Changes in levels of haemoglobin A1c during the first 6 years after diagnosis of clinical type 2 diabetes

Changes in HbA1c during the first six years after the diagnosis of Type 2 diabetes mellitus predict long-term microvascular outcomes

To analyze the association between change in HbA_1c during the first 6 years after diagnosis of Type 2 diabetes mellitus (Type 2 DM) and incident micro- and macrovascular morbidity and mortality during 13 years thereafter. This is an observational study of the participants in the intervention arm of the randomized controlled trial Diabetes Care in General Practice (DCGP) in Denmark. 494 newly diagnosed persons with Type 2 DM aged 40 years and over with three or more measurements of HbA_1c during six years of intervention were included in the analyses. Based on a regression line, fitted through the HbA_1c-measurements from 1 to 6 years after diabetes diagnosis, glycaemic control was characterized by the one-year level of HbA_1c after diagnosis, and the slope of the regression line. Outcomes were incident diabetes-related morbidity and mortality from 6 to 19 years after diabetes diagnosis. The association between change in HbA_1c (the slope of the regression line) and clinical outcomes were assessed in adjusted Cox regression models. The median HbA_1c level at year one was 60 (IQR: 52–71) mmol/mol or (7.65 (IQR: 6.91–8.62) %). Higher HbA_1c levels one year after diagnosis were associated with a higher risk of later diabetes-related morbidity and mortality. An increase in HbA_1c during the first 6 years after diabetes diagnosis was associated with later microvascular complications (HR per 1.1 mmol/mol or 0.1% point increase in HbA_1c per year; 95% CI) = 1.14; 1.05–1.24). Change in HbA_1c did not predict the aggregate outcome ‘any diabetes-related endpoint, all-cause mortality, diabetes-related mortality, myocardial infarction, stroke, or peripheral vascular diseases. We conclude that suboptimal development of glycaemic control during the first 6 years after diabetes diagnosis was an independent risk factor for microvascular complications during the succeeding 13-year follow-up, but not for mortality or macrovascular complications.

Relevant patient characteristics for guiding tailored integrated diabetes primary care: a systematic review

Aim

To identify which patient-related effect modifiers influence the outcomes of integrated care programs for type 2 diabetes in primary care.

Background

Integrated care is a widespread management strategy for the treatment of type 2 diabetes. However, most integrated care programs are not tailored to patients’ needs, preferences and abilities. There is increasing consensus that such a patient-centered approach could improve the management of type 2 diabetes. Thus far, it remains unclear which patient-related effect modifiers should guide such an approach.

Methods

PubMed, CINAHL and EMBASE were searched for empirical studies published after 1998. A systematic literature review was conducted according to the PRISMA guidelines.

Findings

In total, 23 out of 1015 studies were included. A total of 21 studies measured the effects of integrated diabetes care programs on hemoglobin A1c (HbA1c) and three on low-density lipoprotein cholesterol, systolic blood pressure and health-care utilization. In total, 49 patient characteristics were assessed as potential effect modifiers with HbA1c as an outcome, of which 46 were person or health-related and only three were context-related. Younger age, insulin therapy and longer disease duration were associated with higher HbA1c levels in cross-sectional and longitudinal studies. Higher baseline HbA1c was associated with higher HbA1c at follow-up in longitudinal studies. Information on context- and person-related characteristics was limited, but is necessary to help identify the care needs of individual patients and implement an effective integrated type 2 diabetes tailored care program.

Impact of diagnosing diabetic complications on future hemoglobin A1c levels

AIM

To assess how hemoglobin A1c (HbA1c) values might change following the diagnosis of the first complication from diabetes mellitus (DM).

METHODS

Using a nationwide, longitudinal managed care network claims database (2001-2011), we identified patients with DM who experienced an initial diabetes-related complication. A paired t-test was used to compare average HbA1c levels before the initial complication was first diagnosed to average HbA1c levels following the diagnosis of the complication.

RESULTS

518 enrollees met study inclusion criteria. Patients with suboptimally controlled DM (defined as HbA1c>7% (53 mmol/mol)) prior to the diagnosis of their first diabetic complication demonstrated a clinically significant reduction in average HbA1c following the diagnosis of their first complication (mean pre-complication HbA1c=8.5 ± 1.5% (69 ± 17 mmol/mol) vs. mean post-complication HbA1c=7.9 ± 1.7% (63 ± 18 mmol/mol) (p<0.0001)).

CONCLUSION

Enrollees with suboptimally controlled DM may achieve better glycemic control following the diagnosis of a complication from DM. The results from this study, if confirmed in prospective studies, may provide a rationale for the earlier detection of complications from DM to facilitate improved glycemic control among patients with DM.

Achievement of partial combined control of major diabetes targets in primary care correlates with development of chronic complications in T2DM patients--A real life data

AIMS

Strict long term glucose, cholesterol and blood pressure control is advocated in type 2 Diabetes Mellitus (T2DM) patients. It is not known whether combined partial goals' achievement affects development of chronic complications.

METHODS

We evaluated the relative ability or failure of 5369 T2DM ambulatory patients to achieve and maintain control of blood pressure, glycaemia and cholesterol for 3 consecutive years. Correlation between the extent of combined goal achievement, and development of chronic complications was determined.

RESULTS

Only 9 patients (0.17%) fully achieved and none completely failed to achieve all strict goals. Therefore, patients were characterized as either partial achievers (PA) (n=699) or partial non achievers (PNA) (n=322). As compared to PA patients, PNA patients were significantly younger, single, and demonstrated a higher female and Arab ethnicity dominance. PNA patients had higher BMI, received more insulin treatment and consumed more hospital services. The incidence of microvascular complications during 3 years was significantly increased in PNA patients.

CONCLUSIONS

A negligible number of primary care patients completely and persistently achieve or fail to achieve combined control of major diabetes targets. Partial achievement of these targets correlates with specific patients' characteristics and incidence of chronic micro-vascular complications.

Predictors of suboptimal glycaemic control in type 2 diabetes patients: the role of medication adherence and body mass index in the relationship between glycaemia and age

AIMS

To analyse predictors of glycaemic control including medication adherence and body mass index (BMI) in UK general practice patients with sub-optimally controlled type 2 diabetes.

METHODS

Baseline demographic, health- and treatment-related measures were evaluated as predictors of one year glycaemic control defined separately as HbA(1c)≤ 7.5% and a continuous measure of HbA(1c) concentration, using multivariate regression models. Significant predictors were adjusted for objectively assessed medication adherence and BMI.

RESULTS

One-year HbA(1c) concentration was associated with baseline HbA(1c) (p<0.001), BMI (p=0.02), and inversely associated with age (p=0.007) and objectively assessed adherence. Adherent patients had one-year (adjusted) HbA(1c) concentration 0.65% (95% CI -1.04, -0.25; p=0.001) lower than nonadherent. Odds ratios (95% CI) of HbA(1c)≤ 7.5% for 10-year higher age were 1.63 (1.08, 2.45); for adherent compared to non-adherent patients 1.89 (0.84, 4.25); for patients receiving >5 compared to ≤ 5 medications 0.32 (0.13, 0.76); and for each 1% increment in baseline HbA(1c) 0.48 (0.31, 0.73).

CONCLUSIONS

The lower HbA(1c) achieved from greater adherence to glucose lowering treatment is comparable to that achieved with additional medication. Relationships between older age and better glycaemic control are not explained by better adherence, but may partly relate to lower BMI.

Predictors of poor glycaemic control during the initial five years post-diagnosis in rural adults with type 2 diabetes

OBJECTIVE

To identify factors predicting suboptimal glycaemic control in rural adults during the initial five years post-type 2 diabetes diagnosis.

DESIGN

Retrospective medical record audit. Quantitative study.

SETTING

Rural community-based primary health service, South Gippsland, Victoria, Australia.

PARTICIPANTS

Two hundred and seventy-two de-identified medical records randomly selected from the type 2 diabetes outpatient database.

MAIN OUTCOME MEASURES

Demographic, biochemical, anthropometric, pharmacological, co-morbidity and lifestyle data during the first five years post-diabetes diagnosis were retrospectively collected. Univariate analysis was performed to identify variables associated with poor diabetes control (HbA1c ≥ 7%).

RESULTS

Independent predictors of poor glycaemic control in this rural cohort were elevated fasting glucose at diagnosis (odds ratio (OR) 1.97, 95% confidence interval (CI) 1.31-2.97, P < 0.001), weight gain during the initial 2.5 years of diabetes (OR 1.33, 95% CI 1.11-1.59, P < 0.01), excessive body weight at diagnosis (OR 1.07, 95% CI 1.03-1.12, P < 0.001) and younger age at diagnosis (OR 0.94, 95% CI 0.88-1.00, P < 0.05). These variables combined explained 48% of the variation in HbA1c. Gender, body mass index, waist circumference and lifestyle factors at diagnosis were not significant predictors of diabetes control.

CONCLUSIONS

Young-middle-aged adults (≤58 years) with elevated fasting glucose (≥9.0 mmol L(-1) ) and excessive body weight (≥93.1 kg) at type 2 diabetes diagnosis and those unable to lose weight early in the course of the disease are more likely to experience a rapid deterioration in glucose control. Rural clinicians should target these individuals for aggressive diabetes management from the time of diagnosis.

The relationship between HbA1c level, symptoms and self-rated health in type 2 diabetic patients

OBJECTIVE

Improving glycaemic control is generally supposed to reduce symptoms experienced by type 2 diabetic patients, but the relationships between glycated haemoglobin (HbA(1c)), diabetes-related symptoms, and self-rated health (SRH) are unclarified. This study explored the relationships between these aspects of diabetes control.

DESIGN

A cross-sectional study one year after diagnosis of type 2 diabetes.

SUBJECTS

A population-based sample of 606 type 2 diabetic patients, median age 65.6 years at diagnosis, regularly reviewed in primary care.

MAIN OUTCOME MEASURES

The relationships between HbA(1c), diabetes-related symptoms, and SRH.

RESULTS

The patients' median HbA(1c) was 7.8 (reference interval: 5.4-7.4 % at the time of the study). 270 (45.2%) reported diabetes-related symptoms within the past 14 days. SRH was associated with symptom score (γ = 0.30, p < 0.001) and HbA(1c) (γ = 0.17, p = 0.038) after correction for covariates. The relation between HbA(1c) and symptom score was explained by SRH together with other confounders, e.g. hypertension (γ = 0.02, p = 0.40). The relation between the symptom fatigue and SRH was not explained by symptom score and significantly modified the direct association between symptom score and SRH.

CONCLUSIONS

Symptom relief may not occur even when HbA(1c) level is at its lowest average level in the natural history of diabetes, and symptoms and SRH are closely linked. Monitoring symptoms in the clinical encounter to extend information on disease severity, as measured e.g. by HbA(1c), may help general practitioners and patients to understand the possible impact of treatments and of disease manifestations in order to obtain optimum disease control.