1
|
Mellor J, Kuznetsov D, Heller S, Gall MA, Rosilio M, Amiel SA, Ibberson M, McGurnaghan S, Blackbourn L, Berthon W, Salem A, Qu Y, McCrimmon RJ, de Galan BE, Pedersen-Bjergaard U, Leaviss J, McKeigue PM, Colhoun HM. Estimating risk of consequences following hypoglycaemia exposure using the Hypo-RESOLVE cohort: a secondary analysis of pooled data from insulin clinical trials. Diabetologia 2024:10.1007/s00125-024-06225-1. [PMID: 39037602 DOI: 10.1007/s00125-024-06225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/30/2024] [Indexed: 07/23/2024]
Abstract
AIMS/HYPOTHESIS Whether hypoglycaemia increases the risk of other adverse outcomes in diabetes remains controversial, especially for hypoglycaemia episodes not requiring assistance from another person. An objective of the Hypoglycaemia REdefining SOLutions for better liVEs (Hypo-RESOLVE) project was to create and use a dataset of pooled clinical trials in people with type 1 or type 2 diabetes to examine the association of exposure to all hypoglycaemia episodes across the range of severity with incident event outcomes: death, CVD, neuropathy, kidney disease, retinal disorders and depression. We also examined the change in continuous outcomes that occurred following a hypoglycaemia episode: change in eGFR, HbA1c, blood glucose, blood glucose variability and weight. METHODS Data from 84 trials with 39,373 participants were pooled. For event outcomes, time-updated Cox regression models adjusted for age, sex, diabetes duration and HbA1c were fitted to assess association between: (1) outcome and cumulative exposure to hypoglycaemia episodes; and (2) outcomes where an acute effect might be expected (i.e. death, acute CVD, retinal disorders) and any hypoglycaemia exposure within the last 10 days. Exposures to any hypoglycaemia episode and to episodes of given severity (levels 1, 2 and 3) were examined. Further adjustment was then made for a wider set of potential confounders. The within-person change in continuous outcomes was also summarised (median of 40.4 weeks for type 1 diabetes and 26 weeks for type 2 diabetes). Analyses were conducted separately by type of diabetes. RESULTS The maximally adjusted association analysis for type 1 diabetes found that cumulative exposure to hypoglycaemia episodes of any level was associated with higher risks of neuropathy, kidney disease, retinal disorders and depression, with risk ratios ranging from 1.55 (p=0.002) to 2.81 (p=0.002). Associations of a similar direction were found when level 1 episodes were examined separately but were significant for depression only. For type 2 diabetes cumulative exposure to hypoglycaemia episodes of any level was associated with higher risks of death, acute CVD, kidney disease, retinal disorders and depression, with risk ratios ranging from 2.35 (p<0.0001) to 3.00 (p<0.0001). These associations remained significant when level 1 episodes were examined separately. There was evidence of an association between hypoglycaemia episodes of any kind in the previous 10 days and death, acute CVD and retinal disorders in both type 1 and type 2 diabetes, with rate ratios ranging from 1.32 (p=0.017) to 2.68 (p<0.0001). These associations varied in magnitude and significance when examined separately by hypoglycaemia level. Within the range of hypoglycaemia defined by levels 1, 2 and 3, we could not find any evidence of a threshold at which risk of these consequences suddenly became pronounced. CONCLUSIONS/INTERPRETATION These data are consistent with hypoglycaemia being associated with an increased risk of adverse events across several body systems in diabetes. These associations are not confined to severe hypoglycaemia requiring assistance.
Collapse
Affiliation(s)
- Joseph Mellor
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.
| | | | - Simon Heller
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Mari-Anne Gall
- Medical & Science, Insulin, Clinical Drug Development, Novo Nordisk A/S, Soeberg, Denmark
| | - Myriam Rosilio
- Diabetes Medical Unit, Eli Lilly and Company, Neuilly-sur-Seine, France
| | - Stephanie A Amiel
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Mark Ibberson
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Stuart McGurnaghan
- Institute of Genetics and Cancer, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Luke Blackbourn
- Institute of Genetics and Cancer, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - William Berthon
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Adel Salem
- RW Data Assets, AI & Analytics(AIA), Novo Nordisk A/S, Soeberg, Denmark
| | - Yongming Qu
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Bastiaan E de Galan
- Division of Endocrinology and Metabolic Disease, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Paul M McKeigue
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Helen M Colhoun
- Institute of Genetics and Cancer, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
2
|
Grammes J, Schmid S, Bozkurt L, Heinemann L, Hess G, Kubiak T, Küstner E, Priesterroth LS, Stahl C, Holl RW. Continuous glucose monitoring in older adults with diabetes: Data from the diabetes prospective follow-up (DPV) registry. Diabet Med 2024; 41:e15261. [PMID: 38009855 DOI: 10.1111/dme.15261] [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: 09/13/2023] [Revised: 11/10/2023] [Accepted: 11/15/2023] [Indexed: 11/29/2023]
Abstract
AIMS To analyse predictors for continuous glucose monitoring (CGM) use in people with diabetes aged ≥60 years using insulin therapy and to assess the rates of CGM use during recent years (2019-2021). RESEARCH DESIGN AND METHODS Prospective study including 6849 individuals with diabetes and insulin therapy (type 2 diabetes: n = 5320; type 1 diabetes: n = 1529) aged ≥60 years. Data from 129 treatment centres were retrieved from the Diabetes Prospective Follow-up Registry (DPV) in March 2023. RESULTS Sensor use in individuals aged ≥60 years has increased in type 1 (2019: 28%, 2020: 39%, 2021: 45%) and type 2 diabetes (2019: 10%, 2020: 16%, 2021: 18%). Predictors for sensor use in older individuals with type 1 diabetes are younger age and CSII use (p < 0.001). Predictors in older individuals with type 2 diabetes are younger age, longer diabetes duration, higher BMI and CSII use (p < 0.001). CONCLUSIONS CGM has become more common in older adults with diabetes and will presumably increase further. Age is a predictor for sensor use in older adults with diabetes. Age-related physical barriers and insufficient usability of devices, lack of interest in technologies, but possibly also effects of prejudice on the grounds of age may contribute to this finding.
Collapse
Affiliation(s)
- Jennifer Grammes
- Health Psychology, Johannes Gutenberg University, Mainz, Germany
| | - Stefanie Schmid
- Institute of Epidemiology and Medical Biometry, CAQM, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
| | - Latife Bozkurt
- Department of Internal Medicine III and Karl Landsteiner Institute for Metabolic Disorders and Nephrology, Clinic Hietzing, Vienna Health Care Group, Vienna, Austria
| | | | - Gregor Hess
- Diabetology Private Practice, Worms, Germany
| | - Thomas Kubiak
- Health Psychology, Johannes Gutenberg University, Mainz, Germany
| | | | | | | | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, CAQM, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
| |
Collapse
|
3
|
Julián MT, Pérez-Montes de Oca A, Julve J, Alonso N. The double burden: type 1 diabetes and heart failure-a comprehensive review. Cardiovasc Diabetol 2024; 23:65. [PMID: 38347569 PMCID: PMC10863220 DOI: 10.1186/s12933-024-02136-y] [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: 10/06/2023] [Accepted: 01/15/2024] [Indexed: 02/15/2024] Open
Abstract
Heart failure (HF) is increasing at an alarming rate, primary due to the rising in aging, obesity and diabetes. Notably, individuals with type 1 diabetes (T1D) face a significantly elevated risk of HF, leading to more hospitalizations and increased case fatality rates. Several risk factors contribute to HF in T1D, including poor glycemic control, female gender, smoking, hypertension, elevated BMI, and albuminuria. However, early and intensive glycemic control can mitigate the long-term risk of HF in individuals with T1D. The pathophysiology of diabetes-associated HF is complex and multifactorial, and the underlying mechanisms in T1D remain incompletely elucidated. In terms of treatment, much of the evidence comes from type 2 diabetes (T2D) populations, so applying it to T1D requires caution. Sodium-glucose cotransporter 2 inhibitors have shown benefits in HF outcomes, even in non-diabetic populations. However, most of the information about HF and the evidence from cardiovascular safety trials related to glucose lowering medications refer to T2D. Glycemic control is key, but the link between hypoglycemia and HF hospitalization risk requires further study. Glycemic variability, common in T1D, is an independent HF risk factor. Technological advances offer the potential to improve glycemic control, including glycemic variability, and may play a role in preventing HF. In summary, HF in T1D is a complex challenge with unique dimensions. This review focuses on HF in individuals with T1D, exploring its epidemiology, risk factors, pathophysiology, diagnosis and treatment, which is crucial for developing tailored prevention and management strategies for this population.
Collapse
Affiliation(s)
- María Teresa Julián
- Department of Endocrinology and Nutrition, Hospital Germans Trias i Pujol, Badalona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Alejandra Pérez-Montes de Oca
- Department of Endocrinology and Nutrition, Hospital Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep Julve
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
- Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
| | - Nuria Alonso
- Department of Endocrinology and Nutrition, Hospital Germans Trias i Pujol, Badalona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Center for Biomedical Research on Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain.
| |
Collapse
|
4
|
Marx N, Kolkailah AA, Rosenstock J, Johansen OE, Cooper ME, Alexander JH, Toto RD, Wanner C, Espeland MA, Mattheus M, Schnaidt S, Perkovic V, Gollop ND, McGuire DK. Hypoglycemia and Cardiovascular Outcomes in the CARMELINA and CAROLINA Trials of Linagliptin: A Secondary Analysis of Randomized Clinical Trials. JAMA Cardiol 2024; 9:134-143. [PMID: 38170502 PMCID: PMC10765314 DOI: 10.1001/jamacardio.2023.4602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 10/06/2023] [Indexed: 01/05/2024]
Abstract
Importance Previous studies have reported an association between hypoglycemia and cardiovascular (CV) events in people with type 2 diabetes (T2D), but it is unclear if this association is causal or identifies a high-risk patient phenotype. Objective To evaluate the associations between hypoglycemia and CV outcomes. Design, Setting, and Participants This secondary analysis was a post hoc assessment of the multinational, double-blind CARMELINA (Cardiovascular and Renal Microvascular Outcome Study With Linagliptin; 2013-2016) and CAROLINA (Cardiovascular Outcome Trial of Linagliptin vs Glimepiride in Type 2 Diabetes; 2010-2018) randomized clinical trials of the antihyperglycemic drug, linagliptin, a dipeptidyl peptidase 4 inhibitor. Participants were adults with T2D at high CV risk with or without high kidney risk. By design, participants in the CARMELINA trial had longer duration of T2D and had a higher CV risk than participants in the CAROLINA trial. Data analyses were conducted between June 2021 and June 2023. Intervention Linagliptin or placebo in the CARMELINA trial, and linagliptin or glimepiride in the CAROLINA trial. Main Outcomes and Measures The primary outcome for both trials was CV death, myocardial infarction (MI), or stroke (3-point major adverse CV events [3P-MACE]). For the present analyses, hospitalization for heart failure (HF) was added. Hypoglycemia was defined as plasma glucose less than 54 mg/dL or severe hypoglycemia (episodes requiring the assistance of another person). Associations between the first hypoglycemic episode and subsequent CV events and between nonfatal CV events (MI, stroke, hospitalization for HF) and subsequent hypoglycemic episodes were assessed using multivariable Cox proportional hazards regression models. Sensitivity analyses explored the risk of CV events within 60 days after each hypoglycemic episode. Results In the CARMELINA trial (6979 patients; 4390 males [62.9%]; mean [SD] age, 65.9 [9.1] years), there was an association between hypoglycemia and subsequent 3P-MACE plus hospitalization for HF (hazard ratio [HR], 1.23; 95% CI, 1.04-1.46) as well as between nonfatal CV events and subsequent hypoglycemia (HR, 1.39; 95% CI, 1.06-1.83). In the CAROLINA trial (6033 patients; 3619 males (60.0%); mean [SD] age, 64.0 [9.5] years), there was no association between hypoglycemia and subsequent 3P-MACE plus hospitalization for HF (HR, 1.00; 95% CI, 0.76-1.32) and between nonfatal CV events and subsequent hypoglycemia (HR, 1.44; 95% CI, 0.96-2.16). In analyses of CV events occurring within 60 days after hypoglycemia, there was either no association or too few events to analyze. Conclusions and Relevance This study found bidirectional associations between hypoglycemia and CV outcomes in the CARMELINA trial but no associations in either direction in the CAROLINA trial, challenging the notion that hypoglycemia causes adverse CV events. The findings from the CARMELINA trial suggest that both hypoglycemia and CV events more likely identify patients at high risk for both. Trial Registration ClinicalTrials.gov Identifier: NCT01897532 (CARMELINA) and NCT01243424 (CAROLINA).
Collapse
Affiliation(s)
- Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ahmed A. Kolkailah
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
| | | | - Odd Erik Johansen
- Therapeutic Area Cardiometabolism, Boehringer Ingelheim KS, Asker, Norway
| | - Mark E. Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - John H. Alexander
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Robert D. Toto
- Department of Internal Medicine, Division of Nephrology, The University of Texas Southwestern Medical Center, Dallas
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Mark A. Espeland
- Division of Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michaela Mattheus
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany
| | - Sven Schnaidt
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riß, Germany
| | - Vlado Perkovic
- Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales Sydney, Newtown, New South Wales, Australia
| | - Nicholas D. Gollop
- Therapeutic Area Cardiometabolism, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
- Parkland Health, Dallas, Texas
| |
Collapse
|
5
|
Erandathi MA, Wang WYC, Mayo M, Lee CC. Comprehensive Factors for Predicting the Complications of DiabetesMellitus: A Systematic Review. Curr Diabetes Rev 2024; 20:e040124225240. [PMID: 38178670 DOI: 10.2174/0115733998271863231116062601] [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: 07/12/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND This article focuses on extracting a standard feature set for predicting the complications of diabetes mellitus by systematically reviewing the literature. It is conducted and reported by following the guidelines of PRISMA, a well-known systematic review and meta-analysis method. The research articles included in this study are extracted using the search engine "Web of Science" over eight years. The most common complications of diabetes, diabetic neuropathy, retinopathy, nephropathy, and cardiovascular diseases are considered in the study. METHOD The features used to predict the complications are identified and categorised by scrutinising the standards of electronic health records. RESULT Overall, 102 research articles have been reviewed, resulting in 59 frequent features being identified. Nineteen attributes are recognised as a standard in all four considered complications, which are age, gender, ethnicity, weight, height, BMI, smoking history, HbA1c, SBP, eGFR, DBP, HDL, LDL, total cholesterol, triglyceride, use of insulin, duration of diabetes, family history of CVD, and diabetes. The existence of a well-accepted and updated feature set for health analytics models to predict the complications of diabetes mellitus is a vital and contemporary requirement. A widely accepted feature set is beneficial for benchmarking the risk factors of complications of diabetes. CONCLUSION This study is a thorough literature review to provide a clear state of the art for academicians, clinicians, and other stakeholders regarding the risk factors and their importance.
Collapse
Affiliation(s)
| | | | | | - Ching-Chi Lee
- National Chen Kung University Hospital, Tainan, Taiwan
| |
Collapse
|
6
|
Battelino T, Brosius F, Ceriello A, Cosentino F, Green J, Kellerer M, Koob S, Kosiborod M, Lalic N, Marx N, Nedungadi TP, Rydén L, Rodbard HW, Ji L, Sheu WHH, Standl E, Parkin CG, Schnell O. Guideline Development for Medical Device Technology: Issues for Consideration. J Diabetes Sci Technol 2023; 17:1698-1710. [PMID: 35531901 PMCID: PMC10658688 DOI: 10.1177/19322968221093355] [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] [Indexed: 11/15/2022]
Abstract
Advances in the development of innovative medical devices and telehealth technologies create the potential to improve the quality and efficiency of diabetes care through collecting, aggregating, and interpreting relevant health data in ways that facilitate more informed decisions among all stakeholder groups. Although many medical societies publish guidelines for utilizing these technologies in clinical practice, we believe that the methodologies used for the selection and grading of the evidence should be revised. In this article, we discuss the strengths and limitations of the various types of research commonly used for evidence selection and grading and present recommendations for modifying the process to more effectively address the rapid pace of device and technology innovation and new product development.
Collapse
Affiliation(s)
- Tadej Battelino
- University Medical Center Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - Frank Brosius
- University of Arizona College of Medicine–Tucson, AZ, USA
| | | | - Francesco Cosentino
- Cardiology Unit, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Jennifer Green
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Mikhail Kosiborod
- Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Nebojsa Lalic
- Clinic for Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | | | - Lars Rydén
- Department of Medicine K2, Karolinska Institute, Stockholm, Sweden
| | | | - Linong Ji
- Peking University People’s Hospital, Beijing, China
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung City
| | | | | | | |
Collapse
|
7
|
Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 197] [Impact Index Per Article: 197.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
|
8
|
Song SH, Frier BM. Severe hypoglycaemia in adults presenting to a hospital emergency department: Clinical characteristics, comorbidities, and mortality outcomes. Diabetes Obes Metab 2023; 25:2824-2834. [PMID: 37334521 DOI: 10.1111/dom.15170] [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: 03/27/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 06/20/2023]
Abstract
AIMS To determine the clinical characteristics, risk factors and mortality outcomes associated with severe hypoglycaemia (SH) treated at a hospital emergency department. MATERIALS AND METHODS Adult patients presenting with SH to the Northern General Hospital, Sheffield, UK over a 44-month period were assessed for clinical characteristics, coexisting comorbidities and mortality outcomes, including cause of death, and analysed by age of diabetes onset, below and above age 40 years. Factors that predicted mortality were determined. RESULTS A total of 619 episodes of SH occurred in 506 individuals. Most had type 1 (T1D; n = 172 [34.0%]) or type 2 diabetes (T2D; n = 216 [42.7%]), but several attendees did not have diabetes (non-DM; n = 110 [21.7%]). Irrespective of age of diabetes onset, patients with T2D had more socioeconomic deprivation and comorbidities (P < 0.005). SH was uncommon in those with young-onset T2D, who constituted 7.2% of all episodes in diabetes. Hospital admission was high (60%-75%). The T2D cohort had the longest inpatient stay (median 5 days, vs. 2 and 3 days for the T1D and non-DM cohorts, respectively). Survival after the index SH episode was lower and mortality was higher in the non-DM (39.1%) and T2D (38.0%) cohorts than the T1D cohort (13.3%; all P < 0.05), with a median time to death of 13, 113 and 465 days, respectively. Most deaths (78%-86%) were from non-cardiovascular causes. Charlson index predicted mortality and poor survival in T1D and T2D (both P < 0.05). CONCLUSIONS Severe hypoglycaemia requiring emergency hospital treatment is associated with non-cardiovascular deaths and exerts a disproportionately greater impact on mortality in people with T2D and those without diabetes. Multimorbidity is an important risk factor for SH and increases mortality risk.
Collapse
Affiliation(s)
- Soon H Song
- Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Brian M Frier
- The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
9
|
Carreira A, Castro P, Mira F, Melo M, Ribeiro P, Santos L. Acute kidney injury: a strong risk factor for hypoglycaemia in hospitalized patients with type 2 diabetes. Acta Diabetol 2023; 60:1179-1185. [PMID: 37173530 PMCID: PMC10359379 DOI: 10.1007/s00592-023-02112-0] [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: 12/19/2022] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
AIMS Acute kidney injury (AKI) is highly prevalent during hospitalization of patients with type 2 diabetes (T2D). We aimed to assess the impact of AKI and its severity and duration on the risk of hypoglycaemia in hospitalized patients with T2D. METHODS Retrospective cohort analysis of patients with T2D, admitted at a University Hospital in 2018-2019. AKI was defined as an increase in serum creatinine by ≥ 0.3 mg/dl (48 h) or ≥ 1.5 times baseline (7 days), and hypoglycaemia as blood glucose concentration < 70 mg/dl. Patients with chronic kidney disease stage ≥ 4 were excluded. We registered 239 hospitalizations with AKI and randomly selected 239 without AKI (control). Multiple logistic regression was used to adjust for confounding factors and ROC curve analysis to determine a cutoff for AKI duration. RESULTS The risk of hypoglycaemia was higher in the AKI group (crude OR 3.6, 95%CI 1.8-9.6), even after adjusting for covariates (OR 4.2, 95%CI 1.8-9.6). Each day of AKI duration was associated with a 14% increase in the risk of hypoglycaemia (95%CI 1.1-1.2), and a cutoff of 5.5 days of AKI duration was obtained for increased risk of hypoglycaemia and mortality. AKI severity was also associated with mortality, but showed no significant association with hypoglycaemia. Patients with hypoglycaemia had 4.4 times greater risk of mortality (95%CI 2.4-8.2). CONCLUSIONS AKI increased the risk of hypoglycaemia during hospitalization of patients with T2D, and its duration was the main risk factor. These results highlight the need for specific protocols to avoid hypoglycaemia and its burden in patients with AKI.
Collapse
Affiliation(s)
- Ana Carreira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Pedro Castro
- Department of Nephrology, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
- Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Filipe Mira
- Department of Nephrology, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
- Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
- Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Pedro Ribeiro
- Department of Internal Medicine, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Lèlita Santos
- Department of Internal Medicine, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
- Faculty of Medicine, Coimbra University, Coimbra, Portugal
| |
Collapse
|
10
|
Li G, Zhong S, Wang X, Zhuge F. Association of hypoglycaemia with the risks of arrhythmia and mortality in individuals with diabetes - a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1222409. [PMID: 37645418 PMCID: PMC10461564 DOI: 10.3389/fendo.2023.1222409] [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: 05/14/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
Background Hypoglycaemia has been linked to an increased risk of cardiac arrhythmias by causing autonomic and metabolic alterations, which may be associated with detrimental outcomes in individuals with diabetes(IWD), such as cardiovascular diseases (CVDs) and mortality, especially in multimorbid or frail people. However, such relationships in this population have not been thoroughly investigated. For this reason, we conducted a systematic review and meta-analysis. Methods Relevant papers published on PubMed, Embase, Cochrane, Web of Knowledge, Scopus, and CINHAL complete from inception to December 22, 2022 were routinely searched without regard for language. All of the selected articles included odds ratio, hazard ratio, or relative risk statistics, as well as data for estimating the connection of hypoglycaemia with cardiac arrhythmia, CVD-induced death, or total death in IWD. Regardless of the heterogeneity assessed by the I2 statistic, pooled relative risks (RRs) and 95% confidence intervals (CI) were obtained using random-effects models. Results After deleting duplicates and closely evaluating all screened citations, we chose 60 studies with totally 5,960,224 participants for this analysis. Fourteen studies were included in the arrhythmia risk analysis, and 50 in the analysis of all-cause mortality. Hypoglycaemic patients had significantly higher risks of arrhythmia occurrence (RR 1.42, 95%CI 1.21-1.68), CVD-induced death (RR 1.59, 95% CI 1.24-2.04), and all-cause mortality (RR 1.68, 95% CI 1.49-1.90) compared to euglycaemic patients with significant heterogeneity. Conclusion Hypoglycaemic individuals are more susceptible to develop cardiac arrhythmias and die, but evidence of potential causal linkages beyond statistical associations must await proof by additional specifically well planned research that controls for all potential remaining confounding factors.
Collapse
Affiliation(s)
- Gangfeng Li
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Shuping Zhong
- Department of Hospital Management, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Xingmu Wang
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Fuyuan Zhuge
- Department of Endocrine and Metabolism, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| |
Collapse
|
11
|
Shi K, Zhang G, Fu H, Huang S, Xu HY, Gao Y, Shi R, Yan WF, Qian WL, Li Y, Guo YK, Yang ZG. Association of insulin use with LV remodeling and clinical outcomes in diabetic patients with heart failure and reduced ejection fraction: assessed by cardiac MRI. Cardiovasc Diabetol 2023; 22:201. [PMID: 37542280 PMCID: PMC10403944 DOI: 10.1186/s12933-023-01944-y] [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: 04/02/2023] [Accepted: 07/27/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Insulin is commonly used in type 2 diabetes mellitus (T2DM) to achieve glycemic control. However, recent evidence showed that insulin use is associated with poor outcomes in the context of heart failure (HF). Since heart failure with reduced ejection fraction (HFrEF) accounts for approximately 50% of cases in the general HF population, we aimed to evaluate the effect of insulin treatment on left ventricular (LV) remodeling and contractility abnormalities in a HFrEF cohort and assess whether insulin was a predictor of adverse outcomes in this entity. METHODS A total of 377 HFrEF patients who underwent cardiac MRI were included and divided according to diabetes status and the need for insulin treatment. LV structural and functional indices, as well as systolic strains, were measured. The determinants of impaired myocardial strains were assessed using linear regression analysis. The associated endpoints were determined using a multivariable Cox proportional hazards model. RESULTS T2DM patients on insulin displayed a higher indexed LV end-diastolic volume and LV mass than those with T2DM not on insulin or those without T2DM, despite similar LV ejection fractions, accompanied by a higher three-dimensional spherical index (P < 0.01). Worse longitudinal and circumferential peak systolic strain was shown to occur in T2DM patients on insulin (P < 0.01). Insulin treatment was independently associated with impaired magnitudes of systolic strain. The median follow-up duration was 32.4 months (IQR, 15.6-43.2 months). Insulin treatment remained consistently associated with poor outcomes after adjustment for established confounders, with an adjusted hazard ratio of 3.11; (95% CI, 1.45-6.87; P = 0.009) in the overall cohort and 2.16 (95% CI, 1.08-4.59; P = 0.030) in the diabetes cohort. CONCLUSIONS Insulin may further lead to adverse LV remodeling and contractile dysfunction in the context of HFrEF with T2DM. Considerable care should be taken when treating HFrEF patients with insulin.
Collapse
Affiliation(s)
- Ke Shi
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ge Zhang
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiology, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital and Institute, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Hang Fu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shan Huang
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hua-Yan Xu
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yue Gao
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rui Shi
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei-Feng Yan
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wen-Lei Qian
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuan Li
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhi-Gang Yang
- Department of Radiology, Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| |
Collapse
|
12
|
Madar H, Wu Z, Bandini A, Perkins B, Messier V, Pomey MP, Brazeau AS, Rabasa-Lhoret R. Influence of severe hypoglycemia definition wording on reported prevalence in adults and adolescents with type 1 diabetes: a cross-sectional analysis from the BETTER patient-engagement registry analysis. Acta Diabetol 2023; 60:93-100. [PMID: 36245008 DOI: 10.1007/s00592-022-01987-9] [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: 06/22/2022] [Accepted: 09/28/2022] [Indexed: 01/12/2023]
Abstract
AIMS Compare the self-reported prevalence of severe hypoglycemia (level-3-H) in people with type 1 diabetes (PWT1D) according to two wording of definition: by the International Hypoglycemia Study Group (IHSG) and an alternate simplified version developed by patient-partners (PP). METHODS Cross-sectional study (PWT1D > = 14 years) self-reporting risk factors, patient-year incidence and annual prevalence of level-3-H were defined according to either IHSG's wording (low sugar levels requiring help from another person, or use of glucagon, or hospitalization, or loss of consciousness) or with an alternative simpler wording developed by PP (low sugar levels that you would have been unable to treat). RESULTS Among 1430 eligible participants, in the last 12 months, the annual prevalence of level-3-H (IHSG: 242/100 vs. PP: 231/100 patient-years, p = 0.229) and median number of episodes (IHSG: 2.0 [1-3] vs. PP: 1.0 [1-3], p = 0.359) were similar. The prevalence of participants reporting hypoglycemia in the past year was higher with IHSG wording (13.5% vs. 10.5%; p < 0.001); this difference was significantly (p < 0.001) larger among patients with impaired awareness of hypoglycemia. Association of both definitions with level-3-H risk factors was comparable. CONCLUSIONS The level-3-H episodes by PP and IHSG wording were comparable. The simplicity of PP wording may allow better mutual understanding between patients and healthcare team. TRIAL REGISTRATION NCT03720197 (registered on October 19th 2018).
Collapse
Affiliation(s)
- Houssein Madar
- Montreal Clinical Research Institute (IRCM), 110 Av. des Pins, Montreal, QC, H2W 1R7, Canada
| | - Zekai Wu
- Montreal Clinical Research Institute (IRCM), 110 Av. des Pins, Montreal, QC, H2W 1R7, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Aude Bandini
- Department of Philosophy, Faculty of Arts and Sciences, Université de Montréal, Montreal, QC, Canada
| | - Bruce Perkins
- Division of Endocrinology, Leadership Sinai Center for Diabetes, University of Toronto, Toronto, ON, Canada
| | - Virginie Messier
- Montreal Clinical Research Institute (IRCM), 110 Av. des Pins, Montreal, QC, H2W 1R7, Canada
| | - Marie-Pascale Pomey
- Department of Management, Evaluation and Health Policy, School of Public Health, Université de Montréal, Montreal, QC, Canada
- Endocrinology Division and CHUM Research Center, Centre Hospitalier de L'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Anne-Sophie Brazeau
- Montreal Clinical Research Institute (IRCM), 110 Av. des Pins, Montreal, QC, H2W 1R7, Canada
- School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, QC, Canada
- Montreal Diabetes Research Center (MDRC), Montreal, QC, Canada
| | - Rémi Rabasa-Lhoret
- Montreal Clinical Research Institute (IRCM), 110 Av. des Pins, Montreal, QC, H2W 1R7, Canada.
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, QC, Canada.
- Endocrinology Division and CHUM Research Center, Centre Hospitalier de L'Université de Montréal (CHUM), Montreal, QC, Canada.
- Department of Nutrition, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.
- Montreal Diabetes Research Center (MDRC), Montreal, QC, Canada.
| |
Collapse
|
13
|
Iqbal A, Storey RF, Ajjan RA. Prolonged Inflammatory Response Post-Hypoglycemia: Mechanistic Insights Into the Relationship Between Low Glucose and Cardiovascular Risk. Diabetes 2022; 71:2483-2485. [PMID: 36409790 PMCID: PMC9862283 DOI: 10.2337/dbi22-0028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/01/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Ahmed Iqbal
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, U.K
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
| | - Robert F. Storey
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, U.K
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, U.K
| | - Ramzi A. Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K
- Corresponding author: Ramzi Ajjan,
| |
Collapse
|
14
|
Schütt K, Aberle J, Bauersachs J, Birkenfeld A, Frantz S, Ganz M, Jacob S, Kellerer M, Leschke M, Liebetrau C, Marx N, Müller-Wieland D, Raake P, Schulze PC, Tschöpe D, von Haehling S, Zelniker TA, Forst T. Positionspapier Herzinsuffizienz und Diabetes. DIABETOL STOFFWECHS 2022. [DOI: 10.1055/a-1867-3026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
ZusammenfassungDiabetes mellitus (DM) stellt eine wichtige Komorbidität bei Patienten mit Herzinsuffizienz dar, die maßgeblich die Prognose der Patienten determiniert. Von entscheidender Bedeutung zur Verbesserung der Prognose dieser Hochrisiko-Patienten ist daher eine frühzeitige Diagnostik und differenzierte medikamentöse Therapie mit Ausschöpfung aller möglichen Therapieoptionen und Absetzen potenziell schädlicher Substanzen. Das gemeinsame Positionspapier der Deutschen Gesellschaft für Kardiologie (DGK) und der Deutschen Diabetes Gesellschaft (DDG) fasst die vorhandene wissenschaftliche Evidenz zusammen und gibt Empfehlungen, was bei der Diagnose und Therapie der Herzinsuffizienz und des DM zu beachten ist, um die Prognose zu verbessern.
Collapse
Affiliation(s)
- Katharina Schütt
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum RWTH Aachen, Aachen, Deutschland
| | - Jens Aberle
- Ambulanzzentrum für Endokrinologie, Diabetologie, Adipositas und Lipide/Klinik und Poliklinik für Nephrologie, Rheumatologie und Endokrinologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Johann Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Andreas Birkenfeld
- Klinik für Diabetologie, Endokrinologie und Nephrologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
- Helmholtz Zentrum München und Deutsches Zentrum für Diabetesforschung (DZD e. V.), Neuherberg, Deutschland
| | - Stefan Frantz
- Medizinische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Manfred Ganz
- Ganzvital Beratung in der Gesundheitswirtschaft, Bexbach/Saar, Deutschland
| | - Stephan Jacob
- Praxis für Prävention und Therapie, Villingen-Schwenningen, Deutschland
| | - Monika Kellerer
- Klinik für Diabetologie, Endokrinologie, Allgemeine Innere Medizin, Kardiologie, Angiologie, Internistische Intensivmedizin, Marienhospital Stuttgart, Stuttgart, Deutschland
| | - Matthias Leschke
- Klinik für Kardiologie, Angiologie und Pneumologie, Klinikum Esslingen, Esslingen a. N., Deutschland
| | | | - Nikolaus Marx
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum RWTH Aachen, Aachen, Deutschland
| | - Dirk Müller-Wieland
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum RWTH Aachen, Aachen, Deutschland
| | - Philip Raake
- Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Paul Christian Schulze
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Jena, Jena, Deutschland
- Kommission für Klinische Kardiovaskuläre Medizin, Deutsche Gesellschaft für Kardiologie, Düsseldorf, Deutschland
| | - Diethelm Tschöpe
- Herz- und Diabeteszentrum NRW, Universitätsklinik, Ruhr-Universität Bochum, Bad Oeynhausen, Deutschland
- Stiftung DHD (Der herzkranke Diabetiker) in der Deutschen Diabetes-Stiftung, Bad Oeynhausen, Deutschland
| | - Stephan von Haehling
- Klinik für Kardiologie und Pneumologie, Herzzentrum Göttingen, Universitätsmedizin Göttingen, Göttingen, Deutschland
- Standort Göttingen, Deutsches Zentrum für Herz- und Kreislaufforschung (DZHK), Göttingen, Deutschland
| | - Thomas A. Zelniker
- Universitätsklinik für Kardiologie, Medizinische Universität Wien, Wien, Österreich
| | - Thomas Forst
- CRS Clinical Research Services Mannheim GmbH, Mannheim, Deutschland
| |
Collapse
|
15
|
Abdelhafiz AH, Sinclair AJ. Metabolic phenotypes explain the relationship between dysglycaemia and frailty in older people with type 2 diabetes. J Diabetes Complications 2022; 36:108144. [PMID: 35151546 DOI: 10.1016/j.jdiacomp.2022.108144] [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: 10/20/2021] [Revised: 01/17/2022] [Accepted: 01/29/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Dysglycaemia (hyperglycaemia and hypoglycaemia) increase the risk of frailty in older people with diabetes, which appears contradictory. However, the characteristics of patients included in these studies are different and may reflect different metabolic phenotypes of frailty that may explain this apparent contradiction. AIMS To review the characteristics of frail patients included in clinical studies that reported an association between dysglycaemia and frailty in order to explore whether there is any metabolic differences in the profile of these patients. METHODS A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Key words around older people, type 2 diabetes mellitus, frailty, hyperglycaemia and low glycaemia were used in the literature search. RESULTS Only 8 studies met the inclusion criteria. Four studies investigated the risk of frailty associated with low glycaemia. Two studies showed that hypoglycaemia increased the risk of frailty by 44% (HR 1.60, 95% CI 1.14 to 2.42) and predicted greater level of dependency (p < 0.001), respectively. The other two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.0% was associated with increased risk of disability (3.45, 1.02 to 11.6), respectively. Compared with non-frail patients, those with frailty tended to have lower body weight or body mass index (BMI), have features of malnutrition such as low serum albumin or low total cholesterol and suffer from more comorbidities including dementia. Four studies explored the association of high glycaemia with frailty. Higher HbA1c predicted frailty (OR 1.43, 95% CI 1.045 to 1.97) and positively correlated with Edmonton frail score (r = 0.44, p < 0.001), respectively in two studies. The other two studies found that subjects with HbA1c ≥ 6.5% had the greatest prevalence of frailty (70.3%) and subjects with higher HbA1c at baseline to have a higher frailty level throughout later life, respectively. Compared with non-frail patients, those with frailty tended to have higher body weight, waist circumference and BMI. They also have less physical activity, higher cholesterol level and have more comorbidities. CONCLUSIONS Dysglycaemia increases the risk of frailty but the characteristics of patients in these studies suggest different metabolic phenotypes of frailty. Therefore, these metabolic differences in frailty should be taken into consideration in the management of older people with diabetes.
Collapse
Affiliation(s)
- A H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK
| | - A J Sinclair
- King's College, London, UK; Foundation for Diabetes Research in Older People (fDROP), Droitwich Spa WR9 0QH, UK.
| |
Collapse
|
16
|
Nuzzo A, Brignoli A, C Ponziani M, Zavattaro M, Prodam F, Castello LM, Avanzi GC, Marzullo P, Aimaretti G. Aging and comorbidities influence the risk of hospitalization and mortality in diabetic patients experiencing severe hypoglycemia. Nutr Metab Cardiovasc Dis 2022; 32:160-166. [PMID: 34802847 DOI: 10.1016/j.numecd.2021.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/29/2021] [Accepted: 09/12/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS To assess the risk of hospitalization and mortality within 1 year of severe hypoglycaemia and theirs clinical predictors. METHODS AND RESULTS We retrospectively examined 399 admissions for severe hypoglycemia in adults with DM at the Emergency Department (ED) of the University Hospital of Novara (Italy) between 2012-2017, and we compared the clinical differences between older (aged ≥65 years) and younger individuals (aged 18-64 years). A logistic regression model was used to explore predictors of hospitalization following ED access and 1-year later, according to cardiovascular (CV) or not (no-CV) reasons; 1-year all-cause mortality was also detected. The study cohort comprised 302 patients (median [IQR] age 75 [17] years, 50.3% females, 93.4% white, HbA1c level 7.6% [1.0%]). Hospitalization following ED access occurred in 16.2% of patients and kidney failure (OR 0.50 [95% CI 1.29-5.03]) was the only predictor of no-CV specific hospitalization; 1-year hospitalization occurred in 24.5% of patients and obesity (OR 3.17 [95% CI 1.20-8.12]) and pre-existing heart disease (OR 3.20 [95% 1.20-9.39]) were associated with CV specific hospitalization; 1-year all-cause mortality occurred in 14.9% of patients and was associated with older age (OR 1.12 [95% CI 1.07-1.18]) and pre-existing heart disease (OR 2.63 [95% CI 1.19-6.14]) CONCLUSIONS: Severe hypoglycemia is associated with risk of hospitalization and mortality mainly in elderly patients and it may be predictive of future cardiovascular events in diabetic patients with pre-existing heart disease and obesity.
Collapse
Affiliation(s)
- Alessandro Nuzzo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
| | - Andrea Brignoli
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Maria C Ponziani
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Marco Zavattaro
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Flavia Prodam
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Luigi M Castello
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Emergency Medicine Department, AOU Maggiore della Carità, Novara, Italy
| | - Gian C Avanzi
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Emergency Medicine Department, AOU Maggiore della Carità, Novara, Italy
| | - Paolo Marzullo
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Division of General Medicine, Ospedale S. Giuseppe, I.R.C.C.S. Istituto Auxologico Italiano, Verbania, Italy
| | - Gianluca Aimaretti
- Endocrinology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| |
Collapse
|
17
|
Sullivan SD, Freemantle N, Gupta RA, Wu J, Nicholls CJ, Westerbacka J, Bailey TS. Clinical outcomes in high‐hypoglycaemia‐risk patients with type 2 diabetes switching to insulin glargine 300 U/mL versus a first‐generation basal insulin analogue in the United States : Results from the DELIVER High Risk real‐world study. Endocrinol Diabetes Metab 2022; 5:e00306. [PMID: 34807513 PMCID: PMC8754248 DOI: 10.1002/edm2.306] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/07/2021] [Accepted: 10/09/2021] [Indexed: 12/04/2022] Open
Abstract
Aims To compare 12‐month clinical effectiveness of insulin glargine 300 units/mL (Gla‐300) versus first‐generation basal insulin analogues (BIAs) (insulin glargine 100 units/mL [Gla‐100] or insulin detemir [IDet]) in patients with type 2 diabetes (T2D) who were at high risk of hypoglycaemia and switched from one BIA to a different one (Gla‐300 or Gla‐100/IDet) in a real‐world setting. Methods DELIVER High Risk was a retrospective observational cohort study of 2550 patients with T2D who switched BIA to Gla‐300 (Gla‐300 switchers) and were propensity score‐matched (1:1) to patients who switched to Gla‐100 or IDet (Gla‐100/IDet switchers). Outcomes were change in glycated haemoglobin A1c (HbA1c), attainment of HbA1c goals (<7% and <8%), and incidence and event rates of hypoglycaemia (all‐hypoglycaemia and hypoglycaemia associated with an inpatient/emergency department [ED] contact). Results HbA1c reductions were similar following switching to Gla‐300 or Gla‐100/IDet (−0.51% vs. −0.53%; p = .67), and patients showed similar attainment of HbA1c goals. Patients in both cohorts had comparable all‐hypoglycaemia incidence and event rates. However, the Gla‐300 switcher cohort had a significantly lower risk of inpatient/ED‐associated hypoglycaemia (adjusted odds ratio: 0.73, 95% confidence interval: 0.60–0.89; p = .002) and experienced significantly fewer inpatient/ED‐associated hypoglycaemic events (0.21 vs. 0.33 events per patient per year; p < .001). Conclusion In patients with T2D at high risk of hypoglycaemia, switching to Gla‐300 or Gla‐100/IDet achieved similar HbA1c reductions and glycaemic goal attainment, but Gla‐300 switchers had a significantly lower risk of hypoglycaemia associated with an inpatient/ED contact during 12 months after switching.
Collapse
Affiliation(s)
- Sean D. Sullivan
- The CHOICE Institute School of Pharmacy University of Washington Seattle WA USA
| | - Nick Freemantle
- Comprehensive Clinical Trials Unit University College London London UK
| | | | | | | | | | | |
Collapse
|
18
|
Heller SR, Geybels MS, Iqbal A, Liu L, Wagner L, Chow E. A higher non-severe hypoglycaemia rate is associated with an increased risk of subsequent severe hypoglycaemia and major adverse cardiovascular events in individuals with type 2 diabetes in the LEADER study. Diabetologia 2022; 65:55-64. [PMID: 34704120 PMCID: PMC8660716 DOI: 10.1007/s00125-021-05556-7] [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: 04/09/2021] [Accepted: 07/05/2021] [Indexed: 11/06/2022]
Abstract
AIMS/HYPOTHESIS Hypoglycaemia is a common side effect of insulin and some other antihyperglycaemic agents used to treat diabetes. Severe hypoglycaemia has been associated with adverse cardiovascular events in trials of intensive glycaemic control in type 2 diabetes. The relationship between non-severe hypoglycaemic episodes (NSHEs) and severe hypoglycaemia in type 2 diabetes has been documented. However, an association between more frequent NSHEs and cardiovascular events has not been verified. This post hoc analysis of the LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results) trial aimed to confirm whether there is an association between NSHEs and severe hypoglycaemic episodes in individuals with type 2 diabetes. In addition, the possible association between NSHEs and major adverse cardiac events (MACE), cardiovascular death and all-cause mortality was investigated. METHODS LEADER was a double-blind, multicentre, placebo-controlled trial that found that liraglutide significantly reduced the risk of MACE compared with the placebo. In this post hoc analysis, we explored, in all LEADER participants, whether the annual rate of NSHEs (defined as self-measured plasma glucose <3.1 mmol/l [56 mg/dl]) was associated with time to first severe hypoglycaemic episode (defined as an episode requiring the assistance of another person), time to first MACE, time to cardiovascular death and time to all-cause mortality. Participants with <2 NSHEs per year were used as reference for HR estimates. Cox regression with a time-varying covariate was used. RESULTS We demonstrate that there is an association between NSHEs (2-11 NSHEs per year and ≥12 NSHEs per year) and severe hypoglycaemic episodes (unadjusted HRs 1.98 [95% CI 1.43, 2.75] and 5.01 [95% CI 2.84, 8.84], respectively), which was consistent when baseline characteristics were accounted for. Additionally, while no association was found between participants with 2-11 NSHEs per year and adverse cardiovascular outcomes, higher rates of NSHEs (≥12 episodes per year) were associated with higher risk of MACE (HR 1.50 [95% CI 1.01, 2.23]), cardiovascular death (HR 2.08 [95% CI 1.17, 3.70]) and overall death (HR 1.80 [95% CI 1.11, 2.92]). CONCLUSIONS/INTERPRETATION The analysis of data from the LEADER trial demonstrated that higher rates of NSHEs were associated with both a higher risk of severe hypoglycaemia and adverse cardiovascular outcomes in individuals with type 2 diabetes. Therefore, irrespective of the cause of this association, it is important that individuals with high rates of hypoglycaemia are identified so that the potentially increased risk of cardiovascular events can be managed and steps can be taken to reduce NSHEs. TRIAL REGISTRATION ClinicalTrials.gov (NCT01179048).
Collapse
Affiliation(s)
- Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
| | | | - Ahmed Iqbal
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Lei Liu
- Novo Nordisk A/S, Søborg, Denmark
| | | | - Elaine Chow
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| |
Collapse
|
19
|
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.
Collapse
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 ;
| |
Collapse
|
20
|
Chan JCN, Lim LL, Wareham NJ, Shaw JE, Orchard TJ, Zhang P, Lau ESH, Eliasson B, Kong APS, Ezzati M, Aguilar-Salinas CA, McGill M, Levitt NS, Ning G, So WY, Adams J, Bracco P, Forouhi NG, Gregory GA, Guo J, Hua X, Klatman EL, Magliano DJ, Ng BP, Ogilvie D, Panter J, Pavkov M, Shao H, Unwin N, White M, Wou C, Ma RCW, Schmidt MI, Ramachandran A, Seino Y, Bennett PH, Oldenburg B, Gagliardino JJ, Luk AOY, Clarke PM, Ogle GD, Davies MJ, Holman RR, Gregg EW. The Lancet Commission on diabetes: using data to transform diabetes care and patient lives. Lancet 2021; 396:2019-2082. [PMID: 33189186 DOI: 10.1016/s0140-6736(20)32374-6] [Citation(s) in RCA: 303] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 07/06/2020] [Accepted: 11/05/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Juliana C N Chan
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Asia Diabetes Foundation, Hong Kong Special Administrative Region, China.
| | - Lee-Ling Lim
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Asia Diabetes Foundation, Hong Kong Special Administrative Region, China; Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nicholas J Wareham
- Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; School of Life Sciences, La Trobe University, Melbourne, VIC, Australia
| | - Trevor J Orchard
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, KS, USA
| | - Ping Zhang
- Division of Diabetes Translation, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Eric S H Lau
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Asia Diabetes Foundation, Hong Kong Special Administrative Region, China
| | - Björn Eliasson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Endocrinology and Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alice P S Kong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Majid Ezzati
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; Medical Research Council Centre for Environment and Health, Imperial College London, London, UK; WHO Collaborating Centre on NCD Surveillance and Epidemiology, Imperial College London, London, UK
| | - Carlos A Aguilar-Salinas
- Departamento de Endocrinología y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Margaret McGill
- Diabetes Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Naomi S Levitt
- Chronic Disease Initiative for Africa, Department of Medicine, Faculty of Medicine and Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Guang Ning
- Shanghai Clinical Center for Endocrine and Metabolic Disease, Department of Endocrinology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China; Shanghai Institute of Endocrine and Metabolic Diseases, Shanghai, China
| | - Wing-Yee So
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jean Adams
- Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Paula Bracco
- School of Medicine and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Nita G Forouhi
- Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Gabriel A Gregory
- Life for a Child Program, Diabetes NSW and ACT, Glebe, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jingchuan Guo
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, KS, USA
| | - Xinyang Hua
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Emma L Klatman
- Life for a Child Program, Diabetes NSW and ACT, Glebe, NSW, Australia
| | - Dianna J Magliano
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Boon-Peng Ng
- Division of Diabetes Translation, US Centers for Disease Control and Prevention, Atlanta, GA, USA; College of Nursing and Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL, USA
| | - David Ogilvie
- Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Jenna Panter
- Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Meda Pavkov
- Division of Diabetes Translation, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hui Shao
- Division of Diabetes Translation, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nigel Unwin
- Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Martin White
- Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Constance Wou
- Medical Research Council Epidemiology Unit, Institute of Metabolic Science, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Maria I Schmidt
- School of Medicine and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ambady Ramachandran
- India Diabetes Research Foundation and Dr A Ramachandran's Diabetes Hospitals, Chennai, India
| | - Yutaka Seino
- Center for Diabetes, Endocrinology and Metabolism, Kansai Electric Power Hospital, Osaka, Japan; Yutaka Seino Distinguished Center for Diabetes Research, Kansai Electric Power Medical Research Institute, Kobe, Japan
| | - Peter H Bennett
- Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Phoenix, AZ, USA
| | - Brian Oldenburg
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia; WHO Collaborating Centre on Implementation Research for Prevention and Control of NCDs, University of Melbourne, Melbourne, VIC, Australia
| | - Juan José Gagliardino
- Centro de Endocrinología Experimental y Aplicada, UNLP-CONICET-CICPBA, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina
| | - Andrea O Y Luk
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Asia Diabetes Foundation, Hong Kong Special Administrative Region, China
| | - Philip M Clarke
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Graham D Ogle
- Life for a Child Program, Diabetes NSW and ACT, Glebe, NSW, Australia; National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Edward W Gregg
- Division of Diabetes Translation, US Centers for Disease Control and Prevention, Atlanta, GA, USA; Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| |
Collapse
|
21
|
Hypoglycemia, Vascular Disease and Cognitive Dysfunction in Diabetes: Insights from Text Mining-Based Reconstruction and Bioinformatics Analysis of the Gene Networks. Int J Mol Sci 2021; 22:ijms222212419. [PMID: 34830301 PMCID: PMC8620086 DOI: 10.3390/ijms222212419] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 12/16/2022] Open
Abstract
Hypoglycemia has been recognized as a risk factor for diabetic vascular complications and cognitive decline, but the molecular mechanisms of the effect of hypoglycemia on target organs are not fully understood. In this work, gene networks of hypoglycemia and cardiovascular disease, diabetic retinopathy, diabetic nephropathy, diabetic neuropathy, cognitive decline, and Alzheimer's disease were reconstructed using ANDSystem, a text-mining-based tool. The gene network of hypoglycemia included 141 genes and 2467 interactions. Enrichment analysis of Gene Ontology (GO) biological processes showed that the regulation of insulin secretion, glucose homeostasis, apoptosis, nitric oxide biosynthesis, and cell signaling are significantly enriched for hypoglycemia. Among the network hubs, INS, IL6, LEP, TNF, IL1B, EGFR, and FOS had the highest betweenness centrality, while GPR142, MBOAT4, SLC5A4, IGFBP6, PPY, G6PC1, SLC2A2, GYS2, GCGR, and AQP7 demonstrated the highest cross-talk specificity. Hypoglycemia-related genes were overrepresented in the gene networks of diabetic complications and comorbidity; moreover, 14 genes were mutual for all studied disorders. Eleven GO biological processes (glucose homeostasis, nitric oxide biosynthesis, smooth muscle cell proliferation, ERK1 and ERK2 cascade, etc.) were overrepresented in all reconstructed networks. The obtained results expand our understanding of the molecular mechanisms underlying the deteriorating effects of hypoglycemia in diabetes-associated vascular disease and cognitive dysfunction.
Collapse
|
22
|
Abdelhafiz AH, Peters S, Sinclair AJ. Low glycaemic state increases risk of frailty and functional decline in older people with type 2 diabetes mellitus - Evidence from a systematic review. Diabetes Res Clin Pract 2021; 181:109085. [PMID: 34634389 DOI: 10.1016/j.diabres.2021.109085] [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: 07/11/2021] [Revised: 09/18/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
AIMS To explore risk of frailty and functional decline associated with low glycaemia in older people with type 2 diabetes. METHODS Systematic review. RESULTS 11 studies included. Six studies investigated risk of frailty or physical decline with hypoglycaemia. Hypoglycaemia increased risk of incident frailty (HR 1.60, 95% CI 1.14 to 2.42) in one study and risk of fractures in four studies (2.24, 1.56 to 3.21, 1.24, 1.13 to 1.37, 1.94, 1.67 to 2.24 and 1.71, 1.35 to 2.16 respectively). In sixth study, hypoglycaemia associated with dependency (P < 0.001). Five studies explored association of low blood glucose/HbA1c with frailty. One study showed that mean blood glucose decreased with increasing frailty (p = 0.003). Two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.9% increased risk of frailty (HR, 1.41 95% CI 1.12 to 1.78) respectively. Last two studies showed that HbA1c < 6.5% associated with risk of any fracture (HR 1.08, 95% CI 1.06 to 1.11) and HbA1c < 6.0% associated with increased risk of care need (3.45, 1.02 to 11.6) respectively. CONCLUSIONS Low glycaemia increases risk of frailty and functional decline in older people with type 2 diabetes. Management should minimise incidence of low glycaemia in these patients.
Collapse
Affiliation(s)
- A H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, United Kingdom
| | - S Peters
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, United Kingdom
| | - A J Sinclair
- King's College, London, United Kingdom; Foundation for Diabetes Research in Older People (fDROP), Droitwich Spa WR9 0QH, UK.
| |
Collapse
|
23
|
Fernando K, Bain SC, Holmes P, Jones PN, Patel DC. Glucagon-Like Peptide 1 Receptor Agonist Usage in Type 2 Diabetes in Primary Care for the UK and Beyond: A Narrative Review. Diabetes Ther 2021; 12:2267-2288. [PMID: 34309808 PMCID: PMC8312211 DOI: 10.1007/s13300-021-01116-9] [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: 03/26/2021] [Accepted: 07/07/2021] [Indexed: 11/23/2022] Open
Abstract
The scientific landscape of treatments for type 2 diabetes (T2D) has changed rapidly in the last decade with newer treatments becoming available. However, a large proportion of people with T2D are not able to achieve glycaemic goals because of clinical inertia. The majority of T2D management is in primary care, where clinicians (medical, nursing and pharmacist staff) play an important role in addressing patient needs and achieving treatment goals. However, management of T2D is challenging because of the heterogeneity of T2D and complexity of comorbidity, time constraints, guidance overload and the evolving treatments. Additionally, the current coronavirus disease pandemic poses additional challenges to the management of chronic diseases such as T2D, including routine access to patients for monitoring and communication. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) are a class of agents that have evolved rapidly in recent years. These agents act in a glucose-dependent manner to promote insulin secretion and inhibit glucagon secretion, as well as enhancing satiety and reducing hunger. As a result, they are effective treatment options for people with T2D, achieving glycated haemoglobin reductions, weight loss and potential cardiovascular benefit, as monotherapy or as add-on to other glucose-lowering therapies. However, given the complexity of managing T2D, it is important to equip primary care clinicians with clear information regarding efficacy, safety and appropriate positioning of GLP-1 RA therapies in clinical practice. This review provides a summary of clinical and real-world evidence along with practical guidance, with the aim of aiding primary care clinicians in the initiation and monitoring of GLP-1 RAs to help ensure that desired outcomes are realised. Furthermore, a benefit/risk tool has been developed on the basis of current available evidence and guidelines to support primary care clinicians in selecting individuals who are most likely to benefit from GLP-1 RA therapies, in addition to indicating clinical situations where caution is needed.
Collapse
Affiliation(s)
- Kevin Fernando
- North Berwick Health Centre, North Berwick Group Practice, 54 St. Baldred's Road, North Berwick, EH39 4PU, UK.
| | | | | | | | - Dipesh C Patel
- University College London, Royal Free Campus, London, UK
| |
Collapse
|
24
|
Rosano GMC, Vitale C, Maltese G. Interdisciplinary assessment and diagnostic algorithm: The role of the cardiologist. Diabetes Res Clin Pract 2021; 176:108851. [PMID: 33957142 DOI: 10.1016/j.diabres.2021.108851] [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: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
Patients with diabetes have an increased risk of developing heart failure and those with heart failure are at higher risk of developing diabetes. In patients with diabetes antidiabetic medications and the metabolic alterations of diabetes increase the risk of developing heart failure. In diabetic patients with heart failure and in those with an increased likelihood of developing the disease a stepwise approach based on the use of natriuretic peptides and echocardiography to rule out the presence of heart failure should be used. Once the diagnosis of heart failure is established it will be important to define the phenotype according to the left ventricular function and, where appropriate, use additional tests to identify possible additional underlying causes of heart failure like coronary artery disease. A multidisciplinary heart failure management programs is recommended in all patients with diabetes mellitus and heart failure to enable appropriate investigations, accurate diagnosis, and appropriate agreed evidence-based therapy and care plan. The implementation of a multidisciplinary heart failure management program requires a multidisciplinary team that will have to follow the patients throughout the whole heart failure trajectory and that should consider a holistic approach to the diabetic patient with heart failure rather than focussing merely on either heart failure or diabetes.
Collapse
Affiliation(s)
- Giuseppe M C Rosano
- St George's Hospital Medical School, London, United Kingdom; IRCCS San Raffaele Roma, Italy; St Heliers and Epsom Hospital, United Kingdom.
| | - Cristiana Vitale
- St George's Hospital Medical School, London, United Kingdom; IRCCS San Raffaele Roma, Italy; St Heliers and Epsom Hospital, United Kingdom
| | - Giuseppe Maltese
- St George's Hospital Medical School, London, United Kingdom; IRCCS San Raffaele Roma, Italy; St Heliers and Epsom Hospital, United Kingdom
| |
Collapse
|
25
|
Abstract
Hypoglycaemia (blood glucose concentration below the normal range) has been recognised as a complication of insulin treatment from the very first days of the discovery of insulin, and remains a major concern for people with diabetes, their families and healthcare professionals today. Acute hypoglycaemia stimulates a stress response that acts to restore circulating glucose, but plasma glucose concentrations can still fall too low to sustain normal brain function and cardiac rhythm. There are long-term consequences of recurrent hypoglycaemia, which are still not fully understood. This paper reviews our current understanding of the acute and cumulative consequences of hypoglycaemia in insulin-treated diabetes.
Collapse
Affiliation(s)
- Stephanie A Amiel
- Department of Diabetes, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| |
Collapse
|
26
|
Rana JS, Moffet HH, Liu JY, Karter AJ. Severe Hypoglycemia and Risk of Atherosclerotic Cardiovascular Disease in Patients With Diabetes. Diabetes Care 2021; 44:e40-e41. [PMID: 33472863 PMCID: PMC7896254 DOI: 10.2337/dc20-2798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/22/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Jamal S Rana
- Division of Research, Kaiser Permanente Northern California, Oakland, CA .,Division of Cardiology, Kaiser Permanente, Oakland Medical Center, Oakland, CA.,Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jennifer Y Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| |
Collapse
|
27
|
Nguyen JV, Roseberry S, Rivas JA, Cauthon KAB. Hypoglycemia in Older People With Type 2 Diabetes: Prevention and Treatment Strategies for Outpatient and Long-Term Care Facility Settings. Sr Care Pharm 2021; 36:112-123. [PMID: 33509335 DOI: 10.4140/tcp.n.2021.112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hypoglycemia in the older population is a significant problem accounting for increased hospitalizations, emergency room visits, health care costs, and decreased quality of life. Older patients are more susceptible to hypoglycemia because of the increased prevalence of comorbidities requiring multiple medications, age-related physiologic changes, and a progressive decline in health. Older patients are less likely to present with symptoms of hypoglycemia and symptoms may frequently appear at a lower threshold of blood glucose than in younger patients. Consequently, preventing and treating hyperglycemia in older patients can be challenging. If mismanaged, the impact of hypoglycemia in these patients can lead to acute and chronic negative outcomes. Insulin and sulfonylureas should be closely monitored, and deprescribing should be routinely considered in older patients at high risk for hypoglycemia.
Collapse
|
28
|
AANP Forum. J Nurse Pract 2021; 17:6-9. [PMID: 33495687 PMCID: PMC7816942 DOI: 10.1016/j.nurpra.2020.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
29
|
Ibrahim M, Baker J, Cahn A, Eckel RH, El Sayed NA, Fischl AH, Gaede P, Leslie RD, Pieralice S, Tuccinardi D, Pozzilli P, Richelsen B, Roitman E, Standl E, Toledano Y, Tuomilehto J, Weber SL, Umpierrez GE. Hypoglycaemia and its management in primary care setting. Diabetes Metab Res Rev 2020; 36:e3332. [PMID: 32343474 DOI: 10.1002/dmrr.3332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/30/2020] [Accepted: 04/20/2020] [Indexed: 12/14/2022]
Abstract
Hypoglycaemia is common in patients with type 1 diabetes and type 2 diabetes and constitutes a major limiting factor in achieving glycaemic control among people with diabetes. While hypoglycaemia is defined as a blood glucose level under 70 mg/dL (3.9 mmol/L), symptoms may occur at higher blood glucose levels in individuals with poor glycaemic control. Severe hypoglycaemia is defined as an episode requiring the assistance of another person to actively administer carbohydrate, glucagon, or take other corrective actions to assure neurologic recovery. Hypoglycaemia is the most important safety outcome in clinical studies of glucose lowering agents. The American Diabetes Association Standards of Medical Care recommends that a management protocol for hypoglycaemia should be designed and implemented by every hospital, along with a clear prevention and treatment plan. A tailored approach, using clinical and pathophysiologic disease stratification, can help individualize glycaemic goals and promote new therapies to improve quality of life of patients. Data from recent large clinical trials reported low risk of hypoglycaemic events with the use of newer anti-diabetic drugs. Increased hypoglycaemia risk is observed with the use of insulin and/or sulphonylureas. Vulnerable patients with T2D at dual risk of severe hypoglycaemia and cardiovascular outcomes show features of "frailty." Many of such patients may be better treated by the use of GLP-1 receptor agonists or SGLT2 inhibitors rather than insulin. Continuous glucose monitoring (CGM) should be considered for all individuals with increased risk for hypoglycaemia, impaired hypoglycaemia awareness, frequent nocturnal hypoglycaemia and with history of severe hypoglycaemia. Patients with impaired awareness of hypoglycaemia benefit from real-time CGM. The diabetes educator is an invaluable resource and can devote the time needed to thoroughly educate the individual to reduce the risk of hypoglycaemia and integrate the information within the entire construct of diabetes self-management. Conversations about hypoglycaemia facilitated by a healthcare professional may reduce the burden and fear of hypoglycaemia among patients with diabetes and their family members. Optimizing insulin doses and carbohydrate intake, in addition to a short warm up before or after the physical activity sessions may help avoiding hypoglycaemia. Several therapeutic considerations are important to reduce hypoglycaemia risk during pregnancy including administration of rapid-acting insulin analogues rather than human insulin, pre-conception initiation of insulin analogues, and immediate postpartum insulin dose reduction.
Collapse
Affiliation(s)
| | - Jason Baker
- Weill Cornell Medicine, New York, New York, USA
| | - Avivit Cahn
- The Diabetes Unit & Endocrinology and Metabolism Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Robert H Eckel
- University of Colorado Denver Anschutz Medical Campus and University of Colorado Hospital, Denver, Colorado, USA
| | - Nuha Ali El Sayed
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Hess Fischl
- University of Chicago Kovler Diabetes Center, Chicago, Illinois, USA
| | - Peter Gaede
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
| | - R David Leslie
- Blizard Institute, Queen Mary, University of London, London, UK
- Centre of Immunobiology, Barts and the London School of Medicine, Queen Mary, University of London, London, UK
| | - Silvia Pieralice
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Dario Tuccinardi
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Paolo Pozzilli
- Centre of Immunobiology, Barts and the London School of Medicine, Queen Mary, University of London, London, UK
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Bjørn Richelsen
- Steno Diabetes Center Aarhus and Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Eytan Roitman
- Institute of Diabetes, Technology and Research, Clalit Health Services, Herzelia, Israel
| | - Eberhard Standl
- Forschergruppe Diabetes eV at Munich Helmholtz Centre, Munich, Germany
| | - Yoel Toledano
- Division of Maternal Fetal Medicine, Helen Schneider Women's Hospital, Rabin Medical Center, Petah Tikva, Israel
| | | | - Sandra L Weber
- Greenville Health System, University of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA
| | | |
Collapse
|
30
|
Zaccardi F, Ling S, Lawson C, Davies MJ, Khunti K. Severe hypoglycaemia and absolute risk of cause-specific mortality in individuals with type 2 diabetes: a UK primary care observational study. Diabetologia 2020; 63:2129-2139. [PMID: 32728893 PMCID: PMC7476909 DOI: 10.1007/s00125-020-05223-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS Several pathophysiological mechanisms would suggest a causal link between hypoglycaemia and cardiovascular death; conversely, current knowledge would not support a causal relationship with other causes of death. To clarify the nature and the magnitude of the association between hypoglycaemia and death, we investigated the 5 year mortality risks for cardiovascular disease, cancer and other causes in individuals with type 2 diabetes admitted to hospital for a severe hypoglycaemic episode. METHODS We defined in the UK Clinical Practice Research Datalink database a prevalent cohort of adults with type 2 diabetes diagnosed between 1 January 1998 and 1 January 2011 (index date), with available linkage to the Office for National Statistics (ONS) and the Hospital Episode Statistics (HES). A hospital admission reporting hypoglycaemia as the underlying cause was identified before the index date in the HES; date and underlying cause of death were obtained from the ONS. We quantified the 5 year risk of cause-specific death in people with and without admission to hospital for severe hypoglycaemia, adjusting for potential confounders and accounting for competing risk. RESULTS Of the 74,610 subjects included in the cohort, 388 (0.5%) were admitted at least once for a severe hypoglycaemic episode; subjects admitted were older, with higher HbA1c and a greater prevalence of multimorbidity. During a median follow-up of 7.1 years, 236 (60.8%) and 18,539 (25.0%) deaths occurred in subjects with and without a previous severe hypoglycaemia, respectively. Non-cardiovascular causes accounted for 71% of all deaths in both subjects with and without hypoglycaemia. In a 60-year-old person with severe hypoglycaemia, the 5 year absolute risk of death, adjusted for age, sex, ethnicity, systolic blood pressure, total cholesterol, HbA1c, BMI, eGFR, smoking status, alcohol consumption and deprivation (Townsend score), was 6.6%, 1.1% and 13.1% for cardiovascular, cancer and other causes, respectively, while the 5 year absolute risk difference compared with a subject without severe hypoglycaemia was 4.7% (95% CI 1.0, 8.3) for cardiovascular, -1.4% (-4.1, 1.4) for cancer and 11.1% (6.1, 16.1) for other causes of death. Results were consistent in models further adjusted for medications and comorbidities (myocardial infarction, stroke, peripheral artery disease, heart failure, atrial fibrillation, cancer), with sulfonylurea and insulin associated with increased mortality rates (from cause-specific hazard ratio of 1.06 [95% CI 0.99, 1.14] for cancer death with use of sulfonylurea to 1.42 [1.29, 1.56] for cardiovascular death with use of insulin). Results were robust to missing data. CONCLUSIONS/INTERPRETATION The results of this study indicate severe hypoglycaemia as a marker of, rather than causally linked to, an increased risk of long-term mortality. Regardless of the nature of the association, a severe hypoglycaemic episode represents a strong negative prognostic factor in patients with type 2 diabetes. Graphical abstract.
Collapse
Affiliation(s)
- Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK.
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK.
| | - Suping Ling
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - Claire Lawson
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
- National Institute for Health Research, Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| |
Collapse
|
31
|
Runesson B, Xu Y, Qureshi AR, Lindholm B, Barany P, Elinder CG, Carrero JJ. Association between reduced kidney function and incident hypoglycaemia in people with diabetes: The Stockholm Creatinine Measurements (SCREAM) project. Diabetes Obes Metab 2020; 22:1425-1435. [PMID: 32250539 DOI: 10.1111/dom.14051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022]
Abstract
AIM To evaluate possible associations between estimated glomerular filtration rate (eGFR) and hypoglycaemia in adults with diabetes. METHODS We conducted an observational study in adults with diabetes from the Stockholm Creatinine Measurement (SCREAM) project, a Swedish healthcare utilization cohort during 2007 to 2011. We evaluated diagnoses and outpatient glucose tests for incidence rate ratios (IRRs) of hypoglycaemia (overall and by severity) in outpatient care by eGFR strata using zero-inflated negative binomial regression. We identified clinical predictors through ordinal logistic regression and assessed 7-day and 30-day mortality from hypoglycaemia in relation to eGFR with Cox proportional hazard models. RESULTS We identified 29 434 people with diabetes (13% with type 1 diabetes). Their mean age was 66 years, 43% were women and the median eGFR was 80 mL/min/1.73 m2 . During 2 years of follow-up, 1812 patients (6.2%) had hypoglycaemia registered at least once. The risk of hypoglycaemia increased linearly with lower eGFR, with an IRR of 1.2 (95% confidence interval [CI] 1.0-1.4) for eGFR 60-89 mL/min/1.73 m2 and 5.8 (95% CI 3.8-9.0) for eGFR <15 mL/min/1.73 m2 compared to eGFR 90 to 104 mL/min/1.73 m2 . This trend was observed for both mild and severe hypoglycaemia. Both 7-day and 30-day post-hypoglycaemia mortality increased with lower eGFR, peaking in those with eGFR <15 mL/min/1.73 m2 (hazard ratio 21.2, 95% CI 5.1-87.9) as compared to those with eGFR 90 to 104 mL/min/1.73 m2 . Lower eGFR categories, type 1 diabetes, previous hypoglycaemia, liver disease, presence of diabetic complications and use of insulin and sulphonylureas increased the odds of hypoglycaemia. CONCLUSION In this large, observational study, low eGFR was strongly associated with the occurrence, severity and fatality of hypoglycaemia in people with diabetes.
Collapse
Affiliation(s)
| | - Yang Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Abdul R Qureshi
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Peter Barany
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Carl G Elinder
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
32
|
McAlister FA, Zheng Y, Westerhout CM, Buse JB, Standl E, McGuire DK, Van de Werf F, Green JB, Armstrong PW, Holman RR. Association between glycated haemoglobin levels and cardiovascular outcomes in patients with type 2 diabetes and cardiovascular disease: a secondary analysis of the TECOS randomized clinical trial. Eur J Heart Fail 2020; 22:2026-2034. [PMID: 32621557 DOI: 10.1002/ejhf.1958] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/02/2023] Open
Abstract
AIMS Whether glycaemic control is associated with cardiovascular outcomes in patients with type 2 diabetes (T2D) is unclear. Consequently, we assessed the relationship between glycated haemoglobin (HbA1c ) and cardiovascular outcomes in a placebo-controlled randomized trial which demonstrated no cardiovascular effect of sitagliptin in patients with T2D and atherosclerotic vascular disease. METHODS AND RESULTS Secondary analysis of 14 656 TECOS participants with time to event analyses using multivariable Cox proportional hazard models. During a median 3.0 (interquartile range 2.3-3.8) year follow-up, 456 (3.1% of 14 656) patients had first hospitalization for heart failure (HF), 1084 (11.5%) died, 1406 (9.6%) died or were hospitalized for HF, and 1689 (11.5%) had a non-HF cardiovascular event (cardiovascular death, non-fatal stroke, non-fatal myocardial infarction, or hospitalization for unstable angina). Associations between baseline or time-varying HbA1c and cardiovascular outcomes were U-shaped, with the lowest risk when HbA1c was around 7%. Each one-unit increase in the time-varying HbA1c above 7% was associated with an adjusted hazard ratio (HR) of 1.21 [95% confidence interval (CI) 1.11-1.33] for first HF hospitalization, 1.11 (1.03-1.21) for all-cause death, 1.18 (1.09-1.26) for death or HF hospitalization, and 1.10 (1.02-1.17) for non-HF cardiovascular events. Each one-unit decrease in the time-varying HbA1c below 7% was associated with an adjusted HR of 1.35 (95% CI 1.12-1.64) for first HF hospitalization, 1.37 (1.16-1.61) for death, 1.42 (1.23-1.64) for death or HF hospitalization, and 1.22 (1.06-1.41) for non-HF cardiovascular events. CONCLUSION Glycated haemogobin exhibits a U-shaped association with cardiovascular outcomes in patients with T2D and atherosclerotic vascular disease, with nadir around 7%. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00790205.
Collapse
Affiliation(s)
- Finlay A McAlister
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | | | - John B Buse
- Division of Endocrinology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Eberhard Standl
- Diabetes Research Group, Munich Helmholtz Center, Munich, Germany
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Jennifer B Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
| | | |
Collapse
|
33
|
Affiliation(s)
- Lisa Chow
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Elizabeth R Seaquist
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
| |
Collapse
|
34
|
Standl E, Schnell O. Treatment paradigm shifting implications of recent cardiovascular outcome trials: Core insights on the brink of the 2020ies. Diabetes Res Clin Pract 2020; 161:108054. [PMID: 32035874 DOI: 10.1016/j.diabres.2020.108054] [Citation(s) in RCA: 8] [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: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 01/17/2023]
Abstract
Based on cardiovascular (CV) outcome trials (CVOTs) being available on the brink of the 2020ies, CV safety assessed by major adverse CV event outcomes has been established for the classes of glucagon-like-peptide-1 receptor agonists (GLP1 RAs), sodium-glucose-co-transporter-2 inhibitors (SGLT2-is), and dipeptidyl-peptidase-4 inhibitors (DPP4is) in patients at very high CV risk. This should be relevant to the whole population with diabetes in general as well as the fact that no new serious and unexpected side effects have emerged within these trials. At the same time, treatment paradigm shifting CV benefit has been confirmed for two classes of diabetes medications (SGLT2is & GLP1 RAs), with important additional benefit of SGLT2is reducing heart failure and hard renal endpoints, both in patients with such diseases, but also in patients being in primary prevention. Moreover, the "soft" renal outcome of albuminurea progression seems to be attenuated by all three classes of drugs discussed in this overview. Still ongoing CVOTs are not expected to essentially change the current notions, with the potential of some differentiation regarding subgroups of primary heart failure populations in relation to treatment with SGLT2is.
Collapse
Affiliation(s)
- Eberhard Standl
- Forschergruppe Diabetes e.V. at Munich Helmholtz Centre, Germany.
| | - Oliver Schnell
- Forschergruppe Diabetes e.V. at Munich Helmholtz Centre, Germany
| |
Collapse
|
35
|
[Not Available]. MMW Fortschr Med 2020; 162:3. [PMID: 32221903 DOI: 10.1007/s15006-020-0277-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
|