The hypotheses to explain the sizable mortality reduction in EMPA-REG OUTCOME have mainly focused on the potential cardiovascular mechanisms of empagliflozin, but none considered its expected antidiabetes effects. I estimated the portion of the reduction in mortality observed in EMPA-REG OUTCOME expected to be a result of its antidiabetes effects, as measured by glycemic control and the need for additional antidiabetes medication, and contrasted it with LEADER. With use of the mean 0.45% reduction in HbA1c with empagliflozin compared with placebo in EMPA-REG OUTCOME, the rate reduction of 9.2 deaths per 1,000 per year would be expected to be at most 4.5 deaths per 1,000 per year, leaving 4.7 deaths per 1,000 per year otherwise explained. On the other hand, LEADER's rate reduction of 3.7 deaths per 1,000 per year with liraglutide would be expected to be 3.5 by virtue of its effect on HbA1c, leaving 0.2 deaths per 1,000 per year explained otherwise. Similar results were found using the need for additional antidiabetes treatment during follow-up to measure the antidiabetes impact. In conclusion, the expected antidiabetes effects of empagliflozin and liraglutide on the reduction in mortality are important. However, empagliflozin appears to have significant additional effects on survival, possibly due to specific cardiovascular mechanisms, which merit further investigation.
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Affiliation(s)
- Samy Suissa
- Center for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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42
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Cho S, Kim M, Park K. Self-management levels of diet and metabolic risk factors according to disease duration in patients with type 2 diabetes. Nutr Res Pract 2018; 12:69-77. [PMID: 29399299 PMCID: PMC5792259 DOI: 10.4162/nrp.2018.12.1.69] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 12/18/2017] [Accepted: 12/24/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/OBJECTIVES Metabolic risk factors should be managed effectively in patients with type 2 diabetes mellitus (T2DM) to prevent or delay diabetic complications. This study aimed to compare the self-management levels of diet and metabolic risk factors in patients with T2DM, according to the duration of illness, and to examine the trends in self-management levels during the recent decades. SUBJECTS/METHODS Data were collected from the Korea National Health and Nutrition Examination Surveys (KNHANES, 1998-2014). In our analysis, 4,148 patients with T2DM, aged ≥ 30 years, were categorized according to the duration of their illness (< 5 years, 5-9 years, and ≥ 10 years). Demographic and lifestyle information was assessed through self-administered questionnaires, and biomarker levels (e.g., fasting glucose level, blood pressure, or lipid level) were obtained from a health examination. Dietary intake was assessed by a 24-recall, and adherence level to dietary guidelines (meal patterns and intake levels of calories, carbohydrates, vegetable/seaweed, sodium, and alcohol) were assessed. Multivariable generalized linear regression and unconditional logistic regression models were used to compare the prevalence rates of hyperglycemia, dyslipidemia, and hypertension according to the duration of patients' illness, accounting for the complex survey design of the KNHANES. RESULTS In the multivariable adjusted models, patients with a longer duration (≥ 10 years) of T2DM had a higher prevalence of hyperglycemia than those with a shorter duration of T2DM (< 5 years) (odds ratio 2.20, 95% confidence interval 1.61-3.01, P for trend < 0.001). We did not observe any associations of disease duration with the prevalence of hypertension and dyslipidemia. In addition, the adherence levels to dietary recommendations did not significantly differ according to disease duration, except adherence to moderate alcohol consumption. There were significant decreasing trends in the prevalence of hyperglycemia in patients with a duration of illness ≥ 10 years (P for trend = 0.004). CONCLUSION Although the proportion of patients with adequate control of glucose levels has improved in recent decades, poorer self-management has been found in those with a longer disease duration. These findings suggest the need for well-planned and individualized patient education programs to improve self-management levels and quality of life by preventing or delaying diabetic complications.
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Affiliation(s)
- Sukyung Cho
- Department of Food and Nutrition, Yeungnam University, 280 Daehak-ro, Gyeongsan-si, Gyeongbuk 38541, Korea
| | - Minkyeong Kim
- Department of Food and Nutrition, Yeungnam University, 280 Daehak-ro, Gyeongsan-si, Gyeongbuk 38541, Korea
| | - Kyong Park
- Department of Food and Nutrition, Yeungnam University, 280 Daehak-ro, Gyeongsan-si, Gyeongbuk 38541, Korea
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43
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Russell J, Du Toit EF, Peart JN, Patel HH, Headrick JP. Myocyte membrane and microdomain modifications in diabetes: determinants of ischemic tolerance and cardioprotection. Cardiovasc Diabetol 2017; 16:155. [PMID: 29202762 PMCID: PMC5716308 DOI: 10.1186/s12933-017-0638-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/22/2017] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular disease, predominantly ischemic heart disease (IHD), is the leading cause of death in diabetes mellitus (DM). In addition to eliciting cardiomyopathy, DM induces a ‘wicked triumvirate’: (i) increasing the risk and incidence of IHD and myocardial ischemia; (ii) decreasing myocardial tolerance to ischemia–reperfusion (I–R) injury; and (iii) inhibiting or eliminating responses to cardioprotective stimuli. Changes in ischemic tolerance and cardioprotective signaling may contribute to substantially higher mortality and morbidity following ischemic insult in DM patients. Among the diverse mechanisms implicated in diabetic impairment of ischemic tolerance and cardioprotection, changes in sarcolemmal makeup may play an overarching role and are considered in detail in the current review. Observations predominantly in animal models reveal DM-dependent changes in membrane lipid composition (cholesterol and triglyceride accumulation, fatty acid saturation vs. reduced desaturation, phospholipid remodeling) that contribute to modulation of caveolar domains, gap junctions and T-tubules. These modifications influence sarcolemmal biophysical properties, receptor and phospholipid signaling, ion channel and transporter functions, contributing to contractile and electrophysiological dysfunction, cardiomyopathy, ischemic intolerance and suppression of protective signaling. A better understanding of these sarcolemmal abnormalities in types I and II DM (T1DM, T2DM) can inform approaches to limiting cardiomyopathy, associated IHD and their consequences. Key knowledge gaps include details of sarcolemmal changes in models of T2DM, temporal patterns of lipid, microdomain and T-tubule changes during disease development, and the precise impacts of these diverse sarcolemmal modifications. Importantly, exercise, dietary, pharmacological and gene approaches have potential for improving sarcolemmal makeup, and thus myocyte function and stress-resistance in this ubiquitous metabolic disorder.
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Affiliation(s)
- Jake Russell
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Eugene F Du Toit
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Jason N Peart
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia
| | - Hemal H Patel
- VA San Diego Healthcare System and Department of Anesthesiology, University of California San Diego, San Diego, USA
| | - John P Headrick
- Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia. .,School of Medical Science, Griffith University, Southport, QLD, 4217, Australia.
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Herman ME, O'Keefe JH, Bell DSH, Schwartz SS. Insulin Therapy Increases Cardiovascular Risk in Type 2 Diabetes. Prog Cardiovasc Dis 2017; 60:422-434. [PMID: 28958751 DOI: 10.1016/j.pcad.2017.09.001] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022]
Abstract
Insulin therapy increased cardiovascular (CV) risk and mortality among type 2 diabetes (T2D) patients in several recently reported clinical outcomes trials. To assess whether this association is causative or coincidental, PubMed searches were used to query the effects of insulin therapy for T2D on CV health and longevity from large-scale outcomes trials, meta-analyses, and patient registry studies, as well as basic research on insulin's direct and pleiotropic actions. Although several old studies provided conflicting results, the majority of large observational studies show strong dose-dependent associations for injected insulin with increased CV risk and worsened mortality. Insulin clearly causes weight gain, recurrent hypoglycemia, and, other potential adverse effects, including iatrogenic hyperinsulinemia. This over-insulinization with use of injected insulin predisposes to inflammation, atherosclerosis, hypertension, dyslipidemia, heart failure (HF), and arrhythmias. These associations support the findings of large-scale evaluations that strongly suggest that insulin therapy has a poorer short- and long-term safety profile than that found to many other anti-T2D therapies. The potential adverse effects of insulin therapy should be weighed against proven CV benefits noted for select other therapies for T2D as reported in recent large randomized controlled trials.
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Affiliation(s)
- Mary E Herman
- Montclair State University, New Jersey, United States; Social Alchemy Ltd. Building Global Research Competency, United States
| | - James H O'Keefe
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, United States; Saint Luke's Mid America Heart Institute, United States.
| | | | - Stanley S Schwartz
- Main Line Health System, Wynnewood, PA, United States; University of Pennsylvania, Philadelphia, PA, United States
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45
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Danieli C, Abrahamowicz M. Competing risks modeling of cumulative effects of time-varying drug exposures. Stat Methods Med Res 2017; 28:248-262. [PMID: 28882094 DOI: 10.1177/0962280217720947] [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] [Indexed: 02/01/2023]
Abstract
An accurate assessment of drug safety or effectiveness in pharmaco-epidemiology requires defining an etiologically correct time-varying exposure model, which specifies how previous drug use affects the hazard of the event of interest. An additional challenge is to account for the multitude of mutually exclusive events that may be associated with the use of a given drug. To simultaneously address both challenges, we develop, and validate in simulations, a new approach that combines flexible modeling of the cumulative effects of time-varying exposures with competing risks methodology to separate the effects of the same drug exposure on different outcomes. To account for the dosage, duration and timing of past exposures, we rely on a spline-based weighted cumulative exposure modeling. We also propose likelihood ratio tests to test if the cumulative effects of past exposure on the hazards of the competing events are the same or different. Simulation results indicate that the estimated event-specific weight functions are reasonably accurate, and that the proposed tests have acceptable type I error rate and power. In real-life application, the proposed method indicated that recent use of antihypertensive drugs may reduce the risk of stroke but has no effect on the hazard of coronary heart disease events.
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Affiliation(s)
- Coraline Danieli
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
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46
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Schwartz SS, Epstein S, Corkey BE, Grant SFA, Gavin Iii JR, Aguilar RB, Herman ME. A Unified Pathophysiological Construct of Diabetes and its Complications. Trends Endocrinol Metab 2017. [PMID: 28629897 DOI: 10.1016/j.tem.2017.05.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Advances in understanding diabetes mellitus (DM) through basic and clinical research have helped clarify and reunify a disease state fragmented into numerous etiologies and subtypes. It is now understood that a common pathophysiology drives the diabetic state throughout its natural history and across its varied clinical presentations, a pathophysiology involving metabolic insults, oxidative damage, and vicious cycles that aggravate and intensify organ dysfunction and damage. This new understanding of the disease requires that we revisit existing diagnostics and treatment approaches, which were built upon outmoded assumptions. 'The Common Pathophysiologic Origins of Diabetes Mellitus and its Complications Construct' is presented as a more accurate, foundational, and translatable construct of DM that helps make sense of the hitherto ambiguous findings of long-term outcome studies.
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Affiliation(s)
- Stanley S Schwartz
- Main Line Health System, Wynnewood, PA, USA; University of Pennsylvania, Philadelphia, PA, USA.
| | - Solomon Epstein
- Medicine, Endocrinology, Diabetes and Bone Disease, Mount Sinai Hospital, New York, NY, USA
| | - Barbara E Corkey
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Struan F A Grant
- Division of Human Genetics and Center for Applied Genomics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Divisions of Human Genetics and Endocrinology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Mary E Herman
- Montclair State University, Upper Montclair, NJ, USA; Social Alchemy Ltd., Building Global Research Competency, Lynchburg, VA, USA
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47
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Jil M, Rajnikant M, Richard D, Iskandar I. The effects of dual-therapy intensification with insulin or dipeptidylpeptidase-4 inhibitor on cardiovascular events and all-cause mortality in patients with type 2 diabetes: A retrospective cohort study. Diab Vasc Dis Res 2017; 14:295-303. [PMID: 28330386 DOI: 10.1177/1479164116687102] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To compare time to a composite endpoint of non-fatal acute myocardial infarction, non-fatal stroke or all-cause mortality in patients with type 2 diabetes mellitus who had their treatment intensified with a dipeptidylpeptidase-4 inhibitor or insulin following dual-therapy (metformin plus sulfonylurea) failure. METHODS A retrospective cohort study was conducted on 5238 patients newly treated with either a dipeptidylpeptidase-4 inhibitor or insulin following dual-therapy failure (2007-2014). Data were sourced from UK General Practices. The risk of the composite outcome was compared between two treatment groups: metformin + sulfonylurea + insulin ( n = 1584) and metformin + sulfonylurea + dipeptidylpeptidase-4 inhibitor ( n = 3654), while adjusting for baseline covariates. Follow-up was for up to 5 years. Propensity score matching analysis and Cox proportional hazard models were employed. RESULTS Overall, 123 and 171 composite outcome events occurred among patients who added insulin versus dipeptidylpeptidase-4 inhibitor, respectively (44.5 vs 14.6 events per 1000 person-years). Addition of insulin was associated with a significantly higher hazard ratio versus the addition of a dipeptidylpeptidase-4 inhibitor (adjusted hazard ratio = 2.6, 95% confidence interval: 1.9-3.4; p < 0.01), an effect that was more pronounced in obese (body mass index: 30-34.9 kg/m2) patients (corresponding adjusted hazard ratio 3.6, 95% confidence interval: 2.3-5.6; p < 0.01). CONCLUSION In routine clinical practice, intensification of metformin + sulfonylurea therapy by adding insulin is associated with increased risk of cardiovascular events and death compared with adding a dipeptidylpeptidase-4 inhibitor. These findings are in line with suggestions from previous studies regarding the cardiovascular safety of insulin in type 2 diabetes mellitus, but should be interpreted with caution.
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Affiliation(s)
- Mamza Jil
- 1 Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Mehta Rajnikant
- 2 Research Design Services East Midlands, School of Medicine, University of Nottingham, Nottingham, UK
| | - Donnelly Richard
- 1 Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Idris Iskandar
- 1 Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
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48
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Navathe AS, Zhong F, Lei VJ, Chang FY, Sordo M, Topaz M, Navathe SB, Rocha RA, Zhou L. Hospital Readmission and Social Risk Factors Identified from Physician Notes. Health Serv Res 2017; 53:1110-1136. [PMID: 28295260 DOI: 10.1111/1475-6773.12670] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To evaluate the prevalence of seven social factors using physician notes as compared to claims and structured electronic health records (EHRs) data and the resulting association with 30-day readmissions. STUDY SETTING A multihospital academic health system in southeastern Massachusetts. STUDY DESIGN An observational study of 49,319 patients with cardiovascular disease admitted from January 1, 2011, to December 31, 2013, using multivariable logistic regression to adjust for patient characteristics. DATA COLLECTION/EXTRACTION METHODS All-payer claims, EHR data, and physician notes extracted from a centralized clinical registry. PRINCIPAL FINDINGS All seven social characteristics were identified at the highest rates in physician notes. For example, we identified 14,872 patient admissions with poor social support in physician notes, increasing the prevalence from 0.4 percent using ICD-9 codes and structured EHR data to 16.0 percent. Compared to an 18.6 percent baseline readmission rate, risk-adjusted analysis showed higher readmission risk for patients with housing instability (readmission rate 24.5 percent; p < .001), depression (20.6 percent; p < .001), drug abuse (20.2 percent; p = .01), and poor social support (20.0 percent; p = .01). CONCLUSIONS The seven social risk factors studied are substantially more prevalent than represented in administrative data. Automated methods for analyzing physician notes may enable better identification of patients with social needs.
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Affiliation(s)
- Amol S Navathe
- Division of Health Policy, University of Pennsylvania, Philadelphia, PA.,CMC Philadelphia VA Medical Center, Philadelphia, PA.,Leonard Davis Institute of Health Economics, The Wharton School, University of Pennsylvania, Philadelphia, PA.,Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Feiran Zhong
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor J Lei
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Frank Y Chang
- Clinical Informatics, Partners eCare, Partners Healthcare Inc., Boston, MA
| | - Margarita Sordo
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,Clinical Informatics, Partners eCare, Partners Healthcare Inc., Boston, MA
| | - Maxim Topaz
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Shamkant B Navathe
- School of Computer Science, College of Computing, Georgia Institute of Technology, Atlanta, GA
| | - Roberto A Rocha
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,Clinical Informatics, Partners eCare, Partners Healthcare Inc., Boston, MA
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.,Clinical Informatics, Partners eCare, Partners Healthcare Inc., Boston, MA
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49
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Marzona I, Avanzini F, Lucisano G, Tettamanti M, Baviera M, Nicolucci A, Roncaglioni MC. Are all people with diabetes and cardiovascular risk factors or microvascular complications at very high risk? Findings from the Risk and Prevention Study. Acta Diabetol 2017; 54:123-131. [PMID: 27718051 DOI: 10.1007/s00592-016-0899-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/12/2016] [Indexed: 12/23/2022]
Abstract
AIMS To verify whether it is possible, in people with diabetes mellitus (DM) considered at very high cardiovascular (CV) risk, stratify this risk better and identify significant modifiable risk factor (including lifestyle habits) to help patients and clinicians improve CV prevention. METHODS People with DM and microvascular diseases or one or more CV risk factors (hypertension, hyperlipidemia, smoking, poor dietary habits, overweight, physical inactivity) included in the Risk and Prevention study were selected. We considered the combined endpoint of non-fatal acute myocardial infarction and stroke and CV death. A multivariate Cox proportional analysis was carried out to identify relevant predictors. We also used the RECPAM method to identify subgroups of patients at higher risk. RESULTS In our study, the rate of major CV events was lower than expected (5 % in 5 years). Predictors of CV events were age, male, sex, heart failure, previous atherosclerotic disease, atrial fibrillation, insulin treatment, high HbA1c, heart rate and other CV diseases while being physically active was protective. RECPAM analysis indicated that history of atherosclerotic diseases and a low BMI defined worse prognosis (HR 4.51 95 % CI 3.04-6.69). Among subjects with no previous atherosclerotic disease, men with HbA1c more than 8 % were at higher CV risk (HR 2.77; 95 % CI 1.86-4.14) with respect to women. CONCLUSIONS In this population, the rate of major CV events was lower than expected. This prediction model could help clinicians identify people with DM at higher CV risk and support them in achieving goals of physical activity and HbA1c.
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Affiliation(s)
- Irene Marzona
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Via Giuseppe La Masa 19, 20156, Milan, Italy.
| | - Fausto Avanzini
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Via Giuseppe La Masa 19, 20156, Milan, Italy
| | - Giuseppe Lucisano
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Mauro Tettamanti
- Laboratory of Geriatric Neuropsychiatry, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Marta Baviera
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Via Giuseppe La Masa 19, 20156, Milan, Italy
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Maria Carla Roncaglioni
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Via Giuseppe La Masa 19, 20156, Milan, Italy
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50
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Gamble JM, Chibrikov E, Twells LK, Midodzi WK, Young SW, MacDonald D, Majumdar SR. Association of insulin dosage with mortality or major adverse cardiovascular events: a retrospective cohort study. Lancet Diabetes Endocrinol 2017; 5:43-52. [PMID: 27865756 DOI: 10.1016/s2213-8587(16)30316-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/03/2016] [Accepted: 10/13/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Existing studies have shown conflicting evidence regarding the safety of exogenous insulin therapy in patients with type 2 diabetes. In particular, observational studies have reported an increased risk of death and cardiovascular disease among users of higher versus lower doses of insulin. We aimed to quantify the association between increasing dosage of insulin exposure and death and cardiovascular events, while taking into account time-dependent confounding and mediation that might have biased previous studies. METHODS We did a cohort study using primary care records from the UK-based Clinical Practice Research Datalink (CPRD). New users of metformin monotherapy were identified in the period between Jan 1, 2001, and Dec 31, 2012. We then identified those in this group with a new prescription for insulin. Insulin exposure was categorised into groups according to the mean dose (units) per day within 180-day time segments throughout each patient's follow-up. Relative differences in mortality and major adverse cardiovascular events (non-fatal myocardial infarction, non-fatal stroke, cardiovascular-related mortality) were assessed using conventional multivariable Cox proportional hazards models. Marginal structural models were then applied to reduce bias introduced by the time-dependent confounders affected by previous treatment. FINDINGS We identified 165 308 adults with type 2 diabetes in the CPRD database. After applying our exclusion criteria, 6072 (mean age 60 years [SD 12·5], 3281 [54%] men, mean HbA1c 8·5% [SD 1·75], and median follow-up 3·1 years [IQR 1·7-5·3) were new add-on insulin users and were included in the study cohort; 3599 were new add-on insulin users and were included in the subcohort linked to hospital records and death certificate information. Crude mortality rates were comparable between insulin dose groups; <25 units per day (46 per 1000 person-years), 25 to <50 units per day (39 per 1000 person-years), 50 to <75 units per day (27 per 1000 person-years), 75 to <100 units per day (34 per 1000 person-years), and at least 100 units per day (32 per 1000 person-years; p>0·05 for all; mean rate of 31 deaths per 1000 person-years [95% CI 29-33]). With adjustment for baseline covariates, mortality rates were higher for increasing insulin doses: less than 25 units per day [reference group]; 25 to <50 units per day, hazard ratio (HR) 1·41 [95% CI 1·12-1·78]; 50 to <75 units per day, 1·37 [1·04-1·80]; 75 to <100 units per day, 1·85 [1·35-2·53]; and at least 100 units per day, 2·16 [1·58-2·93]. After applying marginal structural models, insulin dose was not associated with mortality in any group (p>0·1 for all). INTERPRETATION In conventional multivariable regression analysis, higher insulin doses are associated with increased mortality after adjustment for baseline covariates. However, this effect seems to be confounded by time-dependent factors such as insulin exposure, glycaemic control, bodyweight gain, and the occurrence of cardiovascular and hypoglycaemic events. This study provides reassurance of the overall safety of insulin use in the treatment of type 2 diabetes and contributes to our understanding of the contrasting conclusions from non-randomised and randomised studies regarding dose-dependent effects of insulin on cardiovascular events and mortality. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and the Newfoundland and Labrador Research and Development Corporation.
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Affiliation(s)
- John-Michael Gamble
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada.
| | - Eugene Chibrikov
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada
| | - Laurie K Twells
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada; Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada
| | - William K Midodzi
- Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada
| | - Stephanie W Young
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada
| | - Don MacDonald
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada; Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada; Newfoundland and Labrador Centre for Health Information, St John's, NL, Canada
| | - Sumit R Majumdar
- Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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