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Fan YP, Lai TH, Lai JN, Yang CC. Impacts of medication adherence and home healthcare on the associations between polypharmacy and the risk of severe hypoglycemia among elderly diabetic patients in Taiwan from 2002 to 2012: A nationwide case-crossover study. Geriatr Nurs 2024; 58:8-14. [PMID: 38729064 DOI: 10.1016/j.gerinurse.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/12/2024] [Accepted: 04/19/2024] [Indexed: 05/12/2024]
Abstract
AIM To assess how medication adherence and home healthcare support influence the role of polypharmacy in induced hypoglycemia events among elderly diabetic patients. METHODS This case-crossover study retrieved records on diabetic patients >=65 years with severe hypoglycemia from 2002 to 2012 in Taiwan. Case period defined as 1-3 days before severe hypoglycemia was compared with a preceding control period of the same length, with an all-washout period of 30 days. Moreover, the modifiable effects of medication adherence and home healthcare service use were evaluated by stratified analysis. RESULTS Totally 2,237 patients were identified. Polypharmacy use was associated with the risk of severe hypoglycemia. Patients receiving polypharmacy without home healthcare services (aOR: 1.34; 95 % CI: 1.16-1.54) and those with poor adherence to anti-diabetic medications (aOR: 1.48; 95 % CI: 1.24-1.77) were significantly associated with an elevated risk of severe hypoglycemia. In patients with good adherence, non-home healthcare users being prescribed with polypharmacy had a higher risk of severe hypoglycemia. In the group that received home healthcare services, patients with poor adherence using polypharmacy had a higher risk of severe hypoglycemia. CONCLUSIONS Good adherence and receiving home healthcare services were associated with a decreased odds of severe hypoglycemic events in elderly diabetic patients, regardless of the fact whether they were prescribed with polypharmacy.
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Affiliation(s)
- Yu-Pei Fan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, Department of Medical Education; MacKay Memorial Hospital, Taipei, Taiwan
| | - Tzu-Hsuan Lai
- Traditional Chinese Medicine-Acupuncture Program, College of Traditional Chinese Medicine Practitioners and Acupuncturists, Kwantlen Polytechnic University, Richmond, Canada
| | - Jung-Nien Lai
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan, Departments of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan.
| | - Chen-Chang Yang
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, Department of Medical Education; Institute of Environmental and Occupational Health Sciences, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
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Khunti K. Diabetes, ethnic minority groups and
COVID
‐19: an inevitable storm. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Kamlesh Khunti
- Leicester Diabetes Research Centre, Leicester General Hospital Leicester UK
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3
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Rao H, Fakourfar N, Sun C, Lewis J. The Use of Continuous Glucose Monitoring in Older People With Type 2 Diabetes. Sr Care Pharm 2021; 36:556-567. [PMID: 34717787 DOI: 10.4140/tcp.n.2021.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To review current guidelines and literature regarding continuous glucose monitoring (CGM) use in the management of type 2 diabetes mellitus (T2DM) in older people. Data Sources A PubMed search of articles published through August 2020 using a combination of the following: older people, T2DM, continuous glucose monitoring, hypoglycemia, and hyperglycemia. Study Selection/Data Extraction Relevant randomized control trials, meta-analyses, and guidelines were assessed for the use of CGM in older patients with T2DM. Articles were included based on relevance to the topic, detailed methods, and complete results. Data Synthesis CGM use in T2DM management in older people is not well defined. CGM may be a valuable technology in older people who face unique challenges, such as hypoglycemia, decline in cognitive function, and variable glucose levels. This article provides a review of recommendations for glucose monitoring in T2DM and discusses the role of specific CGM products. Conclusion CGM is a viable option for older people with T2DM to help improve overall diabetes control. Pharmacists can play an important role in educating patients about this technology.
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Affiliation(s)
- Hindu Rao
- Chapman University, Irvine, California
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4
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Zaccardi F, Ling S, Lawson C, Davies MJ, Khunti K. Severe hypoglycaemia and absolute risk of cause-specific mortality in individuals with type 2 diabetes: a UK primary care observational study. Diabetologia 2020; 63:2129-2139. [PMID: 32728893 PMCID: PMC7476909 DOI: 10.1007/s00125-020-05223-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS Several pathophysiological mechanisms would suggest a causal link between hypoglycaemia and cardiovascular death; conversely, current knowledge would not support a causal relationship with other causes of death. To clarify the nature and the magnitude of the association between hypoglycaemia and death, we investigated the 5 year mortality risks for cardiovascular disease, cancer and other causes in individuals with type 2 diabetes admitted to hospital for a severe hypoglycaemic episode. METHODS We defined in the UK Clinical Practice Research Datalink database a prevalent cohort of adults with type 2 diabetes diagnosed between 1 January 1998 and 1 January 2011 (index date), with available linkage to the Office for National Statistics (ONS) and the Hospital Episode Statistics (HES). A hospital admission reporting hypoglycaemia as the underlying cause was identified before the index date in the HES; date and underlying cause of death were obtained from the ONS. We quantified the 5 year risk of cause-specific death in people with and without admission to hospital for severe hypoglycaemia, adjusting for potential confounders and accounting for competing risk. RESULTS Of the 74,610 subjects included in the cohort, 388 (0.5%) were admitted at least once for a severe hypoglycaemic episode; subjects admitted were older, with higher HbA1c and a greater prevalence of multimorbidity. During a median follow-up of 7.1 years, 236 (60.8%) and 18,539 (25.0%) deaths occurred in subjects with and without a previous severe hypoglycaemia, respectively. Non-cardiovascular causes accounted for 71% of all deaths in both subjects with and without hypoglycaemia. In a 60-year-old person with severe hypoglycaemia, the 5 year absolute risk of death, adjusted for age, sex, ethnicity, systolic blood pressure, total cholesterol, HbA1c, BMI, eGFR, smoking status, alcohol consumption and deprivation (Townsend score), was 6.6%, 1.1% and 13.1% for cardiovascular, cancer and other causes, respectively, while the 5 year absolute risk difference compared with a subject without severe hypoglycaemia was 4.7% (95% CI 1.0, 8.3) for cardiovascular, -1.4% (-4.1, 1.4) for cancer and 11.1% (6.1, 16.1) for other causes of death. Results were consistent in models further adjusted for medications and comorbidities (myocardial infarction, stroke, peripheral artery disease, heart failure, atrial fibrillation, cancer), with sulfonylurea and insulin associated with increased mortality rates (from cause-specific hazard ratio of 1.06 [95% CI 0.99, 1.14] for cancer death with use of sulfonylurea to 1.42 [1.29, 1.56] for cardiovascular death with use of insulin). Results were robust to missing data. CONCLUSIONS/INTERPRETATION The results of this study indicate severe hypoglycaemia as a marker of, rather than causally linked to, an increased risk of long-term mortality. Regardless of the nature of the association, a severe hypoglycaemic episode represents a strong negative prognostic factor in patients with type 2 diabetes. Graphical abstract.
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Affiliation(s)
- Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK.
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK.
| | - Suping Ling
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - Claire Lawson
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
- National Institute for Health Research, Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
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5
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Müller N, Lehmann T, Klöss A, Günster C, Kloos C, Müller UA. Changes in incidence of severe hypoglycaemia in people with type 2 diabetes from 2006 to 2016: analysis based on health insurance data in Germany considering the anti-hyperglycaemic medication. Diabet Med 2020; 37:1326-1332. [PMID: 32145093 DOI: 10.1111/dme.14294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
Abstract
AIM To investigate the incidence of severe hypoglycaemia over the past 10 years, taking into account changes in anti-hyperglycaemic therapy. METHODS This retrospective population-based study used German health insurance data. All adults diagnosed with documented type 2 diabetes (extrapolated to the German population: 6.6 million in 2006; 7.9 million in 2011; 8.86 million in 2016) were screened for severe hypoglycaemia. Anti-hyperglycaemic agents were identified by Anatomical Therapeutic Chemical (ATC) code. RESULTS The event rate for severe hypoglycaemia was 460 per 100 000 people in 2006, 490 per 100 000 in 2011 and 360 per 100 000 in 2016. The proportion of people with severe hypoglycaemia receiving sulfonylureas, as well as receiving combination therapy of metformin and sulfonylureas decreased from 2006 to 2016 (23.6% vs. 6.2%) Among those with severe hypoglycaemia in 2006, there were no prescriptions for dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists or sodium-glucose co-transporter 2 (SGLT2) agonists. The proportions of people with severe hypoglycaemia receiving DPP-4 inhibitors, GLP-1 receptor agonists or SGLT2 agonists in 2011 and 2016 were low. The proportion of people receiving human insulin also decreased (from 11.3% in 2006 to 10.3% in 2011 and 4.3% in 2016); the proportion of people receiving insulin analogues increased from 5.4% in 2006 to 11.5% in 2016. Therapy with mixed insulins was used by 19.7% of people with severe hypoglycaemia in 2006, by 14.0% in 2011 and by 7.3% in 2016. People undergoing therapy with insulin analogues have the highest risk of severe hypoglycaemia adjusted by age, gender, nephropathy diagnosis and year of survey [odds ratio (OR) 14.4, 95% confidence interval (95% CI) 13.5-15.5]. CONCLUSION The incidence of severe hypoglycaemic events in Germany increased between 2006 and 2011, and decreased in 2016.
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Affiliation(s)
- N Müller
- Department for Internal Medicine III, Jena University Hospital, Jena, Germany
| | - T Lehmann
- Centre for Clinical Studies, Jena University Hospital, Jena, Germany
| | - A Klöss
- Research Institute of the Local Health Care Funds, Berlin, Germany
| | - C Günster
- Research Institute of the Local Health Care Funds, Berlin, Germany
| | - C Kloos
- Department for Internal Medicine III, Jena University Hospital, Jena, Germany
| | - U A Müller
- Department for Internal Medicine III, Jena University Hospital, Jena, Germany
- Centre for Outpatient Care, Jena University Hospital, Jena, Germany
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6
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Zaccardi F, Davies MJ, Khunti K. The present and future scope of real-world evidence research in diabetes: What questions can and cannot be answered and what might be possible in the future? Diabetes Obes Metab 2020; 22 Suppl 3:21-34. [PMID: 32250528 DOI: 10.1111/dom.13929] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/18/2019] [Accepted: 11/18/2019] [Indexed: 12/16/2022]
Abstract
The last decade has witnessed an exponential growth in the opportunities to collect and link health-related data from multiple resources, including primary care, administrative, and device data. The availability of these "real-world," "big data" has fuelled also an intense methodological research into methods to handle them and extract actionable information. In medicine, the evidence generated from "real-world data" (RWD), which are not purposely collected to answer biomedical questions, is commonly termed "real-world evidence" (RWE). In this review, we focus on RWD and RWE in the area of diabetes research, highlighting their contributions in the last decade; and give some suggestions for future RWE diabetes research, by applying well-established and less-known tools to direct RWE diabetes research towards better personalized approaches to diabetes care. We underline the essential aspects to consider when using RWD and the key features limiting the translational potential of RWD in generating high-quality and applicable RWE. Only if viewed in the context of other study designs and statistical methods, with its pros and cons carefully considered, RWE will exploit its full potential as a complementary or even, in some cases, substitutive source of evidence compared to the expensive evidence obtained from randomized controlled trials.
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Affiliation(s)
- Francesco Zaccardi
- Diabetes Research Centre, Leicester Diabetes Centre, Leicester, UK
- Leicester Real World Evidence Unit, Leicester Diabetes Centre, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, Leicester Diabetes Centre, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester Diabetes Centre, Leicester, UK
- Leicester Real World Evidence Unit, Leicester Diabetes Centre, Leicester, UK
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7
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Malabu UH, Adegboye O, Hayes OG, Ryan A, Vangaveti VN, Jhamb S, Robertson K, Sangla KS. Influence of Ethnicity on Outcomes of Diabetes Inpatient Hypoglycemia: an Australian Perspective. J Endocr Soc 2020; 4:bvaa009. [PMID: 32104749 PMCID: PMC7039405 DOI: 10.1210/jendso/bvaa009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 01/28/2020] [Indexed: 01/08/2023] Open
Abstract
Abstract
Aims
To evaluate outcomes of diabetic inpatient hypoglycemia among Aboriginal and Torres Strait Islander (ATSI) compared with Australian Caucasian patients.
Methods
A retrospective audit of diabetic patients aged > 18 years admitted at a regional hospital general ward between April 1, 2015, and March 31, 2016, was analyzed. The database contains clinical information at the time of admission and initial discharge and readmission within 4 weeks thereafter.
Results
A total of 1618 (of 6027) patients were admitted with diabetes representing 23.7% of the total ward admissions, of which 484 (29.9%) had inpatient hypoglycemia. Of the 91 patients with available data analyzed, ATSI origin with inpatient hypoglycemia was associated with longer length of stay (LOS) (hazard ratio [HR], 2.1, 95% confidence interval [CI], 1.2-3.5), whereas severe hypoglycemia (≤ 2.2 mmol/L) in both ATSI and non-ATSI was significantly associated with longer LOS (HR, 2.3; 95% CI, 1.2-4.2). No significant differences in LOS were found for gender, age, and Carlson comorbidity index (CCI). The adjusted model for likelihood of readmission, gender, indigenous status, and CCI were not significant risk factors for readmission to the hospital. Readmitted patients were older (50-59 years vs < 50 years, P = 0.001; 60-69 years vs < 50 years, P = 0.032; 70+ years vs < 50 years, P = 0.031).
Conclusion
We reported high rate of inpatient hypoglycemia in our study population. Indigenous Australian diabetic patients with inpatient hypoglycemia had significantly longer LOS compared with non-Indigenous Caucasian counterparts. Further prospective studies on a larger population are needed to confirm our findings.
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Affiliation(s)
- Usman H Malabu
- The Townsville Hospital, Douglas, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Queensland, Australia
| | - Oyelola Adegboye
- Australian Institute of Tropical Health and Medicine, James Cook University, Queensland, Australia
| | | | | | - Venkat N Vangaveti
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
| | - Shaurya Jhamb
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
| | | | - Kunwarjit S Sangla
- The Townsville Hospital, Douglas, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
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8
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Li P, Geng Z, Ladage VP, Wu J, Lorincz I, Doshi JA. Early hypoglycaemia and adherence after basal insulin initiation in a nationally representative sample of Medicare beneficiaries with type 2 diabetes. Diabetes Obes Metab 2019; 21:2486-2495. [PMID: 31297967 DOI: 10.1111/dom.13832] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 11/28/2022]
Abstract
AIMS To estimate risk factors associated with early hypoglycaemia and its impact on adherence to and persistence with therapy in Medicare Part D beneficiaries with type 2 diabetes who are initiating basal insulin (BI). MATERIALS AND METHODS This retrospective analysis used a 5% sample of Medicare files from 2007-2013, identifying beneficiaries with type 2 diabetes initiating BI from 1 January 2008 to 31 December 2012. Early hypoglycaemia was defined as ≥1 hypoglycaemic event ≤6 months postindex. Outcomes included medication adherence and persistence over 12- and 36-month follow-up. Multivariable logistic and Cox regression analyses were conducted to examine factors associated with early hypoglycaemia and BI adherence/persistence. RESULTS Of the 14 466 included patients, 1315 (9.1%) experienced hypoglycaemia ≤6 months after initiating BI. Factors associated with early hypoglycaemia were female sex (odds ratio [OR] 1.16 [95% confidence interval [CI] 1.02-1.32]), receipt of a low-income subsidy under Medicare Part D (OR 1.20 [95% CI 1.01-1.43]), high diabetes complication score index (OR 1.08 [95% CI 1.01-1.15]), and hypoglycaemia during the baseline period (OR 4.24 [95% CI 3.63-4.96]). At 12 months, patients with baseline hypoglycaemia were less likely to be adherent to (OR 0.81 [95% CI 0.70-0.93]) and more likely to discontinue (OR 1.33 [95% CI 1.07-1.66]) their insulin therapy. Results were similar at 36 months. CONCLUSIONS Within 6 months of BI initiation, almost 1 in 10 Medicare Part D beneficiaries experienced hypoglycaemia. Early hypoglycaemia was associated with decreased adherence to BI treatment over 12- and 36-month follow-up.
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Affiliation(s)
- Pengxiang Li
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zhi Geng
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vrushabh P Ladage
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Ilona Lorincz
- Department of Endocrinology, Diabetes, and Metabolism, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jalpa A Doshi
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Robbins TD, Lim Choi Keung SN, Sankar S, Randeva H, Arvanitis TN. Risk factors for readmission of inpatients with diabetes: A systematic review. J Diabetes Complications 2019; 33:398-405. [PMID: 30878296 DOI: 10.1016/j.jdiacomp.2019.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/04/2019] [Accepted: 01/22/2019] [Indexed: 12/16/2022]
Abstract
AIM We have limited understanding of which risk factors contribute to increased readmission rates amongst people discharged from hospital with diabetes. We aim to complete the first review of its kind, to identify, in a systematic way, known risk factors for hospital readmission amongst people with diabetes, in order to better understand this costly complication. METHOD The review was prospectively registered in the PROSPERO database. Risk factors were identified through systematic review of literature in PubMed, EMBASE & SCOPUS databases, performed independently by two authors prior to data extraction, with quality assessment and semi-quantitative synthesis according to PRISMA guidelines. RESULTS Eighty-three studies were selected for inclusion, predominantly from the United States, and utilising retrospective analysis of local or regional data sets. 76 distinct statistically significant risk factors were identified across 48 studies. The most commonly identified risk factors were; co-morbidity burden, age, race and insurance type. Few studies conducted power calculations; unstandardized effect sizes were calculated for the majority of statistically significant risk factors. CONCLUSION This review is important in assessing the current state of the literature and in supporting development of interventions to reduce readmission risk. Furthermore, it provides an important foundation for development of rigorous, pre-specified risk prediction models.
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Affiliation(s)
- Tim D Robbins
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom; Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - S N Lim Choi Keung
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - S Sankar
- Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom
| | - H Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom
| | - T N Arvanitis
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom
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10
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Dhalwani NN, Zaccardi F, Waheed H, Mytton J, Papamargaritis D, Webb DR, Evison F, Lilford R, Davies MJ, Khunti K. Cardiovascular, cancer and mortality events after bariatric surgery in people with and without pre-existing diabetes: A nationwide study. J Diabetes 2019; 11:265-272. [PMID: 30191659 DOI: 10.1111/1753-0407.12851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Bariatric surgery reduces cardiovascular events and mortality risk in obese individuals. However, it is unclear whether diabetes modifies this effect. This study examined mortality, cardiovascular, and cancer risk following bariatric surgery in adults with and without pre-existing diabetes. METHODS Using mortality-linked Hospital Episodes Statistics (2006-14) from England, the risk of death, myocardial infarction, stroke, unstable angina, heart failure, and cancer following bariatric surgery was examined; the risk of death in people undergoing surgery was also compared with mortality rates of the general population. RESULTS Of the 35 887 people undergoing bariatric surgery, 9175 (25.6%) had pre-existing diabetes. During a mean follow-up of 5.3 years, 801 people died, of whom 293 (36.6%) had pre-existing diabetes. The risk of all-cause mortality was 26% higher in people with than without diabetes (adjusted hazard ratio [aHR] 1.26, 95% confidence interval [CI] 1.08-1.46), whereas the risk of cancer was 21% higher (aHR 1.21; 95% CI 1.14-1.77). The risk of cardiovascular events was higher for patients with than without diabetes (aHRs [95% CIs] 2.08 [1.42-3.05], 1.80 [1.29-2.52], 1.61 [1.18-2.19], and 1.42 [1.14-1.77] for myocardial infarction, unstable angina, stroke, and heart failure, respectively). Compared with the general population, the age-standardized mortality rate ratio was 1.70 (1.52-1.91) and 1.35 (1.23-1.48) in people with and without pre-existing diabetes, respectively. CONCLUSIONS For patients with pre-existing diabetes, the risk of death, cardiovascular events, and cancer after bariatric surgery was higher than for those without diabetes, whose mortality risk after surgery remains 35% higher than that of the general population.
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Affiliation(s)
| | | | - Hina Waheed
- University Hospitals Birmingham, Birmingham, UK
| | | | | | - David R Webb
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | | | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
- Leicester Biomedical Research Centre, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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11
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Malawana M, Hutchings A, Mathur R, Robson J. Ethnic variations in the risk of hypoglycaemia among people with Type 2 diabetes prescribed insulins and/or sulfonylureas: a historical cohort study using general practice-recorded data. Diabet Med 2018; 35:1707-1715. [PMID: 30264528 DOI: 10.1111/dme.13828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2018] [Indexed: 01/20/2023]
Abstract
AIM To identify ethnic differences in hypoglycaemic risk among people with Type 2 diabetes prescribed insulins and/or sulfonylureas in community settings. METHODS Using routine general practice-recorded data, two cohorts of adults with Type 2 diabetes from east London were studied between January 2013 and December 2015: (1) adults prescribed insulins ± other antidiabetes medications (n=7269) and (2) adults prescribed sulfonylureas ± other antidiabetes medications excluding insulins (n=12 502). Incidence rate ratios of hypoglycaemia by ethnicity, adjusting for age, sex, socio-economic status and clustering within Clinical Commissioning Groups, were estimated using random effects Poisson regression. RESULTS Compared with white British people prescribed insulins, those of black Caribbean ethnicity were at increased hypoglycaemic risk [adjusted incidence rate ratio 1.56 (95% CI 1.21,2.01)], while Bangladeshi people had a lower risk [adjusted incidence rate ratio 0.49 (95% CI, 0.38,0.64)]. In the sulfonylurea cohort, black Caribbean, black African and Indian people all had increased risks of hypoglycaemia compared with white British people [adjusted incidence rate ratios 1.63 (95% CI 1.15,2.29), 1.90 (95% CI 1.32,2.75) and 1.93 (95% CI 1.39,2.69), respectively]. CONCLUSION The differences in hypoglycaemic risk among people with Type 2 diabetes prescribed insulin and/or sulfonylureas warrant further investigation of any differing biological responses and/or cultural attitudes to antidiabetes therapy among ethnic groups, and should be considered by clinicians evaluating the treatment goals of people with Type 2 diabetes using insulins or sulfonylureas.
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Affiliation(s)
- M Malawana
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - A Hutchings
- Departments of Health Services Research and Policy, London, UK
| | - R Mathur
- Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - J Robson
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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12
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Zaccardi F, Dhalwani NN, Webb DR, Davies MJ, Khunti K. Global burden of hypoglycaemia-related mortality in 109 countries, from 2000 to 2014: an analysis of death certificates. Diabetologia 2018; 61:1592-1602. [PMID: 29717336 PMCID: PMC6438613 DOI: 10.1007/s00125-018-4626-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/04/2018] [Indexed: 12/21/2022]
Abstract
AIMS/HYPOTHESIS In the context of increasing prevalence of diabetes in elderly people with multimorbidity, intensive glucose control may increase the risk of severe hypoglycaemia, potentially leading to death. While rising trends of severe hypoglycaemia rates have been reported in some European, North American and Asian countries, the global burden of hypoglycaemia-related mortality is unknown. We aimed to investigate global differences and trends of hypoglycaemia-related mortality. METHODS We used the WHO mortality database to extract information on death certificates reporting hypoglycaemia or diabetes as the underlying cause of death, and the United Nations demographic database to obtain data on mid-year population estimates from 2000 to 2014. We calculated crude and age-standardised proportions (defined as number of hypoglycaemia-related deaths divided by total number of deaths from diabetes [i.e. the sum of hypoglycaemia- and diabetes-related deaths]) and rates (hypoglycaemia-related deaths divided by mid-year population) of hypoglycaemia-related mortality and compared estimates across countries and over time. RESULTS Data for proportions were extracted from 109 countries (31 had data from all years analysed [2000-2014] available). Combining all countries, the age-standardised proportion of hypoglycaemia-related deaths was 4.49 (95% CI 4.44, 4.55) per 1000 total diabetes deaths. Compared with the overall mean, most Central American, South American and (mainly) Caribbean countries reported higher proportions (five more age-standardised hypoglycaemia-related deaths per 1000 total diabetes deaths in Chile, six in Uruguay, 11 in Belize and 22 in Aruba), as well as Japan (11 more age-standardised hypoglycaemia-related deaths per 1000 total diabetes deaths). In comparison, lower proportions were noted in most European countries, the USA, Canada, New Zealand and Australia. For countries with data available for all years analysed, trend analysis showed a 60% increase in hypoglycaemia-related deaths until 2010 and stable trends onwards. Rising trends were most evident for Argentina, Brazil, Chile, the USA and Japan. Data for rates were available for 105 countries (30 had data for all years analysed [2000-2014] available). Combining all countries, the age-standardised hypoglycaemia-related death rate was 0.79 (95% CI 0.77, 0.80) per 1 million person-years. Most Central American, South American and Caribbean countries similarly reported higher rates of hypoglycaemia-related death, whilst virtually all European countries, the USA, Canada, Japan, New Zealand and Australia reported lower rates compared with the overall mean. Age-standardised rates were very low for most countries (lower than five per 1 million person-years in 89.5% of countries), resulting in small absolute differences among countries. As noted with the proportions analysis, trend analysis showed an overall 60% increase in hypoglycaemia-related deaths until 2010 and stable rate trends onwards; rising rates were particularly evident for Brazil, Chile and the USA. CONCLUSIONS/INTERPRETATION Most countries in South America, Central America and the Caribbean showed the highest proportions of diabetes-related deaths attributable to hypoglycaemia and the highest rates of hypoglycaemia-related deaths. Between 2000 and 2014, rising trends were observed in Brazil, Chile and the USA for both rates and proportions of hypoglycaemia-related death, and in Argentina and Japan for proportions only. Further studies are required to unravel the contribution of clinical and socioeconomic factors, difference in diabetes prevalence and heterogeneity of death certification in determining lower rates and proportions of hypoglycaemia-related deaths in high-income countries in Europe, North America and Asia. DATA AVAILABILITY Data used for these analyses are available at https://doi.org/10.17632/ndp52fbz8r.1.
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Affiliation(s)
- Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK.
| | - Nafeesa N Dhalwani
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - David R Webb
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Rd, Leicester, LE5 4PW, UK
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Conceição J, Dores J, Araújo F, Laires PA, Carr RD, Brodovicz K, Radican L, Nogueira AM. Severe hypoglycaemia among patients with type 2 diabetes requiring emergency hospital admission: The Hypoglycaemia In Portugal Observational Study-Emergency Room (HIPOS-ER). Diabetes Obes Metab 2018; 20:50-59. [PMID: 28581253 DOI: 10.1111/dom.13030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 05/19/2017] [Accepted: 05/30/2017] [Indexed: 11/28/2022]
Abstract
AIMS To analyse the prevalence of severe hypoglycaemia in patients with type 2 diabetes (T2DM) treated with antihyperglycaemic agents (AHA) and requiring emergency room (ER) assistance, and to analyse the prevalence according to type of AHA therapy. METHODS The present study, the Hypoglycaemia In Portugal Observational Study-Emergency Room (HIPOS-ER), was a cross-sectional, observational, multicentre, nationwide study, with specific hypoglycaemia source data collection. RESULTS Within the study period, a total of 425 706 admissions were recorded in the ERs of participating hospitals. The prevalence of severe hypoglycaemic episodes in patients with T2DM was 0.074%. In all, 238 patients were included, more than half of whom were on insulin-based therapy (55.0%) and a third of whom (31.5%) were on oral secretagogue-based therapy. In 61.2% of patients primary care was the main diabetes care setting. The median patient age was 77.5 years and the mean duration of diabetes was 19 years. Missing a meal or low carbohydrate meal content was the most frequent cause of hypoglycaemia (55.9%) and the most frequent triggers for seeking emergency assistance were pre-syncope (19.2%) and transient loss of consciousness (17.4%). A total of 44.1% of patients were hospitalized for a median of 5.1 days. Patients in the secretagogue group were admitted to hospital more often than patients in the insulin group (70.7% vs 29.0%; P < .001). Nine patients died. CONCLUSIONS These findings confirm that severe hypoglycaemia in patients with T2DM requiring ER assistance occurs mainly in those on insulin- and secretagogue-based therapies and is associated with a significant medical burden. Antidiabetic therapy should be individualized to minimize the risk of severe iatrogenic hypoglycaemia, and any intervention to this end should always involve primary care stakeholders.
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Affiliation(s)
- João Conceição
- Medical Affairs, MSD International GmbH (Singapore Branch), Singapore, Singapore
| | - Jorge Dores
- Endocrinology Department, Emergency Department, Centro Hospitalar do Porto, Porto, Portugal
| | - Francisco Araújo
- Internal Medicine Department, Beatriz Ângelo Hospital, Lisbon, Portugal
| | - Pedro A Laires
- Outcomes Research Department, MSD Portugal, Paço de Arcos, Portugal
| | - Richard D Carr
- MSD Europe Canada, Global Medical Affairs Organization, Copenhagen, Denmark
| | | | - Larry Radican
- Global Outcomes Research, Merck & Co., New Jersey, USA
| | - Ana M Nogueira
- Outcomes Research Department, MSD Portugal, Paço de Arcos, Portugal
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Zaccardi F, Khunti K. Diabetes: Predicting severe hypoglycaemia - a step forward. Nat Rev Endocrinol 2017; 13:692-693. [PMID: 29052593 DOI: 10.1038/nrendo.2017.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
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Zaccardi F, Dhalwani NN, Davies MJ, Khunti K. Comment on: "Strengths and Limitations of Healthcare Databases in the Evaluation of Hypoglycaemia". Diabetes Obes Metab 2017; 19:1495-1496. [PMID: 28523737 DOI: 10.1111/dom.13014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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