Strict glycemic control and mortality risk among US adults with type 2 diabetes

Treatment Costs and Factors Associated with Glycemic Control among Patients with Diabetes in the United Arab Emirates

Background

We aimed to estimate the proportion of patients with diabetes who achieved target glycemic control, to estimate diabetes-related costs attributable to poor control, and to identify factors associated with them in the United Arab Emirates.

Methods

This retrospective cohort study used administrative claims data handled by Abu Dhabi Health Authority (January 2010 to June 2012) to determine glycemic control and diabetes-related treatment costs. A total of 4,058 patients were matched using propensity scores to eliminate selection bias between patients with glycosylated hemoglobin (HbA1c) <7% and HbA1c ≥7%. Diabetes-related costs attributable to poor control were estimated using a recycled prediction method. Factors associated with glycemic control were investigated using logistic regression and factors associated with these costs were identified using a generalized linear model.

Results

During the 1-year follow-up period, 46.6% of the patients achieved HbA1c <7%. Older age, female sex, better insurance coverage, non-use of insulin in the index diagnosis month, and non-use of antidiabetic medications during the follow-up period were significantly associated with improved glycemic control. The mean diabetes-related annual costs were $2,282 and $2,667 for patients with and without glycemic control, respectively, and the cost attributable to poor glycemic control was $172 (95% confidence interval [CI], $164–180). The diabetes-related costs were lower with mean HbA1c levels <7% (cost ratio, 0.94; 95% CI, 0.88–0.99). The costs were significantly higher in patients aged ≥65 years than those aged ≤44 years (cost ratio, 1.45; 95% CI, 1.25–1.70).

Conclusion

More than 50% of patients with diabetes had poorly controlled HbA1c. Poor glycemic control may increase diabetes-related costs.

All-cause and cardiovascular mortality risk in U.S. adults with and without type 2 diabetes: Influence of physical activity, pharmacological treatment and glycemic control

AIMS

This study determined the joint association between physical activity, pharmacotherapy, and HbA1c control on all-cause and cardiovascular disease (CVD) mortality risk in adults with and without type 2 diabetes (T2D).

METHODS

12,060 adults from NHANES III and NHANES continuous (1999-2002) surveys were used. Cox proportional hazards analyses were included to estimate mortality risk according to physical activity, pharmacotherapy, and glycemic control (HbA1c <7.0%) status, with physically active, treated and controlled (goal situation) as the referent.

RESULTS

Compared to the referent, adults with T2D who were uncontrolled, or controlled but physically inactive had a higher all-cause mortality risk (p<0.05). Compared to the referent, only adults with T2D who were physically inactive had a higher CVD mortality risk, regardless of treatment or control status (p<0.05). Normoglycemic adults had a similar all-cause and CVD mortality risk as the referent (p>0.05).

CONCLUSIONS

Physical activity and glycemic control are both associated with lower all-cause and CVD mortality risk in adults with T2D. Adults with T2D who are physically active, pharmacologically treated, and obtain glycemic control may attain similar mortality risk as normoglycemic adults.

Clinical utility of insulin and insulin analogs

Diabetes is a pandemic disease characterized by autoimmune, genetic and metabolic abnormalities. While insulin deficiency manifested as hyperglycemia is a common sequel of both Type-1 and Type-2 diabetes (T1DM and T2DM), it does not result from a single genetic defect--rather insulin deficiency results from the functional loss of pancreatic β cells due to multifactorial mechanisms. Since pancreatic β cells of patients with T1DM are destroyed by autoimmune reaction, these patients require daily insulin injections. Insulin resistance followed by β cell dysfunction and β cell loss is the characteristics of T2DM. Therefore, most patients with T2DM will require insulin treatment due to eventual loss of insulin secretion. Despite the evidence of early insulin treatment lowering macrovascular (coronary artery disease, peripheral arterial disease and stroke) and microvascular (diabetic nephropathy, neuropathy and retinopathy) complications of T2DM, controversy exists among physicians on how to initiate and intensify insulin therapy. The slow acting nature of regular human insulin makes its use ineffective in counteracting postprandial hyperglycemia. Instead, recombinant insulin analogs have been generated with a variable degree of specificity and action. Due to the metabolic variability among individuals, optimum blood glucose management is a formidable task to accomplish despite the presence of novel insulin analogs. In this article, we present a recent update on insulin analog structure and function with an overview of the evidence on the various insulin regimens clinically used to treat diabetes.

Patient empowerment and optimal glycemic control

OBJECTIVE

This review updates the clinician on strategies of insulin use and educational approaches to empower their patients to use insulin correctly in self-management treatment plans.

DESIGN AND METHODS

A PubMed literature search was conducted to identify peer-reviewed clinical trials published in English in the last 10 years. Search terms used were 'glycemic control', 'insulin', and 'type 2 diabetes'. An additional search to include the terms 'patient empowerment' and 'self-management' was also conducted. Some articles relevant to this review may not have been identified using these terms. Oral antidiabetes agents in conjunction with insulin are not addressed.

RESULTS

A total of 562 articles were initially identified. Papers that did not provide data pertinent to the efficacy and tolerance of insulin types for treatment of type 2 diabetes mellitus (T2DM) were excluded. Based on methodology, results, and clinical implications, 12 clinical trials were included for discussion in this review.

CONCLUSIONS

Patients with T2DM who are empowered with knowledge about their disease and treatment can take an active role in their diabetes care, and therefore, are more likely to achieve blood glucose and A1C goals, which can slow progression of their disease and the onset of complications. Although concentrating solely on medical information and physiological facts does not guarantee patient empowerment and self-management, educational strategies such as interactive teaching, problem solving and individualized education can have a positive impact. Insulin titration algorithms can empower patients to manage their therapy, and such algorithms are simple to use for patients treated with insulin analogs. As patients with T2DM become empowered by knowledge and gain more control of their disease, their physicians must then serve as their advisors rather than as their directors or prescribers.