Short-term impact of HbA1c on morbidity and all-cause mortality in people with type 2 diabetes: a Danish population-based observational study

Low mean HbA1c does not increase all-cause and cardiovascular mortality in patients with diabetes: Effect-modifications by anemia and chronic kidney disease stages

Background

Previous studies reported that low levels of glycated hemoglobin A1c (HbA1c) were associated with increased mortality. We investigated rates and risks of all-cause and cardiovascular mortality in association with mean HbA1c levels with stratification of anemia and chronic kidney disease (CKD) stages, major causes of low HbA1c.

Methods

47,145 patients with prescription of antidiabetic agents >6 months in the outpatient visits (2003–2018) were linked to Taiwan’s National Death Registry to identify all-cause and cardiovascular mortality. Poisson assumption was used to estimate the mortality rates, and the Cox proportional hazard regression model was used to evaluate the relative hazards of respective mortality in relation to mean HbA1c in different statuses of anemia and CKD stages.

Results

All-cause and cardiovascular mortality rates were the lowest in non-anemic stages 1–2 CKD patients, and the highest in anemic stages 3–5 CKD patients. In stages 1–2 CKD, excessive HRs observed in those with mean HbA1c <6.0% (Hazard Ratio [HR]) 1.58; 95% Confidence Interval [CI] 1.18–2.12) became inconsequential after adjustment of medications and laboratory results (HR: 1.26; 95% CI 0.89–1.79). The similar patterns were observed in anemic stages 1–2 CKD, anemic or non-anemic stages 3–5 CKD. Low HbA1c was not related to cardiovascular mortality in any anemia status or CKD staging.

Conclusions

Higher risks associated with low mean HbA1c and all-cause mortality were attenuated by adjustment of medications and comorbidities. It is imperative for the diabetologists to consider confounding effects of underlying illness before concluding low HbA1c associated higher mortality.

Cardiovascular outcomes after initiating GLP-1 receptor agonist or basal insulin for the routine treatment of type 2 diabetes: a region-wide retrospective study

Aim

We aimed to compare cardiovascular outcomes of patients with type 2 diabetes (T2D) who initiated GLP-1 receptor agonists (GLP-1RA) or basal insulin (BI) under routine care.

Methods

We accessed the administrative claims database of the Veneto Region (Italy) to identify new users of GLP-1RA or BI in 2014–2018. Propensity score matching (PSM) was implemented to obtain two cohorts of patients with superimposable characteristics. The primary endpoint was the 3-point major adverse cardiovascular events (3P-MACE). Secondary endpoints included 3P-MACE components, hospitalization for heart failure, revascularizations, and adverse events.

Results

From a background population of 5,242,201 citizens, 330,193 were identified as having diabetes. PSM produced two very well matched cohorts of 4063 patients each, who initiated GLP-1RA or BI after an average of 2.5 other diabetes drug classes. Patients were 63-year-old and only 15% had a baseline history of cardiovascular disease. During a median follow-up of 24 months in the intention-to-treat analysis, 3P-MACE occurred less frequently in the GLP-1RA cohort (HR versus BI 0.59; 95% CI 0.50–0.71; p < 0.001). All secondary cardiovascular endpoints were also significantly in favor of GLP-1RA. Results were confirmed in the as-treated approach and in several stratified analyses. According to the E-value, confounding by unmeasured variables were unlikely to entirely explain between-group differences in cardiovascular outcomes.

Conclusions

Patients with T2D who initiated a GLP-1RA experienced far better cardiovascular outcomes than did matched patients who initiated a BI in the same healthcare system. These finding supports prioritization of GLP-1RA as the first injectable regimen for the management of T2D.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01414-3.

Improved glycemic control in 3,592 adults with type 2 diabetes mellitus initiating a tubeless insulin management system

AIMS

To compare glycemic outcomes in adults with type 2 diabetes mellitus (T2DM) before and 90 days after initiating Omnipod® or Omnipod DASH® Insulin Management Systems.

METHODS

In this retrospective observational study (N = 3,592) change in HbA1c level, total daily dose (TDD) of insulin (n = 3,053), and frequency of self-reported hypoglycemic events (HE, <70 mg/dL, n = 2,922) were assessed overall and by prior treatment modality (multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII)), age group, and baseline HbA1c category.

RESULTS

Change (mean ± SD) in HbA1c was -1.3 ± 1.7% [-14 ± 19 mmol/mol] overall, -1.4 ± 1.7% [-15 ± 19 mmol/mol] for prior MDI users, and -0.9 ± 1.5% [-10 ± 16 mmol/mol] for prior CSII users (p<0.0001). The percentage of patients with HbA1c ≥9% [≥75 mmol/mol] decreased (49% to 19%), and with HbA1c <7% [<53 mmol/mol] increased (10% to 22%) (p<0.0001). Prior therapy, age, and baseline HbA1c category were factors affecting change in HbA1c (p<0.05). Reductions in TDD (overall, -33 ± 52U, p<0.0001) and HE per week (overall, -0.5 ± 2.0, p<0.0001), were seen regardless of prior treatment, age, or baseline HbA1c.

CONCLUSIONS

Omnipod System use was associated with statistically and clinically meaningful reductions in HbA1c, TDD, and HE compared to prior treatments in T2DM.

Association between Hemoglobin A1c and Stroke Risk in Patients with Type 2 Diabetes

Background and Purpose

The association between hemoglobin A1c (HbA1c) and stroke risk along with its subtypes is rarely reported. We aimed to investigate the association between HbA1c and the risk of incident stroke in patients with type 2 diabetes based on real world data from three healthcare systems.

Methods

We performed a retrospective cohort study of 27,113 African Americans and 40,431 whites with type 2 diabetes. Demographic, anthropometric, laboratory, and medication information were abstracted from the National Patient-Centered Clinical Research Network common data model. Incident stroke events including both ischemic and hemorrhagic stroke were defined.

Results

During a mean follow-up period of 3.79±1.68 years, 7,735 patients developed stroke (6,862 ischemic and 873 hemorrhagic). Multivariable-adjusted hazard ratios across levels of HbA1c at baseline (<6.0%, 6.0% to 6.9% [reference group], 7.0% to 7.9%, 8.0% to 8.9%, 9.0% to 9.9%, and ≥10%) were 1.07, 1.00, 1.13, 1.23, 1.27, and 1.37 (P_trend <0.001) for total stroke, 1.02, 1.00, 1.13, 1.20, 1.24, and 1.35 (P_trend <0.001) for ischemic stroke, and 1.40, 1.00, 1.14, 1.47, 1.47, and 1.51 (P_trend=0.002) for hemorrhagic stroke. When we used an updated mean value of HbA1c, the U-shaped association of HbA1c with stroke risk did not change. This U-shaped association was consistent among patients of different subgroups. The U-shaped association was more pronounced among patients taking antidiabetic, lipid-lowering, and antihypertensive medications compared with those without these medications.

Conclusions

These data suggest that diabetes management may have to be individualized according to the guideline recommendations rather than intensively attempting to lower HbA1c.

Baseline plasma fibrinogen is associated with haemoglobin A1c and 2-year major adverse cardiovascular events following percutaneous coronary intervention in patients with acute coronary syndrome: a single-centre, prospective cohort study

BACKGROUND

Despite revascularisation, a large proportion of acute coronary syndrome (ACS) patients continue to experience major adverse cardiovascular events (MACEs), which are worsened by diabetes mellitus (DM). Fibrinogen (FIB) is a risk factor for MACEs in coronary artery disease and often elevated in DM. However, the relationships between FIB, glucose metabolism (haemoglobin A1c [HbA1c] and fasting blood glucose [FBG]) and MACEs following percutaneous coronary intervention (PCI) in DM, non-DM or whole patients with ACS remains unknown.

METHODS

A total of 411 ACS patients undergoing PCI were enrolled in this study. We compared baseline FIB levels between DM (n = 103) and non-DM (n = 308) patients and divided participants into three groups according to FIB level, i.e. FIB-L, FIB-M and FIB-H, to compare baseline characteristics and MACEs. Linear regression analysis of the relationship between glucose metabolism and FIB, Cox regression, survival and landmark analyses of MACEs were also performed over a median of 27.55 months of follow-up.

RESULTS

Patients with DM had higher FIB levels than non-DM patients (3.56 ± 0.99 mg/dL vs. 3.34 ± 0.80 mg/dL, P < 0.05). HbA1c and FBG were significantly positively correlated with FIB in whole and DM patients but not in non-DM patients (all P < 0.05). Compared with the FIB-L group, the FIB-M (hazard ratio [HR] 1.797, 95% CI 1.117-2.892, P = 0.016) and FIB-H (HR 1.664, 95% CI 1.002-2.763, P = 0.049) groups were associated with higher MACEs in whole; the FIB-M (HR 7.783, 95% CI 1.012-59.854, P = 0.049) was associated with higher MACEs in DM patients. FIB was not associated with MACEs in non-DM patients. During landmark analysis, FIB showed better predictive value for MACEs after PCI in the first 30 months of follow up than in the subsequent period.

CONCLUSION

In this study from China, FIB was positively associated with glucose metabolism (HbA1c and FBG) in whole and DM populations with ACS. Moreover, elevated baseline FIB levels may be an important and independent predictor of MACEs following PCI, especially amongst those with DM. However, as the follow-up period increased, the baseline FIB levels lost their ability to predict MACEs.

Reasonable Glycemic Control Would Help Wound Healing During the Treatment of Diabetic Foot Ulcers

INTRODUCTION

The effect of glycemic control on wound healing in patients with diabetic foot ulcers (DFUs) is inconsistent among different studies. This study was performed to investigate the association between level of hemoglobin A1c (HbA1c) at baseline as well as during treatment and wound healing and mortality in patients with DFU.

METHODS

Hospitalized DFU patients were recruited consecutively with their basic clinical data collected and treated according to clinical practice guidelines. These patients were followed-up for 1 year to observe the outcomes, including ulcer healing and death. The associations between baseline HbA1c level or mean HbA1c level during treatment and wound healing as well as mortality were evaluated in univariate and multivariate logistic regression models.

RESULTS

By the end of the follow-up, 40 (13.4%) patients had died. A total of 168 (65.1%) patients achieved ulcer healing in the remaining 258 living participants. Baseline HbA1c was not associated with ulcer healing in unadjusted or adjusted models (P > 0.05). The wound healing rate was higher (OR 2.01, 95% CI 1.02-3.96, P < 0.05) after adjustment when HbA1c was controlled between 7.0% and 8.0% during treatment compared to HbA1c controlled at less than 7.0%. This probability of ulcer healing increased to 3 (OR = 3.01, 95% CI 1.32-6.86, P = 0.01) after adjustment in the subgroup with baseline HbA1c no more than 8.0%. Neither baseline HbA1c nor mean HbA1c during treatment presented any correlation with 1-year death rate.

CONCLUSION

A reasonable HbA1c target, a range between 7.0% and 8.0% during treatment, could facilitate ulcer healing without increase of mortality in patients with DFU, especially for those with better glycemic control at admission.

Poor glycaemic control and its metabolic and demographic risk factors in a Malaysian community-based study

OBJECTIVES

The lack of population-based evidence on the risk factors for poor glycaemic control in diabetics, particularly in resource-poor settings, is a challenge for the prevention of long-term complications. This study aimed to identify the metabolic and demographic risk factors for poor glycaemic control among diabetics in a rural community in Malaysia.

METHODS

A total of 1844 (780 males and 1064 females) known diabetics aged ≥ 35 years were identified from the South East Asia Community Observatory (SEACO) health and demographic surveillance site database.

RESULTS

41.3% of the sample had poor glycaemic control. Poor glycaemic control was associated with age and ethnicity, with older participants (65+) better controlled than younger adults (45-54), and Malaysian Indians most poorly controlled, followed by Malay and then Chinese participants. Metabolic risk factors were also highly associated with poor glycaemic control.

CONCLUSIONS

There is a critical need for evidence for a better understanding of the mechanisms of the associations between risk factors and glycaemic control.

Hemoglobin A1c is associated with severity of coronary artery stenosis but not with long term clinical outcomes in diabetic and nondiabetic patients with acute myocardial infarction undergoing primary angioplasty

Background

Acute myocardial infarction (AMI) patients with type 2 diabetes mellitus are known to present with multiple vessel lesions during coronary angiography. The underlying mechanism remains elusive and there is a shortage of serum prediction markers. In this study, we investigate the relationship between admission HbA_1c and severity of coronary artery stenosis and subsequent prognosis in AMI patients with or without diabetes.

Research design and methods

We measured admission HbA_1c, and vessel scores based on the number of diseased coronary vessels with significant stenosis in 628 patients diagnosed with AMI. Simple and multi-regression analysis were performed to investigate the correlation between HbA_1c and the severity of coronary artery stenosis. Major adverse cardiovascular events (MACE), including new-onset myocardial infarction, acute heart failure and cardiac death, were documented during the follow-up. 272 non-DM participants and 137 DM participants were separated into two groups based on HbA_1c levels for survival analysis during a 2-year follow up.

Results

448 non-DM patients and 180 DM patients were included in the initial observational analysis. 272 non-DM patients and 137 DM patients were included in the follow-up survival analysis. The admission HbA_1c level was found to be significantly positively correlated to the number of affected vessels suffering from significant coronary artery stenosis both in DM (R square = 0.012; 95% CI 0.002 to 0.623, P = 0.049) and non DM patients (R square = 0.025; 95% CI 0.009 to 0.289, P = 0.037). Kaplan–Meier survival analysis revealed no significant difference with regard to different HbA_1c levels either in DM or non-DM patients at the end of follow-up.

Conclusions

In patients with AMI, admission HbA_1c is an important predictor for the severity of coronary artery stenosis in non-DM and DM patients. Further studies are needed to determine whether longer term follow-up could further identify the prognosis effect of HbA_1c on MACE.

Early Glycemic Control and Magnitude of HbA1c Reduction Predict Cardiovascular Events and Mortality: Population-Based Cohort Study of 24,752 Metformin Initiators

OBJECTIVE

We investigated the association of early achieved HbA_1c level and magnitude of HbA_1c reduction with subsequent risk of cardiovascular events or death in patients with type 2 diabetes who initiate metformin.

RESEARCH DESIGN AND METHODS

This was a population-based cohort study including all metformin initiators with HbA_1c tests in Northern Denmark, 2000-2012. Six months after metformin initiation, we classified patients by HbA_1c achieved (<6.5% or higher) and by magnitude of HbA_1c change from the pretreatment baseline. We used Cox regression to examine subsequent rates of acute myocardial infarction, stroke, or death, controlling for baseline HbA_1c and other confounding factors.

RESULTS

We included 24,752 metformin initiators (median age 62.5 years, 55% males) with a median follow-up of 2.6 years. The risk of a combined outcome event gradually increased with rising levels of HbA_1c achieved compared with a target HbA_1c of <6.5%: adjusted hazard ratio (HR) 1.18 (95% CI 1.07-1.30) for 6.5-6.99%, HR 1.23 (1.09-1.40) for 7.0-7.49%, HR 1.34 (1.14-1.57) for 7.5-7.99%, and HR 1.59 (1.37-1.84) for ≥8%. Results were consistent for individual outcome events and robust by age-group and other patient characteristics. A large absolute HbA_1c reduction from baseline also predicted outcome: adjusted HR 0.80 (0.65-0.97) for Δ = -4, HR 0.98 (0.80-1.20) for Δ = -3, HR 0.92 (0.78-1.08) for Δ = -2, and HR 0.99 (0.89-1.10) for Δ = -1 compared with no HbA_1c change (Δ = 0).

CONCLUSIONS

A large initial HbA_1c reduction and achievement of low HbA_1c levels within 6 months after metformin initiation are associated with a lower risk of cardiovascular events and death in patients with type 2 diabetes.

Impact of Pharmacist Intervention on Appropriate Insulin Pen Use in Older Patients with Type 2 Diabetes Mellitus in a Rural Area in Iran

OBJECTIVE

The aim of this study was to evaluate the impact of pharmacist-conducted educational intervention on reducing errors related to inappropriate insulin pen use.

METHODS

This was a prospective, before-after study with an educational intervention component. The study was conducted on 122 elderly diabetic patients. Data were collected through interviews using researcher-administered questionnaires as well as patients' medical records. Patients were asked about the preparation, injection, and storage techniques, they followed when using insulin pens. Blood glucose parameters were extracted from laboratory records. After the detection of errors, patients and their caregivers were instructed about the insulin pen use by the pharmacist. Patients were reevaluated after 12 weeks.

FINDINGS

Patients' mean age was 67.2 ± 3.5 with male: female ratio of 71:51. Mean diabetes duration was 7.1 ± 2.8 years. Fifty-four patients (44.2%) stated that they had received instructions for insulin pen use previously. The majority of this group (24 cases, 44.4%) reported that the instructions were given by a pharmacist. The mean number of errors decreased from 3.99 ± 0.22 errors per patient to 1.49 ± 0.13 errors (odds ratio: 0.28, 95% confidence interval: 0.23-0.33,P < 0.05). Of eleven evaluated insulin pen-related medication error items, nine items experienced a significant decrease after patient education. Fasting plasma glucose (FPG) levels decreased significantly from 161.7 ± 12.5 to 147.3 ± 13.1 mg/dL (P < 0.05). However, glycated hemoglobin levels did not change significantly after 3 months (P = 0.18). Controlled FPG had a significant rise from 45% before education to 63.9% postintervention (P < 0.05).

CONCLUSION

Pharmacists can play an important role in safe and efficient use of insulin pen in elderly diabetic patients by minimizing the likelihood of medication errors associated with insulin pen use.

Single, community-based blood glucose readings may be a viable alternative for community surveillance of HbA1c and poor glycaemic control in people with known diabetes in resource-poor settings

Background

The term HbA_1c (glycated haemoglobin) is commonly used in relation to diabetes mellitus. The measure gives an indication of the average blood sugar levels over a period of weeks or months prior to testing. For most low- and middle-income countries HbA_1c measurement in community surveillance is prohibitively expensive. A question arises about the possibility of using a single blood glucose measure for estimating HbA_1c and therefore identifying poor glycaemic control in resource-poor settings.

Design

Using data from the 2011–2012 US National Health and Nutrition Examination Surveys, we examined the relationship between HbA_1c and a single fasting measure of blood glucose in a non-clinical population of people with known diabetes (n=333). A linear equation for estimating HbA_1c from blood glucose was developed. Appropriate blood glucose cut-off values were set for poor glycaemic control (HbA_1c≥69.4 mmol/mol).

Results

The HbA_1c and blood glucose measures were well correlated (r=0.7). Three blood glucose cut-off values were considered for classifying poor glycaemic control: 8.0, 8.9, and 11.4 mmol/L. A blood glucose of 11.4 had a specificity of 1, but poor sensitivity (0.37); 8.9 had high specificity (0.94) and moderate sensitivity (0.7); 8.0 was associated with good specificity (0.81) and sensitivity (0.75).

Conclusions

Where HbA_1c measurement is too expensive for community surveillance, a single blood glucose measure may be a reasonable alternative. Generalising the specific results from these US data to low resource settings may not be appropriate, but the general approach is worthy of further investigation.

Mortality in Individuals Aged 80 and Older with Type 2 Diabetes Mellitus in Relation to Glycosylated Hemoglobin, Blood Pressure, and Total Cholesterol

Objectives

To evaluate whether low glycosylated hemoglobin (HbA1c), blood pressure (BP), and total cholesterol (TC) are associated with lower risk of all‐cause mortality in very old individuals with type 2 diabetes mellitus.

Design

Population‐based cohort study.

Setting

Primary care database in the United Kingdom.

Participants

Individuals aged 80 and older with type 2 diabetes mellitus (N = 25,966).

Measurements

Associations between baseline HbA1c, BP, and TC and all‐cause mortality were evaluated in Cox proportional hazards models. Analyses were adjusted for sex, age, duration of diabetes mellitus, lifestyle variables, HbA1c, BP, TC, comorbidities, prescribing of antidiabetic and cardiovascular drugs, and participants’ general practice.

Results

There were 4,490 deaths during follow‐up (median 2.0 years; mortality 104.7 per 1,000 person‐years). Mortality in participants with low (<6.0% (<42 mmol/mol)) or high (≥8.5% (≥69 mmol/mol)) HbA1c was similar to that in those with the reference HbA1c (8.0–8.4% (64–68 mmol/mol)). Mortality was lowest in individuals with HbA1c of 7.0–7.4% (53–57 mmol/mol) (80.9 per 1,000 person‐years, adjusted hazard ratio (aHR) = 0.80, 95% confidence interval (CI) = 0.70–0.91, P = .001). Mortality was higher in individuals with lower BP (e.g., <130/70 mmHg, 151.7 per 1,000 person‐years, aHR = 1.52, 95% CI = 1.34–1.72, P < .001 vs reference BP <150/90 mmHg) and in the lowest TC category (<3.0 mmol/L, 138.7 per 1,000 person‐years, aHR = 1.42, 95% CI = 1.24–1.64, P < .001 vs reference TC 4.5–4.9 mmol/L). The relationship between TC and mortality varied according to sex and prescription of lipid‐lowering drugs.

Conclusion

Low HbA1c, BP, and TC may be associated with higher mortality in very old adults with type 2 diabetes mellitus. Further research is required to understand these associations and to identify optimal treatment targets in this population.

Optimizing diabetes control in people with Type 2 diabetes through nurse-led telecoaching

AIMS

To study the effect of a target-driven telecoaching intervention on HbA1c and other modifiable risk factors in people with Type 2 diabetes.

METHODS

We conducted a randomized controlled trial in patients receiving hypoglycaemic agents. The primary outcome was HbA1c level at 6 months in the entire sample and in a subgroup with HbA1c levels ≥ 53 mmol/mol (7%) at baseline. Secondary outcomes were HbA1c at 18 months; total cholesterol, LDL, HDL, triglycerides, blood pressure, BMI and proportion of people who had achieved guideline-recommended targets at 6 and 18 months.

RESULTS

A total of 287 participants were randomized to telecoaching and 287 to usual care. The mean (sd) baseline HbA1c level was 53 (11) mmol/mol [7.0 (1.0)%] overall and 63 (10) mmol/mol [7.9 (0.9)%] in the elevated HbA1c subgroup. At 6 months, the between-group differences in favour of telecoaching were: HbA1c -2 (95% CI -4; -1) mmol/mol [-0.2 (95% CI -0.3;-0.1)%; P=0.003] overall and -4 (95% CI -7; -2) mmol/mol [-0.4 (95% CI -0.7; -0.2)%; P=0.001] in the elevated HbA1c subgroup; BMI -0.4 kg/m(2) (95% CI -0.6; -0.1; P=0.003); total cholesterol -6 mg/dl (95% CI -11; -1, P=0.012). The proportion of participants on target for the composite of HbA1c , LDL and blood pressure increased by 8.9% in the intervention group and decreased by 1.3% in the control group (P=0.011). At 18 months, the difference in HbA1c was: -2 (95% CI -3;-0) mmol/mol [-0.2 (95% CI -0.3; -0.0)%; P=0.046] overall and -4 (-7; -1) mmol/mol [-0.4 (95% CI -0.7; -0.1)%; P=0.023] in the elevated HbA1c subgroup.

CONCLUSION

Nurse-led telecoaching improved glycaemic control, total cholesterol levels and BMI in people with Type 2 diabetes. Twelve months after the intervention completion, there were sustained improvements in glycaemic control.

Knowledge, Attitude, and Self Care Practices Amongsts Patients WithType 2 Diabetes in Pakistan

Background:

In this age, diabetes is one of the most prevalent, incurable diseases present. The aim of this study was to assess knowledge, attitude and self-care practicesrelated to diabetes in an urban population in Pakistan.

Methods:

A cross sectional survey to assess the knowledge and practices of people with diabetes was conducted in general urbanpopulace. People with diabetes were interviewed using a structured questionnaire from which data was collected. A total of 139 diabetics were included into the study. Basic knowledge about diabetes and its complications were assessed as well as the frequency of practices such as keeping a blood glucometer at home and checking blood sugar with it.

Results:

A total of n=139 participants fulfilling the inclusion criteria were recruited in the survey. Only 18.7% had knowledge regarding the complications of diabetes mellitus. Only 8.6% of participants checked their blood glucose levels at homeregularly, and only 4.3% visited their physiciansregularlyfor check-ups. With regard to practices, a minority attested to have changed their lifestyle and commit to basic practices in order to reduce diabetes related complications with women being more prone to changes than men.

Conclusion:

The results show that most participants had a negative attitude and very little knowledge regarding diabetes. There is a need for increased diabetes related education and for developing positive attitudes towards reduction of diabetes related complications. The Pakistani population is seen to be almost completely unprepared to fight against an increase in type 2 diabetes prevalence.

HbA1c and all-cause mortality risk among patients with type 2 diabetes

BACKGROUND

Several prospective studies have evaluated the association between glycosylated hemoglobin (HbA1c) and death risk among diabetic patients. However, the results have been inconsistent.

METHODS

We performed a prospective study which included 13,334 men and 21,927 women with type 2 diabetes. Cox proportional hazards regression models were used to estimate the association of different levels of HbA1c with all-cause mortality.

RESULTS

During a mean follow up of 8.7 years, 4199 (2082 men and 2117 women) patients died. The multivariable-adjusted hazard ratios (HRs) of all-cause mortality associated with different levels of HbA1c at baseline (<6.0%, 6.0-6.9% [reference], 7.0-7.9, 8.0-8.9%, 9.0-9.9%, 10.0-10.9%, and ≥11.0%) were 1.06, 1.00, 1.10, 0.93, 1.26, 1.18 and 1.31 (Pnon-linear=0.008) for men, and 1.21, 1.00, 1.01, 1.08, 1.30, 1.30 and 1.74 (Pnon-linear<0.001) for women, respectively. The J-shaped association of HbA1c with all-cause mortality was confirmed among African American and white diabetic patients, patients who were more than 50 years old, never smoked or used insulin. When we used an updated mean value of HbA1c, the J-shaped association of HbA1c with the risk of all-cause mortality did not change.

CONCLUSIONS

Our study demonstrated a J-shaped association between HbA1c and the risk of all-cause mortality among men and women with type 2 diabetes. Both high and low levels of HbA1c were associated with an increased risk of all-cause mortality.

Impaired glucose metabolism among those with and without diagnosed diabetes and mortality: a cohort study using Health Survey for England data

BACKGROUND

The extent that controlled diabetes impacts upon mortality, compared with uncontrolled diabetes, and how pre-diabetes alters mortality risk remain issues requiring clarification.

METHODS

We carried out a cohort study of 22,106 Health Survey for England participants with a HbA1C measurement linked with UK mortality records. We estimated hazard ratios (HRs) of all-cause, cancer and cardiovascular disease (CVD) mortality and 95% confidence intervals (CI) using Cox regression.

RESULTS

Average follow-up time was seven years and there were 1,509 deaths within the sample. Compared with the non-diabetic and normoglycaemic group (HbA1C <5.7% [<39 mmol/mol] and did not indicate diabetes), undiagnosed diabetes (HbA1C ≥6.5% [≥48 mmol/mol] and did not indicate diabetes) inferred an increased risk of mortality for all-causes (HR 1.40, 1.09-1.80) and CVD (1.99, 1.35-2.94), as did uncontrolled diabetes (diagnosed diabetes and HbA1C ≥6.5% [≥48 mmol/mol]) and diabetes with moderately raised HbA1C (diagnosed diabetes and HbA1C 5.7-<6.5% [39-<48 mmol/mol]). Those with controlled diabetes (diagnosed diabetes and HbA<5.7% [<39 mmol/mol]) had an increased HR in relation to mortality from CVD only. Pre-diabetes (those who did not indicate diagnosed diabetes and HbA1C 5.7-<6.5% [39-<48 mmol/mol]) was not associated with increased mortality, and raised HbA1C did not appear to have a statistically significant impact upon cancer mortality. Adjustment for BMI and socioeconomic status had a limited impact upon our results. We also found women had a higher all-cause and CVD mortality risk compared with men.

CONCLUSIONS

We found higher rates of all-cause and CVD mortality among those with raised HbA1C, but not for those with pre-diabetes, compared with those without diabetes. This excess differed by sex and diabetes status. The large number of deaths from cancer and CVD globally suggests that controlling blood glucose levels and policies to prevent hyperglycaemia should be considered public health priorities.

Uncontrolled diabetes mellitus: prevalence and risk factors among people with type 2 diabetes mellitus in an Urban District of Karachi, Pakistan

AIMS

This study aimed to explore the prevalence of, and factors associated with, uncontrolled diabetes mellitus (UDM) in a community setting in Pakistan.

METHODOLOGY

A single-center, cross-sectional study, conducted in a community-based specialized care center (SCC) for diabetes in District Central Karachi, in 2003, registered 452 type 2 DM participants, tested for HbA1c and interviewed face-to-face for other information. Logistic regression analysis was conducted to identify factors associated with UDM.

RESULTS

Prevalence of UDM among diabetes patients was found to be 38.9% (95% CI: 34.4-43.4%). Multivariable logistic regression model analysis indicated that age <50 years (OR: 1.9; 95% CI: 1.2-2.9), being diagnosed in a hospital (vs. a clinic) (OR: 1.8; 95% CI: 1.1-2.8), diabetes information from a doctor or nurse only (vs. multiple sources) (OR: 1.8; 95% CI: 1.2-2.9), higher monthly treatment cost (OR: 1.3; 95% CI: 1.1-1.6; for every extra 500 PKR), and higher consumption of tea (OR: 1.5; 95% CI: 1.0-2.2; for every 2 extra cups) were independently associated with UDM.

CONCLUSION

The prevalence of UDM was approximately 39% among persons with type 2 diabetes visiting a community based SCC for diabetes. Modifiable risk factors such as sources of diabetes information and black tea consumption can be considered as potential targets of interventions in Karachi.

Relationship of HbA1c variability, absolute changes in HbA1c, and all-cause mortality in type 2 diabetes: a Danish population-based prospective observational study

OBJECTIVE

We assessed the relationship of mortality with glycated hemoglobin (HbA1c) variability and with absolute change in HbA1c.

DESIGN

A population-based prospective observational study with a median follow-up time of 6 years.

METHODS

Based on a validated algorithm, 11 205 Danish individuals with type 2 diabetes during 2001-2006 were identified from public data files, with at least three HbA1c measurements: one index measure, one closing measure 22-26 months later, and one measurement in-between. Medium index HbA1c was 7.3%, median age was 63.9 years, and 48% were women. HbA1c variability was defined as the mean absolute residual around the line connecting index value with closing value. Cox proportional hazard models with restricted cubic splines were used, with all-cause mortality as the outcome.

RESULTS

Variability between 0 and 0.5 HbA1c percentage point was not associated with mortality, but for index HbA1c ≤8% (64 mmol/mol), a variability above 0.5 was associated with increased mortality (HR of 1 HbA1c percentage point variability was 1.3 (95% CI 1.1 to 1.5) for index HbA1c 6.6-7.4%). For index HbA1c≤8%, mortality increased when HbA1c declined, but was stable when HbA1c rose. For index HbA1c>8%, change in HbA1c was associated with mortality, with the lowest mortality for greatest decline (HR=0.9 (95% CI 0.80 to 0.98) for a 2-percentage point decrease).

CONCLUSIONS

For individuals with an index HbA1c below 8%, both high HbA1c variability and a decline in HbA1c were associated with increased mortality. For individuals with index HbA1c above 8%, change in HbA1c was associated with mortality, whereas variability was not.

Real life treatment of diabetes mellitus type 2 patients: an analysis based on a large sample of 394,828 German patients

OBJECTIVES

The aim of this claims-based data analysis was to describe the care of German T2DM patients and to determine which subgroups could be differentiated in terms of the achieved T2DM-related treatment results, the underlying comorbidities, and the achieved comorbidity-related treatment results.

METHODS

We included all T2DM patients insured by a large sickness fund in 2010/2011. We defined 12 subgroups according to observed HbA1C, blood pressure and Charlson Comorbidity Index (CCI). For each subgroup, available sociodemographic and clinical information were reported. Different treatment variables were described. T2DM-related events leading to acute hospitalisations were reported.

RESULTS

We included 394,828 T2DM patients in our analysis; for 228,703 patients' detailed data as basis for subgroup classification were available. For 4.5% of these patients, a HbA1C >9% was observed. 21,833 of the T2DM patients were affected by a T2DM-related event; the risk was 5.53% per patient year; 1.74% of the patients suffered from more than one event. Most frequent event types were hospitalisation with T2DM as primary diagnosis (2.39%), vascular interventions/stent implantations (1.92%), and ischaemic stroke (1.19%). There were significant differences between the observed subgroups in terms of T2DM-related event risk.

CONCLUSION

Overall, our data indicate that the typically treated T2DM patient has a number of comorbidities and thus treatment focused solely on T2DM is neither possible nor clinically meaningful. Particularly those patients who reached HbA1C goals, but had also achieved relevant additional treatment goals reached low yearly T2DM event rates whereas subgroups failing to achieve one or several treatment goals are facing much higher event risks.

The HbA1c and all-cause mortality relationship in patients with type 2 diabetes is J-shaped: a meta-analysis of observational studies

BACKGROUND

Low blood glucose and HbA1c levels are recommended in the literature on management of diabetes. However, data have shown that low blood glucose is associated with serious adverse effects for the patients and the recommendation has been criticized. Therefore, this article revisits the relationship between HbA1c and all-cause mortality by a meta-analysis of observational studies.

AIM

The aim of this study is to determine whether there is a J- or U-shaped non-linear relationship between HbA1c and all-cause mortality in type 2 diabetes patients, implying an increased risk to premature all-cause mortality at high and low levels of HbA1c.

METHODS

A comprehensive literature search was conducted using PubMed, Medline, and Cochrane Library databases with strict inclusion/exclusion criteria. The published adjusted hazard ratios (HR) with 95% confidence intervals of all-cause mortality for each HbA1c category and per study were analyzed. Fractional polynomial regression was used with random effect modeling to assess the non-linear relationship of the HR trends between studies. Seven eligible observational studies with a total of 147,424 participants were included in the study.

RESULTS

A significant J-shaped relationship was observed between HbA1c and all-cause mortality. Crude relative risk for all-cause mortality identified a decreased risk per 1% increase in HbA1c below 7.5% (58 mmol/mol) (0.90, CI 0.86-0.94) and an increased risk per 1% increase in HbA1c above 7.5% (58 mmol/mol) (1.04, CI 1.01-1.06). Observational studies revealed a J-shaped relationship between HbA1c and all-cause mortality, equivalent to an increased risk of mortality at high and low HbA1c levels.

CONCLUSIONS

This increased mortality at high and low HbA1c levels has significant implications on investigating optimum clinical HbA1c targets as it suggests that there are upper and lower limits for creating a 'security zone' for diabetes management.

Glycemic goals in diabetes: trade-off between glycemic control and iatrogenic hypoglycemia

The selection of a glycemic goal in a person with diabetes is a compromise between the documented upside of glycemic control-the partial prevention or delay of microvascular complications-and the documented downside of glycemic control-the recurrent morbidity and potential mortality of iatrogenic hypoglycemia. The latter is not an issue if glycemic control is accomplished with drugs that do not cause hypoglycemia or with substantial weight loss. However, hypoglycemia becomes an issue if glycemic control is accomplished with a sulfonylurea, a glinide, or insulin, particularly in the setting of absolute endogenous insulin deficiency with loss of the normal decrease in circulating insulin and increase in glucagon secretion and attenuation of the sympathoadrenal response as plasma glucose concentrations fall. Then the selection of a glycemic goal should be linked to the risk of hypoglycemia. A reasonable individualized glycemic goal is the lowest A1C that does not cause severe hypoglycemia and preserves awareness of hypoglycemia, preferably with little or no symptomatic or even asymptomatic hypoglycemia, at a given stage in the evolution of the individual's diabetes.

Defining the relationship between average glucose and HbA1c in patients with type 2 diabetes and chronic kidney disease

AIMS

To examine the relationship between average glucose (AG) and HbA1c in patients with and without chronic kidney disease (CKD) and type 2 diabetes.

MATERIALS AND METHODS

43 patients with diabetes and CKD (stages 3-5) with stable glycaemic control, and glucose-lowering and erythropoiesis stimulating agent (ESA) doses, were prospectively studied for 3 months and compared to 104 age-matched controls with diabetes, without CKD from the ADAG study. Over 3 months, AG was calculated from 7 to 8 point self-monitored blood glucose measurements (SMBG) and from continuous glucose monitoring (CGMS), and mean HbA1c was calculated from 4 measurements. AG and HbA1c relationships were determined using multivariable linear regression analyses.

RESULTS

The CKD and non-CKD groups were well matched for age and gender. Mean AG tended to be higher (p=0.08) but HbA1c levels were similar (p=0.68) in the CKD compared with non-CKD groups. A linear relationship between AG and HbA1c was observed irrespective of the presence and stage of CKD. The relationship was weaker in patients with stage 4-5 CKD (non-CKD R2=0.75, stage 3 CKD R2=0.79 and stage 4-5 CKD R2=0.34, all p<0.01). The inclusion of ESA use in the model rendered the effect of CKD stage insignificant (R2=0.67, p<0.01).

CONCLUSIONS

In patients with type 2 diabetes and CKD there is a linear relationship between HbA1c and AG that is attenuated by ESA use, suggesting that ESA results in a systematic underestimation of AG derived from HbA1c.