Seasonal variation in hospital encounters with hypoglycaemia and hyperglycaemia

Morning exercise and pre-breakfast metformin interact to reduce glycaemia in people with type 2 diabetes: a randomized crossover trial

Exercise is recommended in the treatment of type 2 diabetes and can improve insulin sensitivity. However, previous evidence suggests that exercise at different times of the day in people with type 2 diabetes may have opposing outcomes on glycaemia. Metformin is the most commonly prescribed initial pharmacological intervention in type 2 diabetes, and may alter adaptions to exercise. It is unknown if there is an interaction between metformin and diurnal exercise outcomes. We aimed to investigate glycaemic outcomes of moderate intensity morning vs. evening exercise in people with type 2 diabetes being prescribed metformin monotherapy. In this study, nine males and nine females with type 2 diabetes undergoing metformin monotherapy (age 61 ± 8.2 years, mean ± SD) completed a 16-week crossover trial including 2-week baseline recording, 6 weeks randomly assigned to a morning exercise (07.00-10.00 h) or evening exercise (16.00-19.00 h) and a 2-week wash-out period. Exercise arms consisted of 30 min of walking at 70% of estimated max heart rate every other day. Glucose levels were measured with continuous glucose monitors and activity measured by wrist-worn monitors. Food-intake was recorded by 4-day food diaries during baseline, first and last 2 weeks of each exercise arm. There was no difference in exercise intensity, total caloric intake or total physical activity between morning and evening arms. As primary outcomes, acute (24 h) glucose area under the curve (AUC), was lower (P = 0.02) after acute morning exercise (180.6 ± 68.4 mmol/l) compared to baseline (210.3 ± 76.7 mmol/l); and there were no differences identified for glucose (mmol/l) between baseline, morning and evening exercise at any specific time point when data were analysed with two-way ANOVA. As secondary outcomes, acute glucose AUC was significantly lower (P = 0.01) in participants taking metformin before breakfast (152.5 ± 29.95 mmol/l) compared with participants taking metformin after breakfast (227.2 ± 61.51 mmol/l) only during the morning exercise arm; and during weeks 5-6 of the exercise protocol, glucose AUC was significantly lower (P = 0.04) for participants taking metformin before breakfast (168.8 ± 15.8 mmol/l), rather than after breakfast (224.5 ± 52.0 mmol/l), only during morning exercise. Our data reveal morning moderate exercise acutely lowers glucose levels in people with type 2 diabetes being prescribed metformin. This difference appears to be driven by individuals that consumed metformin prior to breakfast rather than after breakfast. This beneficial effect upon glucose levels of combined morning exercise and pre-breakfast metformin persisted through the final 2 weeks of the trial. Our findings suggest that morning moderate intensity exercise combined with pre-breakfast metformin intake may benefit the management of glycaemia in people with type 2 diabetes. KEY POINTS: Morning moderate exercise acutely lowers glucose levels in people with type 2 diabetes being prescribed metformin. This difference appears to be driven by individuals that consumed metformin prior to breakfast rather than after breakfast. Morning exercise combined with pre-breakfast metformin persistently reduced glucose compared to morning exercise combined with post-breakfast metformin through the final week (week 6) of the intervention. Our study suggests it may be possible to make simple changes to the time that people with type 2 diabetes take metformin and perform exercise to improve their blood glucose.

Ambient heat and diabetes hospitalizations: Does the timing of heat exposure matter?

BACKGROUND

Although ambient heat exposure is linked with diabetes mortality, the impacts of heat exposure on diabetes-related hospitalizations remain controversial. Previous research did not examine the timing of heat-diabetes associations and relation with comorbidities/risk factors.

OBJECTIVE

We examined the association between heat exposure and diabetes-related hospitalizations in the transitional and summer months and identified populations vulnerable to heat.

METHODS

We conducted a time-stratified case-crossover study. Data on diabetes hospital admissions (primary diagnosis of type 1 and type 2 diabetes, 2013-2020) were collected by the New York State (NYS) Department of Health under the state legislative mandate. We treated temperature and air pollutants as continuous variables and defined the heat exposure as per interquartile range (IQR, a measure between the 25th and 75th percentiles) increase of daily mean temperature. Conditional logistic regressions were performed to quantify the heat-diabetes associations after controlling for air pollutants and time variant variables. Multiplicative-scale interactions between heat and demographics/comorbidities/risk factors on diabetes hospitalizations were investigated.

RESULTS

Each IQR increase in temperature was associated with significantly increased risks for diabetes admissions that occurred immediately and lasted for an entire week during multi-day lags in the transitional month of May (ranges of excess risk: 3.1 %-4.8 %) but not in the summer (June-August) (ranges of excess risk: -0.3 %-1.3 %). The significant increases in the excess risk of diabetes were also found among diabetes patients with complications of neuronopathy (excess risk: 27.7 %) and hypoglycemia (excess risk: 19.1 %). Furthermore, the modification effects on the heat-diabetes association were significantly stronger in females, Medicaid enrollees, non-compliant patients, and individuals with comorbidities of atherosclerotic heart disease and old myocardial infarction.

CONCLUSIONS

Ambient heat exposure significantly increased the burden of hospital admissions for diabetes in transitional rather than summer months indicating the importance of exposure timing. Vulnerability to heat varied by demographics and heart comorbidity.

Analysis of primary care prescription trends in England during the COVID-19 pandemic compared against a predictive model

Objectives

The COVID-19 pandemic has had an unprecedented impact across primary care. Primary care services have seen an upheaval, and more and more patients are engaging in telephone consultations in order to maintain social distancing. In the present study, we seek to quantify the effect of the pandemic on primary care prescribing.

Design

We conducted a retrospective analysis of the English Prescribing Dataset from January 2014 to November 2020, totalling 7 542 293 921 prescriptions. Data were separated into prepandemic and pandemic sets. A Holt-Winters predictive model was used to forecast individual drug prescribing based on historic trends. Observed data were compared with the forecast quantitatively and qualitatively.

Setting

All prescriptions signed in England and dispensed during the years 2014–2020.

Participants

All residents of England who received a prescription from primary care facilities during 2014–2020.

Results

Prescribing of numerous health-critical medications was above predicted in March 2020, including salbutamol (53.0% (99% CI (41.2% to 66.9%))), insulin aspart (26.9% (99% CI (18.5% to 36.6%))) and tacrolimus (18.6% (99% CI (8.3% to 31.1%))). Medications for end-of-life symptom control increased in April, including levomepromazine hydrochloride (94.7% (99% CI (54.6% to 163.0%))). Medications requiring face-to-face visits decreased, including the local anaesthetic bupivacaine hydrochloride (86.6% (99% CI (89.3% to 82.0%))). There was no observed change in medications relating to type 2 diabetes, hypertension or mental health conditions.

Conclusions

Significantly increased prescribing of several medications was observed, especially among those critical for health. A dramatic spike in end-of-life prescribing highlights the adversity faced by community practitioners during 2020. Medications involving face-to-face consultations declined, as did contraceptives, travel-related vaccines and drugs used in dementia and Parkinson’s disease. Drugs relating to type 2 diabetes, hypertension and mental health were unchanged.

Seasonal pattern of incidence and outcome of Acute Kidney Injury: A national study of Welsh AKI electronic alerts

OBJECTIVES

To identify any seasonal variation in the occurrence of, and outcome following Acute Kidney Injury.

METHODS

The study utilised the biochemistry based AKI electronic (e)-alert system established across the Welsh National Health Service to collect data on all AKI episodes to identify changes in incidence and outcome over one calendar year (1st October 2015 and the 30th September 2016).

RESULTS

There were total of 48 457 incident AKI alerts. The highest proportion of AKI episodes was seen in the quarter of January to March (26.2%), and the lowest in the quarter of October to December (23.3%, P < .001). The same trend was seen for both community-acquired and hospital-acquired AKI sub-sets. Overall 90 day mortality for all AKI was 27.3%. In contrast with the seasonal trend in AKI occurrence, 90 day mortality after the incident AKI alert was significantly higher in the quarters of January to March and October to December compared with the quarters of April to June and July to September (P < .001) consistent with excess winter mortality reported for likely underlying diseases which precipitate AKI.

CONCLUSIONS

In summary we report for the first time in a large national cohort, a seasonal variation in the incidence and outcomes of AKI. The results demonstrate distinct trends in the incidence and outcome of AKI.