A meta-analysis of the relative risk of mortality for type 1 diabetes patients compared to the general population: exploring temporal changes in relative mortality

Allo Beta Cell transplantation: specific features, unanswered questions, and immunological challenge

Type 1 diabetes (T1D) presents a persistent medical challenge, demanding innovative strategies for sustained glycemic control and enhanced patient well-being. Beta cells are specialized cells in the pancreas that produce insulin, a hormone that regulates blood sugar levels. When beta cells are damaged or destroyed, insulin production decreases, which leads to T1D. Allo Beta Cell Transplantation has emerged as a promising therapeutic avenue, with the goal of reinstating glucose regulation and insulin production in T1D patients. However, the path to success in this approach is fraught with complex immunological hurdles that demand rigorous exploration and resolution for enduring therapeutic efficacy. This exploration focuses on the distinct immunological characteristics inherent to Allo Beta Cell Transplantation. An understanding of these unique challenges is pivotal for the development of effective therapeutic interventions. The critical role of glucose regulation and insulin in immune activation is emphasized, with an emphasis on the intricate interplay between beta cells and immune cells. The transplantation site, particularly the liver, is examined in depth, highlighting its relevance in the context of complex immunological issues. Scrutiny extends to recipient and donor matching, including the utilization of multiple islet donors, while also considering the potential risk of autoimmune recurrence. Moreover, unanswered questions and persistent gaps in knowledge within the field are identified. These include the absence of robust evidence supporting immunosuppression treatments, the need for reliable methods to assess rejection and treatment protocols, the lack of validated biomarkers for monitoring beta cell loss, and the imperative need for improved beta cell imaging techniques. In addition, attention is drawn to emerging directions and transformative strategies in the field. This encompasses alternative immunosuppressive regimens and calcineurin-free immunoprotocols, as well as a reevaluation of induction therapy and recipient preconditioning methods. Innovative approaches targeting autoimmune recurrence, such as CAR Tregs and TCR Tregs, are explored, along with the potential of stem stealth cells, tissue engineering, and encapsulation to overcome the risk of graft rejection. In summary, this review provides a comprehensive overview of the inherent immunological obstacles associated with Allo Beta Cell Transplantation. It offers valuable insights into emerging strategies and directions that hold great promise for advancing the field and ultimately improving outcomes for individuals living with diabetes.

Decreased Diastolic Blood Pressure and Average Grip Strength in Adults With Type 1 Diabetes Compared With Controls: An Analysis of Data From the Canadian Longitudinal Study on Aging

OBJECTIVES

Our aim in this study was to determine whether aging individuals with type 1 diabetes (T1D) have differences in cardiovascular health, assessed by blood pressure, and skeletal muscle function, assessed by grip strength, compared with matched nondiabetic controls (CON).

METHODS

This investigation was a retrospective cohort analysis using baseline and 3-year follow-up data from the Canadian Longitudinal Study on Aging. Bivariate and multivariate regression analyses were used to examine the association between sociodemographic, health, behavioural and T1D-specific variables on blood pressure and grip strength in T1D and CON groups. Generalized estimating equations were used to model the average population changes in blood pressure and grip strength from baseline to follow up.

RESULTS

The sample included 126 individuals (63 T1D and 63 CON). Systolic blood pressure was not significantly different between groups at baseline or follow up (p>0.05). However, compared with CON, diastolic blood pressure was significantly lower at both time-points in the T1D group (p<0.001). Grip strength was consistently lower among persons with T1D (p=0.03). In the multivariate regression model, body mass index, age and sex were significantly associated with diastolic blood pressure and grip strength in both groups. In the T1D group, disease duration accounted for a large proportion of the variance in diastolic blood pressure and grip strength (17% and 9%, respectively). The rate of decline in diastolic blood pressure and grip strength did not differ between groups (p>0.05).

CONCLUSIONS

Diastolic blood pressure and grip strength appear to be consistently lower and differentially regulated in individuals with T1D vs CON. Aging individuals with T1D may be at risk of premature morbidity and mortality.

Benefits and Hurdles of Pancreatic β-Cell Replacement

Insulin represents a life-saving treatment in patients with type 1 diabetes, and technological advancements have improved glucose control in an increasing number of patients. Despite this, adequate control is often still difficult to achieve and insulin remains a therapy and not a cure for the disease. β-cell replacement strategies can potentially restore pancreas endocrine function and aim to maintain normoglycemia; both pancreas and islet transplantation have greatly progressed over the last decades and, in subjects with extreme glycemic variability and diabetes complications, represent a concrete and effective treatment option. Some issues still limit the adoption of this approach on a larger scale. One is represented by the strict selection criteria for the recipient who can benefit from a transplant and maintain the lifelong immunosuppression necessary to avoid organ rejection. Second, with regard to islet transplantation, up to 40% of islets can be lost during hepatic engraftment. Recent studies showed very preliminarily but promising results to overcome these hurdles: the ability to induce β-cell maturation from stem cells may represent a solution to the organ shortage, and the creation of semi-permeable membranes that envelope or package cells in either micro- or macro- encapsulation strategies, together with engineering cells to be hypo-immunogenic, pave the way for developing strategies without immunosuppression. The aim of this review is to describe the state of the art in β-cell replacement with a focus on its efficacy and clinical benefits, on the actual limitations and still unmet needs, and on the latest findings and future directions.

Physical Function in Middle-aged and Older Adults With Type 1 Diabetes: Long-term Follow-up of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study

OBJECTIVE

To describe the prevalence and clinical correlates of functional limitations in middle-aged and older adults with long-standing type 1 diabetes.

RESEARCH DESIGN AND METHODS

Functional limitations were assessed for 1,094 participants in the Epidemiology of Diabetes Interventions and Complications (EDIC) study, a multicenter, longitudinal, observational follow-up of participants with type 1 diabetes randomly assigned to intensive or conventional diabetes therapy during the Diabetes Control and Complications Trial (DCCT). The primary outcome measure was a score <10 on the Short Physical Performance Battery (SPPB). The secondary outcome, self-reported functional limitation, was assessed by written questionnaire. Logistic regression models were used to assess associations of both outcomes with demographic and clinical factors (glycemic and nonglycemic factors, micro- and macrovascular complications, DCCT cohort, and treatment assignment).

RESULTS

Participants were 53% male, with mean ± SD age 59.5 ± 6.8 years and diabetes duration 37.9 ± 4.9 years. The prevalence of SPPB score <10 was 21%. The prevalence of self-reported functional limitations was 48%. While DCCT treatment assignment was not associated with physical function outcomes measured ∼25 years after the end of the DCCT, the time-weighted mean DCCT/EDIC HbA1c was associated with both outcomes. Other clinical factors associated with both outcomes in multivariable analyses were BMI, general psychological distress, and cardiac autonomic neuropathy.

CONCLUSIONS

Almost half of the middle-aged and older adults with long-standing type 1 diabetes reported functional limitations, which were associated with higher HbA1c and BMI, general psychological distress, and cardiac autonomic neuropathy. Future research is needed to determine whether these findings are generalizable.

Type 1 diabetes, cognitive ability and incidence of cardiovascular disease and death over 60 years of follow-up time in men

AIMS

There are few cohorts of type 1 diabetes that follow individuals over more than half a century in terms of health outcomes. The aim of this study was to examine associations between type 1 diabetes, diagnosed before age 18, and long-term morbidity and mortality, and to investigate whether cognitive ability plays a role in long-term morbidity and mortality risk.

METHODS

In a Swedish cohort, 120 men with type 1 diabetes and 469 without type 1 diabetes were followed between 18 and 77 years of age as regards morbidity and mortality outcomes, and impact of cognitive ability at military conscription for the outcomes. In Cox regression analyses and Kaplan-Meier analyses with log-rank tests, associations between diabetes and cognitive ability respectively, and outcomes (mortality, cardiovascular morbidity and diabetes complications) were investigated.

RESULTS

Men with type 1 diabetes suffered from dramatically higher mortality (HR 4.62, 95% CI: 3.56-5.60), cardiovascular mortality (HR 5.60, 95% CI: 3.27-9.57), and cardiovascular events (HR 3.97, 95% CI: 2.79-5.64) compared to men without diabetes. Higher cognitive ability at military conscription was associated with lower mortality in men without diabetes, but was not associated with any outcome in men with diabetes.

CONCLUSIONS

In this historical cohort study with 60 years of follow-up time and a less effective treatment of diabetes than today, mortality rates and cardiovascular outcomes were high for men with type 1 diabetes. Morbidity or mortality did not differ between those that had low to normal or high cognitive ability among men with type 1 diabetes.

Mortality amongst children and adolescents with type 1 diabetes in sub-Saharan Africa: The case study of the Changing Diabetes in Children program in Cameroon

INTRODUCTION

Type 1 diabetes in Africa has been associated with high mortality attributed mainly to poor insulin access. Free insulin provision programs for people with type 1 diabetes have been introduced across Africa recently. We aimed to determine the mortality rate and associated factors in a cohort of children and adolescents with type 1 diabetes who receive free insulin treatment in sub-Saharan Africa.

METHODS

We conducted a retrospective analysis using the Changing Diabetes in Children (CDiC) medical records in Cameroon between 2011 and 2015.

RESULTS

The overall mortality rate was 33.0 per 1000 person-years (95% CI 25.2-43.2). Most deaths (71.7%) occurred outside of the hospital setting, and the cause of death was known only in 13/53 (24.5%). Mortality was substantially higher in CDiC participants followed up in regional clinics compared to the main urban CDiC clinic in Yaounde; 41 per 1000 years (95% CI 30.8-56.0) versus 17.5 per 1000 years (95% CI 9.4-32.5), and in those with no formal education compared to those who had some level of education; 68.0 per 1000 years (95% CI 45.1-102.2) versus 23.6 per 1000 years (95% CI 16.5-33.8). In Cox proportional multivariable analysis, urban place of care (HR = 0.23, 95% CI 0.09-0.57; p = 0.002) and formal education (HR = 0.42, 95% CI 0.22-0.79; p = 0.007) were independently associated with mortality.

CONCLUSION

Despite free insulin provision, mortality remains high in children and adolescents with type 1 diabetes in Cameroon and is substantially higher in rural settings and those with no formal education.

Felix dies natalis, insulin… ceterum autem censeo "beta is better"

One hundred years after its discovery, insulin remains the life-saving therapy for many patients with diabetes. It has been a 100-years-old success story thanks to the fact that insulin therapy has continuously integrated the knowledge developed over a century. In 1982, insulin becomes the first therapeutic protein to be produced using recombinant DNA technology. The first "mini" insulin pump and the first insulin pen become available in 1983 and 1985, respectively. In 1996, the first generation of insulin analogues were produced. In 1999, the first continuous glucose-monitoring device for reading interstitial glucose was approved by the FDA. In 2010s, the ultra-long action insulins were introduced. An equally exciting story developed in parallel. In 1966. Kelly et al. performed the first clinical pancreas transplant at the University of Minnesota, and now it is a well-established clinical option. First successful islet transplantations in humans were obtained in the late 1980s and 1990s. Their ability to consistently re-establish the endogenous insulin secretion was obtained in 2000s. More recently, the possibility to generate large numbers of functional human β cells from pluripotent stem cells was demonstrated, and the first clinical trial using stem cell-derived insulin producing cell was started in 2014. This year, the discovery of this life-saving hormone turns 100 years. This provides a unique opportunity not only to celebrate this extraordinary success story, but also to reflect on the limits of insulin therapy and renew the commitment of the scientific community to an insulin free world for our patients.

Development of a life expectancy table for individuals with type 1 diabetes

AIMS/HYPOTHESIS

Tables reporting life expectancies by common risk factors are available for individuals with type 2 diabetes; however, there is currently no published equivalent for individuals with type 1 diabetes. We aimed to develop a life expectancy table using a recently published simulation model for individuals with type 1 diabetes.

METHODS

The simulation model was developed using data from a real-world population of patients with type 1 diabetes selected from the Swedish National Diabetes Register. The following six important risk factors were included in the life table: sex; age; current smoking status; BMI; eGFR; and HbA_1c. For each of 1024 cells in the life expectancy table, a synthetic cohort containing 1000 individuals was created, with other risk factors assigned values representative of the real-world population. The simulations were executed for all synthetic cohorts and life expectancy for each cell was calculated as mean survival time of the individuals in the respective cohort.

RESULTS

There was a substantial variation in life expectancy across patients with different risk factor levels. Life expectancy of 20-year-old men varied from 29.3 years to 50.6 years, constituting a gap of 21.3 years between those with worst and best risk factor levels. In 20-year-old women, this gap was 18.9 years (life expectancy range 35.0-53.9 years). The variation in life expectancy was a function of the combination of risk factor values, with HbA_1c and eGFR consistently showing a negative and positive correlation, respectively, with life expectancy at any level combination of other risk factors. Individuals with the lowest level (20 kg/m²) and highest level of BMI (35 kg/m²) had a lower life expectancy compared with those with a BMI of 25 kg/m². Non-smokers and women had a higher life expectancy than smokers and men, respectively, with the difference in life expectancy ranging from 0.4 years to 2.7 years between non-smokers and smokers, and from 1.9 years to 5.9 years between women and men, depending on levels of other risk factors.

CONCLUSIONS/INTERPRETATION

The life expectancy table generated in this study shows a substantial variation in life expectancy across individuals with different modifiable risk factors. The table allows for rapid communications of risk in an easily understood format between healthcare professionals, health economists, researchers, policy makers and patients. Particularly, it supports clinicians in their discussion with patients about the benefits of improving risk factors.

Overall and Cause-Specific Mortality in Patients With Type 1 Diabetes Mellitus: A Population-Based Cohort Study in Taiwan From 1998 Through 2014

Background

To investigate all-cause and cause-specific mortality in Taiwanese patients with type 1 diabetes.

Methods

A cohort of 17,203 patients with type 1 diabetes were identified from Taiwan’s National Health Insurance claims in the period of 1998–2014. Person-years were accumulated for each individual from date of type 1 diabetes registration to date of death or the last day of 2014. Age, sex, and calendar year standardized mortality ratios (SMRs) were calculated with reference to the general population.

Results

In up to 17 years of follow-up, 4,916 patients died from 182,523 person-years. Diabetes (30.15%), cancer (20.48%), circulatory diseases (13.14%), and renal diseases (11.45%) were the leading underlying causes of death. Mortality rate (26.93 per 1,000 person-years) from type 1 diabetes in Taiwan was high, the cause of death with the highest mortality rate was diabetes (8.12 per 1,000 person-years), followed by cancer (5.52 per 1,000 person-years), and circulatory diseases (3.54 per 1,000 person-years). The all-cause SMR was significantly elevated at 4.16 (95% confidence interval, 4.04–4.28), with a greater all-cause SMR noted in females than in males (4.62 vs 3.79). The cause-specific SMR was highly elevated for diabetes (SMR, 16.45), followed by renal disease (SMR, 14.48), chronic hepatitis and liver cirrhosis (SMR, 4.91) and infection (SMR, 4.59). All-cause SMRs were also significantly increased for all ages, with the greatest figure noted for 15–24 years (SMR, 8.46).

Conclusions

Type 1 diabetes in both genders and all ages was associated with significantly elevated SMRs for all-cause and mostly for diabetes per se and renal disease.

Factors associated with clinically significant hypoglycemia in patients with type 1 diabetes using sensor-augmented pump therapy with predictive low-glucose management: A multicentric study on iberoamerica

BACKGROUND AND AIMS

Despite using sensor-augmented pump therapy (SAPT) with predictive low-glucose management (PLGM), hypoglycemia is still an issue in patients with type 1 Diabetes (T1D). Our aim was to determine factors associated with clinically significant hypoglycemia (<54 mg/dl) in persons with T1D treated with PLGM-SAPT.

METHOD

ology: This is a multicentric prospective real-life study performed in Colombia, Chile and Spain. Patients with T1D treated with PLGM-SAPT, using sensor ≥70% of time, were included. Data regarding pump and sensor use patterns and carbohydrate intake from 28 consecutive days were collected. A bivariate and multivariate Poisson regression analysis was carried out, to evaluate the association between the number of events of <54 mg/dl with the clinical variables and patterns of sensor and pump use.

RESULTS

188 subjects were included (41 ± 13.8 years-old, 23 ± 12 years disease duration, A1c 7.2% ± 0.9). The median of events <54 mg/dl was four events/patient/month (IQR 1-10), 77% of these events occurred during day time. Multivariate analysis showed that the number of events of hypoglycemia were higher in patients with previous severe hypoglycemia (IRR1.38; 95% CI 1.19-1.61; p < 0.001), high glycemic variability defined as Coefficient of Variation (CV%) > 36% (IRR 2.09; 95%CI 1.79-2.45; p < 0.001) and hypoglycemia unawareness. A protector effect was identified for adequate sensor calibration (IRR 0.77; 95%CI 0.66-0.90; p:0.001), and the use of bolus wizard >60% (IRR 0.74; 95%CI 0.58-0.95; p:0.017).

CONCLUSION

In spite of using advanced SAPT, clinically significant hypoglycemia is still a non-negligible risk. Only the identification and intervention of modifiable factors could help to prevent and reduce hypoglycemia in clinical practice.

Comparative characteristics of older people with type 1 diabetes treated with continuous subcutaneous insulin infusion or insulin injection therapy: data from the German/Austrian DPV registry

AIM

To compare clinical characteristics and outcomes in adults with type 1 diabetes aged ≥ 60 years using continuous subcutaneous insulin infusion (CSII) vs. insulin injection therapy. Further, to determine the percentage of older adults with type 1 diabetes using CSII.

RESEARCH DESIGN AND METHODS

Retrospective study using data of the Diabetes Prospective Follow-up Registry (DPV). Including percentage CSII use from 2008 to 2018, and the characteristics of 9547 individuals extracted from the DPV in March 2019 (N = 1404 CSII; N = 8143 insulin injection therapy). Wilcoxon rank sum tests were used for continuous variables and chi-square tests for categorical variables to compare clinical characteristics of people using CSII vs. insulin injection therapy. Adjusted analyses used generalized linear models to compare diabetes-related outcomes.

RESULTS

CSII usage has increased in older adults (from 12% in 2008 to 23% in 2018). After adjustment, CSII was associated with lower HbA_1c [60.7 mmol/mol (7.7 ± 0.1%) vs. 62.8% (7.9 ± 0.1%)], lower daily insulin dose (0.49 ± 0.02 vs. 0.61 ± 0.01 IU/kg), fewer days in hospital (8.1 ± 0.12 vs. 11.2 ± 0.11 days/person-year), fewer severe hypoglycaemic events (0.16 ± 0.02 vs. 0.21 ± 0.03 events/person-year) and fewer diabetic ketoacidosis (0.06 ± 0.01 vs. 0.08 ± 0.01 events/person-year). Individuals on CSII showed lower rates of microalbuminuria and also have a diagnosis of depression and neuropathy.

CONCLUSIONS

A growing number of older adults are using insulin pumps. Older age in itself should not be seen as a contraindication for CSII.

Efficacy and safety of dapagliflozin in Japanese patients with inadequately controlled type 1 diabetes (DEPICT-5): 52-week results from a randomized, open-label, phase III clinical trial

AIMS

To investigate the safety and tolerability of 5 and 10 mg dapagliflozin added to insulin therapy over 52 weeks in Japanese patients with inadequately controlled type 1 diabetes mellitus (T1DM).

MATERIALS AND METHODS

This randomized, open-label, parallel-group, multicentre phase III clinical trial was conducted from October 26, 2015 to June 15, 2017. The primary endpoint was the occurrence of adverse events such as hypoglycaemia and diabetic ketoacidosis. Secondary endpoints included changes in glycaemic parameters, total daily insulin dosage and body weight over time. The efficacy of dapagliflozin in patients stratified by body mass index (BMI) <25.0 and ≥25.0 kg/m² was evaluated in a subgroup analysis.

RESULTS

In total, 151 patients received 5 mg (n = 76) or 10 mg (n = 75) dapagliflozin once daily for 52 weeks. Adverse events were observed in 88.2% and 73.3% of patients in the 5 and 10 mg dapagliflozin groups, respectively. Severe hypoglycaemia was reported in 2.6% (n = 2) and 6.7% (n = 5) of patients, and diabetic ketoacidosis in 2.6% (n = 2) and 1.3% (n = 1) of patients in the 5 and 10 mg dapagliflozin groups, respectively. The adjusted mean (95% confidence interval) changes in glycated haemoglobin at week 52 were -0.33% (-0.50, -0.15) and -0.36% (-0.53, -0.18) in the 5 and 10 mg dapagliflozin groups, respectively. There were no differences in efficacy parameters when stratified by BMI.

CONCLUSIONS

This study demonstrated the long-term safety and tolerability of dapagliflozin added to insulin therapy in Japanese patients with inadequately controlled T1DM.

Alcohol and illicit drug use in people with diabetes

As the prevalence of type 1 and type 2 diabetes increases and population-level patterns of alcohol and illicit drug use evolve, clinicians will continue to encounter people with diabetes whose substance use is affecting health outcomes. Substance use contributes substantially to the population-level prevalence of cardiovascular events, cerebrovascular events, cancers, mental health conditions, road trauma, and domestic violence. Alcohol and drug use also have a measurable effect on diabetes incidence and the development of both acute and chronic diabetes-related complications. In this Review, we examine the effect of alcohol and illicit drug use on people with type 1 or type 2 diabetes. We describe evidence for substance use as a risk factor for new-onset diabetes, prevalence of use in people with diabetes, evidence linking substance use with diabetes-related health outcomes, and evidence on the management of these co-occurring conditions.

Young adult patients with type 1 diabetes have a higher risk of mortality than those of similar age with type 2 diabetes: A nationwide analysis in Hungary

BACKGROUND

There are few papers comparing complications of type 1 diabetes with those of a similarly young age with type 2 diabetes. The aim of our nationwide study was to compare the risks of mortality and morbidities between the two types of diabetes (age ≤ 40).

METHODS

We identified all young adult patients with type 1 diabetes who were recorded in the database of the Hungarian National Health Insurance Fund between 2001 and 2014 (n = 11 863) and compared them with a population of similar age with young adult type 2 diabetes (n = 47 931). The incidence of all-cause mortality, myocardial infarction, stroke, any type of cancer, diabetic ketoacidosis, and hypoglycemia was followed from the onset of diabetes to the date of death or end of study period.

RESULTS

The risks of all-cause mortality were significantly higher in patients with type 1 compared with patients with type 2 diabetes (hazard ratio, 95%CI; 2.17, 1.95-2.41; P < .0001). The risks of myocardial infarction (0.90, 0.71-1.13; P = 0.36) and stroke (1.06, 0.87-1.29; P = .582) were not significantly different in type 1 compared with type 2. In contrast, the risk of cancer (1.35, 1.15-1.59; P = .0003), dialysis (2.20, 1.76-2.75; P < .0001), hypoglycemia (7.70, 6.45-9.18; P < .0001), and ketoacidosis (22.12, 19.60-25.00; P < .0001) was higher among patients with type 1 compared with those with type 2 diabetes.

CONCLUSIONS

A comparatively higher incidence of diabetic ketoacidosis and hypoglycemia and higher risk of cancer and dialysis in patients with type 1 diabetes than in those with type 2 may play a role in the higher risk of mortality.

Advanced Technology in the Management of Diabetes: Which Comes First-Continuous Glucose Monitor or Insulin Pump?

PURPOSE OF REVIEW

In this article, we consider advanced technologies for the management of diabetes.

RECENT FINDINGS

Specifically, we pose the question of which should come first: an insulin pump (CSII) or a continuous glucose monitor (CGM)? Historical perspective on both insulin delivery and glucose measurement is provided. Recently published clinical trials are reviewed. Practical issues including quality of life, patient education, and out-of-pocket cost are discussed. Based on available evidence and clinical experience, we favor CGM as a first-line technology recommendation for the treatment of type 1 diabetes (T1D).

An Analysis of The Morbidity and Mortality of Diabetes Mellitus in a Forensic Context

To investigate the spectrum of diseases seen in diabetes mellitus in a forensic context, all autopsy reports of diabetic individuals who presented to Forensic Science, South Australia (FSSA), over a 5-year period from 2005 to 2009 were studied. The leading cause of death was cardiovascular disease (55.0%), followed by unnatural deaths (15.4%) and infections (9.4%). In type 1 diabetics, principal causes of death included cardiovascular disease (44.7%), acute metabolic complications (18.7%), unnatural deaths (17.9%), and infections (8.9%). However, frequencies of these diseases differed in type 2 diabetics, with cardiovascular events responsible for 56.6% of cases, followed by unnatural deaths (15.0%) and infections (10.9%). A larger number of male deaths were seen in all disease categories, except respiratory and gastrointestinal where the frequencies were similar to females. Cardiovascular disease was the leading overall cause of death across all ages except in those under the age of 30 where metabolic complications were more common.

The Prime Diabetes Model: Novel Methods for Estimating Long-Term Clinical and Cost Outcomes in Type 1 Diabetes Mellitus

BACKGROUND

Recent publications describing long-term follow-up from landmark trials and diabetes registries represent an opportunity to revisit modeling options in type 1 diabetes mellitus (T1DM).

OBJECTIVES

To develop a new product-independent model capable of predicting long-term clinical and cost outcomes.

METHODS

After a systematic literature review to identify clinical trial and registry data, a model was developed (the PRIME Diabetes Model) to simulate T1DM progression and complication onset. The model runs as a patient-level simulation, making use of covariance matrices for cohort generation and risk factor progression, and simulating myocardial infarction, stroke, angina, heart failure, nephropathy, retinopathy, macular edema, neuropathy, amputation, hypoglycemia, ketoacidosis, mortality, and risk factor evolution. Several approaches novel to T1DM modeling were used, including patient characteristics and risk factor covariance, a glycated hemoglobin progression model derived from patient-level data, and model averaging approaches to evaluate complication risk.

RESULTS

Validation analyses comparing modeled outcomes with published studies demonstrated that the PRIME Diabetes Model projects long-term patient outcomes consistent with those reported for a number of long-term studies. Macrovascular end points were reliably reproduced across five different populations and microvascular complication risk was accurately predicted on the basis of comparisons with landmark studies and published registry data.

CONCLUSIONS

The PRIME Diabetes Model is product-independent, available online, and has been developed in line with good practice guidelines. Validation has indicated that outcomes from long-term studies can be reliably reproduced. The model offers new approaches to long-standing challenges in diabetes modeling and may become a valuable tool for informing health care policy.

Data-driven metabolic subtypes predict future adverse events in individuals with type 1 diabetes

AIMS/HYPOTHESIS

Previously, we proposed that data-driven metabolic subtypes predict mortality in type 1 diabetes. Here, we analysed new clinical endpoints and revisited the subtypes after 7 years of additional follow-up.

METHODS

Finnish individuals with type 1 diabetes (2059 men and 1924 women, insulin treatment before 35 years of age) were recruited by the national multicentre FinnDiane Study Group. The participants were assigned one of six metabolic subtypes according to a previously published self-organising map from 2008. Subtype-specific all-cause and cardiovascular mortality rates in the FinnDiane cohort were compared with registry data from the entire Finnish population. The rates of incident diabetic kidney disease and cardiovascular endpoints were estimated based on hospital records.

RESULTS

The advanced kidney disease subtype was associated with the highest incidence of kidney disease progression (67.5% per decade, p < 0.001), ischaemic heart disease (26.4% per decade, p < 0.001) and all-cause mortality (41.5% per decade, p < 0.001). Across all subtypes, mortality rates were lower in women compared with men, but standardised mortality ratios (SMRs) were higher in women. SMRs were indistinguishable between the original study period (1994-2007) and the new period (2008-2014). The metabolic syndrome subtype predicted cardiovascular deaths (SMR 11.0 for men, SMR 23.4 for women, p < 0.001), and women with the high HDL-cholesterol subtype were also at high cardiovascular risk (SMR 16.3, p < 0.001). Men with the low-cholesterol or good glycaemic control subtype showed no excess mortality.

CONCLUSIONS/INTERPRETATION

Data-driven multivariable metabolic subtypes predicted the divergence of complication burden across multiple clinical endpoints simultaneously. In particular, men with the metabolic syndrome and women with high HDL-cholesterol should be recognised as important subgroups in interventional studies and public health guidelines on type 1 diabetes.

Parity and mortality in cases of childhood-onset diabetes mellitus

AIMS

This study aims to assess the association between parity and mortality in adults with childhood-onset type 1 diabetes (T1D) and their matched controls.

METHODS

Individual data (308 617 person-years) on mortality and the reproductive histories of a Finnish cohort of 2307 women and 2819 men with T1D, each with two matched controls, were obtained from the National Population Register. All persons with diabetes had been diagnosed with T1D in 1965-1979 at the age of 17 or under.

RESULTS

All-cause mortality in people without offspring was significantly higher than that in people with children among both people with diabetes and non-diabetic control persons in both sexes (all p-values <0.01). In men with offspring, the decrease of mortality rate compared with men without offspring was less marked among those with diabetes (9% reduction in mortality hazard ratio (HR) with one offspring, 47% with two) than among those without diabetes (33% HR (p = 0.025) and 61% HR (p = 0.023) reduction, respectively). In women with offspring, the association between parity and mortality was independent of diabetes status. Having at least two offspring was associated with a decreased hazard of diabetes-related death regardless of sex; among women with diabetes, even having one offspring was associated with a decreased hazard of dying from diabetes (HR = 0.46; 95% CI 0.31, 0.69).

CONCLUSIONS

The association between parity and mortality follows different patterns in men and women with T1D. To what extent this reflects effects of health on family planning decisions in people with T1D cannot be defined without further studies. Copyright © 2016 John Wiley & Sons, Ltd.

Recent trends in life expectancy for people with type 1 diabetes in Sweden

AIMS/HYPOTHESIS

People with type 1 diabetes have reduced life expectancy (LE) compared with the general population. Our aim is to quantify mortality changes from 2002 to 2011 in people with type 1 diabetes in Sweden.

METHODS

This study uses health records from the Swedish National Diabetes Register (NDR) linked with death records. Abridged period life tables for those with type 1 diabetes aged 20 years and older were derived for 2002-06 and 2007-11 using Chiang's method. Cox proportional hazard models were used to assess trends in overall and cause-specific mortality.

RESULTS

There were 27,841 persons aged 20 years and older identified in the NDR as living with type 1 diabetes between 2002 and 2011, contributing 194,685 person-years of follow-up and 2,018 deaths. For men with type 1 diabetes, the remaining LE at age 20 increased significantly from 47.7 (95% CI 46.6, 48.9) in 2002-06 to 49.7 years (95% CI 48.9, 50.6) in 2007-11. For women with type 1 diabetes there was no significant change, with an LE at age 20 of 51.7 years (95% CI 50.3, 53.2) in 2002-06 and 51.9 years (95% CI 50.9, 52.9) in 2007-11. Cardiovascular mortality significantly reduced, with a per year HR of 0.947 (95% CI 0.917, 0.978) for men and 0.952 (95% CI 0.916, 0.989) for women.

CONCLUSIONS/INTERPRETATION

From 2002-06 to 2007-11 the LE at age 20 of Swedes with type 1 diabetes increased by approximately 2 years for men but minimally for women. These recent gains have been driven by reduced cardiovascular mortality.

Cardiovascular disease and type 1 diabetes: prevalence, prediction and management in an ageing population

Cardiovascular disease (CVD) is a major cause of mortality in type 1 diabetes mellitus (T1D). However, evidence of its risks and management is often extrapolated from studies in type 2 diabetic (T2D) patients or the general population. This approach is unsatisfactory given that the underlying pathology, demographics and natural history of the disease differ between T1D and T2D. Furthermore, with a rising life expectancy, a greater number of T1D patients are exposed to the cardiovascular (CV) risk factors associated with an ageing population. The aim of this review is to examine the existing literature around CVD in T1D. We pay particular attention to CVD prevalence, how well we manage risk, potential biomarkers, and whether the studies included the older aged patients (defined as aged over 65). We also discuss approaches to the management of CV risk in the older aged. The available data suggest a significant CVD burden in patients with T1D and poor management of CV risk factors. This is underpinned by a poor evidence base for therapeutic management of CV risk specifically for patients with T1D, and in the most relevant population - the older aged patients. We would suggest that important areas remain to be addressed, particularly exploring the risks and benefits of therapeutic approaches to CVD management in the older aged.