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Ebert T, Sattar N, Greig M, Lamina C, Froissart M, Eckardt KU, Floege J, Kronenberg F, Stenvinkel P, Wheeler DC, Fotheringham J. Use of Analog and Human Insulin in a European Hemodialysis Cohort With Type 2 Diabetes: Associations With Mortality, Hospitalization, MACE, and Hypoglycemia. Am J Kidney Dis 2024; 83:18-27. [PMID: 37657634 DOI: 10.1053/j.ajkd.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 09/03/2023]
Abstract
RATIONALE & OBJECTIVE Poor glycemic control may contribute to the high mortality rate in patients with type 2 diabetes receiving hemodialysis. Insulin type may influence glycemic control, and its choice may be an opportunity to improve outcomes. This study assessed whether treatment with analog insulin compared with human insulin is associated with different outcomes in people with type 2 diabetes and kidney failure receiving hemodialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS People in the Analyzing Data, Recognizing Excellence and Optimizing Outcomes (AROii) study with kidney failure commencing hemodialysis and type 2 diabetes being treated with insulin within 288 dialysis facilities between 2007 and 2009 across 7 European countries. Study participants were followed for 3 years. People with type 1 diabetes were excluded using an established administrative data algorithm. EXPOSURE Treatment with an insulin analog or human insulin. OUTCOME All-cause mortality, major adverse cardiovascular events (MACE), all-cause hospitalization, and confirmed hypoglycemia (blood glucose<3.0mmol/L sampled during hemodialysis). ANALYTICAL APPROACH Inverse probability weighted Cox proportional hazards models to estimate hazard ratios for analog insulin compared with human insulin. RESULTS There were 713 insulin analog and 733 human insulin users. Significant variation in insulin type by country was observed. Comparing analog with human insulin at 3 years, the percentage of patients experiencing end points and adjusted hazard ratios (AHR) were 22.0% versus 31.4% (AHR, 0.808 [95% CI, 0.66-0.99], P=0.04) for all-cause mortality, 26.8% versus 35.9% (AHR, 0.817 [95% CI, 0.68-0.98], P=0.03) for MACE, and 58.2% versus 75.0% (AHR, 0.757 [95% CI, 0.67-0.86], P<0.001) for hospitalization. Hypoglycemia was comparable between insulin types at 14.1% versus 15.0% (AHR, 1.169 [95% CI, 0.80-1.72], P=0.4). Consistent strength and direction of the associations were observed across sensitivity analyses. LIMITATIONS Residual confounding, lack of more detailed glycemia data. CONCLUSIONS In this large multinational cohort of people with type 2 diabetes and kidney failure receiving maintenance hemodialysis, treatment with analog insulins was associated with better clinical outcomes when compared with human insulin. PLAIN-LANGUAGE SUMMARY People with diabetes who are receiving dialysis for kidney failure are at high risk of cardiovascular disease and death. This study uses information from 1,446 people with kidney failure from 7 European countries who are receiving dialysis, have type 2 diabetes, and are prescribed either insulin identical to that made in the body (human insulin) or insulins with engineered extra features (insulin analog). After 3 years, fewer participants receiving analog insulins had died, had been admitted to the hospital, or had a cardiovascular event (heart attack, stroke, heart failure, or peripheral vascular disease). These findings suggest that analog insulins should be further explored as a treatment leading to better outcomes for people with diabetes on dialysis.
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Affiliation(s)
- Thomas Ebert
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Medical Department III, Endocrinology, Nephrology, Rheumatology, University of Leipzig Medical Center, Leipzig, Germany
| | - Nosheen Sattar
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield
| | - Marni Greig
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield; Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield
| | - Claudia Lamina
- Medical University of Innsbruck, Institute of Genetic Epidemiology, Innsbruck, Austria
| | - Marc Froissart
- Centre de Recherche Clinique (CRC), Lausanne University Hospital, Lausanne, Switzerland
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Aachen, Germany
| | - Florian Kronenberg
- Medical University of Innsbruck, Institute of Genetic Epidemiology, Innsbruck, Austria
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield; Sheffield Kidney Institute, Northern General Hospital, Sheffield.
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Xuan Y, Zhang W, Wang Y, Wang B, Xia F, Zhang K, Li Q, Wang N, Lu Y. Association Between Uric Acid to HDL Cholesterol Ratio and Diabetic Complications in Men and Postmenopausal Women. Diabetes Metab Syndr Obes 2023; 16:167-177. [PMID: 36760595 PMCID: PMC9869791 DOI: 10.2147/dmso.s387726] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/15/2022] [Indexed: 01/20/2023] Open
Abstract
AIM Previous studies have implicated the uric acid to high-density lipoprotein cholesterol (HDL-C) ratio (UHR) was associated with type 2 diabetes. However, the association between UHR and diabetes-related vascular damages is still unclear. METHODS The total of 4551 patients with type 2 diabetes from the cross-sectional Environmental Pollutant Exposure and Metabolic Diseases in Shanghai study (METAL study) were enrolled. UHR was calculated as uric acid to HDL-C ratio. Cardiovascular disease (CVD) was defined as previously diagnosed with stroke, coronary heart disease, or peripheral arterial disease. Chronic kidney disease (CKD) was defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m2 and/or urinary albumin to creatinine ratio ≥30 mg/g. Fundus image was examined by trained individuals and degree of diabetic retinopathy (DR) was evaluated. RESULTS UHR was positively correlated with CVD (OR = 1.28, 95% CI: 1.02-1.61) and CKD (OR = 1.78, 95% CI: 1.39-2.27) after adjusting for all confounders. No association was found between UHR and DR. In stratified analyses, UHR was predominantly correlated with CVD in diabetic patients with age older than 65 (OR = 1.41, 95% CI: 1.08-1.85), female (OR = 1.43, 95% CI: 1.06-1.94) and BMI≥24kg/m2 (OR = 1.57, 95% CI: 1.17-2.11). A 1-SD increment of UHR was also positively associated with CVD (OR 1.26, 95% CI 1.03, 1.15) and CKD (OR 1.28, 95% CI 1.20,1.39). UHR was positively associated with CKD in all subgroups analysis. No significant interaction effect was observed between UHR and all subgroup variables in CVD and CKD risk. CONCLUSION Our study reported a positive association between the UHR and diabetic-related vascular complications in men and postmenopausal women. The relationship between the UHR and DR seems to be uncertain and requires further investigation. And no significant interaction effect was observed between the UHR and all subgroup variables in CVD and CKD risk.
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Affiliation(s)
- Yan Xuan
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
- Department of Endocrinology, Luwan Branch, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200020, People’s Republic of China
| | - Wen Zhang
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Yuying Wang
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Bin Wang
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Fangzhen Xia
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Kun Zhang
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Qing Li
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Ningjian Wang
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
| | - Yingli Lu
- Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China
- Correspondence: Yingli Lu, Institute and Department of Endocrinology and Metabolism, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 200011, People’s Republic of China, Tel +86-13636352507, Fax +86-21-63136856, Email
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Mannucci E, Targher G, Nreu B, Pintaudi B, Candido R, Giaccari A, Gallo M, Monami M. Effects of insulin on cardiovascular events and all-cause mortality in patients with type 2 diabetes: A meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis 2022; 32:1353-1360. [PMID: 35422359 DOI: 10.1016/j.numecd.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/31/2022] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
Abstract
AIM In 2019, the Italian Society of Diabetology and the Italian Association of Clinical Diabetologists nominated an expert panel to develop guidelines for drug treatment of type 2 diabetes. This expert panel, after identifying the effects of glucose-lowering agents on major adverse cardiovascular events (MACEs), all-cause mortality, and hospitalization for heart failure (HHF) as critical outcomes, decided to perform a systematic review and meta-analysis on the effect of insulin with this respect. DATA SYNTHESIS A MEDLINE database search was performed to identify all RCTs, up to June 1st, 2021, with duration≥52 weeks, in which insulin was compared with either placebo or active comparators. The principal endpoints were MACE and HHF (restricted for RCT reporting MACEs within their outcomes), all-cause mortality (irrespective of the inclusion of MACEs among the pre-specified outcomes). Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for all the endpoints considered. Six RCTs (enrolling 8091 patients and 10,139 in the insulin and control group, respectively) were included in the analysis for MACEs and HF, and 18 in that for all-cause mortality (9760 and 11,694 patients in the insulin and control group, respectively). Treatment with insulin neither significantly increased nor reduced the risk of MACE, all-cause mortality, and HHF in comparison with placebo/active comparators (MH-OR: 1.09, 95% CI 0.97-1.23; 0.99, 95% CI 0.91, 1.08; and 0.90, 95% CI 0.78, 1.04, respectively). CONCLUSIONS This meta-analysis showed no significant effects of insulin on incident MACE, all-cause mortality, and HHF.
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Affiliation(s)
| | - Giovanni Targher
- Endocrinology, Diabetes and Metabolism, University of Verona, Italy
| | - Besmir Nreu
- Diabetology, Careggi Hospital and University of Florence, Italy
| | | | - Riccardo Candido
- Diabetes Centre District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Via Puccini 48/50, 34100, Trieste, Italy
| | - Andrea Giaccari
- Centro per le Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Marco Gallo
- Endocrinology and Metabolic Diseases Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Matteo Monami
- Diabetology, Careggi Hospital and University of Florence, Italy.
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Hassanein M, Al Dahi W, Radhi HT, AIMahfouz A, Al Kaabi J, Alshammari A, Alfutaisi A, AlMalki MH, Malik R. Expert-Group Practical Advice on Insulin Initiation and Titration for Patients with Type 2 Diabetes in the Gulf Region. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2022. [DOI: 10.1159/000521437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The type 2 diabetes mellitus (T2DM) management represents a major challenge in the Gulf region. Hyperglycemia is a major risk factor for microvascular and macrovascular complications and increased mortality. Early dietary and lifestyle changes alongside a step-wise targeted pharmacological approach to achieve a glycated hemoglobin (HbA<sub>1c</sub>) level of <7% are recommended to limit these complications. However, achievement of this HbA<sub>1c</sub> target remains a major challenge, especially in the Gulf region. Both physician and patient-led barriers limit timely initiation and titration of insulin. An expert-group advisory committee reviewed the current guideline recommendations, strategized best practice, and curated clinical practical advices to enable primary-care physicians to optimally initiate and titrate insulin in patients with T2DM.
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Rados DV, Falcetta MRR, Pinto LC, Leitão CB, Gross JL. All-cause mortality and cardiovascular safety of basal insulin treatment in patients with type 2 diabetes mellitus: A systematic review with meta-analysis and trial sequential analysis. Diabetes Res Clin Pract 2021; 173:108688. [PMID: 33549676 DOI: 10.1016/j.diabres.2021.108688] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 09/04/2020] [Accepted: 01/24/2021] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the risk of all-cause and cardiovascular mortality, acute myocardial infarction, and stroke associated with insulin treatment in patients with type 2 diabetes. METHODS A systematic review with meta-analysis of randomized clinical trials (RCTs) was performed. EMBASE, Cochrane, and PubMed databases were searched for RCTs reporting mortality or cardiovascular events and comparing basal insulin to any treatment in patients with type 2 diabetes. Data were summarized with Mantel-Haenzel relative risk (RR). Trial sequential analysis (TSA) was used to evaluate the reliability of the results considering a 20% relative risk difference between treatments. PROSPERO Registry: CRD42018087336. RESULTS In total, 2351 references were identified, and 26 studies (24348 patients) were included. Most studies evaluated glargine insulin (69%), compared insulin to GLP-1 analogs (57%), and evaluated add-on therapy with metformin (77%). Insulin was not associated with increased all-cause mortality (RR 0.99; 95% confidence interval (CI) 0.92-1.06), cardiovascular mortality (RR 1.01; 95% CI 0.91-1.13), myocardial infarction (RR 1.02; 95% CI 0.92-1.15), or stroke (RR 0.87; 95% CI 0.68-1.12). Insulin treatment increased severe hypoglycemia risk (RR 2.98; 95% CI 2.47-3.61). All analyses had low statistical heterogeneity. TSA confirmed these findings: optimal sample size (myocardial infarction), futility boundary (all-cause mortality, cardiovascular mortality, and stroke) and harm boundary (hypoglycemia) were reached. CONCLUSION Treatment with basal insulin of patients with type 2 diabetes does not increase the risk of cardiovascular events or death. Despite the increased risk of hypoglycemia, these findings reinforce that insulin is a safe option in the treatment of type 2 diabetes.
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Affiliation(s)
- Dimitris Varvaki Rados
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil.
| | - Mariana Rangel Ribeiro Falcetta
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil
| | - Lana Catani Pinto
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil
| | - Cristiane Bauermann Leitão
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil.
| | - Jorge Luiz Gross
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre/Post-graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2350, Prédio 12, 4 andar, Porto Alegre, RS 90035-903, Brazil
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Rainkie DC, Abedini ZS, Abdelkader NN. Reporting and methodological quality of systematic reviews and meta-analysis with protocols in Diabetes Mellitus Type II: A systematic review. PLoS One 2020; 15:e0243091. [PMID: 33326429 PMCID: PMC7743973 DOI: 10.1371/journal.pone.0243091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/15/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Systematic reviews with or without meta-analyses (SR/MAs) are strongly encouraged to work from a protocol to facilitate high quality, transparent methodology. The completeness of reporting of a protocol (PRISMA-P) and manuscript (PRISMA) is essential to the quality appraisal (AMSTAR-2) and appropriate use of SR/MAs in making treatment decisions. OBJECTIVES The objectives of this study were to describe the completeness of reporting and quality of SR/MAs, assess the correlations between PRISMA-P, PRISMA, and AMSTAR-2, and to identify reporting characteristics between similar items of PRISMA-P and PRISMA. METHODS We performed a systematic review of Type 2 Diabetes Mellitus SR/MAs of hypoglycemic agents with publicly available protocols. Cochrane reviews, guidelines, and specific types of MA were excluded. Two reviewers independently, (i) searched PubMed and Embase between 1/1/2015 to 20/3/2019; (ii) identified protocols of included studies by searching the manuscript bibliography, supplementary material, PROSPERO, and Google; (iii) completed PRISMA-P, PRISMA, and AMSTAR-2 tools. Data analysis included descriptive statistics, Pearson correlation, and multivariable linear regression. RESULTS Of 357 relevant SR/MAs, 51 had available protocols and were included. The average score for PRISMA-P was 15.8±3.3 (66%; maximum 24) and 25.2±1.1 (93%; maximum 27) for PRISMA. The quality of SR/MAs assessed using the AMSTAR-2 tool identified an overall poor quality (63% critically low, 18% low, 8% moderate, 12% high). The correlation between the PRISMA-P and PRISMA was not significant (r = 0.264; p = 0.06). Correlation was significant between PRISMA-P and AMSTAR-2 (r = 0.333; p = 0.02) and PRISMA and AMSTAR-2 (r = 0.555; p<0.01). Discrepancies in reporting were common between similar PRISMA-P and PRISMA items. CONCLUSION Adherence to protocol reporting guidance was poor while manuscript reporting was comprehensive. Protocol completeness is not associated with a completely reported manuscript. Independently, PRISMA-P and PRISMA scores were weakly associated with higher quality assessments but insufficient as a surrogate for quality. Critical areas for quality improvement include protocol description, investigating causes of heterogeneity, and the impact of risk of bias on the evidence synthesis.
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Pietraszek A. Cardiovascular Effects of Hypoglycemic Agents in Diabetes Mellitus. Curr Drug Saf 2020; 16:32-51. [PMID: 32881674 DOI: 10.2174/1574886315666200902154736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/01/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite substantial improvements over the years, diabetes mellitus is still associated with cardiovascular disease, heart failure, and excess mortality. OBJECTIVE The objective of this article is to examine existing data on the reduction of cardiovascular morbidity and mortality in diabetes. Control of glycemia, lipid levels, and blood pressure are described in brief. The main scope of this article is, however, to review the glucose-independent cardiovascular effect of antidiabetic pharmacological agents (mainly other than insulin). METHODS The article is a narrative review based on recently published reviews and meta-analyses complemented with data from individual trials, when relevant. RESULTS AND DISCUSSION Older data suggest a cardioprotective role of metformin (an inexpensive and safe drug); a role to date not convincingly challenged. The cardiovascular effects of thiazolidinediones, sulphonylurea, and glinides are debatable. Recent large-scale cardiovascular outcome trials suggest a neutral profile of dipeptidyl peptidase 4 inhibitors, yet provide compelling evidence of cardioprotective effects of glucagon-like 1 receptor antagonists and sodium-glucose transporter 2 inhibitors. CONCLUSION Metformin may have a role in primary and secondary prevention of cardiovascular disease; glucagon-like 1 receptor antagonists and sodium-glucose co-transporter 2 inhibitors play a role in secondary prevention of atherosclerotic cardiovascular disease. Sodium-glucose transporter 2 inhibitors have a role to play in both primary and secondary prevention of heart failure; yet, they carry a small risk of the potentially dangerous adverse effect, euglycemic diabetic ketoacidosis.
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Affiliation(s)
- Anna Pietraszek
- Steno Diabetes Center North Jutland, Aalborg University Hospital, Aalborg, Aalborg, Denmark
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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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Neugebauer R, Schroeder EB, Reynolds K, Schmittdiel JA, Loes L, Dyer W, Desai JR, Vazquez-Benitez G, Ho PM, Anderson JP, Pimentel N, O’Connor PJ. Comparison of Mortality and Major Cardiovascular Events Among Adults With Type 2 Diabetes Using Human vs Analogue Insulins. JAMA Netw Open 2020; 3:e1918554. [PMID: 31977057 PMCID: PMC6991251 DOI: 10.1001/jamanetworkopen.2019.18554] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/15/2019] [Indexed: 12/25/2022] Open
Abstract
Importance The comparative cardiovascular safety of analogue and human insulins in adults with type 2 diabetes who initiate insulin therapy in usual care settings has not been carefully evaluated using machine learning and other rigorous analytic methods. Objective To examine the association of analogue vs human insulin use with mortality and major cardiovascular events. Design, Setting, and Participants This retrospective cohort study included 127 600 adults aged 21 to 89 years with type 2 diabetes at 4 health care delivery systems who initiated insulin therapy from January 1, 2000, through December 31, 2013. Machine learning and rigorous inference methods with time-varying exposures were used to evaluate associations of continuous exposure to analogue vs human insulins with mortality and major cardiovascular events. Data were analyzed from September 1, 2017, through June 30, 2018. Exposures On the index date (first insulin dispensing), participants were classified as using analogue insulin with or without human insulin or human insulin only. Main Outcomes and Measures Overall mortality, mortality due to cardiovascular disease (CVD), myocardial infarction (MI), stroke or cerebrovascular accident (CVA), and hospitalization for congestive heart failure (CHF) were evaluated. Marginal structural modeling (MSM) with inverse probability weighting was used to compare event-free survival in separate per-protocol analyses. Adjusted and unadjusted hazard ratios and cumulative risk differences were based on logistic MSM parameterizations for counterfactual hazards. Propensity scores were estimated using a data-adaptive approach (machine learning) based on 3 nested covariate adjustment sets. Sensitivity analyses were conducted to address potential residual confounding from unmeasured differences in risk factors across delivery systems. Results The 127 600 participants (mean [SD] age, 59.4 [12.6] years; 68 588 men [53.8%]; mean [SD] body mass index, 32.3 [7.1]) had a median follow-up of 4 quarters (interquartile range, 3-9 quarters) and experienced 5464 deaths overall (4.3%), 1729 MIs (1.4%), 1301 CVAs (1.0%), and 3082 CHF hospitalizations (2.4%). There were no differences in adjusted hazard ratios for continuous analogue vs human insulin exposure during 10 quarters for overall mortality (1.15; 95% CI, 0.97-1.34), CVD mortality (1.26; 95% CI, 0.86-1.66), MI (1.11; 95% CI, 0.77-1.45), CVA (1.30; 95% CI, 0.81-1.78), or CHF hospitalization (0.93; 95% CI, 0.75-1.11). Conclusions and Relevance Insulin-naive adults with type 2 diabetes who initiate and continue treatment with human vs analogue insulins had similar observed rates of major cardiovascular events, CVD mortality, and overall mortality.
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Affiliation(s)
- Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Linda Loes
- HealthPartners Institute, Minneapolis, Minnesota
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jay R. Desai
- HealthPartners Institute, Minneapolis, Minnesota
| | | | - P. Michael Ho
- Rocky Mountain Regional Veterans Affairs and University of Colorado (Anschutz) Medical Center, Denver
| | | | - Noel Pimentel
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Patrick J. O’Connor
- HealthPartners Institute, Minneapolis, Minnesota
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
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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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11
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Landoni G, Pisano A, Lomivorotov V, Alvaro G, Hajjar L, Paternoster G, Nigro Neto C, Latronico N, Fominskiy E, Pasin L, Finco G, Lobreglio R, Azzolini ML, Buscaglia G, Castella A, Comis M, Conte A, Conte M, Corradi F, Dal Checco E, De Vuono G, Ganzaroli M, Garofalo E, Gazivoda G, Lembo R, Marianello D, Baiardo Redaelli M, Monaco F, Tarzia V, Mucchetti M, Belletti A, Mura P, Musu M, Pala G, Paltenghi M, Pasyuga V, Piras D, Riefolo C, Roasio A, Ruggeri L, Santini F, Székely A, Verniero L, Vezzani A, Zangrillo A, Bellomo R. Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process. J Cardiothorac Vasc Anesth 2017; 31:719-730. [DOI: 10.1053/j.jvca.2016.07.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Indexed: 11/11/2022]
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12
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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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13
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Chow W, Miyasato G, Kokkotos FK, Bailey RA, Buysman EK, Henk HJ. Real-world Canagliflozin Utilization: Glycemic Control Among Patients With Type 2 Diabetes Mellitus—A Multi-Database Synthesis. Clin Ther 2016; 38:2071-82. [DOI: 10.1016/j.clinthera.2016.07.168] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/22/2016] [Indexed: 01/29/2023]
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14
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Strandberg AY, Hoti FJ, Strandberg TE, Christopher S, Haukka J, Korhonen P. All-Cause and Cause-Specific Mortality among Users of Basal Insulins NPH, Detemir, and Glargine. PLoS One 2016; 11:e0151910. [PMID: 27031113 PMCID: PMC4816506 DOI: 10.1371/journal.pone.0151910] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 03/07/2016] [Indexed: 12/29/2022] Open
Abstract
Background Insulin therapy in type 2 diabetes may increase mortality and cancer incidence, but the impact of different types of basal insulins on these endpoints is unclear. Compared to the traditional NPH insulin, the newer, longer-acting insulin analogues detemir and glargine have shown benefits in randomized controlled trials. Whether these advantages translate into lower mortality among users in real life is unknown. Objective To estimate the differences in all-cause and cause-specific mortality rates between new users of basal insulins in a population-based study in Finland. Methods 23 751 individuals aged ≥40 with type 2 diabetes, who initiated basal insulin therapy in 2006–2009 were identified from national registers, with comprehensive data for mortality, causes of death, and background variables. Propensity score matching was performed on characteristics. Follow-up time was up to 4 years (median 1.7 years). Results 2078 deaths incurred. With NPH as reference, the adjusted HRs for all-cause mortality were 0.39 (95% CI, 0.30–0.50) for detemir, and 0.55 (95% CI, 0.44–0.69) for glargine. As compared to glargine, the HR was 0.71 (95% CI, 0.54–0.93) among detemir users. Compared to NPH, the mortality risk for both cardiovascular causes as well as cancer were also significantly lower for glargine, and especially for detemir in adjusted analysis. Furthermore, the results were robust in various sensitivity analyses. Conclusion In real clinical practice, mortality was substantially higher among users of NPH insulin as compared to insulins detemir or glargine. Considering the large number of patients who require insulin therapy, this difference in risk may have major clinical and public health implications. Due to limitations of the observational study design, further investigation using an interventional study design is warranted.
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Affiliation(s)
- Arto Y. Strandberg
- University of Helsinki, Clinicum, Helsinki, Finland
- Aava Medical Centre, Kerava, Finland
- * E-mail:
| | | | - Timo E. Strandberg
- University of Helsinki, Clinicum, Helsinki, Finland
- Helsinki University Central Hospital, Helsinki, Finland
- University of Oulu, Center for Life Course Health Research, Oulu, Finland
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15
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Giugliano D, Chiodini P, Maiorino MI, Bellastella G, Esposito K. Intensification of insulin therapy with basal-bolus or premixed insulin regimens in type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Endocrine 2016; 51:417-28. [PMID: 26281001 DOI: 10.1007/s12020-015-0718-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022]
Abstract
The purpose of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the effect of intensified insulin regimens (basal-bolus versus premixed) on glycemic control in patients with type 2 diabetes. We conducted an electronic search until March 2015 on many electronic databases including online registries of ongoing trials. All RCTs comparing basal-bolus with premixed insulin regimens, with a duration of >12 weeks and with >30 patients per arm, were included. Investigators extracted data on study characteristics, outcome measures, and methodological quality. We found thirteen RCTs lasting 16-60 weeks and involving 5255 patients assessed for the primary endpoint (reduction of HbA1c from baseline). Meta-analysis of change in HbA1c level between basal-bolus and premixed insulin regimens resulted in a small and non-significant difference of 0.09% (95% CI -0.03 to 0.21), with substantial heterogeneity between studies (I(2) = 74.4%). There was no statistically significant difference in the event rate for overall hypoglycemia (0.16 episode/patient/year, 95%CI -2.07 to 2.3), weight change (-0.21 kg, -0.164 to 0.185), and daily insulin dose (-0.54 U/day, -2.7 to 1.6). The likelihood for reaching the HbA1c <7% was 8% higher (3-13%, I(2) = 68.8%) with the basal-bolus as compared with the premixed regimen. There is no clinically relevant difference in the efficacy of basal-bolus versus premixed insulin regimens for HbA1c decrease in type 2 diabetic patients. These findings may be helpful to adapt treatment to individual patient needs.
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Affiliation(s)
- Dario Giugliano
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, Naples, Italy.
| | - Paolo Chiodini
- Department of Mental and Physical Health, Second University of Naples, Naples, Italy
- Medical Statistics Unit, Second University of Naples, Naples, Italy
| | - Maria Ida Maiorino
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Giuseppe Bellastella
- Division of Endocrinology and Metabolic Diseases, Department of Medical, Surgical, Neurological, Metabolic Sciences and Aging, Second University of Naples, Naples, Italy
| | - Katherine Esposito
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
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16
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Tsapas A, Karagiannis T, Bekiari E. Premixed insulin regimens for type 2 diabetes. Endocrine 2016; 51:387-9. [PMID: 26649859 DOI: 10.1007/s12020-015-0821-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 11/24/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Hippokratio General Hospital, 49 Konstantinoupoleos Street, 54642, Thessaloniki, Greece.
- Diabetes Centre, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece.
- Harris Manchester College, University of Oxford, Oxford, UK.
| | - Thomas Karagiannis
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Hippokratio General Hospital, 49 Konstantinoupoleos Street, 54642, Thessaloniki, Greece
| | - Eleni Bekiari
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Hippokratio General Hospital, 49 Konstantinoupoleos Street, 54642, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
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17
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Mameli C, Mazzantini S, Ben Nasr M, Fiorina P, Scaramuzza AE, Zuccotti GV. Explaining the increased mortality in type 1 diabetes. World J Diabetes 2015; 6:889-895. [PMID: 26185597 PMCID: PMC4499523 DOI: 10.4239/wjd.v6.i7.889] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 04/07/2015] [Accepted: 04/20/2015] [Indexed: 02/05/2023] Open
Abstract
Despite large improvements in the management of glucose levels and in the treatment of cardiovascular risk factors, the mortality rate in individuals with type 1 diabetes (T1D) is still high. Recently, Lind et al found that T1D individuals with glycated hemoglobin levels of 6.9% or lower had a risk of death from any cause or from cardiovascular causes that is twice as high as the risk for matched controls. T1D is a chronic disease with an early onset (e.g., pediatric age) and thus in order to establish a clear correlation between death rate and the glycometabolic control, the whole history of glycemic control should be considered; particularly in the early years of diabetes. The switch from a normo- to hyperglycemic milieu in an individual with T1D in the pediatric age, represents a stressful event that may impact outcomes and death rate many years later. In this paper we will discuss the aforementioned issues, and offer our view on these findings, paying a particular attention to the several alterations occurring in the earliest phases of T1D and to the many factors that may be associated with the chronic history of T1D. This may help us to better understand the recently published death rate data and to develop future innovative and effective preventive strategies.
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18
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Price HI, Agnew MD, Gamble JM. Comparative cardiovascular morbidity and mortality in patients taking different insulin regimens for type 2 diabetes: a systematic review. BMJ Open 2015; 5:e006341. [PMID: 25762229 PMCID: PMC4360720 DOI: 10.1136/bmjopen-2014-006341] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 02/15/2015] [Accepted: 02/16/2015] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To summarise the literature evaluating the association between different insulin regimens and the incidence of cardiovascular morbidity and mortality in adults with type 2 diabetes. DESIGN Systematic review. METHODS Multiple biomedical databases (The Cochrane Library, PubMed, EMBASE, and International Pharmaceutical Abstracts) were searched from their inception to February 2014. References of included studies were hand searched. Randomised controlled trials (RCTs), cohort studies or case-control studies examining adults (≥18 years) with type 2 diabetes taking any type, dose and/or regimen of insulin were eligible for inclusion in this review. OUTCOME MEASURES Primary outcomes were cardiovascular morbidity and mortality including fatal and/or non-fatal myocardial infarction, fatal and/or non-fatal stroke, major adverse cardiac events and cardiovascular death. All-cause mortality was assessed as a secondary outcome. RESULTS Of the 3122 studies identified, 2 RCTs and 6 cohort studies were selected. No case-control studies met the inclusion criteria. The studies examined a total of 109,910 patients. Quantitative synthesis of the results from included studies was not possible due to a large amount of clinical heterogeneity. Each study evaluated cardiovascular outcomes across different insulin-exposure contrasts. RCTs did not identify any difference in cardiovascular risks among a fixed versus variable insulin regimen, or a prandial versus basal regimen, albeit clinically important risks and benefits cannot be ruled out due to wide CIs. Findings from cohort studies were variable with an increased and decreased risk of cardiovascular events and all-cause mortality being reported. CONCLUSIONS This systematic review of randomised and non-randomised studies identifies a substantive gap in the literature surrounding the cardiovascular morbidity and mortality of patients using different regimens of insulin. There is a need for more consistent high-quality evidence investigating the impact of insulin use on cardiovascular outcomes in patients with type 2 diabetes. TRIAL REGISTRATION NUMBER PROSPERO CRD42014007631.
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Affiliation(s)
- Hilary I Price
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Meghan D Agnew
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - John-Michael Gamble
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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