The comparative risk of new-onset diabetes after prescription of drugs for cardiovascular risk prevention in primary care: a national cohort study

A pharmacovigilance study of chronic kidney disease in diabetes mellitus patients with statin treatment by using the US Food and Drug Administration adverse event reporting system

Background

Statins were regarded as a main medication for managing hypercholesterolemia. Administration of statin therapy could reduce the incidence of cardiovascular disease in individuals diagnosed with type 2 diabetes mellitus (DM), which was recognized by multipal clinical guidelines. But previous studies had conflicting results on whether the long-term use of statins could benefit the renal function in diabetic patients.

Aim

To evaluate the association between statin treatment and Chronic Kidney Disease in DM patients.

Methods

This is a retrospective disproportionality analysis and cohort study based on real-world data. All DM cases reported in US Food and Drug Administration adverse event reporting system (FAERS) between the first quarter of 2004 and the fourth quarter of 2022 were included. Disproportionality analyses were conducted by estimating the reporting odds ratio (ROR) and the information component (IC). We further compared the CKD odds ratio (OR) between the statins group and the other primary suspected drug group among the included diabetes mellitus cases.

Results

We finally included 593647 DM cases from FAERS, 5113 (5.31%) CKD cases in the statins group and 8810 (1.77%) CKD cases in the control group. Data analysis showed that the statins group showed a significant CKD signal (ROR: 3.11, 95% CI: 3.00-3.22; IC: 1.18, 95% CI: 1.07-1.29). In case group with two or more statins treatment history, the CKD signal was even stronger (ROR: 19.56, 95% CI: 18.10-21.13; IC: 3.70, 95% CI:3.44-3.93) compared with cases with one statin treatment history.

Conclusion

The impact of statin therapy on the progression of renal disease in individuals diagnosed with type 2 diabetes mellitus (DM) remains inconclusive. After data mining on the current FAERS dataset, we discovered significant signals between statin treatment and CKD in diabetic patients. Furthermore, the incidence rate of CKD was higher among DM patients who used statins compared to those who did not.

Statins aggravate insulin resistance through reduced blood glucagon-like peptide-1 levels in a microbiota-dependent manner

Statins are currently the most common cholesterol-lowering drug, but the underlying mechanism of statin-induced hyperglycemia is unclear. To investigate whether the gut microbiome and its metabolites contribute to statin-associated glucose intolerance, we recruited 30 patients with atorvastatin and 10 controls, followed up for 16 weeks, and found a decreased abundance of the genus Clostridium in feces and altered serum and fecal bile acid profiles among patients with atorvastatin therapy. Animal experiments validated that statin could induce glucose intolerance, and transplantation of Clostridium sp. and supplementation of ursodeoxycholic acid (UDCA) could ameliorate statin-induced glucose intolerance. Furthermore, oral UDCA administration in humans alleviated the glucose intolerance without impairing the lipid-lowering effect. Our study demonstrated that the statin-induced hyperglycemic effect was attributed to the Clostridium sp.-bile acids axis and provided important insights into adjuvant therapy of UDCA to lower the adverse risk of statin therapy.

Possible link between statin and iron deficiency anemia: A South Korean nationwide population-based cohort study

An extensive evaluation of disease occurrence after statin use based on a "hypothesis-free" approach remains scarce. To examine the effect of statin use on the potential risk of developing diseases, a propensity score-matched cohort study was executed using data from the National Sample Cohort in South Korea. A total of 7847 statin users and 39,235 nonstatin users were included in the final analysis. The period of statin use was defined as our main time-dependent exposure and was divided into three periods: current, recent, and past. The main outcomes were defined as new-onset diseases with ≥100 events based on the International Statistical Classification of Diseases, 10th Revision. We calculated the adjusted hazard ratios and 95% confidence intervals (CIs) using Cox regression. We found that statin use significantly increased the risk of developing iron deficiency anemia up to 5.04 times (95% CI, 2.11 to 12.03). Therefore, the iron levels of patients using statins should be monitored carefully.

Time-varying and dose-dependent effect of long-term statin use on risk of type 2 diabetes: a retrospective cohort study

BACKGROUND

We evaluated the effect of statin use on new-onset type 2 diabetes among individuals without atherosclerotic cardiovascular disease (ASCVD) using nationally representative South Korean claims data (2002-2013, N = 1,016,820).

METHODS

A total of 13,698 patients (statin users 5273, non-statin users 5273) aged 40-74 years, newly diagnosed with dyslipidemia but without any history of diabetes or ASCVD, were selected in 2005. We followed up the final sample until 2013 and evaluated the cumulative incidence of type 2 diabetes. We used extended Cox regression models to estimate the time-varying adjusted hazard ratios of statin use on new-onset type 2 diabetes. We performed further analyses based on the cumulative defined daily dose of statin received per year to evaluate the degree of risk compared to non-statin users.

RESULTS

Over the mean follow-up period of 7.1 years, 3034 patients developed type 2 diabetes; the number of statin users exceeded that of non-users, demonstrating that statin use significantly increased the risk of new-onset type 2 diabetes. The risk of new-onset type 2 diabetes differed among statin users according to cDDD per year (adjusted HR = 1.31 [95% CI 1.18-1.46] for less than 30 cDDD per year; 1.58 [1.43-1.75] for 30-120 cDDD per year; 1.83 [1.62-2.08] for 120-180 cDDD per year; and 2.83 [2.51-3.19] for more than 180 cDDD per year). The diabetogenic effect of pitavastatin was not statistically significant, but the risk was the largest for atorvastatin. Long-term exposure (≥ 5 years) to statins was associated with a statistically significant increase in the risk of new onset type 2 diabetes in all statin subtypes explored, with the highest magnitude for simvastatin (HR = 1.916, 95% CI 1.647-2.228) followed by atorvastatin (HR = 1.830, 95% CI 1.487-2.252).

CONCLUSIONS

Statin use was significantly associated with an increased risk of new-onset type 2 diabetes. We also found a dose-response relationship in terms of statin use duration and dose maintenance. Periodic screening and monitoring for incident type 2 diabetes may be warranted in long-term statin users.

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?

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.

Evidence of heterogeneity in statin-associated type 2 diabetes mellitus risk: A meta-analysis of randomized controlled trials and observational studies

AIMS

To conduct a meta-analysis of statin-associated type 2 diabetes mellitus (T2D) risk among randomized controlled trials (RCTs) and observational studies (OBSs), excluding studies conducted among secondary prevention populations.

METHODS

Studies were identified by searching PubMed (1994-present) and EMBASE (1994-present). Articles had to meet the following criteria: (1) follow-up >one year; (2) >50% of participants free of clinically diagnosed ASCVD; (3) adult participants ≥30 years old; (4) reported statin-associated T2D effect estimates; and (5) quantified precision using 95% confidence interval. Data were pooled using random-effects model.

RESULTS

We identified 23 studies (35% RCTs) of n = 4,012,555 participants. OBS participants were on average younger (mean difference = 6.2 years) and had lower mean low-density lipoprotein cholesterol (LDL-C, mean difference = 20.6 mg/dL) and mean fasting plasma glucose (mean difference = 5.2 mg/dL) compared to RCT participants. There was little evidence for publication bias (P > 0.1). However, evidence of heterogeneity was observed overall and among OBSs and RCTs (PCochran = <0.05). OBS designs, younger baseline mean ages, lower LDL-C concentrations, and high proportions of never or former smokers were significantly associated with increased statin-associated T2D risk.

CONCLUSIONS

Potentially elevated statin-associated T2D risk in younger populations with lower LDL-C merits further investigation in light of evolving statin guidelines targeting primary prevention populations.

Comparative risk of new-onset diabetes following commencement of antipsychotics in New Zealand: a population-based clustered multiple baseline time series design

OBJECTIVE

Newer antipsychotics are increasingly prescribed off-label for non-psychotic ailments both in primary and secondary care settings, despite the purported risk of weight gain and development of type 2 diabetes mellitus. This study aims to determine any relationship between the development of clinically significant new-onset type 2 diabetes mellitus and novel antipsychotic use in New Zealand using hypnotic drugs as control.

DESIGN

A population-based clustered multiple baseline time series design.

SETTING

Routinely collected data from a complete national pharmaceutical database in New Zealand between 2005 and 2011.

PARTICIPANTS

Patients aged 40-60 years in the year 2006 who were ever dispensed antipsychotics (exposure groups-first-generation antipsychotics, second-generation antipsychotics and antipsychotics with low, medium and high risk for weight gain) or hypnotics (control group) between 2006 and 2011.

MAIN OUTCOME MEASURE

First ever metformin dispensed to patients in each study group between 2006 and 2011 as proxy for development of clinically significant type 2 diabetes mellitus, no longer amendable by lifestyle modifications.

RESULTS

Patients dispensed a second-generation antipsychotic had 1.49 times increased risk (95% CI 1.10 to 2.03, p=0.011) of subsequently commencing metformin. Patients dispensed an antipsychotic with high risk of weight gain also had a 2.41 times increased risk of commencing on metformin (95% CI 1.42 to 4.09, p=0.001).

CONCLUSIONS

Patients dispensed a second-generation antipsychotic and antipsychotics with high risk of weight gain appear to be at increased risk of being secondarily dispensed metformin. Caution should be taken with novel antipsychotic use for patients with increased baseline risk of type 2 diabetes mellitus.

Analysis of glycemic status in diabetes-naïve patients on statins: A hospital-based cross-sectional study

INTRODUCTION:

Randomized controlled trials, observational studies, and meta-analysis suggest risk of hyperglycemia in patients on statins, and this association is being viewed with renewed interest globally. The present study has tried to explore the possible diabetogenic effect of statins, the mechanism of this effect, and various comorbidities associated with this causation.

MATERIALS AND METHODS:

This cross-sectional study was carried out at the Department of Cardiology from October 2015 to March 2017. Patients on statins for at least 1 year and normoglycemic at the time of statin initiation were recruited in the study. The outcome of the present study was development of new-onset diabetes mellitus (NODM). Blood glucose levels and insulin levels were estimated. Other adverse reactions of statins and associated comorbidities in the patients were recorded. Descriptive statistics were used to analyze adverse drug reactions.

RESULTS:

A total of 104 patients met the inclusion criteria, of which eight patients (7.7%) developed NODM and 4 (3.8%) developed prediabetes. Atorvastatin 40 mg was most commonly prescribed statin. About 25% of patients taking atorvastatin 80 mg developed diabetes

CONCLUSION:

Statins have a mild-to-moderate risk of developing NODM. The dose of statins is an important factor that increases the risk of diabetes in statin users

Statin use and risk of new-onset diabetes: A meta-analysis of observational studies

BACKGROUND AND AIMS

Meta-analyses of randomized control trials investigating the association between incident diabetes and statin use showed an increased risk of new-onset diabetes (NOD) from 9% to 13% associated with statins. However, short follow-up period, unpowered sample size, and lack of pre-specified diagnostic criteria for diabetes detection could be responsible of an underestimation of this risk. We conducted a meta-analysis of published observational studies to evaluate the association between statins use and risk of NOD.

METHODS AND RESULTS

PubMed, EMBASE and MEDLINE databases were searched from inception to June 30, 2016 for cohort and case-control studies with risk of NOD in users vs nonusers, on ≥1000 subjects followed-up for ≥1 year. Two review authors assessed study eligibility and risk of bias and undertook data extraction independently. Pooled estimates were calculated by a random-effects model and between-study heterogeneity was tested and measured by I² index. Furthermore, stratified analyses and the evaluation of publication bias were performed. Finally, the meta-analysis included 20 studies, 18 cohort and 2 case-control studies. Overall, NOD risk was higher in statin users than nonusers (RR 1.44; 95% CI 1.31-1.58). High between-study heterogeneity (I² = 97%) was found. Estimates for all single statins showed a class effect, from rosuvastatin (RR 1.61; 1.30-1.98) to simvastatin (RR 1.38; 1.19-1.61).

CONCLUSIONS

The present meta-analysis confirms and reinforces the evidence of a diabetogenic effect by statins utilization. These observations confirm the need of a rigorous monitoring of patients taking statins, in particular pre-diabetic patients or patients presenting with established risk factors for diabetes.

Association of statins with diabetes mellitus and diabetic complications: role of confounders during follow-up

Studies have associated statin use with increased risk of diabetes and diabetic complications. These studies often ensure comparability of statin users and non-users at baseline; however, most studies neglect to consider confounders that occur during follow-up. Failure to consider these confounders, such as new medications or procedures, may result in identification of a spurious association between statins and outcomes. The objective of this study was to examine the association of statins with diabetes mellitus and diabetic complications; and to examine potential confounders during the follow-up period that might affect this relationship. We conducted a retrospective cohort study using Tricare data (from October 1, 2003 to March 31, 2012). We propensity score-matched statin users and non-users on 115 baseline characteristics before starting statins; these characteristics would be potentially associated with the use of statins or the outcomes of interest. Outcomes included the risk of diabetes mellitus and diabetic complications. Out of 60,455 patients (10,910 statin users and 49,545 non-users), we propensity score-matched 6728 statin users to 6728 non-users. Statin users had higher ORs for diabetes (OR 1.34, 95% CI 1.24 to 1.44) and diabetes with complications (OR 1.28, 95% CI 1.16 to 1.42). Adjustment for potential confounders that occurred during the follow-up period did not explain or diminish the association between statins and adverse outcomes. Statin users in comparison to similar non-users were more commonly diagnosed with diabetes and diabetic complications, even after adjustment for potential confounders that occurred during the follow-up period.

Statin Adverse Events in Primary Prevention: Between Randomized Trials and Observational Studies

Considerable debate exists regarding who might benefit from statins for primary prevention. Statins have wide pleotropic effects, which contribute to their efficacy in lowering cardiovascular disease but may also result in adverse events (AEs). Caveats in identifying AEs in randomized controlled trials (RCTs) include the lack of a standardized definition of statin-associated AEs, the differences in properties of different statins, the selectivity of RCTs in choosing their participants, the presence of high rate of nonadherence/withdrawal from trials and other concerns related to study design and conflict of interest. Caveats in identifying or overestimating AEs in observational studies include failure to identify baseline confounders, ascertainment bias, confounding by indication and healthy user bias. Statin use in observational studies may be a surrogate marker for higher socioeconomic standards, access to health care or use of other preventive services. Integrating evidence from both RCTs and observational studies is of paramount importance for appropriate patient-centered decision.

Statins and New-Onset Diabetes Mellitus and Diabetic Complications: A Retrospective Cohort Study of US Healthy Adults

BACKGROUND

Statin use is associated with increased incidence of diabetes and possibly with increased body weight and reduced exercise capacity. Data on the long-term effects of these associations in healthy adults, however, are very limited. In addition, the relationship between these effects and diabetic complications has not been adequately studied.

OBJECTIVE

To examine the association between statin use and new-onset diabetes, diabetic complications, and overweight/obesity in a cohort of healthy adults.

RESEARCH DESIGN

This was a retrospective cohort study.

PARTICIPANTS

Subjects were Tricare beneficiaries who were evaluated between October 1, 2003 and March 1, 2012. Patients were divided into statin users and nonusers.

INTERVENTION

We excluded patients who, at baseline, had a preexisting disease indicative of cardiovascular diseases, any positive element of the Charlson comorbidity index (including diabetes mellitus), or life-limiting chronic diseases. Using 42 baseline characteristics, we generated a propensity score to match statin users and nonusers.

MAIN MEASURES

Outcomes assessed included new-onset diabetes, diabetic complications, and overweight/obesity.

KEY RESULTS

A total of 25,970 patients (3982 statin users and 21,988 nonusers) were identified as healthy adults at baseline. Of these, 3351 statins users and 3351 nonusers were propensity score-matched. Statin users had higher odds of new-onset diabetes (odds ratio [OR] 1.87; 95 % confidence interval [95 % CI] 1.67-2.01), diabetes with complications (OR 2.50; 95 % CI 1.88-3.32), and overweight/obesity (OR 1.14; 95 % CI 1.04-1.25). Secondary and sensitivity analyses demonstrated similar findings.

CONCLUSIONS

Diabetes, diabetic complications, and overweight/obesity were more commonly diagnosed among statin-users than similar nonusers in a healthy cohort of adults. This study demonstrates that short-term clinical trials might not fully describe the risk/benefit of long-term statin use for primary prevention.

Risk of new-onset diabetes associated with statin use

OBJECTIVE

To identify and assess studies investigating the association between statins and new-onset diabetes and determine the clinical significance of this risk.

DATA SOURCES

A MEDLINE (1977-April 2015), Google Scholar (1997-April 2015), and International Pharmaceutical Abstracts (1977-April 2015) search was performed using the search terms hydroxymethylglutaryl-CoA reductase inhibitors, hydroxymethylglutaryl-CoA reductase inhibitors/adverse effects, statins, adverse effects, diabetes mellitus, diabetes mellitus/etiology, and drug-induced. Citations of identified articles and clinical practice guidelines were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

Articles describing results from original investigations or meta-analyses specifically designed to assess the association between statins and new-onset diabetes and published in English were included.

DATA SYNTHESIS

A total of 13 cohort studies and seven meta-analyses were included. In all, 11 were retrospective cohort studies and reported some degree of increased risk of new-onset diabetes associated with statins. The two prospective cohort studies differed. One identified increased risk of new-onset diabetes, but the other did not. Increased risk was not identified when any statin was compared to placebo alone, individual statins were compared, or in the single meta-analysis that included observational studies. Overall, the meta-analyses suggest that statin therapy is associated with an increased risk of new-onset diabetes when compared to placebo or active control, and when intensive therapy is compared to moderate therapy.

CONCLUSION

Statins have been associated with a small, but statistically significant risk of new-onset diabetes. Patients with risk factors for developing diabetes mellitus may be at higher risk. This risk is likely outweighed by the benefits of reducing cardiovascular risk.

Higher potency statins and the risk of new diabetes: multicentre, observational study of administrative databases

OBJECTIVE

To evaluate the incremental increase in new onset diabetes from higher potency statins compared with lower potency statins when used for secondary prevention.

DESIGN

Eight population based cohort studies and a meta-analysis.

SETTING

Six Canadian provinces and two international databases from the UK and US.

PARTICIPANTS

136,966 patients aged ≥ 40 years newly treated with statins between 1 January 1997 and 31 March 2011.

METHODS

Within each cohort of patients newly prescribed a statin after hospitalisation for a major cardiovascular event or procedure, we performed as-treated, nested case-control analyses to compare diabetes incidence in users of higher potency statins with incidence in users of lower potency statins. Rate ratios of new diabetes events were estimated using conditional logistic regression on different lengths of exposure to higher potency versus lower potency statins; adjustment for confounding was achieved using high dimensional propensity scores. Meta-analytic methods were used to estimate overall effects across sites.

MAIN OUTCOME MEASURES

Hospitalisation for new onset diabetes, or a prescription for insulin or an oral antidiabetic drug.

RESULTS

In the first two years of regular statin use, we observed a significant increase in the risk of new onset diabetes with higher potency statins compared with lower potency agents (rate ratio 1.15, 95% confidence interval 1.05 to 1.26). The risk increase seemed to be highest in the first four months of use (rate ratio 1.26, 1.07 to 1.47).

CONCLUSIONS

Higher potency statin use is associated with a moderate increase in the risk of new onset diabetes compared with lower potency statins in patients treated for secondary prevention of cardiovascular disease. Clinicians should consider this risk when prescribing higher potency statins in secondary prevention patients.