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Yu X, Fan M, Zhao X, Ding Y, Liu X, Yang S, Zhang X. Prevalence of impaired awareness of hypoglycaemia in people with diabetes mellitus: A systematic review and meta-analysis from 21 countries and regions. Diabet Med 2023; 40:e15129. [PMID: 37143390 DOI: 10.1111/dme.15129] [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: 12/01/2022] [Revised: 04/25/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023]
Abstract
AIMS Impaired awareness of hypoglycaemia (IAH) is a complication of glucose-lowering therapies for diabetes. The purpose of this review was to estimate the pooled prevalence of IAH and unawareness of hypoglycaemia (UAH). METHODS We searched the major databases from inception to 8 August 2022 and included all cross-sectional and cohort studies reporting IAH prevalence in people with diabetes. A random-effects model was used to pool effect values. Subgroup analysis and meta-regression were used to identify study-level characteristics affecting prevalence. RESULTS Sixty-two studies from 21 countries published between 2000 and 2022 were included, with 39,180 participants (type 1 diabetes: 19,304 vs. Type 2 diabetes: 14,650). The pooled prevalence was 23.2% (95% CI: 18.4%-29.3%) via the Clarke questionnaire, 26.2% (95% CI: 22.9%-29.9%) via the Gold score, and 58.5% (95% CI: 53.0%-64.6%) via the Pedersen-Bjergaard method, all from studies classified as presenting a moderate and low risk of bias. The prevalence of IAH was generally higher in people with type 1 diabetes than in those with type 2 diabetes and lowest in Europe. Meta-regression results show that the duration of diabetes was a factor influencing the prevalence of IAH. The prevalence of UAH by the Pedersen-Bjergaard method was 17.6 (95% CI: 14.9%-20.3%). CONCLUSIONS IAH is a prevalent risk event among people with type 1 and type 2 diabetes, showing clinical heterogeneity and regional variability. UAH, an adverse progression of IAH, is also a serious burden. More primary research on the prevalence of IAH is needed in areas with a high diabetes burden.
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Affiliation(s)
- Xiaohui Yu
- School of Nursing, Anhui Medical University, Hefei, Anhui, China
| | - Min Fan
- School of Nursing, Anhui Medical University, Hefei, Anhui, China
| | - Xia Zhao
- School of Nursing, Anhui Medical University, Hefei, Anhui, China
| | - Yanan Ding
- School of Nursing, Anhui Medical University, Hefei, Anhui, China
| | - Xueli Liu
- School of Nursing, Anhui Medical University, Hefei, Anhui, China
| | - Shengju Yang
- Department of Endocrinology, The First Affiliated Hospital of the University of Science and Technology of China (Anhui Provincial Hospital), Hefei, Anhui, China
| | - Xinqiong Zhang
- School of Nursing, Anhui Medical University, Hefei, Anhui, China
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Stegherr R, Beyersmann J, Bramlage P, Bluhmki T. Modeling unmeasured baseline information in observational time-to-event data subject to delayed study entry. Stat Methods Med Res 2023:9622802231163334. [PMID: 36924264 DOI: 10.1177/09622802231163334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Unmeasured baseline information in left-truncated data situations frequently occurs in observational time-to-event analyses. For instance, a typical timescale in trials of antidiabetic treatment is "time since treatment initiation", but individuals may have initiated treatment before the start of longitudinal data collection. When the focus is on baseline effects, one widespread approach is to fit a Cox proportional hazards model incorporating the measurements at delayed study entry. This has been criticized because of the potential time dependency of covariates. We tackle this problem by using a Bayesian joint model that combines a mixed-effects model for the longitudinal trajectory with a proportional hazards model for the event of interest incorporating the baseline covariate, possibly unmeasured in the presence of left truncation. The novelty is that our procedure is not used to account for non-continuously monitored longitudinal covariates in right-censored time-to-event studies, but to utilize these trajectories to make inferences about missing baseline measurements in left-truncated data. Simulating times-to-event depending on baseline covariates we also compared our proposal to a simpler two-stage approach which performed favorably. Our approach is illustrated by investigating the impact of baseline blood glucose levels on antidiabetic treatment failure using data from a German diabetes register.
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Affiliation(s)
| | - Jan Beyersmann
- Institute of Statistics, 9189Ulm University, Ulm, Germany
| | - Peter Bramlage
- Institute of Pharmacology and Preventive Medicine, Mahlow, Germany
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Xue L, Wang H, He Y, Sui M, Li H, Mei L, Ying X. Incidence and risk factors of diabetes mellitus in the Chinese population: a dynamic cohort study. BMJ Open 2022; 12:e060730. [PMID: 36410801 PMCID: PMC9680191 DOI: 10.1136/bmjopen-2021-060730] [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] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Diabetes mellitus is a common condition often associated with an ageing population. However, only few longitudinal studies in China have investigated the incidence of diabetes and identified its risk factors. Therefore, this study aimed to investigate the incidence and risk factors of diabetes in Chinese people aged ≥45 years using the harmonised China Health and Retirement Longitudinal Study (CHARLS) data. DESIGN A dynamic cohort study. SETTING The harmonised CHARLS 2011-2018. PARTICIPANTS 19 988 adults aged ≥45 years. PRIMARY OUTCOME MEASURE Incident diabetes from 2011 to 2018. RESULTS The harmonised CHARLS is a representative longitudinal survey of people aged ≥45 years. Using data extracted from the harmonised CHARLS, we calculated the incidence of diabetes and used a competing risk model to determine risk factors of diabetes. In 2011-2013, 2013-2015, 2015-2018, the crude incidence of diabetes among middle-aged and older people in China was 1403.21 (1227.09 to 1604.19), 1673.22 (1485.73 to 1883.92) and 3919.83 (3646.01 to 4213.30) per 100 000 person-years, respectively, with a significant increasing trend. There were no geographical variations in the incidence of diabetes. Age, obesity and alcohol consumption were associated with an increased risk of incident diabetes. CONCLUSION The incidence of diabetes increased annually, without any geographical differences. Age, obesity and alcohol consumption were found to be risk factors for incident diabetes.
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Affiliation(s)
- Long Xue
- Department of Health Economics, Fudan University School of Public Health, Shanghai, China
| | - Huiying Wang
- Department of Medical Services, Huashan Hospital Fudan University, Shanghai, China
| | - YunZhen He
- Department of Health Economics, Fudan University School of Public Health, Shanghai, China
| | - Mengyun Sui
- Department of Health Economics, Fudan University School of Public Health, Shanghai, China
| | - Hongzheng Li
- Department of Health Economics, Fudan University School of Public Health, Shanghai, China
| | - Lin Mei
- Department of Medical Services, Huashan Hospital Fudan University, Shanghai, China
| | - Xiaohua Ying
- Department of Health Economics, Fudan University School of Public Health, Shanghai, China
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Grimsmann JM, Tittel SR, Bramlage P, Mayer B, Fritsche A, Seufert J, Laimer M, Zimny S, Meyhoefer SM, Hummel M, Holl RW. Disease heterogeneity of adult diabetes based on routine clinical variables at diagnosis: Results from the German/Austrian Diabetes Follow-up Registry. Diabetes Obes Metab 2022; 24:2253-2262. [PMID: 35791641 DOI: 10.1111/dom.14812] [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: 01/24/2022] [Revised: 06/29/2022] [Accepted: 07/01/2022] [Indexed: 11/29/2022]
Abstract
AIM To cluster adults with diabetes using variables from real-world clinical care at manifestation. MATERIALS AND METHODS We applied hierarchical clustering using Ward's method to 56 869 adults documented in the prospective Diabetes Follow-up Registry (DPV). Clustering variables included age, sex, body mass index (BMI), HbA1c, diabetic ketoacidosis (DKA), components of the metabolic syndrome (hypertension/dyslipidaemia/hyperuricaemia) and beta-cell antibody status. Time until use of oral antidiabetic drugs (OADs), use of insulin, chronic kidney disease (CKD), cardiovascular disease (CVD), retinopathy or neuropathy were assessed using Kaplan-Meier analysis and Cox regression models. RESULTS We identified eight clusters: four clusters comprised early diabetes onset (median age 40-50 years) but differed with regard to BMI, HbA1c, DKA and antibody positivity. Two clusters included adults with diabetes onset aged in their early 60s who met target HbA1c, but differed in BMI and sex distribution. Two clusters were characterized by late diabetes onset (median age 69 and 77 years) and comparatively low BMI, but differences in HbA1c. Earlier insulin use was observed in adults with high HbA1c, and earlier OAD use was observed in those with high BMI. Time until CKD or CVD was shorter in those with late onset, whereas retinopathy occurred earlier in adults with late onset and high HbA1c, and in adults with early onset, but high HbA1c and high percentage of antibody positivity. CONCLUSIONS Adult diabetes is heterogeneous beyond classical type 1/type 2 diabetes, based on easily available variables in clinical practice using an automated clustering algorithm that allows both continuous and binary variables.
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Affiliation(s)
- Julia M Grimsmann
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany
- German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Sascha R Tittel
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany
- German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Andreas Fritsche
- German Center for Diabetes Research, Eberhard Karl University, Tuebingen, Germany
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Medicine II, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Markus Laimer
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Zimny
- Department of General Internal Medicine, Endocrinology and Diabetology, Helios Clinic Schwerin, Schwerin, Germany
| | - Sebastian M Meyhoefer
- German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Institute for Endocrinology & Diabetes, University of Lübeck, Lübeck, Germany
| | | | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany
- German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany
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Kobori T, Onishi Y, Yoshida Y, Tahara T, Kikuchi T, Kubota T, Iwamoto M, Hamano S, Kasuga M. Clinical features and sulfonylurea usage among outpatients with diabetes aged ≥90 years in an urban diabetes clinic in Tokyo. J Diabetes Investig 2022; 13:2010-2017. [PMID: 36121186 DOI: 10.1111/jdi.13901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/21/2022] [Accepted: 08/21/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS/INTRODUCTION Aging of society is accelerating in many countries. The purpose of this study was to describe the clinical features and sulfonylurea usage among diabetes outpatients aged ≥90 years (nonagenarians). MATERIALS AND METHODS This study was a retrospective observational study. The study population consisted of 69 nonagenarian diabetes outpatients and 857 diabetes outpatients aged <90 years. Patients were classified into four groups: group 1, <65 years; group 2, 65-74 years; group 3, 75-89 years; and group 4, ≥90 years. The presence of hypoglycemic episodes was defined as having self-reported symptoms, or self-monitored or clinically measured blood glucose level <70 mg/dL. RESULTS The median glycated hemoglobin (HbA1c) in group 1 and group 4 was 7.0% and 7.2%, respectively (P = 0.506). The proportion of sulfonylurea treatment in group 4 was 45.5%, which is significantly higher compared with the other three groups (20.0-27.8%, P < 0.001). In group 4, there was no difference between patients with or without sulfonylurea in age, sex, body mass index, HbA1c and number of antihyperglycemic agents. Five out of 25 nonagenarian sulfonylurea-treated patients had hypoglycemic episodes within the last 2 years, their HbA1c were all 7.0 ≤ HbA1c < 8.0, and sulfonylurea or insulin was tapered in all cases after confirming hypoglycemia. Tapering dosage was attempted in all 25 sulfonylurea-treated nonagenarian patients, but 15 needed to continue sulfonylurea for glycemic control, and 10 continued sulfonylurea with unknown reasons from their medical records. CONCLUSIONS Although tapering the dosage of sulfonylurea was attempted in nonagenarian patients, sulfonylurea was widely continued for glycemic control. Reverse clinical inertia may exist in some sulfonylurea-treated nonagenarian patients.
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Affiliation(s)
- Toshiko Kobori
- Division of Diabetes and Metabolism, The Institute of Medical Science, Asahi Life Foundation, Tokyo, Japan
| | - Yukiko Onishi
- Division of Diabetes and Metabolism, The Institute of Medical Science, Asahi Life Foundation, Tokyo, Japan
| | - Yoko Yoshida
- Division of Diabetes and Metabolism, The Institute of Medical Science, Asahi Life Foundation, Tokyo, Japan
| | - Tazu Tahara
- Division of Diabetes and Metabolism, The Institute of Medical Science, Asahi Life Foundation, Tokyo, Japan
| | - Takako Kikuchi
- Division of Diabetes and Metabolism, The Institute of Medical Science, Asahi Life Foundation, Tokyo, Japan
| | - Tetsuya Kubota
- Division of Diabetes and Metabolism, The Institute of Medical Science, Asahi Life Foundation, Tokyo, Japan
| | - Masahiko Iwamoto
- Division of Diabetes and Metabolism, The Institute of Medical Science, Asahi Life Foundation, Tokyo, Japan
| | - Shoko Hamano
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masato Kasuga
- Division of Diabetes and Metabolism, The Institute of Medical Science, Asahi Life Foundation, Tokyo, Japan
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van Mark G, Tittel SR, Welp R, Gloyer J, Sziegoleit S, Barion R, Jehle PM, Erath D, Bramlage P, Lanzinger S. DIVE/DPV registries: benefits and risks of analog insulin use in individuals 75 years and older with type 2 diabetes mellitus. BMJ Open Diabetes Res Care 2021; 9:9/1/e002215. [PMID: 34083247 PMCID: PMC8183199 DOI: 10.1136/bmjdrc-2021-002215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The aims of this study were to characterize insulin-treated individuals aged ≥75 years with type 2 diabetes using basal insulin analogs (BIA) or regular insulins (human insulin (HI)/neutral protamine Hagedorn (NPH)) and to compare the benefits and risks. RESEARCH DESIGN AND METHODS The analysis was based on data from the DPV (Diabetes-Patienten-Verlaufsdokumentation) and DIVE (DIabetes Versorgungs-Evaluation) registries. To balance for confounders, propensity score matching for age, sex, diabetes duration, body mass index and hemoglobin A1c (HbA1c) as covariates was performed. RESULTS Among 167 300 patients aged ≥75 years with type 2 diabetes (mean age, 80.3 years), 9601 subjects used insulin regimens with basal insulin (HI/NPH or BIA). Of these 8022 propensity score-matched subjects were identified. The mean diabetes duration was ~12 years and half of the patients were male. At the time of switch, patients provided with BIA experienced more dyslipidemia (89.3% vs 85.9%; p=0.002) and took a greater number of medications (4.3 vs 3.7; p<0.001) and depression was more prevalent (8.4% vs 6.5%; p=0.01). Aggregated to the most actual treatment year, BIA was associated with a higher percentage of patients using basal-supported oral therapy (42.6% vs 14.4%) and intensified conventional insulin therapy (44.3% vs 29.4%) and lower total daily insulin doses (0.24 IU/kg/day vs 0.30 IU/kg/day; p<0.001). The study did not reveal significant differences in efficacy (HbA1c 7.4% vs 7.3%; p=0.06), hospitalizations (0.7 vs 0.8 per patient-year (PY); p=0.15), length of stay (16.3 vs 16.1 days per PY; p=0.53), or rates of severe hypoglycemia (4.07 vs 4.40 per 100 PY; p=0.88), hypoglycemia with coma (3.64 vs 3.26 per 100 PY; p=0.88) and diabetic ketoacidosis (0.01 vs 0.03 per 100 PY; p=0.36). CONCLUSION BIA were used in more individually and patient-centered therapy regimens compared with HI/NPH in patients with a mean age of 80 years. Both groups were slightly overtreated with mean HbA1c <7.5%. The risk of severe hypoglycemia was low and independent of insulin type. Further analyses of elderly patients with type 2 diabetes are needed to provide evidence for best practice approaches in this age group.
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Affiliation(s)
- Gesine van Mark
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Sascha R Tittel
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Reinhard Welp
- Department of Internal Medicine, Knappschaftskrankenhaus Bottrop, Bottrop, Germany
| | - Jörg Gloyer
- Center for Diabetes Ludwigsburg, Ludwigsburg, Germany
| | | | - Ralf Barion
- Medical Practice for Internal Medicine and Diabetology Rhein-Sieg, Niederkassel-Rheidt, Germany
| | - Peter M Jehle
- Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, University Medicine, Academic Hospital Paul-Gerhardt-Stift, Lutherstadt Wittenberg, Germany
| | - Dieter Erath
- Medical Practice for Internal Medicine Rottweil, Rottweil, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Stefanie Lanzinger
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
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