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Esposito D, Olsson DS, Franzén S, Miftaraj M, Nåtman J, Gudbjörnsdottir S, Johannsson G. Effect of Diabetes on Morbidity and Mortality in Patients With Acromegaly. J Clin Endocrinol Metab 2022; 107:2483-2492. [PMID: 35779017 PMCID: PMC9387713 DOI: 10.1210/clinem/dgac400] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Diabetes is a major risk factor for cardiovascular disease and death but its effect on outcomes in acromegaly is unknown. OBJECTIVE This work aimed to study whether diabetes affects morbidity and mortality in patients with acromegaly. METHODS A nationwide (Sweden), observational, matched-cohort study was conducted. Patients diagnosed with acromegaly between 1987 and 2020 were identified in the Swedish National Patient Registry and those with concomitant type 2 diabetes in the National Diabetes Registry and Drug Registry. The risk of overall mortality, and cardiovascular mortality and morbidity were estimated using Cox regression. RESULTS The study included 254 patients with acromegaly and concomitant type 2 diabetes (ACRO-DM group) and 532 without diabetes (ACRO group). Mean (SD) age at baseline was 62.6 (11.4) and 60.0 (12.1) years (P = .004) and the mean (SD) duration of acromegaly was 6.8 (8.1) and 6.0 (6.2) years (P = .098) in the ACRO-DM and ACRO groups, respectively. Overall mean follow-up was 9.2 years. The unadjusted overall mortality rate per 1000 person-years was 35.1 (95% CI, 27.2-44.7) and 20.1 (95% CI, 16.5-24.3) in the respective groups. The hazard ratio (HR) for overall mortality adjusted for multiple confounders was 1.58 (95% CI, 1.12-2.23) in the ACRO-DM group compared with the ACRO group. Cardiovascular mortality (HR 2.11; 95% CI, 1.09-4.10) and morbidity (HR 1.49; 95% CI, 1.21-1.82) were also increased in the ACRO-DM group. CONCLUSION The presence of diabetes in patients with acromegaly was associated with increased overall mortality as well as increased cardiovascular mortality and morbidity.
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Affiliation(s)
- Daniela Esposito
- Correspondence: Daniela Esposito, MD, PhD, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology at Sahlgrenska University Hospital, Gröna Stråket 8, 41345 Gothenburg, Sweden.
| | - Daniel S Olsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
| | - Stefan Franzén
- Health Metrics Group, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, 41345 Gothenburg, Sweden
| | - Jonatan Nåtman
- National Diabetes Register, Centre of Registers, 41345 Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- National Diabetes Register, Centre of Registers, 41345 Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, 41345 Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
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Lugner M, Gudbjörnsdottir S, Sattar N, Svensson AM, Miftaraj M, Eeg-Olofsson K, Eliasson B, Franzén S. Comparison between data-driven clusters and models based on clinical features to predict outcomes in type 2 diabetes: nationwide observational study. Diabetologia 2021; 64:1973-1981. [PMID: 34059937 PMCID: PMC8382658 DOI: 10.1007/s00125-021-05485-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/16/2021] [Indexed: 01/18/2023]
Abstract
AIMS/HYPOTHESIS Research using data-driven cluster analysis has proposed five novel subgroups of diabetes based on six measured variables in individuals with newly diagnosed diabetes. Our aim was (1) to validate the existence of differing clusters within type 2 diabetes, and (2) to compare the cluster method with an alternative strategy based on traditional methods to predict diabetes outcomes. METHODS We used data from the Swedish National Diabetes Register and included 114,231 individuals with newly diagnosed type 2 diabetes. k-means clustering was used to identify clusters based on nine continuous variables (age at diagnosis, HbA1c, BMI, systolic and diastolic BP, LDL- and HDL-cholesterol, triacylglycerol and eGFR). The elbow method was used to determine the optimal number of clusters and Cox regression models were used to evaluate mortality risk and risk of CVD events. The prediction models were compared using concordance statistics. RESULTS The elbow plot, with values of k ranging from 1 to 10, showed a smooth curve without any clear cut-off points, making the optimal value of k unclear. The appearance of the plot was very similar to the elbow plot made from a simulated dataset consisting only of one cluster. In prediction models for mortality, concordance was 0.63 (95% CI 0.63, 0.64) for two clusters, 0.66 (95% CI 0.65, 0.66) for four clusters, 0.77 (95% CI 0.76, 0.77) for the ordinary Cox model and 0.78 (95% CI 0.77, 0.78) for the Cox model with smoothing splines. In prediction models for CVD events, the concordance was 0.64 (95% CI 0.63, 0.65) for two clusters, 0.66 (95% CI 0.65, 0.67) for four clusters, 0.77 (95% CI 0.77, 0.78) for the ordinary Cox model and 0.78 (95% CI 0.77, 0.78) for the Cox model with splines for all variables. CONCLUSIONS/INTERPRETATION This nationwide observational study found no evidence supporting the existence of a specific number of distinct clusters within type 2 diabetes. The results from this study suggest that a prediction model approach using simple clinical features to predict risk of diabetes complications would be more useful than a cluster sub-stratification.
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Affiliation(s)
- Moa Lugner
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Soffia Gudbjörnsdottir
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ann-Marie Svensson
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | | | - Björn Eliasson
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Franzén
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
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Hero C, Karlsson SA, Franzén S, Svensson AM, Miftaraj M, Gudbjörnsdottír S, Andersson-Sundell K, Eliasson B, Eeg-Olofsson K. Impact of Socioeconomic Factors and Gender on Refill Adherence and Persistence to Lipid-Lowering Therapy in Type 1 Diabetes. Diabetes Ther 2021; 12:2371-2386. [PMID: 34292559 PMCID: PMC8384944 DOI: 10.1007/s13300-021-01115-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/06/2021] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Lipid-lowering therapy (LLT) reduces the risk of cardiovascular disease (CVD) in patients with type 1 diabetes (T1D). However, socioeconomic factors and gender may have an impact on the adherence to and non-persistence with LLT. METHODS This was a nationwide register-based cohort study that included 6192 individuals with T1D aged ≥ 18 years who were registered in the Swedish National Diabetes Register and had initiated novel use of LLT. Information on socioeconomic parameters (source: Statistics Sweden) and comorbidity (source: National Patient Register) was collected. The individuals were followed for 36 months, and adherence to LLT was analyzed according to age, socioeconomics and gender. The medication possession ratio (MPR; categorized into ≤ 80% and > 80%) and non-persistence (discontinuation) with medication was calculated after 18 and 36 months. RESULTS Individuals older than 53 years were more adherent to LLT (MPR > 80%) than those younger than 36 years (odds ratio [(OR] 1.30, p < 0.0001) at 36 months. Women were more adherent and less prone to discontinue LLT at 18 months (OR 1.05, p = 0.0005 and OR 0.95, p = 0.0004, respectively), but not at 36 months. Divorced individuals were less adherent than married ones (OR 0.93, p = 0.0005) and discontinued LLT more often than the latter (OR 1.06, p = 0.003). Education had no impact on adherence, but individuals with higher incomes discontinued LLT less frequently than those with lower incomes. Individuals with a country of origin other than Sweden discontinued LLT more often. CONCLUSION Lower adherence to LLT in individuals with T1D was associated with male gender, younger age, marital status and country of birth. These factors should be considered when evaluating adherence to LLT in clinical practice, with the aim to help patients achieve full cardioprotective treatment.
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Affiliation(s)
- Christel Hero
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
| | - Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
- Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottír
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
| | - Karolina Andersson-Sundell
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Medical Evidence and Observational Research, Astra Zeneca AB, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
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Nathanson D, Svensson AM, Miftaraj M, Franzén S, Bolinder J, Eeg-Olofsson K. Effect of flash glucose monitoring in adults with type 1 diabetes: a nationwide, longitudinal observational study of 14,372 flash users compared with 7691 glucose sensor naive controls. Diabetologia 2021; 64:1595-1603. [PMID: 33774713 PMCID: PMC8187189 DOI: 10.1007/s00125-021-05437-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/02/2021] [Indexed: 11/04/2022]
Abstract
AIMS/HYPOTHESIS The aim of this work was to evaluate changes in glycaemic control (HbA1c) and rates of severe hypoglycaemia over a 2 year period after initiation of flash glucose monitoring (FM) in type 1 diabetes. METHODS Using data from the Swedish National Diabetes Registry, 14,372 adults with type 1 diabetes with a new registration of FM during 2016-2017 and with continued FM for two consecutive years thereafter, and 7691 control individuals using conventional self-monitoring of blood glucose (SMBG) during the same observation period, were included in a cohort study. Propensity sores and inverse probability of treatment weighting (IPTW) were used to balance FM users with SMBG users. Changes in HbA1c and events of severe hypoglycaemia were compared. RESULTS After the start of FM, the difference in IPTW change in HbA1c was slightly greater in FM users compared with the control group during the follow-up period, with an estimated mean absolute difference of -1.2 mmol/mol (-0.11%) (95% CI -1.64 [-0.15], -0.75 [-0.07]; p < 0.0001) after 15-24 months. The change in HbA1c was greatest in those with baseline HbA1c ≥70 mmol/mol (8.5%), with the estimated mean absolute difference being -2.5 mmol/mol (-0.23%) (95% CI -3.84 [-0.35], -1.18 [-0.11]; p = 0.0002) 15-24 months post index. The change was also significant in the subgroups with initial HbA1c ≤52 mmol/mol (6.9%) and 53-69 mmol/mol (7.0-8.5%). Risk of severe hypoglycaemic episodes was reduced by 21% for FM users compared with control individuals using SMBG (OR 0.79 [95% CI 0.69, 0.91]; p = 0.0014)]. CONCLUSIONS/INTERPRETATION In this large cohort, the use of FM was associated with a small and sustained improvement in HbA1c, most evident in those with higher baseline HbA1c levels. In addition, FM users experienced lower rates of severe hypoglycaemic events compared with control individuals using SMBG for self-management of glucose control.
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Affiliation(s)
- David Nathanson
- Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Centre of Registers Västra Götaland, Gothenburg, Sweden
| | | | - Stefan Franzén
- Centre of Registers Västra Götaland, Gothenburg, Sweden
- Health Metrics, Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Bolinder
- Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institute, Stockholm, Sweden.
| | - Katarina Eeg-Olofsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenberg, Sweden
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Lilja E, Gottsäter A, Miftaraj M, Ekelund J, Eliasson B, Svensson AM, Zarrouk M, Acosta S. Diabetes mellitus was not associated with lower amputation-free survival after open revascularization for chronic limb-threatening ischemia - A nationwide propensity score adjusted analysis. Vasc Med 2021; 26:507-514. [PMID: 34004125 PMCID: PMC8493412 DOI: 10.1177/1358863x211008249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The risk of major amputation is higher after urgently planned endovascular
therapy for chronic limb-threatening ischemia (CLTI) in patients with diabetes
mellitus (DM). The aim of this nationwide cohort study was to compare outcomes
between patients with and without DM following urgently planned open
revascularization for CLTI from 2010 to 2014. Out of 1537 individuals registered
in the Swedish Vascular Registry, 569 were registered in the National Diabetes
Register. A propensity score adjusted Cox regression analysis was conducted to
compare outcome between the groups with and without DM. Median follow-up was 4.3
years and 4.5 years for patients with and without DM, respectively. Patients
with DM more often had foot ulcers (p = 0.034) and had
undergone more previous amputations (p = 0.001) at baseline. No
differences in mortality, cardiovascular death, major adverse cardiovascular
events (MACE), or major amputation were observed between groups. The incidence
rate of stroke was 70% higher (95% CI: 1.11–2.59; p = 0.0137)
and the incidence rate of acute myocardial infarction (AMI) 39% higher (95% CI:
1.00–1.92; p = 0.0472) among patients with DM in comparison to
those without. Open vascular surgery remains a first-line option for a
substantial number of patients with CLTI, especially for limb salvage in
patients with DM. The higher incidence rates of stroke and AMI among patients
with DM following open vascular surgery for infrainguinal CLTI require specific
consideration preoperatively with the aim of optimizing medical treatment to
improve cardiovascular outcome postoperatively.
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Affiliation(s)
- Erika Lilja
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardio-Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Mervete Miftaraj
- Centre of Registers, National Diabetes Register, Göteborg, Sweden
| | - Jan Ekelund
- Centre of Registers, National Diabetes Register, Göteborg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Göteborg, Sweden
| | - Ann-Marie Svensson
- Centre of Registers, National Diabetes Register, Göteborg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Göteborg, Sweden
| | - Moncef Zarrouk
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardio-Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Cardio-Thoracic Surgery and Vascular Diseases, Vascular Center, Skåne University Hospital, Malmö, Sweden
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Höskuldsdóttir G, Sattar N, Miftaraj M, Näslund I, Ottosson J, Franzén S, Svensson AM, Eliasson B. Potential Effects of Bariatric Surgery on the Incidence of Heart Failure and Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus and Obesity and on Mortality in Patients With Preexisting Heart Failure: A Nationwide, Matched, Observational Cohort Study. J Am Heart Assoc 2021; 10:e019323. [PMID: 33754795 PMCID: PMC8174344 DOI: 10.1161/jaha.120.019323] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Obesity and diabetes mellitus are strongly associated with heart failure (HF) and atrial fibrillation (AF). The benefits of bariatric surgery on cardiovascular outcomes are known in people with or without diabetes mellitus. Surgical treatment of obesity might also reduce the incidence of HF and AF in individuals with obesity and type 2 diabetes mellitus (T2DM). Methods and Results In this register‐based nationwide cohort study we compared individuals with T2DM and obesity who underwent Roux‐en‐Y gastric bypass surgery with matched individuals not treated with surgery. The main outcome measures were hospitalization for HF and/or AF and mortality in patients with preexisting HF. We identified 5321 individuals with T2DM and obesity who had undergone Roux‐en‐Y gastric bypass surgery between January 2007 and December 2013 and 5321 matched controls. The individuals included were 18 to 65 years old and had a body mass index >27.5 kg/m2. The follow‐up time for hospitalization was until the end of 2015 (mean 4.5 years) and the end of 2016 for death. Our results show a 73% lower risk for HF (hazard ratio [HR], 0.27; CI, 0.19–0.38), 41% for AF (HR, 0.59; CI, 0.44–0.78), and 77% for concomitant AF and HF (HR, 0.23; CI, 0.12–0.46) in the surgically treated group. In patients with preexisting HF we observed significantly lower mortality in the group who underwent surgery (HR, 0.23; 95% CI, 0.12–0.43). Conclusions Bariatric surgery may reduce risk for HF and AF in patients with T2DM and obesity, speculatively via positive cardiovascular and renal effects. Obesity treatment with surgery may also be a valuable alternative in selected patients with T2DM and HF.
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Affiliation(s)
- Gudrún Höskuldsdóttir
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
| | - Naveed Sattar
- The Institute of Cardiovascular and Medical Sciences University of Glasgow United Kingdom
| | - Mervete Miftaraj
- Centre of Registers National Diabetes Register Gothenburg Sweden
| | - Ingmar Näslund
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Johan Ottosson
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Stefan Franzén
- Centre of Registers National Diabetes Register Gothenburg Sweden.,Health Metrics Unit Sahlgrenska AcademyUniversity of Gothenburg Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Centre of Registers National Diabetes Register Gothenburg Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
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Lugner M, Sattar N, Miftaraj M, Ekelund J, Franzén S, Svensson AM, Eliasson B. Cardiorenal and other diabetes related outcomes with SGLT-2 inhibitors compared to GLP-1 receptor agonists in type 2 diabetes: nationwide observational study. Cardiovasc Diabetol 2021; 20:67. [PMID: 33752680 PMCID: PMC7983265 DOI: 10.1186/s12933-021-01258-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/13/2021] [Indexed: 02/07/2023] Open
Abstract
Background
Major prospective randomized clinical safety trials have demonstrated beneficial effects of treatment with glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium–glucose co-transporter-2 inhibitors (SGLT-2i) in people with type 2 diabetes and elevated cardiovascular risk, and recent clinical treatment guidelines therefore promote early use of these classes of pharmacological agents. In this Swedish nationwide observational study, we compared cardiorenal outcomes and safety of new treatment with GLP-1RA and SGLT-2i in people with type 2 diabetes. Methods We linked data from national Swedish databases to capture patient characteristics and outcomes and used propensity-score based matching to account for differences between the two groups. The treatments were compared using Cox regression models. Results
We identified 9648 participants starting GLP-1RA and 12,097 starting SGLT-2i with median follow-up times 1.7 and 1.1 years, respectively. The proportion of patients with a history of MACE were 15.8%, and 17.0% in patients treated with GLP-1RA and SGLT-2i, respectively. The mean age was 61 years with 7.6 years duration of diabetes. Mean HbA1c were 8.3% (67.6 mmol/mol) and 8.3% (67.2 mmol/mol), and mean BMI 33.3 and 32.5 kg/m2 in patients treated with GLP-1RA or SGLT-2i, respectively. The cumulative mortality risk was non-significantly lower in the group treated with SGLT-2i, HR 0.78 (95% CI 0.61–1.01), as were incident heart failure outcomes, but the risks of cardiovascular or renal outcomes did not differ. The risks of stroke and peripheral artery disease were higher in the SGLT-2i group relative to GLP-1RA, with HR 1.44 (95% CI 0.99–2.08) and 1.68 (95% CI 1.04–2.72), respectively. Conclusions This observational study suggests that treatment with GLP-1RA and SGLT-2i result in very similar cardiorenal outcomes. In the short term, treatment with GLP-1RA seem to be associated with lower risks of stroke and peripheral artery disease, whereas SGLT-2i seem to be nominally associated with lower risk of heart failure and total mortality. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01258-x.
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Affiliation(s)
- Moa Lugner
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Jan Ekelund
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Stefan Franzén
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.,National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.,National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Björn Eliasson
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Svensson A, Toll A, Lebrec J, Miftaraj M, Franzén S, Eliasson B. Treatment persistence in patients with type 2 diabetes treated with glucagon-like peptide-1 receptor agonists in clinical practice in Sweden. Diabetes Obes Metab 2021; 23:720-729. [PMID: 33289287 PMCID: PMC7953897 DOI: 10.1111/dom.14276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/12/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022]
Abstract
AIM To compare treatment persistence in patients with type 2 diabetes initiating the glucagon-like peptide-1 receptor agonists (GLP-1 RAs) dulaglutide, exenatide once-weekly (QW), liraglutide or lixisenatide in routine clinical practice in Sweden and assess clinical outcomes. MATERIALS AND METHODS We performed a retrospective study using data from several nationwide Swedish health registries, including the National Diabetes Register and other mandatory and population-based registries. Individual level data were collected from 17 361 patients who initiated GLP-1 RA treatment from 23 May 2015 to 15 October 2017, up to 2.5 years postindex (treatment start date). Treatment persistence and modification, predictors of discontinuation, HbA1c and body weight were recorded. Non-persistence was defined as a treatment gap of more than 45 days. Treatment modification included switching and augmentation. Confounding was addressed through the use of propensity scores. RESULTS Treatment persistence was higher and treatment modifications were lower in patients initiating dulaglutide compared with those on exenatide QW, liraglutide and lixisenatide. Patients who remained on the same treatment for 1-year postindex experienced greater HbA1c reductions and a steadier decrease in body weight. CONCLUSIONS Our study suggests that in clinical practice in Sweden there is a greater persistence of treatment among patients initiating dulaglutide compared with those on exenatide QW, liraglutide and lixisenatide. Persistence with the index GLP-1 RA was closely correlated with positive clinical outcomes and thus should be considered a critical factor of patient-centric treatment in Sweden.
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Affiliation(s)
- Ann‐Marie Svensson
- National Diabetes Register, Centre of RegistersGothenburgSweden
- University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
| | | | | | | | - Stefan Franzén
- National Diabetes Register, Centre of RegistersGothenburgSweden
- University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
| | - Björn Eliasson
- University of Gothenburg, Sahlgrenska University HospitalGothenburgSweden
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Lilja E, Gottsäter A, Miftaraj M, Ekelund J, Eliasson B, Svensson AM, Zarrouk M, Nilsson P, Acosta S. The impact of diabetes mellitus on major amputation among patients with chronic limb threatening ischemia undergoing elective endovascular therapy- a nationwide propensity score adjusted analysis. J Diabetes Complications 2021; 35:107675. [PMID: 32828647 DOI: 10.1016/j.jdiacomp.2020.107675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 01/13/2023]
Abstract
AIM To investigate the risk of major amputation after elective endovascular therapy in patients with chronic limb threatening ischemia (CLTI) comparing patients with and without diabetes mellitus (DM). METHODS In this nationwide cohort study, all patients registered in the Swedish Vascular Register after elective endovascular therapy for CLTI caused by infra-inguinal arterial disease from 2010 to 2014 were included. Among 4578 individuals, 2251 had DM and were registered in the National Diabetes Register between 2009 and 2014. A propensity score adjusted Cox regression analysis was conducted to compare outcomes between groups. Median follow-up was 4.0 and 3.6 years for patients with DM and without DM, respectively. RESULTS The incidence rates of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23-1.67) and 37% (95% CI 1.13-1.67) higher, respectively, among patients with DM compared to patients without DM. There was no difference in mortality (HR 1.04, 95% CI 0.95-1.14). CONCLUSIONS Patients with DM had a higher risk of major amputation and AMI compared to those without DM after elective endovascular therapy for CLTI. Prevention of DM with CLTI is of utmost importance to reduce the risk of adverse limb and cardiovascular outcomes.
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Affiliation(s)
- Erika Lilja
- Department of Clinical Sciences, Malmö, Lund University, Sweden.
| | - Anders Gottsäter
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Jan Ekelund
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Björn Eliasson
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Moncef Zarrouk
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
| | - Peter Nilsson
- Department of Clinical Sciences, Malmö, Lund University, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
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10
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Dakhel A, Zarrouk M, Ekelund J, Acosta S, Miftaraj M, Eliasson B, Svensson AM, Gottsäter A. Higher long-term cardiovascular morbidity after open surgery for intermittent claudication caused by infrainguinal atherosclerotic disease in patients with diabetes - a nationwide observational cohort study. VASA 2020; 50:224-230. [PMID: 33334201 DOI: 10.1024/0301-1526/a000929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background: Diabetes mellitus (DM) is a risk factor for peripheral arterial disease (PAD). Indications for open surgery in infrainguinal intermittent claudication (IC) are limited, and reports are lacking regarding outcomes in DM patients. Study aims were to compare short and long-term effects on major adverse cardiovascular events (MACE), acute myocardial infarction (AMI), stroke, major amputation, and mortality after infrainguinal open surgery for IC in patients with and without DM, and to evaluate relationships between glycaemic control and outcomes. Methods: Nationwide observational cohort study of all patients registered in the Swedish Vascular Registry after planned infrainguinal open surgery for IC from January 1st 2010 to December 31st 2014. Patients registered in the National Diabetes Registry were compared with patients without diabetes by propensity score adjusted comparison of MACE, AMI, stroke, major amputation, and mortality. Results: After 30 days, there were no differences in MACE, AMI, stroke, major amputation, or mortality between patients with (n = 323, mean age 70.5 [SD 7.4] years, 92 [28.5%] females) and without (n = 679, mean age 69.7 years [SD 11.2], 234 [34.5%] females) DM. At last follow-up after median 5.2 years, patients with DM showed higher rates of MACE (Hazard ratio [HR] 1.33, confidence interval [CI] 1.08-1.62; p < 0.01), and AMI (HR 2.21, CI 1.46-3.35; p < 0.01) than patients without diabetes. Among DM patients, higher glycated haemoglobin (HbA1c) was associated with higher rates of MACE (HR 1.02, CI 1.00-1.03; p = 0.02), stroke (HR 1.05, CI 1.00-1.11; p = 0.04), and total mortality (HR 1.03, CI 1.01-1.06; p < 0.01), during follow-up, whereas duration of diabetes was associated with higher rate of major amputation (HR 1.08, CI 1.02-1.15; p < 0.01). Conclusions: DM patients showed higher rates of MACE and AMI in propensity score adjusted analysis five years after planned infrainguinal open surgery for IC. Higher HbA1c was associated with MACE, stroke, and total mortality in patients with DM, whereas longer duration of DM was associated with major amputation.
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Affiliation(s)
- Ardwan Dakhel
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Moncef Zarrouk
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Jan Ekelund
- Swedish National Diabetes Register, Gothenburg, Sweden
| | - Stefan Acosta
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | | | - Ann-Marie Svensson
- Swedish National Diabetes Register, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Anders Gottsäter
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
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11
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Höskuldsdóttir G, Ekelund J, Miftaraj M, Wallenius V, Ottosson J, Näslund I, Gudbjörnsdottir S, Sattar N, Svensson AM, Eliasson B. Potential Benefits and Harms of Gastric Bypass Surgery in Obese Individuals With Type 1 Diabetes: A Nationwide, Matched, Observational Cohort Study. Diabetes Care 2020; 43:3079-3085. [PMID: 33023988 DOI: 10.2337/dc20-0388] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 09/13/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To study the potential long-term benefits and possible complications of bariatric surgery in patients with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS In this register-based nationwide cohort study, we compared individuals with T1D and obesity who underwent Roux-en-Y gastric bypass (RYGB) surgery with patients with T1D and obesity matched for age, sex, BMI, and calendar time that did not undergo surgery. By linking the Swedish National Diabetes Register and Scandinavian Obesity Surgery Registry study individuals were included between 2007 and 2013. Outcomes examined included all-cause mortality, cardiovascular disease, stroke, heart failure, and hospitalization for serious hypo- or hyperglycemic events, amputation, psychiatric disorders, changes in kidney function, and substance abuse. RESULTS We identified 387 individuals who had undergone RYGB and 387 control patients. Follow-up for hospitalization was up to 9 years. Analysis showed lower risk for cardiovascular disease (hazard ratio [HR] 0.43; 95% CI 0.20-0.9), cardiovascular death (HR 0.15; 95% CI 0.03-0.68), hospitalization for heart failure (HR 0.32; 95% CI 0.15-0.67), and stroke (HR 0.18; 95% CI 0.04-0.82) for the RYGB group. There was a higher risk for serious hyperglycemic events (HR 1.99; 95% CI 1.07-3.72) and substance abuse (HR 3.71; 95% CI 1.03-3.29) after surgery. CONCLUSIONS This observational study suggests bariatric surgery may yield similar benefits on risk for cardiovascular outcomes and mortality in patients with T1D and obesity as for patients with type 2 diabetes. However, some potential serious adverse effects suggest need for careful monitoring of such patients after surgery.
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Affiliation(s)
- Gudrun Höskuldsdóttir
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden .,Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Jan Ekelund
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Ville Wallenius
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institution of Clinical Sciences, Department of Surgery, University of Gothenburg, Gothenburg, Sweden
| | - Johan Ottosson
- Department of Surgery, Örebro University, Örebro, Sweden
| | - Ingmar Näslund
- Department of Surgery, Örebro University, Örebro, Sweden
| | | | - Naveed Sattar
- The Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | | | - Björn Eliasson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
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12
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Eliasson B, Ekelund J, Miftaraj M, Ranthe MF, Mårdby AC, Da Rocha Fernandes JD, Svensson AM. Persistence with IDegLira in Patients in Clinical Practice: A Nationwide Observational Study in Sweden. Diabetes Ther 2020; 11:1807-1820. [PMID: 32617849 PMCID: PMC7376998 DOI: 10.1007/s13300-020-00872-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 01/10/2023] Open
Abstract
AIMS To explore persistence with insulin degludec/liraglutide (IDegLira) treatment, clinical characteristics and concomitant medications in a large population of patients in clinical practice. METHODS This was an observational study in patients with type 2 diabetes (n = 2432) who initiated IDegLira between 26 May 2015 and 31 December 2017. Data were obtained from Swedish nationwide registers and linked on an individual level using unique Swedish personal identifiers. Dose calculations were made for patients with ≥ 180 days between the first and last collections of IDegLira prescription. Changes in clinical parameters were evaluated as change from the last observation during 12 months prior to the initiation date until ± 90 days from the last collection of IDegLira. RESULTS Pre-index regimens (index date being the date of filling the first prescription of IDegLira) included: multiple daily insulin injections (45.1%); insulin and glucagon-like peptide-1 receptor agonist (GLP-1 RA) (19.7%); long-acting insulins (11.8%); non-injectable therapy only (11.4%); GLP-1 RA only (9.8%); and no collection of diabetes medication during the 6-month pre-index period (2.3%). The majority of patients (94 and 84%) were persistent with IDegLira at 6 and 12 months, respectively. The most commonly used concomitant medication was metformin (69.4%). Mean daily dose was 33 dose steps. Overall, there was a mean decrease in HbA1c (approx. 10 mmol/mol [1%]) and body weight (- 1.1 kg). Improvements in HbA1c were observed regardless of pre-index treatment. CONCLUSION After 12 months, 84% of patients were persistent on IDegLira, with improved glycaemic control and reductions in body weight.
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Affiliation(s)
- Björn Eliasson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Jan Ekelund
- Centre of Registers Västra Götaland, Gothenburg, Sweden
| | | | | | - Ann-Charlotte Mårdby
- Medical Affairs, Novo Nordisk, Malmö, Sweden
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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13
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Liakopoulos V, Franzén S, Svensson AM, Sattar N, Miftaraj M, Björck S, Ottosson J, Näslund I, Gudbjörnsdottir S, Eliasson B. Renal and Cardiovascular Outcomes After Weight Loss From Gastric Bypass Surgery in Type 2 Diabetes: Cardiorenal Risk Reductions Exceed Atherosclerotic Benefits. Diabetes Care 2020; 43:1276-1284. [PMID: 32152136 DOI: 10.2337/dc19-1703] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 01/22/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We examined detailed renal and cardiovascular (CV) outcomes after gastric bypass (GBP) surgery in people with obesity and type 2 diabetes mellitus (T2DM), across several renal function categories, in a nationwide cohort study. RESEARCH DESIGN AND METHODS We linked data from the National Diabetes Register and the Scandinavian Obesity Surgery Register with four national databases holding information on socioeconomic variables, medications, hospitalizations, and causes of death and matched 5,321 individuals with T2DM who had undergone GBP with 5,321 who had not (age 18-65 years, mean BMI >40 kg/m2, mean follow-up >4.5 years). The risks of postoperative outcomes were assessed with Cox regression models. RESULTS During the first years postsurgery, there were small reductions in creatinine and albuminuria and stable estimated glomerular filtration rate (eGFR) in the GBP group. The incidence rates of most outcomes relating to renal function, CV disease, and mortality were lower after GBP, being particularly marked for heart failure (hazard ratio [HR] 0.33 [95% CI 0.24, 0.46]) and CV mortality (HR 0.36 [(95% CI 0.22, 0.58]). The risk of a composite of severe renal disease or halved eGFR was 0.56 (95% CI 0.44, 0.71), whereas nonfatal CV risk was lowered less (HR 0.82 [95% CI 0.70, 0.97]) after GBP. Risks for key outcomes were generally lower after GBP in all eGFR strata, including in individuals with eGFR <30 mL/min/1.73 m2. CONCLUSIONS Our data suggest robust benefits for renal outcomes, heart failure, and CV mortality after GBP in individuals with obesity and T2DM. These results suggest that marked weight loss yields important benefits, particularly on the cardiorenal axis (including slowing progression to end-stage renal disease), whatever the baseline renal function status.
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Affiliation(s)
- Vasileios Liakopoulos
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden .,Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Center of Registers, Gothenburg, Sweden.,Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,National Diabetes Register, Center of Registers, Gothenburg, Sweden
| | - Naveed Sattar
- The Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Mervete Miftaraj
- National Diabetes Register, Center of Registers, Gothenburg, Sweden
| | - Staffan Björck
- National Diabetes Register, Center of Registers, Gothenburg, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ingmar Näslund
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,National Diabetes Register, Center of Registers, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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14
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Svensson AM, Ekelund J, Miftaraj M, Eliasson B. Efficacy and Safety of Treatment with New Basal Insulin Analogues in Type 1 Diabetes: Nation-Wide Survey. Diabetes Ther 2020; 11:725-734. [PMID: 31994008 PMCID: PMC7048893 DOI: 10.1007/s13300-020-00767-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION To date, only a few studies have addressed the long-term safety of basal insulins. We have therefore investigated the efficacy and safety of all available basal insulins used in the treatment of type 1 diabetes, using data from national databases in Sweden. METHODS We assessed patients with type 1 diabetes who were using insulin glargine 100 U/mL (IG100) and who either continued using IG100 or switched to insulin glargine 300 U/mL (IG300) or insulin degludec (ID) for differences in clinical characteristics at baseline (index date) and subsequent changes in glycated haemoglobin (HbA1c), weight and hospitalizations caused by hypoglycaemia, cardiovascular disease or death. RESULTS The mean follow-up time was 1.1 years for patients who switched to IG300 and ID and 1.6 years for those remaining on IG100. There were no marked differences in clinical characteristics between the groups, but patients on IG100 were slightly older and had used insulin pumps or continuous glucose monitors more seldom. The mean HbA1c levels were similar, and 4% of the patients had a history of cardiovascular disease. HbA1c decreased in all groups during follow-up, while the body mass index remained virtually unchanged. Rates of severe hypo- or hyperglycaemia were low and similar between the groups. Sixteen patients (0.7%) treated with IG300 and 13 patients (0.8%) treated with ID died during follow-up, while 221 patients (1.95%) on IG100 therapy died. All other severe adverse events were numerically more frequent in those patients receiving IG100, while there were no apparent differences between those receiving IG300 and those on ID. CONCLUSION The long-term effects and safety of IG300 and ID appear to be very similar in adult patients with type 1 diabetes. The results of this study suggest that these basal insulin analogues may provide benefits compared with the established reference IG100.
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Affiliation(s)
- Ann-Marie Svensson
- Institute of Medicine, Sahlgrenska University Hospital-University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Jan Ekelund
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Björn Eliasson
- Institute of Medicine, Sahlgrenska University Hospital-University of Gothenburg, Gothenburg, Sweden.
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden.
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15
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Rawshani A, Rawshani A, Sattar N, Franzén S, McGuire DK, Eliasson B, Svensson AM, Zethelius B, Miftaraj M, Rosengren A, Gudbjörnsdottir S. Relative Prognostic Importance and Optimal Levels of Risk Factors for Mortality and Cardiovascular Outcomes in Type 1 Diabetes Mellitus. Circulation 2020; 139:1900-1912. [PMID: 30798638 DOI: 10.1161/circulationaha.118.037454] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The strength of association and optimal levels for risk factors related to excess risk of death and cardiovascular outcomes in type 1 diabetes mellitus have been sparsely studied. METHODS In a national observational cohort study from the Swedish National Diabetes Register from 1998 to 2014, we assessed relative prognostic importance of 17 risk factors for death and cardiovascular outcomes in individuals with type 1 diabetes mellitus. We used Cox regression and machine learning analyses. In addition, we examined optimal cut point levels for glycohemoglobin, systolic blood pressure, and low-density lipoprotein cholesterol. Patients with type 1 diabetes mellitus were followed up until death or study end on December 31, 2013. The primary outcomes were death resulting from all causes, fatal/nonfatal acute myocardial infarction, fatal/nonfatal stroke, and hospitalization for heart failure. RESULTS Of 32 611 patients with type 1 diabetes mellitus, 1809 (5.5%) died during follow-up over 10.4 years. The strongest predictors for death and cardiovascular outcomes were glycohemoglobin, albuminuria, duration of diabetes mellitus, systolic blood pressure, and low-density lipoprotein cholesterol. Glycohemoglobin displayed ≈2% higher risk for each 1-mmol/mol increase (equating to ≈22% per 1% glycohemoglobin difference), whereas low-density lipoprotein cholesterol was associated with 35% to 50% greater risk for each 1-mmol/L increase. Microalbuminuria or macroalbuminuria was associated with 2 to 4 times greater risk for cardiovascular complications and death. Glycohemoglobin <53 mmol/mol (7.0%), systolic blood pressure <140 mm Hg, and low-density lipoprotein cholesterol <2.5 mmol/L were associated with significantly lower risk for outcomes observed. CONCLUSIONS Glycohemoglobin, albuminuria, duration of diabetes mellitus, systolic blood pressure, and low-density lipoprotein cholesterol appear to be the most important predictors for mortality and cardiovascular outcomes in patients with type 1 diabetes mellitus. Lower levels for glycohemoglobin, systolic blood pressure, and low-density lipoprotein cholesterol than contemporary guideline target levels appear to be associated with significantly lower risk for outcomes.
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Affiliation(s)
- Aidin Rawshani
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (A. Rawshani, A. Rawshani, B.E., A. Rosengren, S.G.).,Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (A. Rawshani, A. Rawshani, S.F., B.E., A.-M.S., M.M., S.G.)
| | - Araz Rawshani
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (A. Rawshani, A. Rawshani, B.E., A. Rosengren, S.G.).,Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (A. Rawshani, A. Rawshani, S.F., B.E., A.-M.S., M.M., S.G.)
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (N.S.)
| | - Stefan Franzén
- Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (A. Rawshani, A. Rawshani, S.F., B.E., A.-M.S., M.M., S.G.).,Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Sweden (S.F.)
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (A. Rawshani, A. Rawshani, B.E., A. Rosengren, S.G.).,Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (A. Rawshani, A. Rawshani, S.F., B.E., A.-M.S., M.M., S.G.)
| | - Ann-Marie Svensson
- Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (A. Rawshani, A. Rawshani, S.F., B.E., A.-M.S., M.M., S.G.)
| | - Björn Zethelius
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Sweden (B.Z.)
| | - Mervete Miftaraj
- Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (A. Rawshani, A. Rawshani, S.F., B.E., A.-M.S., M.M., S.G.)
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (A. Rawshani, A. Rawshani, B.E., A. Rosengren, S.G.)
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (A. Rawshani, A. Rawshani, B.E., A. Rosengren, S.G.).,Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (A. Rawshani, A. Rawshani, S.F., B.E., A.-M.S., M.M., S.G.)
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16
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Hero C, Karlsson SA, Franzén S, Svensson AM, Miftaraj M, Gudbjörnsdottir S, Andersson Sundell K, Eliasson B, Eeg-Olofsson K. Adherence to lipid-lowering therapy and risk for cardiovascular disease and death in type 1 diabetes mellitus: a population-based study from the Swedish National Diabetes Register. BMJ Open Diabetes Res Care 2020; 8:8/1/e000719. [PMID: 31958300 PMCID: PMC7039602 DOI: 10.1136/bmjdrc-2019-000719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 11/04/2019] [Accepted: 11/22/2019] [Indexed: 12/18/2022] Open
Abstract
Dyslipidemia is an important modifiable risk factor and lipid-lowering treatment (LLT) is essential to reduce the risk of cardiovascular disease (CVD). Studies in type 2 diabetes indicate that low adherence to statin therapy is a barrier to reach full protective potential, and less is known in type 1 diabetes (T1D). The aim was to assess risk of CVD by adherence and nonpersistence to LLT in T1D. METHOD: A population-based study with a retrospective longitudinal design was conducted between 2006 and 2010, with follow-up until December 2013. In total, 6192 adult individuals with T1D, initiating LLT between 2006 and 2010, were included. Information on LLT, socioeconomic characteristics, comorbidities and cardiovascular events were collected. After 18 months, refill adherence was estimated by calculating medication possession ratio (MPR). Nonpersistence was defined as being without medicines on hand for at least 180 days. Individuals were thereafter followed until CVD, death or end of follow-up in December 2013. Cox regression analyses were performed to assess adherence level and nonpersistence of LLT as predictor of CVD. Analyses were adjusted for cardiovascular risk factors and socioeconomic status. RESULTS: Mean MPR was 72%, 52% of the participants had an MPR above 80% and 27% discontinued LLT. There were 637 nonfatal and 58 fatal CVD events, mean follow-up 3.6 and 3.9 years, respectively. MPR above 80% was associated with reduced risk for nonfatal CVD compared with lower MPR, HR 0.78 (95% CI 0.65 to 0.93)). For fatal CVD, results indicated a negative effect of high adherence but the association did not reach statistical significance, HR 1.96 (0.96 to 4.01). Individuals discontinuing LLT had higher risk of nonfatal CVD, HR 1.43 (95% CI 1.18 to 1.73). CONCLUSIONS/INTERPRETATION: In T1D, the risk for nonfatal CVD was lower among individuals with high adherence and higher among those discontinuing LLT within 18 months. It is important to evaluate and emphasize adherence to prescribed LLT at clinical visits to achieve treatment goals and reduce the risk of CVD.
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Affiliation(s)
- Christel Hero
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers, Västra Götaland, Gothenburg, Sweden
- Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Västra Götaland, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Västra Götaland, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Västra Götaland, Gothenburg, Sweden
| | - Karolina Andersson Sundell
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Medical Evidence and Observational Research Centre, AstraZeneca AB, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Taimour S, Franzén S, Zarrouk M, Acosta S, Nilsson P, Miftaraj M, Eliasson B, Svensson AM, Gottsäter A. Nationwide comparison of long-term survival and cardiovascular morbidity after acute aortic aneurysm repair in patients with and without type 2 diabetes. J Vasc Surg 2020; 71:30-38.e3. [DOI: 10.1016/j.jvs.2019.01.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/20/2019] [Indexed: 12/18/2022]
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18
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Dakhel A, Zarrouk M, Ekelund J, Acosta S, Nilsson P, Miftaraj M, Eliasson B, Svensson AM, Gottsäter A. Worse cardiovascular prognosis after endovascular surgery for intermittent claudication caused by infrainguinal atherosclerotic disease in patients with diabetes. Ther Adv Endocrinol Metab 2020; 11:2042018820960294. [PMID: 33149883 PMCID: PMC7580142 DOI: 10.1177/2042018820960294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/30/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is an established risk factor for intermittent claudication (IC) and other manifestations of atherosclerotic peripheral arterial disease. Indications for surgery in infrainguinal IC are debated, and there are conflicting reports regarding its outcomes in patients with DM. Aims of this study were to compare both short- and long-term effects on total- and cardiovascular (CV) mortality, major adverse cardiovascular events (MACEs), acute myocardial infarction (AMI), stroke, and major amputation following infrainguinal endovascular surgery for IC in patients with and without DM. We also evaluated potential relationships between diabetic control and outcomes in patients with DM. METHODS Nationwide observational cohort study of patients registered in the Swedish Vascular Registry and the Swedish National Diabetes Registry. Propensity score adjusted comparison of total and CV mortality, MACE, AMI, stroke, and major amputation after elective infrainguinal endovascular surgery for IC in 626 patients with and 1112 without DM at 30 postoperative days and after median 5.2 [interquartile range (IQR) 4.2-6.3] years of follow-up for patients with DM, and 5.4 (IQR 4.3-6.5) years for those without. RESULTS In propensity score adjusted Cox regression after 30 postoperative days, there were no differences between groups in morbidity or mortality. At last follow-up, patients with DM showed higher rates of MACE [hazard ratio (HR) 1.26, confidence interval (CI) 1.07-1.48; p < 0.01], AMI (HR 1.48, CI 1.09-2.00; p = 0.01), and major amputation (HR 2.31, CI 1.24-4.32; p < 0.01). Among patients with DM, higher HbA1c was associated with higher total mortality during follow-up (HR 1.01, CI 1.00-1.03; p = 0.045). CONCLUSION Patients with DM have higher rates of MACE, AMI, and major amputation in propensity score adjusted analysis during 5 years of follow-up after infrainguinal endovascular surgery for IC. Furthermore, HbA1c is associated with total mortality in patients with DM. Prevention and treatment of DM is important to improve cardiovascular and limb outcomes.
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Affiliation(s)
| | - Moncef Zarrouk
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Jan Ekelund
- Swedish National Diabetes Register, Gothenburg, Sweden
| | - Stefan Acosta
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Peter Nilsson
- Department of Internal Medicine, Clinical Research Unit, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - Björn Eliasson
- Swedish National Diabetes Register, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Anders Gottsäter
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
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19
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Björkström K, Franzén S, Eliasson B, Miftaraj M, Gudbjörnsdottir S, Trolle-Lagerros Y, Svensson AM, Hagström H. Risk Factors for Severe Liver Disease in Patients With Type 2 Diabetes. Clin Gastroenterol Hepatol 2019; 17:2769-2775.e4. [PMID: 31009793 DOI: 10.1016/j.cgh.2019.04.038] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/21/2019] [Accepted: 04/13/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Type 2 diabetes is a risk factor for development of cirrhosis and hepatocellular carcinoma. However, risk factors that identify persons with the highest risk for these outcomes are missing from unselected, population-based cohorts. METHODS The National Diabetes Register contains data on about 90% of persons in Sweden with type 2 diabetes. In this cohort study, persons with type 2 diabetes listed in the National Diabetes Register were compared with 5 individuals from the general population (controls), matched for age, sex, and county. In total, 406 770 persons with type 2 diabetes and 2 033 850 controls were included and followed for 21 596 934 person-years. We used population-based registers to determine the incidence of severe liver disease, defined as a diagnosis of hepatocellular carcinoma, cirrhosis, decompensation, liver failure and/or death due to liver disease during follow up. Cox regression was performed to estimate the risk of severe liver disease and to examine risk factors in persons with type 2 diabetes. RESULTS Risk for severe liver disease was increased in patients with type 2 diabetes compared to controls (hazard ratio, 2.28; 95% CI, 2.21-2.36). Risk factors associated with severe liver disease in persons with type 2 diabetes were higher age, male sex, hypertension, higher body mass index, lower glomerular filtration rate, microalbuminuria, and smoking. Statins were associated with a decreased risk of severe liver disease. CONCLUSIONS Persons with type 2 diabetes have an increased risk for severe liver disease. Knowledge of risk factors can be helpful in identifying persons with type 2 diabetes who have a high risk for severe liver disease.
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Affiliation(s)
- Karl Björkström
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Franzén
- Swedish National Diabetes Register, Centre of Registers in Region, Sweden
| | - Björn Eliasson
- Swedish National Diabetes Register, Centre of Registers in Region, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mervete Miftaraj
- Swedish National Diabetes Register, Centre of Registers in Region, Sweden
| | - Soffia Gudbjörnsdottir
- Swedish National Diabetes Register, Centre of Registers in Region, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ylva Trolle-Lagerros
- Unit of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ann-Marie Svensson
- Swedish National Diabetes Register, Centre of Registers in Region, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Hannes Hagström
- Unit of Clinical Epidemiology, Department of Medicine Solna, Karolinska University Hospital, Stockholm, Sweden; Unit of Hepatology, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden.
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20
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Taimour S, Avdic T, Franzén S, Zarrouk M, Acosta S, Nilsson P, Miftaraj M, Eliasson B, Svensson AM, Gottsäter A. Survival, cardiovascular morbidity, and reinterventions after elective endovascular aortic aneurysm repair in patients with and without diabetes: A nationwide propensity-adjusted analysis. Vasc Med 2019; 24:539-546. [PMID: 31441381 DOI: 10.1177/1358863x19870243] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Epidemiological data indicate decreased risk for development and growth of abdominal aortic aneurysm (AAA) among patients with diabetes mellitus (DM). On the other hand, DM adds to increased cardiovascular (CV) morbidity and mortality. In a nationwide observational cohort study of patients registered in the Swedish Vascular Register and the Swedish National Diabetes Register, we evaluated potential effects of DM on total mortality, CV morbidity, and the need for reintervention after elective endovascular aneurysm repair (EVAR) for AAA. We compared 748 patients with and 2630 without DM with propensity score-adjusted analysis, during a median 4.22 years of follow-up for patients with DM, and 4.05 years for those without. In adjusted analysis, diabetic patients showed higher rates of acute myocardial infarction (AMI) during follow-up (relative risk (RR) 1.44, 95% CI 1.06-1.95; p = 0.02), but lower need for reintervention (RR 0.12, CI 0.02-0.91; p = 0.04). There were no differences in total (RR 0.88, CI 0.74-1.05; p = 0.15) or CV (RR 1.58, CI 0.87-2.86; p = 0.13) mortality, or stroke (RR 0.95, CI 0.68-1.32; p = 0.75) during follow-up. In conclusion, patients with DM had higher rates of AMI and lower need for reintervention after elective EVAR than those without DM, whereas neither total nor CV mortality differed between groups. The putative protective effects of DM towards further AAA enlargement and late sac rupture may help explain the lower need for reintervention and absence of excess mortality.
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Affiliation(s)
- Soumia Taimour
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Tarik Avdic
- Swedish National Diabetes Register, Gothenburg, Sweden
| | | | - Moncef Zarrouk
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Peter Nilsson
- Department of Internal Medicine, Clinical Research Unit, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - Björn Eliasson
- Swedish National Diabetes Register, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Anders Gottsäter
- Department of Vascular Diseases, Lund University, Skåne University Hospital, Malmö, Sweden
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21
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Eliasson B, Ekelund J, Amberntsson R, Miftaraj M, Svensson AM. Cardiovascular Disease in Patients with Type 2 Diabetes and in Patients Starting Empagliflozin Treatment: Nationwide Survey. Diabetes Ther 2019; 10:1523-1530. [PMID: 31089969 PMCID: PMC6612325 DOI: 10.1007/s13300-019-0632-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Were the participants of the EMPA-REG OUTCOME trial representative of patients receiving empagliflozin in clinical practice? The aim of the present study was to examine the prevalence of cardiovascular disease (CVD) in type 2 diabetes patients starting empagliflozin treatment in routine clinical practice in Sweden. METHODS We used nationwide data from the Swedish National Diabetes Register (NDR), the Swedish Prescribed Drug Register, and the Swedish National Patient Register to provide clinical characteristics and ongoing treatments. RESULTS The total study cohort included 460,558 patients, of whom 130,508 (28.3%) had a history of CVD. The number of patients starting empagliflozin during the study period was 16,985. Among these, 1952 (11.5%) had a history of CVD. The patients starting empagliflozin were younger than the total cohort and were more likely to have retinopathy despite having a similar duration of diabetes to the overall cohort. They also exhibited higher BMI, HbA1c, and eGFR, and were more likely to be treated with insulin and lipid-lowering and blood-pressure-lowering medications. The patients with CVD who were starting empagliflozin were slightly older and had been diabetic for slightly longer than the patients without CVD who were starting empagliflozin, but they also had lower eGFR. Among the patients with CVD who were starting empagliflozin, 87% had coronary heart disease, 8% had suffered a stroke, 13% had peripheral artery disease, 16% had atrial fibrillation, and 20% had congestive heart failure. CONCLUSION The prevalence of CVD in patients with type 2 diabetes in clinical practice in Sweden was 28.3% during the study period, and it was 11.5% in the patients starting empagliflozin treatment. Patients of the latter cohort were, however, younger, more obese, and more likely to have unsatisfactory glycemic control, requiring additional treatment. Overall, a large proportion of type 2 diabetes patients should be considered at high cardiovascular risk. FUNDING Boehringer Ingelheim AB, Sweden.
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Affiliation(s)
- Björn Eliasson
- Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.
| | - Jan Ekelund
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | | | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
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22
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Chantzichristos D, Persson A, Miftaraj M, Eliasson B, Svensson AM, Johannsson G. SAT-378 Thyroid Disease, a Severe Infection, and Glucagon Prescription Should Raise the Awareness of Addison's Disease in Patients with Type 1 Diabetes: A National Swedish Study. J Endocr Soc 2019. [PMCID: PMC6551735 DOI: 10.1210/js.2019-sat-378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | | | | | - Björn Eliasson
- Sahlgrenska University Hospital & University of Gothenburg, Gothenburg, , Sweden
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23
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Toresson Grip E, Svensson AM, Miftaraj M, Eliasson B, Franzén S, Gudbjörnsdottir S, Steen Carlsson K. Real-World Costs of Continuous Insulin Pump Therapy and Multiple Daily Injections for Type 1 Diabetes: A Population-Based and Propensity-Matched Cohort From the Swedish National Diabetes Register. Diabetes Care 2019; 42:545-552. [PMID: 30705062 DOI: 10.2337/dc18-1850] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/02/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate real-world costs of continuous insulin pump therapy compared with multiple daily injection (MDI) therapy for type 1 diabetes. RESEARCH DESIGN AND METHODS Individuals with type 1 diabetes and pump therapy in the Swedish National Diabetes Register (NDR) since 2002 were eligible. Control subjects on MDI were matched 2:1 using time-varying propensity scores. Longitudinal data on health care resource use, antidiabetes treatment, sickness absence, and early retirement were taken from national registers for 2005-2013. Mean annual costs were analyzed using univariate analysis. Regression analyses explored the role of sociodemographic factors. Subgroup and sensitivity analyses were performed. RESULTS A total of 14,238 individuals with type 1 diabetes entered in the NDR between 2005 and 2013 (insulin pump n = 4,991, MDI n = 9,247, with switches allowed during the study) were included. Mean age at baseline was 34 years, with 21 years of diabetes duration and a mean HbA1c of 8.1% (65 mmol/mol). We had 73,920 person-years of observation with a mean follow-up of 5 years per participant. Mean annual costs were higher for pump therapy than for MDI therapy ($12,928 vs. $9,005, respectively; P < 0.001; mean difference $3,923 [95% CI $3,703-$4,143]). Health care costs, including medications and disposables, accounted for 73% of the costs for pump therapy and 63% of the costs for MDI therapy. Regression analyses showed higher costs for low education, low disposable income, women, and older age. CONCLUSIONS Nine years of real-world data on all measurable diabetes-related resource use show robust results for additional costs of insulin pump therapy in adults by subgroup and alternative propensity score specifications. Identification of tangible and intangible benefits of pump therapy over time remain important to support resource allocation decisions.
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Affiliation(s)
| | - Ann-Marie Svensson
- National Diabetes Register, Centre of Registers in Västra Götaland, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers in Västra Götaland, Gothenburg, Sweden
| | - Björn Eliasson
- National Diabetes Register, Centre of Registers in Västra Götaland, Gothenburg, Sweden.,Department of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers in Västra Götaland, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- National Diabetes Register, Centre of Registers in Västra Götaland, Gothenburg, Sweden.,Department of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Steen Carlsson
- Swedish Institute for Health Economics, Lund, Sweden .,Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
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24
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Chantzichristos D, Persson A, Miftaraj M, Eliasson B, Svensson AM, Johannsson G. Early Clinical Indicators of Addison Disease in Adults With Type 1 Diabetes: A Nationwide, Observational, Cohort Study. J Clin Endocrinol Metab 2019; 104:1148-1157. [PMID: 30476180 DOI: 10.1210/jc.2018-02064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 11/16/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with type 1 diabetes mellitus (T1DM) have an increased risk of Addison disease (AD) development, but prediction of those at risk is not possible. OBJECTIVE To determine whether there are early clinical indicators that may denote the development of AD in adults with T1DM. DESIGN Observational, matched-cohort study. SETTING Patient data from Swedish national registries [National Diabetes Register (NDR), Inpatient Register, and Prescription Drug Register]. PARTICIPANTS All patients with T1DM diagnosed with concomitant AD (n = 66) among the 36,514 adult patients with T1DM in the NDR between 1998 and 2013. Each case was matched to five controls with T1DM alone (n = 330). MAIN OUTCOME MEASURES Clinical data and drug prescriptions were assessed prior to baseline (inclusion into the study) and prior to AD diagnosis. Analysis of covariance and estimated group proportions were used for comparisons. RESULTS Prior to baseline, cases had a higher frequency of thyroid/antithyroid drug prescription than controls (9.1% vs 1.8%). Prior to AD diagnosis, cases had higher frequencies of diabetic retinopathy (12.1% vs 2.1%), infections requiring hospital admission (16.7% vs 2.1%), thyroid/antithyroid drug prescription (28.8% vs 7.0%), and glucagon prescription (18.2% vs 6.4%). There was no difference in glycated Hb between the groups prior to baseline or prior to AD diagnosis. CONCLUSIONS These data suggest that medical treatment of thyroid disease, a severe infection, and glucagon prescription for severe hypoglycemia should raise the suspicion of AD development in adults with T1DM. Development of diabetic retinopathy might also be associated with glucocorticoid deficiency and the development of AD among patients with T1DM.
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Affiliation(s)
- Dimitrios Chantzichristos
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Persson
- National Diabetes Register at Centre of Registers, Department of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register at Centre of Registers, Department of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
- National Diabetes Register at Centre of Registers, Department of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- National Diabetes Register at Centre of Registers, Department of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
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Liakopoulos V, Franzén S, Svensson AM, Miftaraj M, Ottosson J, Näslund I, Gudbjörnsdottir S, Eliasson B. Pros and cons of gastric bypass surgery in individuals with obesity and type 2 diabetes: nationwide, matched, observational cohort study. BMJ Open 2019; 9:e023882. [PMID: 30782717 PMCID: PMC6340417 DOI: 10.1136/bmjopen-2018-023882] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Long-term effects of gastric bypass (GBP) surgery have been presented in observational and randomised studies, but there are only limited data for persons with obesity and type 2 diabetes mellitus (T2DM) regarding postoperative complications. DESIGN This is a nationwide observational study based on two quality registers in Sweden (National Diabetes Register, NDR and Scandinavian Obesity Surgery Register, SOReg) and other national databases. SETTING After merging the data, we matched individuals with T2DM who had undergone GBP with those not surgically treated for obesity on propensity score, based on sex, age, body mass index (BMI) and calendar time. The risks of postoperative outcomes (rehospitalisations) were assessed using Cox regression models. PARTICIPANTS We identified 5321 patients with T2DM in the SOReg and 5321 matched controls in the NDR, aged 18-65 years, with BMI >27.5 kg/m² and followed for up to 9 years. PRIMARY AND SECONDARY OUTCOME MEASURES We assessed risks for all-cause mortality and hospitalisations for cardiovascular disease, severe kidney disease, along with surgical and other medical conditions. RESULTS The results agree with the previously suggested lower risks of all-cause mortality (49%) and cardiovascular disease (34%), and we also found positive effects for severe kidney disease but significantly increased risks (twofold to ninefold) of several short-term complications after GBP, such as abdominal pain and gastrointestinal conditions, frequently requiring surgical procedures, apart from reconstructive plastic surgery. Long-term, the risk of anaemia was 92% higher, malnutrition developed approximately three times as often, psychiatric diagnoses were 33% more frequent and alcohol abuse was three times as great as in the control group. CONCLUSIONS This nationwide study confirms the benefits and describes the panorama of adverse events after bariatric surgery in persons with obesity and T2DM. Long-term postoperative monitoring and support, as better selection of patients by appropriate specialists in interdisciplinary settings, should be provided to optimise the outcomes.
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Affiliation(s)
- Vasileios Liakopoulos
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
- Health Metrics Unit, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ingmar Näslund
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medical Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
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Karlsson SA, Eliasson B, Franzén S, Miftaraj M, Svensson AM, Andersson Sundell K. Risk of cardiovascular event and mortality in relation to refill and guideline adherence to lipid-lowering medications among patients with type 2 diabetes mellitus in Sweden. BMJ Open Diabetes Res Care 2019; 7:e000639. [PMID: 31114701 PMCID: PMC6501851 DOI: 10.1136/bmjdrc-2018-000639] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/15/2019] [Accepted: 03/04/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To analyze the risk of cardiovascular (CV) events and mortality in relation to adherence to lipid-lowering medications by healthcare centers and patients with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS We included 121 914 patients (12% secondary prevention) with T2DM reported by 1363 healthcare centers. Patients initiated lipid-lowering medications between July 2006 and December 2012 and were followed from cessation of the first filled supply until multidose dispensed medications, migration, CV events, death or December 2016. The study period was divided into 4-month intervals through 2014, followed by annual intervals through 2016. Adherence measures were assessed for each interval. Patients' (refill) adherence was measured using the medication possession ratio (MPR). Healthcare centers' (guideline) adherence represented the prescription prevalence of lipid-lowering medications according to guidelines. The risk of CV events and mortality was analyzed for each interval using Cox proportional hazard regression and Kaplan-Meier. RESULTS Compared with high-adherent patients (MPR >80%), low-adherent primary prevention patients (MPR ≤80%) showed higher risk of all outcomes: 44%-51 % for CV events, doubled for all-cause mortality and 79%-90% for CV mortality. Corresponding risks for low-adherent secondary prevention patients were 17%-19% for CV events, 88%-97% for all-cause and 66%-79% for CV mortality. Primary prevention patients treated by low-adherent healthcare centers (guideline adherence <48%) had a higher risk of CV events and CV mortality. Otherwise, no difference in the risk of CV events or mortality was observed by guideline adherence level. CONCLUSIONS Our results demonstrate the importance of high refill adherence and thus the value of individualized care among patients with T2DM.
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Affiliation(s)
- Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska academy, University of Gothenburg, Goteborg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | | | - Karolina Andersson Sundell
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska academy, University of Gothenburg, Goteborg, Sweden
- Global Medical Affairs, Medical Evidence and Observational Research, AstraZeneca AB, Mölndal, Sweden
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27
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Karlsson SA, Franzén S, Svensson AM, Miftaraj M, Eliasson B, Andersson Sundell K. Prescription of lipid-lowering medications for patients with type 2 diabetes mellitus and risk-associated LDL cholesterol: a nationwide study of guideline adherence from the Swedish National Diabetes Register. BMC Health Serv Res 2018; 18:900. [PMID: 30486824 PMCID: PMC6260691 DOI: 10.1186/s12913-018-3707-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/12/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Management of type 2 diabetes mellitus (T2DM) encompasses intensive glycaemic control, along with treatment of comorbidities and complications to handle the increased risk of cardiovascular disease (CVD). Improved control of LDL-cholesterol (LDL-C) with lipid-lowering medications is associated with reduced CVD risk in T2DM patients. Thus, treatment guidelines recommend lipid-lowering medications for T2DM patients with LDL-C above risk-associated thresholds. This study aimed to assess healthcare provider adherence to guidelines regarding lipid-lowering medication prescription among T2DM patients and to analyse factors associated with lipid-lowering medication prescription. METHODS Observations in 2007 - 2014 for T2DM patients age ≥ 18 were collected from the Swedish National Diabetes Register. Observations were excluded if they lacked information about LDL-C, lipid-lowering medication prescription or CVD. Observations with established CVD were attributed to secondary prevention; remaining observations were attributed to primary prevention. The analyses included primary and secondary prevention observations with LDL-C above risk-associated thresholds (LDL-C ≥ 2.5 mmol/l and LDL-C ≥ 1.8 mmol/l respectively). Guideline adherence was analysed as the probability of prescribing lipid-lowering medications using mixed-effect model regression adjusted for potential confounders. Factors associated with prescribing lipid-lowering medications were analysed for patient and healthcare provider characteristics using mixed-effect model regression and odds ratio. RESULTS A total of 1,204,376 observations from 322,046 patients reported by 1352 healthcare providers were included. Primary prevention accounted for 63%; 52% were men, mean age was 64 and mean LDL-C was 3.4 mmol/l. For secondary prevention, 60% were men, mean age was 72 and mean LDL-C was 2.7 mmol/l. During 2007-2014, guideline adherence ranged from 36 to 47% for primary prevention and 59 to 69% for secondary prevention. In general, concomitant prescription of diabetes medications, antiplatelets and antihypertensives along with smoking and specialised care were associated with higher prescription of lipid-lowering medications. Patients age ≥ 80 were associated with lower prescription of lipid-lowering medications. Higher prescription was associated with longer diabetes duration in primary prevention and men in secondary prevention. CONCLUSIONS Adherence to treatment guidelines levelled off after an initial increase in both prevention groups. Lipid-lowering medication prescription was based on individualised CVD risk.
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Affiliation(s)
- Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, BOX 453, SE-405 30 Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | | | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karolina Andersson Sundell
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, BOX 453, SE-405 30 Gothenburg, Sweden
- AstraZeneca AB, Medical Evidence and Observational Research, Mölndal, Sweden
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Rawshani A, Rawshani A, Franzén S, Sattar N, Eliasson B, Svensson AM, Zethelius B, Miftaraj M, McGuire DK, Rosengren A, Gudbjörnsdottir S. Risk Factors, Mortality, and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med 2018; 379:633-644. [PMID: 30110583 DOI: 10.1056/nejmoa1800256] [Citation(s) in RCA: 760] [Impact Index Per Article: 126.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with diabetes are at higher risk for death and cardiovascular outcomes than the general population. We investigated whether the excess risk of death and cardiovascular events among patients with type 2 diabetes could be reduced or eliminated. METHODS In a cohort study, we included 271,174 patients with type 2 diabetes who were registered in the Swedish National Diabetes Register and matched them with 1,355,870 controls on the basis of age, sex, and county. We assessed patients with diabetes according to age categories and according to the presence of five risk factors (elevated glycated hemoglobin level, elevated low-density lipoprotein cholesterol level, albuminuria, smoking, and elevated blood pressure). Cox regression was used to study the excess risk of outcomes (death, acute myocardial infarction, stroke, and hospitalization for heart failure) associated with smoking and the number of variables outside target ranges. We also examined the relationship between various risk factors and cardiovascular outcomes. RESULTS The median follow-up among all the study participants was 5.7 years, during which 175,345 deaths occurred. Among patients with type 2 diabetes, the excess risk of outcomes decreased stepwise for each risk-factor variable within the target range. Among patients with diabetes who had all five variables within target ranges, the hazard ratio for death from any cause, as compared with controls, was 1.06 (95% confidence interval [CI], 1.00 to 1.12), the hazard ratio for acute myocardial infarction was 0.84 (95% CI, 0.75 to 0.93), and the hazard ratio for stroke was 0.95 (95% CI, 0.84 to 1.07). The risk of hospitalization for heart failure was consistently higher among patients with diabetes than among controls (hazard ratio, 1.45; 95% CI, 1.34 to 1.57). In patients with type 2 diabetes, a glycated hemoglobin level outside the target range was the strongest predictor of stroke and acute myocardial infarction; smoking was the strongest predictor of death. CONCLUSIONS Patients with type 2 diabetes who had five risk-factor variables within the target ranges appeared to have little or no excess risk of death, myocardial infarction, or stroke, as compared with the general population. (Funded by the Swedish Association of Local Authorities and Regions and others.).
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Affiliation(s)
- Aidin Rawshani
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Araz Rawshani
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Stefan Franzén
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Naveed Sattar
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Björn Eliasson
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Ann-Marie Svensson
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Björn Zethelius
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Mervete Miftaraj
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Darren K McGuire
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Annika Rosengren
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Soffia Gudbjörnsdottir
- From the Department of Molecular and Clinical Medicine, Institute of Medicine (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Health Metrics Unit, Sahlgrenska Academy (S.F.), University of Gothenburg, and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, and the Department of Public Health and Caring Sciences-Geriatrics, Uppsala University, and the Swedish Medical Products Agency, Uppsala (B.Z.) - all in Sweden; the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.); and the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
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Karlsson SA, Hero C, Svensson AM, Franzén S, Miftaraj M, Gudbjörnsdottir S, Eeg-Olofsson K, Eliasson B, Andersson Sundell K. Association between refill adherence to lipid-lowering medications and the risk of cardiovascular disease and mortality in Swedish patients with type 2 diabetes mellitus: a nationwide cohort study. BMJ Open 2018; 8:e020309. [PMID: 29602853 PMCID: PMC5884334 DOI: 10.1136/bmjopen-2017-020309] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To analyse the association between refill adherence to lipid-lowering medications, and the risk of cardiovascular disease (CVD) and mortality in patients with type 2 diabetes mellitus. DESIGN Cohort study. SETTING National population-based cohort of Swedish patients with type 2 diabetes mellitus. PARTICIPANTS 86 568 patients aged ≥18 years, registered with type 2 diabetes mellitus in the Swedish National Diabetes Register, who filled at least one prescription for lipid-lowering medication use during 2007-2010, 87% for primary prevention. EXPOSURE AND OUTCOME MEASURES Refill adherence of implementation was assessed using the medication possession ratio (MPR), representing the proportion of days with medications on hand during an 18-month exposure period. MPR was categorised by five levels (≤20%, 21%-40%, 41%-60%, 61%-80% and >80%). Patients without medications on hand for ≥180 days were defined as non-persistent. Risk of CVD (myocardial infarction, ischaemic heart disease, stroke and unstable angina) and mortality by level of MPR and persistence was analysed after the exposure period using Cox proportional hazards regression and Kaplan-Meier, adjusted for demographics, socioeconomic status, concurrent medications and clinical characteristics. RESULTS The hazard ratios for CVD ranged 1.33-2.36 in primary prevention patients and 1.19-1.58 in secondary prevention patients, for those with MPR ≤80% (p<0.0001). The mortality risk was similar regardless of MPR level. The CVD risk was 74% higher in primary prevention patients and 33% higher in secondary prevention patients, for those who were non-persistent (p<0.0001). The mortality risk was 6% higher in primary prevention patients and 18% higher in secondary prevention patients, for non-persistent patients (p<0.0001). CONCLUSIONS Higher refill adherence to lipid-lowering medications was associated with lower risk of CVD in primary and secondary prevention patients with type 2 diabetes mellitus.
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Affiliation(s)
- Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christel Hero
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Stefan Franzén
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karolina Andersson Sundell
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- AstraZeneca, Medical Evidence and Observational Research, Gothenburg, Sweden
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Vestberg D, Rosengren A, Eeg-Olofsson K, Miftaraj M, Franzen S, Svensson AM, Lind M. Body mass index as a risk factor for coronary events and mortality in patients with type 1 diabetes. Open Heart 2018; 5:e000727. [PMID: 29387430 PMCID: PMC5786904 DOI: 10.1136/openhrt-2017-000727] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/02/2017] [Accepted: 12/29/2017] [Indexed: 01/24/2023] Open
Abstract
Objective To investigate the potential relationship between body mass index (BMI) and the risk for myocardial infarction and coronary death in patients with type 1 diabetes. Methods We studied patients with type 1 diabetes included in the Swedish National Diabetes Registry during 2002-2004 and followed them until a discharge diagnosis for myocardial infarction, acute coronary event, death or until 31 December 2011. Cox regression was used to estimate relative risks. Results In 17 499 patients with type 1 diabetes (mean age 39.4 years; mean BMI 25.2 kg/m2), 819 were diagnosed with myocardial infarction as a primary or secondary diagnosis during a mean follow-up of 8.5 years (maximum 9.9 years). Estimated with Cox regression, there was no significant effect of increased BMI on the risk of myocardial infarction (HR 1.4 (95% CI 0.7 to 2.5) in the group with BMI >35 kg/m2 compared with BMI 18.5-25 kg/m2. There was no association between BMI and coronary mortality, acute coronary events or all-cause mortality after adjusting for other known risk factors. Underweight patients (BMI <18.5 kg/m2) had increased hazard for coronary (HR 5.0 (95% CI 1.5 to 16.9)) and all-cause mortality (HR 5.4 (95% CI 3.1 to 9.6)) compared with BMI 18.5-25 kg/m2. Conclusions Among patients with type 1 diabetes, increased BMI is not a significant independent risk factor for myocardial infarction or coronary death after adjustment for other risk factors. Low BMI (less than 18.5 kg/m2) is associated with mortality from coronary or any cause.
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Affiliation(s)
- Daniel Vestberg
- Department of Medicine, NU-Hospital Organization, Trollhättan, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Stefan Franzen
- Center of Registers in Region Västra Götaland, Goteborg, Sweden
| | | | - Marcus Lind
- Department of Medicine, NU-Hospital Organization, Trollhättan, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Chantzichristos D, Persson A, Eliasson B, Miftaraj M, Franzén S, Svensson AM, Johannsson G. Incidence, prevalence and seasonal onset variation of Addison's disease among persons with type 1 diabetes mellitus: nationwide, matched cohort studies. Eur J Endocrinol 2018; 178:113-120. [PMID: 29066573 DOI: 10.1530/eje-17-0751] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 10/14/2017] [Accepted: 10/23/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES We determined the incidence and prevalence of Addison's disease (AD) among persons with or without type 1 diabetes mellitus (T1DM) in nationwide, matched cohort studies. METHODS Persons with T1DM were identified from the Swedish National Diabetes Register and each was matched for age, sex, year and county to five controls randomly selected from the general population. Persons with AD were identified from the Swedish National Inpatient Register. Baseline demographics and seasonal onset variation of AD were presented by descriptive statistics. Prevalence and incidence were estimated by proportions and incidence rates, respectively. Times to AD were analyzed using the Cox proportional hazard model. RESULTS Between 1998 and 2013, 66 persons with T1DM were diagnosed with AD at a mean age (s.d.) of 36.4 (13.0) years among 36 514 persons with T1DM, while 32 were diagnosed with AD at a mean age of 42.7 (15.2) years among 182 570 controls. The difference in mean age at diagnosis of AD between the groups was 6.3 years (P value = 0.036). The incidence of AD for a person with or without T1DM was therefore 193 and 18 per million person-years, respectively. The adjusted relative risk increase of developing AD in T1DM was 10.8 (95% CI: 7.1-16.5). The highest incidence of AD was observed during February-March and September-October. The prevalence of AD in persons with or without T1DM in December 2012 was 3410 and 208 per million, respectively. The odds ratio for AD in persons with T1DM vs controls was 16.5 (95% CI: 11.1-24.5). CONCLUSION The risk to develop AD among persons with T1DM is more than 10 times higher than in persons without T1DM. Persons with T1DM develop AD at a younger age. The incidence of AD may have a seasonal pattern.
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Affiliation(s)
- Dimitrios Chantzichristos
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Persson
- Department of Medicine, National Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Medicine, National Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Mervete Miftaraj
- Department of Medicine, National Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Franzén
- Department of Medicine, National Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Department of Medicine, National Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
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Nyström T, Sartipy U, Franzén S, Eliasson B, Gudbjörnsdottir S, Miftaraj M, Lagerqvist B, Svensson AM, Holzmann MJ. PCI Versus CABG in Patients With Type 1 Diabetes and Multivessel Disease. J Am Coll Cardiol 2017; 70:1441-1451. [DOI: 10.1016/j.jacc.2017.07.744] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 07/18/2017] [Accepted: 07/21/2017] [Indexed: 12/21/2022]
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Karlsson SA, Hero C, Eliasson B, Franzén S, Svensson AM, Miftaraj M, Gudbjörnsdottir S, Eeg-Olofsson K, Andersson Sundell K. Refill adherence and persistence to lipid-lowering medicines in patients with type 2 diabetes: A nation-wide register-based study. Pharmacoepidemiol Drug Saf 2017; 26:1220-1232. [PMID: 28799214 PMCID: PMC5656892 DOI: 10.1002/pds.4281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 04/27/2017] [Accepted: 07/04/2017] [Indexed: 12/21/2022]
Abstract
Purpose This study aimed to describe and compare refill adherence and persistence to lipid‐lowering medicines in patients with type 2 diabetes by previous cardiovascular disease (CVD). Methods We followed 97 595 patients (58% men; 23% with previous CVD) who were 18 years of age or older when initiating lipid‐lowering medicines in 2007–2010 until first fill of multi‐dose dispensed medicines, death, or 3 years. Using personal identity numbers, we linked individuals' data from the Swedish Prescribed Drug Register, the Swedish National Diabetes Register, the National Patient Register, the Cause of Death Register, and the Longitudinal Integration Database for Health Insurance and Labour Market Studies. We assessed refill adherence using the medication possession ratio (MPR) and the maximum gap method, and measured persistence from initiation to discontinuation of treatment or until 3 years after initiation. We analyzed differences in refill adherence and persistence by previous CVD in multiple regression models, adjusted for socioeconomic status, concurrent medicines, and clinical characteristics. Results The mean age of the study population was 64 years, 80% were born in Sweden, and 56% filled prescriptions for diabetes medicines. Mean MPR was 71%, 39% were adherent according to the maximum gap method, and mean persistence was 758 days. Patients with previous CVD showed higher MPR (3%) and lower risk for discontinuing treatment (12%) compared with patients without previous CVD (P < 0.0001). Conclusions Patients with previous CVD were more likely to be adherent to treatment and had lower risk for discontinuation compared with patients without previous CVD.
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Affiliation(s)
- Sofia Axia Karlsson
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Christel Hero
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Stefan Franzén
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | | | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Katarina Eeg-Olofsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Karolina Andersson Sundell
- Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.,AstraZeneca AB, Medical Evidence and Observational Research, Gothenburg, Sweden
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Svensson AM, Miftaraj M, Franzén S, Eliasson B. Clinical effects, cardiovascular and renal outcomes associated with rapid-acting insulin analogs among individuals with type 2 diabetes: a nation-wide observational cohort study. Clin Diabetes Endocrinol 2017; 3:5. [PMID: 28702259 PMCID: PMC5477297 DOI: 10.1186/s40842-017-0043-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/15/2017] [Indexed: 12/27/2022] Open
Abstract
Background Rapid-acting insulin analogs (RAIs) have not been examined for long-term safety in randomized clinical trials. We performed a nationwide longitudinal cohort study among individuals with type 2 diabetes (T2DM) to address cardiovascular safety and mortality among users of lispro, aspart and glulisine insulins. Methods We used four national registers, following patients previously not treated with RAI but with continuous use of RAIs in 2005-2014 up to 6.4 years, to examine HbA1c and weight, and the occurrence of severe hyperglycemia or hypoglycemia, renal failure, cardiovascular events or death. The treatment groups were compared using a weighted Cox proportional hazards model. Results We included 17,620 patients, mean age slightly higher than 60 years, diabetes duration 9.9–11.7 years, mean BMI 30.5 kg/m2, HbA1c around 70 mmol/mol (8.6% NGSP), and 40.9–54.0% of the patients exhibiting eGFR <60 ml/min/1.73 m2 in the three groups. Around 95% of the patients also used another insulin, and 24.2–24.7% had a history of cardiovascular disease (CVD). Mean HbA1c and weight levels were stable and similar. Incidence rates of death were 234.4, 284.9 and 156.7 per 1000 person-years among users of lispro, aspart, and glulisine; incidence rates of all cardiovascular events were 668.4, 622.4, and 699.5 per 1000 person-years, respectively. There were no differences in mortality, CVD, renal failure or severe hypoglycemia or hyperglycemia, although a lower mortality risk in patients on glulisine compared with aspart, and lower risk of stroke in users of glulisine was suggested. The risk of severe hyperglycemia was higher with lispro than aspart, and lower of severe hypoglycemia than aspart or glulisine among the older age group. Conclusions Overall, there do not appear to be any major important differences in effects on hypoglycemia, hyperglycemia, weight or long-term safety between the three available RAIs among insulin-naive individuals with T2DM in clinical practice.
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Affiliation(s)
- Ann-Marie Svensson
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden.,Department of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mervete Miftaraj
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Stefan Franzén
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Sahlgrenska University Hospital, S-423 45 Gothenburg, Sweden
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Rawshani A, Rawshani A, Franzén S, Eliasson B, Svensson AM, Miftaraj M, McGuire DK, Sattar N, Rosengren A, Gudbjörnsdottir S. Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes. N Engl J Med 2017; 376:1407-1418. [PMID: 28402770 DOI: 10.1056/nejmoa1608664] [Citation(s) in RCA: 738] [Impact Index Per Article: 105.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Long-term trends in excess risk of death and cardiovascular outcomes have not been extensively studied in persons with type 1 diabetes or type 2 diabetes. METHODS We included patients registered in the Swedish National Diabetes Register from 1998 through 2012 and followed them through 2014. Trends in deaths and cardiovascular events were estimated with Cox regression and standardized incidence rates. For each patient, controls who were matched for age, sex, and county were randomly selected from the general population. RESULTS Among patients with type 1 diabetes, absolute changes during the study period in the incidence rates of sentinel outcomes per 10,000 person-years were as follows: death from any cause, -31.4 (95% confidence interval [CI], -56.1 to -6.7); death from cardiovascular disease, -26.0 (95% CI, -42.6 to -9.4); death from coronary heart disease, -21.7 (95% CI, -37.1 to -6.4); and hospitalization for cardiovascular disease, -45.7 (95% CI, -71.4 to -20.1). Absolute changes per 10,000 person-years among patients with type 2 diabetes were as follows: death from any cause, -69.6 (95% CI, -95.9 to -43.2); death from cardiovascular disease, -110.0 (95% CI, -128.9 to -91.1); death from coronary heart disease, -91.9 (95% CI, -108.9 to -75.0); and hospitalization for cardiovascular disease, -203.6 (95% CI, -230.9 to -176.3). Patients with type 1 diabetes had roughly 40% greater reduction in cardiovascular outcomes than controls, and patients with type 2 diabetes had roughly 20% greater reduction than controls. Reductions in fatal outcomes were similar in patients with type 1 diabetes and controls, whereas patients with type 2 diabetes had smaller reductions in fatal outcomes than controls. CONCLUSIONS In Sweden from 1998 through 2014, mortality and the incidence of cardiovascular outcomes declined substantially among persons with diabetes, although fatal outcomes declined less among those with type 2 diabetes than among controls. (Funded by the Swedish Association of Local Authorities and Regions and others.).
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Affiliation(s)
- Aidin Rawshani
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Araz Rawshani
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Stefan Franzén
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Björn Eliasson
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Ann-Marie Svensson
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Mervete Miftaraj
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Darren K McGuire
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Naveed Sattar
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Annika Rosengren
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
| | - Soffia Gudbjörnsdottir
- From the Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren, S.G.), and the Swedish National Diabetes Register, Center of Registers in Region (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.), Gothenburg, Sweden; the Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (N.S.)
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Rawshani A, Rawshani A, Franzén S, Eliasson B, Svensson AM, Miftaraj M, McGuire DK, Sattar N, Rosengren A, Gudbjörnsdottir S. Range of Risk Factor Levels: Control, Mortality, and Cardiovascular Outcomes in Type 1 Diabetes Mellitus. Circulation 2017; 135:1522-1531. [PMID: 28416524 PMCID: PMC5400410 DOI: 10.1161/circulationaha.116.025961] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 02/09/2017] [Indexed: 11/17/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Individuals with type 1 diabetes mellitus (T1DM) have a high risk of cardiovascular complications, but it is unknown to what extent fulfilling all cardiovascular treatment goals is associated with residual risk of mortality and cardiovascular outcomes in those with T1DM compared with the general population. Methods: We included all patients ≥18 years of age with T1DM who were registered in the Swedish National Diabetes Register from January 1, 1998, through December 31, 2014, a total of 33 333 patients, each matched for age and sex with 5 controls without diabetes mellitus randomly selected from the population. Patients with T1DM were categorized according to number of risk factors not at target: glycohemoglobin, blood pressure, albuminuria, smoking, and low-density lipoprotein cholesterol. Risk of all-cause mortality, acute myocardial infarction, heart failure hospitalization, and stroke was examined in relation to the number of risk factors at target. Results: The mean follow-up was 10.4 years in the diabetes group. Overall, 2074 of 33 333 patients with diabetes mellitus and 4141 of 166 529 controls died. Risk for all outcomes increased stepwise for each additional risk factor not at target. Adjusted hazard ratios for patients achieving all risk factor targets compared with controls were 1.31 (95% confidence interval [CI], 0.93–1.85) for all-cause mortality, 1.82 (95% CI, 1.15–2.88) for acute myocardial infarction, 1.97 (95% CI, 1.04–3.73) for heart failure hospitalization, and 1.17 (95% CI, 0.51–2.68) for stroke. The hazard ratio for patients versus controls with none of the risk factors meeting target was 7.33 (95% CI, 5.08–10.57) for all-cause mortality, 12.34 (95% CI, 7.91–19.48) for acute myocardial infarction, 15.09 (95% CI, 9.87–23.09) for heart failure hospitalization, and 12.02 (95% CI, 7.66–18.85) for stroke. Conclusions: A steep-graded association exists between decreasing number of cardiovascular risk factors at target and major adverse cardiovascular outcomes among patients with T1DM. However, risks for all outcomes were numerically higher for patients with T1DM compared with controls, even when all risk factors were at target, with risk for acute myocardial infarction and heart failure hospitalization statistically significantly higher.
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Affiliation(s)
- Aidin Rawshani
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.).
| | - Araz Rawshani
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
| | - Stefan Franzén
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
| | - Björn Eliasson
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
| | - Ann-Marie Svensson
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
| | - Mervete Miftaraj
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
| | - Darren K McGuire
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
| | - Naveed Sattar
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
| | - Annika Rosengren
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
| | - Soffia Gudbjörnsdottir
- From Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, B.E., A. Rosengren); Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden (Aidin Rawshani, Araz Rawshani, S.F., B.E., A.-M.S., M.M., S.G.); Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (D.K.M.); and Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK (N.S.)
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Chantzichristos D, Persson A, Eliasson B, Miftaraj M, Franzén S, Bergthorsdottir R, Gudbjörnsdottir S, Svensson AM, Johannsson G. Mortality in patients with diabetes mellitus and Addison's disease: a nationwide, matched, observational cohort study. Eur J Endocrinol 2017; 176:31-39. [PMID: 27928991 DOI: 10.1530/eje-16-0657] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/05/2016] [Accepted: 10/12/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Our hypothesis was that patients with diabetes mellitus obtain an additional risk of death if they develop Addison's disease (AD). DESIGN AND METHODS Nationwide, matched, observational cohort study cross-referencing the Swedish National Diabetes Register with Inpatient, Cancer and Cause of Death Registers in patients with diabetes (type 1 and 2) and AD and matched controls with diabetes. Clinical characteristics at baseline, overall, and cause-specific mortality were assessed. The relative risk of death was assessed using a Cox proportional hazards regression model. RESULTS Between January 1996 and December 2012, 226 patients with diabetes and AD were identified and matched with 1129 controls with diabetes. Median (interquartile range) follow-up was 5.9 (2.7-8.6) years. When patients with diabetes were diagnosed with AD, they had an increased frequency of diabetes complications, but both medical history of cancer and coronary heart disease did not differ compared with controls. Sixty-four of the 226 patients with diabetes and AD (28%) died, while 112 of the 1129 controls (10%) died. The estimated relative risk increase (hazard ratio) in overall mortality in the diabetes and AD group was 3.89 (95% confidence interval 2.84-5.32) compared with controls with diabetes. The most common cause of death was cardiovascular in both groups, but patients with diabetes and AD showed an increased death rate from diabetes complications, infectious diseases and unknown causes. CONCLUSIONS Patients with the rare combination of diabetes and AD showed a markedly increased mortality and died more frequently from infections and unknown causes than patients with diabetes alone. Improved strategy for the management of this combination of metabolic disorders is needed.
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Affiliation(s)
- Dimitrios Chantzichristos
- Department of Internal Medicine and Clinical NutritionInstitute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-MetabolismSahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Persson
- Department of MedicineNational Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Internal Medicine and Clinical NutritionInstitute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-MetabolismSahlgrenska University Hospital, Gothenburg, Sweden
- Department of MedicineNational Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Mervete Miftaraj
- Department of MedicineNational Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Stefan Franzén
- Department of MedicineNational Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Internal Medicine and Clinical NutritionInstitute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-MetabolismSahlgrenska University Hospital, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Internal Medicine and Clinical NutritionInstitute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-MetabolismSahlgrenska University Hospital, Gothenburg, Sweden
- Department of MedicineNational Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Department of MedicineNational Diabetes Register, Centre of Registers, University of Gothenburg, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical NutritionInstitute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology-Diabetes-MetabolismSahlgrenska University Hospital, Gothenburg, Sweden
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Ekström N, Svensson AM, Miftaraj M, Franzén S, Zethelius B, Eliasson B, Gudbjörnsdottir S. Cardiovascular safety of glucose-lowering agents as add-on medication to metformin treatment in type 2 diabetes: report from the Swedish National Diabetes Register. Diabetes Obes Metab 2016; 18:990-8. [PMID: 27282621 DOI: 10.1111/dom.12704] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 05/26/2016] [Accepted: 06/04/2016] [Indexed: 12/20/2022]
Abstract
AIM To investigate the relative safety of various glucose-lowering agents as add-on medication to metformin in type 2 diabetes in an observational study linking five national health registers. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes who had been on metformin monotherapy and started another agent in addition to metformin were eligible for inclusion. The study period was 2005-2012. Adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of mortality, cardiovascular disease (CVD), coronary heart disease (CHD), stroke and congestive heart failure (CHF) were estimated using Cox proportional hazards models, weighted for a propensity score. RESULTS Of the 20 422 patients included in the study, 43% started on second-line treatment with sulphonylurea (SU), 21% basal insulin, 12% thiazolidinedione (TZD), 11% meglitinide, 10% dipeptidyl peptidase-4 (DPP-4) inhibitor, 1% glucagon-like peptide-1 (GLP-1) receptor agonist and 1% acarbose. At the index date, the mean patient age was ~60 years for all groups except the GLP-1 receptor agonist (56.0 years) and SU (62.9 years) groups. Diabetes duration and glycated haemoglobin levels were similar in all groups. When compared with SU, basal insulin was associated with an 18% higher risk and TZD with a 24% lower risk of mortality [HR 1.18 (95% CI 1.03-1.36) and 0.76 (95% CI 0.62-0.94)], respectively. DPP-4 inhibitor treatment was associated with significantly lower risks of CVD, fatal CVD, CHD, fatal CHD and CHF. CONCLUSIONS This nationwide observational study showed that second-line treatment with TZD and DPP-4 inhibitor as add-on medication to metformin were associated with significantly lower risks of mortality and cardiovascular events compared with SU, whereas basal insulin was associated with a higher risk of mortality.
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Affiliation(s)
- Nils Ekström
- Department of Medicine, University of Gothenburg, Gothenburg, Sweden.
- Department of Medicine Solna, Center for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.
| | | | - Mervete Miftaraj
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Stefan Franzén
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Björn Zethelius
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden
- Medical Products Agency, Uppsala, Sweden
| | - Björn Eliasson
- Department of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Medicine, University of Gothenburg, Gothenburg, Sweden
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
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Lak V, Svensson AM, Miftaraj M, Franzén S, Eliasson B. Clinical Effects and Safety of Direct-Acting Insulin Analogs in Patients with Type 1 Diabetes: A Nation-Wide Observational Cohort Study. Diabetes Ther 2016; 7:561-73. [PMID: 27517679 PMCID: PMC5014797 DOI: 10.1007/s13300-016-0191-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Indexed: 10/29/2022] Open
Abstract
INTRODUCTION Studies comparing direct-acting insulin analogs (DAIs) in terms of effectiveness and long-term safety are scarce. Our aim was to explore these variables in clinical practice among patients with type 1 diabetes, including the elderly and those with renal impairment. METHODS We linked four national registers in a population-based cohort study. Patients with type 1 diabetes and continuous use of all currently available DAIs (lispro, aspart, or glulisine) in 2005-2013 were monitored for up to 7.5 years. Inverse probability of treatment weighting was used to adjust for differences in baseline characteristics between treatment groups. Unadjusted mean HbA1c and weights were plotted. Hazard ratios and 95% confidence intervals of cardiovascular events (CVEs) and mortality were estimated using Cox proportional hazards regression models. RESULTS We included 41,165 patients-14,047 lispro, 26,813 aspart, and 305 glulisine users. At baseline, the mean age was highest among glulisine users (49.4 years), followed by 41.0 years for lispro users and 40.1 years for aspart users. A total of 9.2% of the patients were 65 years or older. Diabetes duration was shortest among glulisine users (11.6 years), followed by 15.4 years for aspart users and 19.5 years for lispro users. The mean HbA1c and weights during the follow-up period were similar. The numerical differences at baseline were subsequently adjusted for. There were no significant differences between groups regarding hyperglycemia requiring hospitalization, CVE, or mortality, while Cox regression suggested lower rates of hypoglycemia among glulisine users. Severe hypoglycemia was more common, and severe hyperglycemia was less common among patients aged 65 years or older, while severe hypoglycemia and hyperglycemia were more common in patients with low renal function (estimated glomerular filtration rate). CONCLUSION There were no pronounced differences in effectiveness and long-term cardiovascular safety and mortality between the DAIs, although there were some differences in clinical characteristics between patients using the three types of insulin. Severe hypoglycemia was more common among older patients, while severe hypoglycemia and hyperglycemia were more common among patients with impaired renal function. FUNDING Sanofi.
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Affiliation(s)
- Vincent Lak
- Department of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Göteborg, Sweden.
| | | | | | - Stefan Franzén
- Center of Registers in Region Västra Götaland, Göteborg, Sweden
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Göteborg, Sweden
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Adamsson Eryd S, Gudbjörnsdottir S, Manhem K, Rosengren A, Svensson AM, Miftaraj M, Franzén S, Björck S. Blood pressure and complications in individuals with type 2 diabetes and no previous cardiovascular disease: national population based cohort study. BMJ 2016; 354:i4070. [PMID: 27492939 PMCID: PMC4975020 DOI: 10.1136/bmj.i4070] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To compare the risk associated with systolic blood pressure that meets current recommendations (that is, below 140 mm Hg) with the risk associated with lower levels in patients who have type 2 diabetes and no previous cardiovascular disease. DESIGN Population based cohort study with nationwide clinical registries, 2006-12. The mean follow-up was 5.0 years. SETTING 861 Swedish primary care units and hospital outpatient clinics. PARTICIPANTS 187 106 patients registered in the Swedish national diabetes register who had had type 2 diabetes for at least a year, age 75 or younger, and with no previous cardiovascular or other major disease. MAIN OUTCOME MEASURES Clinical events were obtained from the hospital discharge and death registers with respect to acute myocardial infarction, stroke, a composite of acute myocardial infarction and stroke (cardiovascular disease), coronary heart disease, heart failure, and total mortality. Hazard ratios were estimated for different levels of baseline systolic blood pressure with clinical characteristics and drug prescription data as covariates. RESULTS The group with the lowest systolic blood pressure (110-119 mm Hg) had a significantly lower risk of non-fatal acute myocardial infarction (adjusted hazard ratio 0.76, 95% confidence interval 0.64 to 0.91; P=0.003), total acute myocardial infarction (0.85, 0.72 to 0.99; P=0.04), non-fatal cardiovascular disease (0.82, 0.72 to 0.93; P=0.002), total cardiovascular disease (0.88, 0.79 to 0.99; P=0.04), and non-fatal coronary heart disease (0.88, 0.78 to 0.99; P=0.03) compared with the reference group (130-139 mm Hg). There was no indication of a J shaped relation between systolic blood pressure and the endpoints, with the exception of heart failure and total mortality. CONCLUSIONS Lower systolic blood pressure than currently recommended is associated with significantly lower risk of cardiovascular events in patients with type 2 diabetes. The association between low blood pressure and increased mortality could be due to concomitant disease rather than antihypertensive treatment.
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Affiliation(s)
- Samuel Adamsson Eryd
- Centre of Registers Västra Götaland, Gothenburg, Sweden Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Centre of Registers Västra Götaland, Gothenburg, Sweden Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Manhem
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
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Svensson M, Miftaraj M, Svensson AM, Eliasson B, Afghahi H. SP459BOTH LOW AND HIGH SYSTOLIC BLOOD PRESSURE INCREASES THE RISK OF CARDIOVASCULAR EVENTS AND ALL-CAUSE OF MORTALITY IN PATIENTS WITH TYPE 2-DIABETES AND RENAL IMPAIRMENT WITHOUT PREVIOUS CARDIOVASCULAR DISEASE OR CONGESTIVE HEART FAILURE- THE SWEDISH NATIONAL DIABETES REGISTER (NDR). Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv195.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ekström N, Svensson AM, Miftaraj M, Andersson Sundell K, Cederholm J, Zethelius B, Eliasson B, Gudbjörnsdottir S. Durability of oral hypoglycemic agents in drug naïve patients with type 2 diabetes: report from the Swedish National Diabetes Register (NDR). BMJ Open Diabetes Res Care 2015; 3:e000059. [PMID: 25815205 PMCID: PMC4368982 DOI: 10.1136/bmjdrc-2014-000059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/19/2015] [Accepted: 02/20/2015] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To analyze the durability of monotherapy with different classes of oral hypoglycemic agents (OHAs) in drug naïve patients with type 2 diabetes mellitus (T2DM) in real life. METHODS Men and women with T2DM, who were new users of OHA monotherapy and registered in the Swedish National Diabetes Register July 2005-December 2011, were available (n=17 309) and followed for up to 5.5 years. Time to monotherapy failure, defined as discontinuation of continuous use with the initial agent, switch to a new agent, or add-on treatment of a second agent, was analyzed as a measure of durability. Baseline characteristics were balanced by propensity score matching 1:5 between groups of sulfonylurea (SU) versus metformin (n=4303) and meglitinide versus metformin (n=1308). HRs with 95% CIs were calculated using Cox regression models. RESULTS SU and meglitinide, as compared with metformin, were associated with increased risk of monotherapy failure (HR 1.74; 95% CI 1.56 to 1.94 and 1.66; 1.37 to 2.00 for SU and meglitinide, respectively). When broken down by type of monotherapy failure, SU and meglitinide were associated with an increased risk of add-on treatment of a second agent (HR 3.14; 95% CI 2.66 to 3.69 and 2.52; 1.89 to 3.37 for SU and meglitinide, respectively) and of switch to a new agent (HR 2.81; 95% CI 2.01 to 3.92 and 3.78; 2.25 to 6.32 for SU and meglitinide, respectively). The risk of discontinuation did not differ significantly between the groups. CONCLUSIONS In this nationwide observational study reflecting clinical practice, SU and meglitinide showed substantially increased risk of switch to a new agent or add on of a second agent compared with metformin. These results indicate superior glycemic durability with metformin compared with SU and also meglitinide in real life.
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Affiliation(s)
- Nils Ekström
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | | | | | | | - Jan Cederholm
- Department of Public Health and Caring Sciences/Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Björn Zethelius
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden
- Medical Products Agency, Uppsala, Sweden
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Centre of Registers in Region Västra Götaland, Göteborg, Sweden
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Afghahi H, Miftaraj M, Svensson AM, Hadimeri H, Gudbjörnsdottir S, Eliasson B, Svensson MK. Ongoing treatment with renin-angiotensin-aldosterone-blocking agents does not predict normoalbuminuric renal impairment in a general type 2 diabetes population. J Diabetes Complications 2013; 27:229-34. [PMID: 23246248 DOI: 10.1016/j.jdiacomp.2012.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 09/12/2012] [Accepted: 10/17/2012] [Indexed: 11/30/2022]
Abstract
AIM To examine the prevalence and the clinical characteristics associated with normoalbuminuric renal impairment (RI) in a general type 2 diabetes (T2D) population. METHODS We included 94 446 patients with T2D (56% men, age 68.3±11.6 years, BMI 29.6±5.3 kg/m², diabetes duration 8.5±7.1 years; means±SD) with renal function (serum creatinine) reported to the Swedish National Diabetes Register (NDR) in 2009. RI was defined as estimated glomerular filtration (eGFR)<60 ml/min/1.73 m² and albuminuria as a urinary albumin excretion rate (AER) >20 μg/min. We linked the NDR to the Swedish Prescribed Drug Register, and the Swedish Cause of Death and the Hospital Discharge Register to evaluate ongoing medication and clinical outcomes. RESULTS 17% of the patients had RI, and 62% of these patients were normoalbuminuric. This group of patients had better metabolic control, lower BMI, lower systolic blood pressure and were more often women, non-smokers and more seldom had a history of cardiovascular disease as compared with patients with albuminuric RI. 28% of the patients with normoalbuminuric RI had no ongoing treatment with any RAAS-blocking agent. Retinopathy was most common in patients with RI and albuminuria (31%). CONCLUSIONS The majority of patients with type 2 diabetes and RI were normoalbuminuric despite the fact that 25% of these patients had no ongoing treatment with RAAS-blocking agents. Thus, RI in many patients with type 2 diabetes is likely to be caused by other factors than diabetic microvascular disease and ongoing RAAS-blockade.
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Affiliation(s)
- Hanri Afghahi
- Department of Nephrology, Kärnsjukhuset, Skövde, Sweden
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Ekström N, Cederholm J, Zethelius B, Eliasson B, Fhärm E, Rolandsson O, Miftaraj M, Svensson AM, Gudbjörnsdottir S. Aspirin treatment and risk of first incident cardiovascular diseases in patients with type 2 diabetes: an observational study from the Swedish National Diabetes Register. BMJ Open 2013; 3:bmjopen-2013-002688. [PMID: 23604419 PMCID: PMC3641436 DOI: 10.1136/bmjopen-2013-002688] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To investigate the benefits and risks associated with aspirin treatment in patients with type 2 diabetes and no previous cardiovascular disease (CVD) in clinical practice. DESIGN Population-based cohort study between 2005 and 2009, mean follow-up 3.9 years. SETTING Hospital outpatient clinics and primary care in Sweden. PARTICIPANTS Men and women with type 2 diabetes, free from CVD, including atrial fibrillation and congestive heart failure, at baseline, registered in the Swedish National Diabetes Register, with continuous low-dose aspirin treatment (n=4608) or no aspirin treatment (n=14 038). MAIN OUTCOME MEASURES Risks of CVD, coronary heart disease (CHD), stroke, mortality and bleedings, associated with aspirin compared with no aspirin, were analysed in all patients and in subgroups by gender and estimated cardiovascular risk. Propensity scores were used to adjust for several baseline risk factors and characteristics at Cox regression, and the effect of unknown covariates was evaluated in a sensitivity analysis. RESULTS There was no association between aspirin use and beneficial effects on risks of CVD or death. Rather, there was an increased risk of non-fatal/fatal CHD associated with aspirin; HR 1.19 (95% CI 1.01 to 1.41), p=0.04. The increased risk of cardiovascular outcomes associated with aspirin was seen when analysing women separately; HR 1.41 (95% CI 1.07 to 1.87), p=0.02, and HR 1.28 (95% CI 1.01 to 1.61), p=0.04, for CHD and CVD, respectively, but not for men separately. There was a trend towards increased risk of a composite of bleedings associated with aspirin, n=157; HR 1.41 (95% CI 0.99 to 1.99). CONCLUSIONS The results support the trend towards more restrictive use of aspirin in patients with type 2 diabetes and no previous CVD. More research is needed to explore the differences in aspirin's effects in women and men.
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Affiliation(s)
- Nils Ekström
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Jan Cederholm
- Department of Public Health and Caring Sciences/Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Björn Zethelius
- Department of Public Health and Caring Sciences/Geriatrics, Uppsala University and Medical Products Agency, Uppsala, Sweden
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Eva Fhärm
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Olov Rolandsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | | | - Soffia Gudbjörnsdottir
- Department of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Centre of Registers in Region Västra Götaland, Göteborg, Sweden
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Ekström N, Miftaraj M, Svensson AM, Andersson Sundell K, Cederholm J, Zethelius B, Gudbjörnsdottir S, Eliasson B. Glucose-lowering treatment and clinical results in 163 121 patients with type 2 diabetes: an observational study from the Swedish national diabetes register. Diabetes Obes Metab 2012; 14:717-26. [PMID: 22364580 DOI: 10.1111/j.1463-1326.2012.01591.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To analyse clinical characteristics and treatment results in unselected type 2 diabetes mellitus (T2DM) patients, with non-pharmacological treatment as well as the most commonly used pharmacological glucose-lowering treatment regimens, in everyday clinical practice. METHODS In this population-based cross-sectional study, information was linked from the Swedish National Diabetes Register, Prescribed Drug Register and Patient Register. T2DM patients with non-pharmacological treatment and T2DM patients continuously using the 12 most common pharmacological treatment regimens were included in the study (n = 163121). RESULTS There were statistically significant differences in clinical characteristics between the groups. Patients with insulin-based treatment regimens had the longest duration of diabetes and more cardiovascular risk factors than the T2DM-population in general. The proportion of patients reaching HbA1c ≤ 7% varied between 70.1% (metformin) and 25.0% [premixed insulin (PMI) + SU) in patients with pharmacological treatment. 84.8% of the patients with non-pharmacological treatment reached target. Compared to patients on metformin, patients on other pharmacological treatments had a lower likelihood, with hazard ratios ranging from 0.58; 95% confidence interval (CI), 0.54-0.63 to 0.97;0.94-0.99, of having HbA1c ≤ 7% (adjusted for covariates). Patients on insulin-based treatments had the lowest likelihood, while non-pharmacological treatment was associated with an increased likelihood of having HbA1c ≤ 7%. CONCLUSION This nation-wide study shows insufficiently reached treatment goals for haemoglobin A1c (HbA1c) in all treatment groups. Patients on insulin-based treatment regimens had the longest duration of diabetes, more cardiovascular risk factors and the highest proportions of patients not reaching HbA1c target.
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Affiliation(s)
- N Ekström
- Department of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.
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Eliasson B, Svensson AM, Miftaraj M, Jonasson JM, Eeg-Olofsson K, Sundell KA, Gudbjörnsdóttir S. Clinical use and effectiveness of lipid lowering therapies in diabetes mellitus--an observational study from the Swedish National Diabetes Register. PLoS One 2011; 6:e18744. [PMID: 21559521 PMCID: PMC3084707 DOI: 10.1371/journal.pone.0018744] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 03/09/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To describe the use and evaluate the effectiveness of different lipid lowering therapies in unselected patients with type 1 and type 2 diabetes in clinical practice. DESIGN Observational population-based study using the personal identification number to link information from the National Diabetes Register, the Prescribed Drug Register and the Patient register in Sweden. All patients in the NDR aged 18-75 years with diabetes more than one year were eligible, but only patients starting any lipid lowering treatment with at least three prescriptions 1 July 2006-30 June 2007 were included (n = 37,182). The mean blood lipid levels in 2008 and reductions in LDL cholesterol were examined. RESULTS Blood lipid levels were similar in patients treated with simvastatin, atorvastatin and rosuvastatin, showing similar lipid lowering effect as currently used. Users of pravastatin, fluvastatin, ezetimib and fibrate more seldom reach treatment goals. Moderate daily doses of the statins were used, with 76% of simvastatin users taking 20 mg or less, 48% of atorvastatin users taking 10 mg, 55% of pravastatin users taking 20 mg, and 76% of rosuvastatin users taking 5 or 10 mg. CONCLUSIONS This observational study shows that the LDL-C levels in patients taking simvastatin, atorvastatin or rosuvastatin are very similar as currently used, as well as their LDL-C lowering abilities. There is potential to intensify lipid lowering treatment to reduce the remaining high residual risk and achieve better fulfilment of treatment goals, since the commonly used doses are only low to moderate.
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Affiliation(s)
- Björn Eliasson
- Department of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, Sweden.
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