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Klein KR, Abrahamsen TJ, Kahkoska AR, Alexander GC, Chute CG, Haendel M, Hong SS, Mehta H, Moffitt R, Stürmer T, Kvist K, Buse JB. Association of Premorbid GLP-1RA and SGLT-2i Prescription Alone and in Combination with COVID-19 Severity. Diabetes Ther 2024; 15:1169-1186. [PMID: 38536629 PMCID: PMC11043305 DOI: 10.1007/s13300-024-01562-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/04/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION People with type 2 diabetes are at heightened risk for severe outcomes related to COVID-19 infection, including hospitalization, intensive care unit admission, and mortality. This study was designed to examine the impact of premorbid use of glucagon-like peptide-1 receptor agonist (GLP-1RA) monotherapy, sodium-glucose cotransporter-2 inhibitor (SGLT-2i) monotherapy, and concomitant GLP1-RA/SGLT-2i therapy on the severity of outcomes in individuals with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS Utilizing observational data from the National COVID Cohort Collaborative through September 2022, we compared outcomes in 78,806 individuals with a prescription of GLP-1RA and SGLT-2i versus a prescription of dipeptidyl peptidase 4 inhibitors (DPP-4i) within 24 months of a positive SARS-CoV-2 PCR test. We also compared concomitant GLP-1RA/SGLT-2i therapy to GLP-1RA and SGLT-2i monotherapy. The primary outcome was 60-day mortality, measured from the positive test date. Secondary outcomes included emergency room (ER) visits, hospitalization, and mechanical ventilation within 14 days. Using a super learner approach and accounting for baseline characteristics, associations were quantified with odds ratios (OR) estimated with targeted maximum likelihood estimation (TMLE). RESULTS Use of GLP-1RA (OR 0.64, 95% confidence interval [CI] 0.56-0.72) and SGLT-2i (OR 0.62, 95% CI 0.57-0.68) were associated with lower odds of 60-day mortality compared to DPP-4i use. Additionally, the OR of ER visits and hospitalizations were similarly reduced with GLP1-RA and SGLT-2i use. Concomitant GLP-1RA/SGLT-2i use showed similar odds of 60-day mortality when compared to GLP-1RA or SGLT-2i use alone (OR 0.92, 95% CI 0.81-1.05 and OR 0.88, 95% CI 0.76-1.01, respectively). However, lower OR of all secondary outcomes were associated with concomitant GLP-1RA/SGLT-2i use when compared to SGLT-2i use alone. CONCLUSION Among adults who tested positive for SARS-CoV-2, premorbid use of either GLP-1RA or SGLT-2i is associated with lower odds of mortality compared to DPP-4i. Furthermore, concomitant use of GLP-1RA and SGLT-2i is linked to lower odds of other severe COVID-19 outcomes, including ER visits, hospitalizations, and mechanical ventilation, compared to SGLT-2i use alone. Graphical abstract available for this article.
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Affiliation(s)
- Klara R Klein
- Division of Endocrinology and Metabolism, Department of Medicine, University of North Carolina School of Medicine, Campus Box #7172, 8072 Burnett Womack, 160 Dental Circle, Chapel Hill, NC, 27599, USA.
| | | | - Anna R Kahkoska
- Division of Endocrinology and Metabolism, Department of Medicine, University of North Carolina School of Medicine, Campus Box #7172, 8072 Burnett Womack, 160 Dental Circle, Chapel Hill, NC, 27599, USA
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Christopher G Chute
- Schools of Medicine, Public Health, and Nursing, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Melissa Haendel
- Center for Health AI, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stephanie S Hong
- Division of General Internal Medicine, Johns Hopkins Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Hemalkumar Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Richard Moffitt
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, NY, USA
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - John B Buse
- Division of Endocrinology and Metabolism, Department of Medicine, University of North Carolina School of Medicine, Campus Box #7172, 8072 Burnett Womack, 160 Dental Circle, Chapel Hill, NC, 27599, USA
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Dang LE, Fong E, Tarp JM, Clemmensen KKB, Ravn H, Kvist K, Buse JB, van der Laan M, Petersen M. Case study of semaglutide and cardiovascular outcomes: An application of the C ausal Roadmap to a hybrid design for augmenting an RCT control arm with real-world data. J Clin Transl Sci 2023; 7:e231. [PMID: 38028337 PMCID: PMC10643919 DOI: 10.1017/cts.2023.656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/09/2023] [Accepted: 10/14/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Increasing interest in real-world evidence has fueled the development of study designs incorporating real-world data (RWD). Using the Causal Roadmap, we specify three designs to evaluate the difference in risk of major adverse cardiovascular events (MACE) with oral semaglutide versus standard-of-care: (1) the actual sequence of non-inferiority and superiority randomized controlled trials (RCTs), (2) a single RCT, and (3) a hybrid randomized-external data study. Methods The hybrid design considers integration of the PIONEER 6 RCT with RWD controls using the experiment-selector cross-validated targeted maximum likelihood estimator. We evaluate 95% confidence interval coverage, power, and average patient time during which participants would be precluded from receiving a glucagon-like peptide-1 receptor agonist (GLP1-RA) for each design using simulations. Finally, we estimate the effect of oral semaglutide on MACE for the hybrid PIONEER 6-RWD analysis. Results In simulations, Designs 1 and 2 performed similarly. The tradeoff between decreased coverage and patient time without the possibility of a GLP1-RA for Designs 1 and 3 depended on the simulated bias. In real data analysis using Design 3, external controls were integrated in 84% of cross-validation folds, resulting in an estimated risk difference of -1.53%-points (95% CI -2.75%-points to -0.30%-points). Conclusions The Causal Roadmap helps investigators to minimize potential bias in studies using RWD and to quantify tradeoffs between study designs. The simulation results help to interpret the level of evidence provided by the real data analysis in support of the superiority of oral semaglutide versus standard-of-care for cardiovascular risk reduction.
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Affiliation(s)
- Lauren E. Dang
- Department of Biostatistics, University of California, Berkeley, CA, USA
| | | | | | | | | | | | - John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark van der Laan
- Department of Biostatistics, University of California, Berkeley, CA, USA
| | - Maya Petersen
- Department of Biostatistics, University of California, Berkeley, CA, USA
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Dang LE, Gruber S, Lee H, Dahabreh IJ, Stuart EA, Williamson BD, Wyss R, Díaz I, Ghosh D, Kıcıman E, Alemayehu D, Hoffman KL, Vossen CY, Huml RA, Ravn H, Kvist K, Pratley R, Shih MC, Pennello G, Martin D, Waddy SP, Barr CE, Akacha M, Buse JB, van der Laan M, Petersen M. A causal roadmap for generating high-quality real-world evidence. J Clin Transl Sci 2023; 7:e212. [PMID: 37900353 PMCID: PMC10603361 DOI: 10.1017/cts.2023.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/01/2023] [Accepted: 09/17/2023] [Indexed: 10/31/2023] Open
Abstract
Increasing emphasis on the use of real-world evidence (RWE) to support clinical policy and regulatory decision-making has led to a proliferation of guidance, advice, and frameworks from regulatory agencies, academia, professional societies, and industry. A broad spectrum of studies use real-world data (RWD) to produce RWE, ranging from randomized trials with outcomes assessed using RWD to fully observational studies. Yet, many proposals for generating RWE lack sufficient detail, and many analyses of RWD suffer from implausible assumptions, other methodological flaws, or inappropriate interpretations. The Causal Roadmap is an explicit, itemized, iterative process that guides investigators to prespecify study design and analysis plans; it addresses a wide range of guidance within a single framework. By supporting the transparent evaluation of causal assumptions and facilitating objective comparisons of design and analysis choices based on prespecified criteria, the Roadmap can help investigators to evaluate the quality of evidence that a given study is likely to produce, specify a study to generate high-quality RWE, and communicate effectively with regulatory agencies and other stakeholders. This paper aims to disseminate and extend the Causal Roadmap framework for use by clinical and translational researchers; three companion papers demonstrate applications of the Causal Roadmap for specific use cases.
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Affiliation(s)
- Lauren E. Dang
- Department of Biostatistics, University of California, Berkeley, CA, USA
| | | | - Hana Lee
- Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Issa J. Dahabreh
- CAUSALab, Department of Epidemiology and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brian D. Williamson
- Biostatistics Division, Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Richard Wyss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Debashis Ghosh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Katherine L. Hoffman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Carla Y. Vossen
- Syneos Health Clinical Solutions, Amsterdam, The Netherlands
| | | | | | | | - Richard Pratley
- AdventHealth Translational Research Institute, Orlando, FL, USA
| | - Mei-Chiung Shih
- Cooperative Studies Program Coordinating Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Gene Pennello
- Division of Imaging Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - David Martin
- Global Real World Evidence Group, Moderna, Cambridge, MA, USA
| | - Salina P. Waddy
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Charles E. Barr
- Graticule Inc., Newton, MA, USA
- Adaptic Health Inc., Palo Alto, CA, USA
| | | | - John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark van der Laan
- Department of Biostatistics, University of California, Berkeley, CA, USA
| | - Maya Petersen
- Department of Biostatistics, University of California, Berkeley, CA, USA
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Bergenstal RM, Hachmann-Nielsen E, Kvist K, Peters A, Tarp JM, Buse JB. Increased Derived Time in Range is Associated with Reduced Risk of Major Adverse Cardiovascular Events, Severe Hypoglycemia, and Microvascular Events in Type 2 Diabetes: A Post Hoc Analysis of DEVOTE. Diabetes Technol Ther 2023. [PMID: 37017470 PMCID: PMC10398723 DOI: 10.1089/dia.2022.0447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
Time spent in glycemic target range (time in range [TIR]; plasma glucose 70-180 mg/dL [3.9-10.0 mmol/L]) as a surrogate endpoint for long-term diabetes-related outcomes requires validation. This post hoc analysis investigated the association between TIR, derived from 8-point glucose profiles (dTIR) at 12 months, and time to cardiovascular or severe hypoglycemic episodes in people with type 2 diabetes in the DEVOTE trial. At 12 months, dTIR was significantly negatively associated with time to first major adverse cardiovascular event (P = 0.0087), severe hypoglycemic episode (P < 0.0001), or microvascular event (P = 0.024). A non-significant trend was seen towards association between 12-month hemoglobin A1c (HbA1c) and these outcomes, but this was no longer seen after addition of dTIR to the model. The results support targeting TIR >70% and suggest dTIR could be used in addition to, or in some instances in place of, HbA1c as a clinical biomarker.
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Affiliation(s)
- Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis , Minnesota, United States;
| | | | | | - Anne Peters
- USC Keck School of Medicine, 12223, Los Angeles, California, United States;
| | | | - John B Buse
- University of North Carolina at Chapel Hill School of Medicine, 6797, Department of Medicine, Chapel Hill, North Carolina, United States;
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5
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Chen D, Petersen ML, Rytgaard HC, Grøn R, Lange T, Rasmussen S, Pratley RE, Marso SP, Kvist K, Buse J, van der Laan MJ. Beyond the Cox Hazard Ratio: A Targeted Learning Approach to Survival Analysis in a Cardiovascular Outcome Trial Application. Stat Biopharm Res 2023. [DOI: 10.1080/19466315.2023.2173644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Affiliation(s)
- David Chen
- Division of Biostatistics, UC Berkeley School of Public Health, Berkeley, CA
| | - Maya L. Petersen
- Division of Biostatistics, UC Berkeley School of Public Health, Berkeley, CA
| | | | | | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Steven P. Marso
- Midwest Heart and Vascular Institute, HCA Midwest Health, Overland Park, KS
| | | | - John Buse
- Division of Endocrinology and Metabolism, UNC School of Medicine, Chapel Hill, NC
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Nørgaard CH, Friedrich S, Hansen CT, Gerds T, Ballard C, Møller DV, Knudsen LB, Kvist K, Zinman B, Holm E, Torp-Pedersen C, Mørch LS. Treatment with glucagon-like peptide-1 receptor agonists and incidence of dementia: Data from pooled double-blind randomized controlled trials and nationwide disease and prescription registers. Alzheimers Dement (N Y) 2022; 8:e12268. [PMID: 35229024 PMCID: PMC8864443 DOI: 10.1002/trc2.12268] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 01/20/2022] [Indexed: 12/21/2022]
Abstract
Introduction People with type 2 diabetes have increased risk of dementia. Glucagon‐like peptide‐1 (GLP‐1) receptor agonists (RAs) are among the promising therapies for repurposing as a treatment for Alzheimer's disease; a key unanswered question is whether they reduce dementia incidence in people with type 2 diabetes. Methods We assessed exposure to GLP‐1 RAs in patients with type 2 diabetes and subsequent diagnosis of dementia in two large data sources with long‐term follow‐up: pooled data from three randomized double‐blind placebo‐controlled cardiovascular outcome trials (15,820 patients) and a nationwide Danish registry‐based cohort (120,054 patients). Results Dementia rate was lower both in patients randomized to GLP‐1 RAs versus placebo (hazard ratio [HR]: 0.47 (95% confidence interval [CI]: 0.25–0.86) and in the nationwide cohort (HR: 0.89; 95% CI: 0.86–0.93 with yearly increased exposure to GLP‐1 RAs). Discussion Treatment with GLP‐1 RAs may provide a new opportunity to reduce the incidence of dementia in patients with type 2 diabetes.
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Affiliation(s)
- Caroline Holm Nørgaard
- Department of Cardiology and Clinical Research Nordsjællands University Hospital Hillerød Denmark.,Department of Medicine University of California Irvine Irvine California USA
| | - Sarah Friedrich
- Department of Medical Statistics University Medical Center Göttingen Göttingen Germany
| | | | - Thomas Gerds
- Section of Biostatistics Copenhagen University Østerbro Denmark
| | - Clive Ballard
- St Luke's Campus University of Exeter College of Medicine and Health Exeter UK
| | | | | | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute Mount Sinai Hospital University of Toronto Toronto Ontario Canada
| | - Ellen Holm
- Department of Medicine Nykøbing Falster Hospital Hospitalsvej Nykøbing Falster Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Research Nordsjællands University Hospital Hillerød Denmark.,Department of Cardiology Aalborg University Hospital Aalborg Denmark
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Klein KR, Franek E, Marso S, Pieber TR, Pratley RE, Gowda A, Kvist K, Buse JB. Hemoglobin glycation index, calculated from a single fasting glucose value, as a prediction tool for severe hypoglycemia and major adverse cardiovascular events in DEVOTE. BMJ Open Diabetes Res Care 2021; 9:9/2/e002339. [PMID: 34819298 PMCID: PMC8614152 DOI: 10.1136/bmjdrc-2021-002339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/31/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Hemoglobin glycation index (HGI) is the difference between observed and predicted glycated hemoglobin A1c (HbA1c), derived from mean or fasting plasma glucose (FPG). In this secondary, exploratory analysis of data from DEVOTE, we examined: whether insulin initiation/titration affected the HGI; the relationship between baseline HGI tertile and cardiovascular and hypoglycemia risk; and the relative strengths of HGI and HbA1c in predicting these risks. RESEARCH DESIGN AND METHODS In DEVOTE, a randomized, double-blind, cardiovascular outcomes trial, people with type 2 diabetes received once per day insulin degludec or insulin glargine 100 units/mL. The primary outcome was time to first occurrence of a major adverse cardiovascular event (MACE), comprising cardiovascular death, myocardial infarction or stroke; severe hypoglycemia was a secondary outcome. In these analyses, predicted HbA1c was calculated using a linear regression equation based on DEVOTE data (HbA1c=0.01313 FPG (mg/dL) (single value)+6.17514), and the population data were grouped into HGI tertiles based on the calculated HGI values. The distributions of time to first event were compared using Kaplan-Meier curves; HRs and 95% CIs were determined by Cox regression models comparing risk of MACE and severe hypoglycemia between tertiles. RESULTS Changes in HGI were observed at 12 months after insulin initiation and stabilized by 24 months for the whole cohort and insulin-naive patients. There were significant differences in MACE risk between baseline HGI tertiles; participants with high HGI were at highest risk (low vs high, HR: 0.73 (0.61 to 0.87)95% CI; moderate vs high, HR: 0.67 (0.56 to 0.81)95% CI; p<0.0001). No significant differences between HGI tertiles were observed in the risk of severe hypoglycemia (p=0.0911). With HbA1c included within the model, HGI no longer significantly predicted MACE. CONCLUSIONS High HGI was associated with a higher risk of MACE; this finding is of uncertain significance given the association of HGI with insulin initiation and HbA1c. TRIAL REGISTRATION NUMBER NCT01959529.
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Affiliation(s)
- Klara R Klein
- Division of Endocrinology and Metabolism, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Edward Franek
- Mossakowski Medical Research Centre, Polish Academy of Sciences, Central Clinical Hospital MSW, Warsaw, Poland
| | - Steven Marso
- HCA Midwest Health Heart and Vascular Institute, Overland Park, Kansas, USA
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Richard E Pratley
- AdventHealth Translational Research Institute, Orlando, Florida, USA
| | | | | | - John B Buse
- Division of Endocrinology and Metabolism, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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Kahkoska AR, Abrahamsen TJ, Alexander GC, Bennett TD, Chute CG, Haendel MA, Klein KR, Mehta H, Miller JD, Moffitt RA, Stürmer T, Kvist K, Buse JB. Association Between Glucagon-Like Peptide 1 Receptor Agonist and Sodium-Glucose Cotransporter 2 Inhibitor Use and COVID-19 Outcomes. Diabetes Care 2021; 44:1564-1572. [PMID: 34135013 PMCID: PMC8323175 DOI: 10.2337/dc21-0065] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/23/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the respective associations of premorbid glucagon-like peptide-1 receptor agonist (GLP1-RA) and sodium-glucose cotransporter 2 inhibitor (SGLT2i) use, compared with premorbid dipeptidyl peptidase 4 inhibitor (DPP4i) use, with severity of outcomes in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. RESEARCH DESIGN AND METHODS We analyzed observational data from SARS-CoV-2-positive adults in the National COVID Cohort Collaborative (N3C), a multicenter, longitudinal U.S. cohort (January 2018-February 2021), with a prescription for GLP1-RA, SGLT2i, or DPP4i within 24 months of positive SARS-CoV-2 PCR test. The primary outcome was 60-day mortality, measured from positive SARS-CoV-2 test date. Secondary outcomes were total mortality during the observation period and emergency room visits, hospitalization, and mechanical ventilation within 14 days. Associations were quantified with odds ratios (ORs) estimated with targeted maximum likelihood estimation using a super learner approach, accounting for baseline characteristics. RESULTS The study included 12,446 individuals (53.4% female, 62.5% White, mean ± SD age 58.6 ± 13.1 years). The 60-day mortality was 3.11% (387 of 12,446), with 2.06% (138 of 6,692) for GLP1-RA use, 2.32% (85 of 3,665) for SGLT2i use, and 5.67% (199 of 3,511) for DPP4i use. Both GLP1-RA and SGLT2i use were associated with lower 60-day mortality compared with DPP4i use (OR 0.54 [95% CI 0.37-0.80] and 0.66 [0.50-0.86], respectively). Use of both medications was also associated with decreased total mortality, emergency room visits, and hospitalizations. CONCLUSIONS Among SARS-CoV-2-positive adults, premorbid GLP1-RA and SGLT2i use, compared with DPP4i use, was associated with lower odds of mortality and other adverse outcomes, although DPP4i users were older and generally sicker.
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Affiliation(s)
- Anna R Kahkoska
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD
| | - Tellen D Bennett
- Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Christopher G Chute
- Schools of Medicine, Public Health, and Nursing, Johns Hopkins University, Baltimore, MD
| | - Melissa A Haendel
- Center for Health AI, University of Colorado School of Medicine, Aurora, CO
| | - Klara R Klein
- Division of Endocrinology and Metabolism, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Hemalkumar Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Joshua D Miller
- Division of Endocrinology and Metabolism, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Richard A Moffitt
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, NY
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - John B Buse
- Division of Endocrinology and Metabolism, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC .,NC Translational and Clinical Sciences Institute, University of North Carolina School of Medicine, Chapel Hill, NC
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Buse JB, Holst I, Knop FK, Kvist K, Thielke D, Pratley R. Prototype of an evidence-based tool to aid individualized treatment for type 2 diabetes. Diabetes Obes Metab 2021; 23:1666-1671. [PMID: 33764641 PMCID: PMC8251774 DOI: 10.1111/dom.14381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/05/2021] [Accepted: 03/19/2021] [Indexed: 12/18/2022]
Abstract
Data-driven tools are needed to inform individualized treatment decisions for people with type 2 diabetes (T2D). To show how treatment might be individualized, an interactive outline tool was developed to predict treatment outcomes. Individualized predictions were generated for change in HbA1c and body weight after initiation of newer antidiabetes drugs recommended by current guidelines. These predictions were based on data from randomized controlled trials of glucose-lowering drugs. The data included patient demographics and clinical characteristics (sex, age, body mass index, weight, diabetes duration, HbA1c level, current diabetes treatment and renal function). Predicted outcomes were determined using prespecified statistical models from original trial protocols and estimated coefficients for selected baseline characteristics. This prototype illustrates how evidence-based individualized treatment might be facilitated in the clinic for people with T2D. Further and ongoing development is required to improve the tool's prognostic value, including the addition of disease co-morbidities and patient-orientated outcomes. Patient engagement and data-sharing by sponsors of clinical trials, as well as real-world evidence, are needed to provide reliable predicted outcomes to inform shared patient-physician decision-making.
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Affiliation(s)
- John B. Buse
- University of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | | | - Filip K. Knop
- Gentofte HospitalUniversity of CopenhagenHellerupDenmark
- Steno Diabetes Center CopenhagenGentofteDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
- Novo Nordisk Center for Basic Metabolic Research, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | | | | | - Richard Pratley
- AdventHealth Translational Research InstituteOrlandoFloridaUSA
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10
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Ballard C, Nørgaard CH, Friedrich S, Mørch LS, Gerds T, Møller DV, Knudsen LB, Kvist K, Zinman B, Holm E, Torp‐Pedersen C, Hansen CT. Liraglutide and semaglutide: Pooled post hoc analysis to evaluate risk of dementia in patients with type 2 diabetes. Alzheimers Dement 2020. [DOI: 10.1002/alz.042909] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Clive Ballard
- The University of Exeter College of Medicine and Health Exeter United Kingdom
| | | | | | - Lina Steinrud Mørch
- Cancer Surveillance and Pharmacoepidemiology Danish Cancer Society Copenhagen Denmark
| | | | | | | | | | - Bernard Zinman
- Lunenfeld–Tanenbaum Research Institute Mount Sinai Hospital University of Toronto Toronto ON Canada
| | - Ellen Holm
- Nykøbing Falster Hospital Nykøbing Falster Denmark
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Heller S, Lingvay I, Marso SP, Philis‐Tsimikas A, Pieber TR, Poulter NR, Pratley RE, Hachmann‐Nielsen E, Kvist K, Lange M, Moses AC, Andresen MT, Buse JB. Risk of severe hypoglycaemia and its impact in type 2 diabetes in DEVOTE. Diabetes Obes Metab 2020; 22:2241-2247. [PMID: 32250536 PMCID: PMC7754351 DOI: 10.1111/dom.14049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/30/2020] [Indexed: 01/10/2023]
Abstract
AIMS To undertake a post-hoc analysis, utilizing a hypoglycaemia risk score based on DEVOTE trial data, to investigate if a high risk of severe hypoglycaemia was associated with an increased risk of cardiovascular events, and whether reduced rates of severe hypoglycaemia in patients identified as having the highest risk affected the risk of cardiovascular outcomes. MATERIALS AND METHODS The DEVOTE population was divided into quartiles according to patients' individual hypoglycaemia risk scores. For each quartile, the observed incidence and rate of severe hypoglycaemia, major adverse cardiovascular event (MACE) and all-cause mortality were determined to investigate whether those with the highest risk of hypoglycaemia were also at the greatest risk of MACE and all-cause mortality. In addition, treatment differences within each risk quartile [insulin degludec (degludec) vs. insulin glargine 100 units/mL (glargine U100)] in terms of severe hypoglycaemia, MACE and all-cause mortality were investigated. RESULTS Patients with the highest risk scores had the highest rates of severe hypoglycaemia, MACE and all-cause mortality. Treatment ratios between degludec and glargine U100 in the highest risk quartile were 95% confidence interval (CI) 0.56 (0.39; 0.80) (severe hypoglycaemia), 95% CI 0.76 (0.58; 0.99) (MACE) and 95% CI 0.77 (0.55; 1.07) (all-cause mortality). CONCLUSIONS The risk score demonstrated that a high risk of severe hypoglycaemia was associated with a high incidence of MACE and all-cause mortality and that, in this high-risk group, those treated with degludec had a lower incidence of MACE. These observations support the hypothesis that hypoglycaemia is a risk factor for cardiovascular events.
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Affiliation(s)
- Simon Heller
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
| | - Ildiko Lingvay
- Department of Internal Medicine and Department of Population and Data SciencesUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Steven P. Marso
- HCA Midwest Health Heart and Vascular InstituteOverland ParkKansasUSA
| | | | - Thomas R. Pieber
- Department of Internal MedicineMedical University of GrazGrazAustria
| | - Neil R. Poulter
- Imperial Clinical Trials Unit, National Heart and Lung InstituteImperial College LondonLondonUK
| | | | | | | | | | - Alan C. Moses
- Novo Nordisk A/SSøborgDenmark
- Independent consultant, Novo Nordisk A/SPortsmouthNew HampshireUSA
| | | | - John B. Buse
- University of North Carolina School of MedicineChapel HillNorth CarolinaUSA
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12
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Heller S, Lingvay I, Marso SP, Philis‐Tsimikas A, Pieber TR, Poulter NR, Pratley RE, Hachmann‐Nielsen E, Kvist K, Lange M, Moses AC, Trock Andresen M, Buse JB. Development of a hypoglycaemia risk score to identify high-risk individuals with advanced type 2 diabetes in DEVOTE. Diabetes Obes Metab 2020; 22:2248-2256. [PMID: 32996693 PMCID: PMC7756403 DOI: 10.1111/dom.14208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 12/21/2022]
Abstract
AIMS The ability to differentiate patient populations with type 2 diabetes at high risk of severe hypoglycaemia could impact clinical decision making. The aim of this study was to develop a risk score, using patient characteristics, that could differentiate between populations with higher and lower 2-year risk of severe hypoglycaemia among individuals at increased risk of cardiovascular disease. MATERIALS AND METHODS Two models were developed for the risk score based on data from the DEVOTE cardiovascular outcomes trials. The first, a data-driven machine-learning model, used stepwise regression with bidirectional elimination to identify risk factors for severe hypoglycaemia. The second, a risk score based on known clinical risk factors accessible in clinical practice identified from the data-driven model, included: insulin treatment regimen; diabetes duration; sex; age; and glycated haemoglobin, all at baseline. Both the data-driven model and simple risk score were evaluated for discrimination, calibration and generalizability using data from DEVOTE, and were validated against the external LEADER cardiovascular outcomes trial dataset. RESULTS Both the data-driven model and the simple risk score discriminated between patients at higher and lower hypoglycaemia risk, and performed similarly well based on the time-dependent area under the curve index (0.63 and 0.66, respectively) over a 2-year time horizon. CONCLUSIONS Both the data-driven model and the simple hypoglycaemia risk score were able to discriminate between patients at higher and lower risk of severe hypoglycaemia, the latter doing so using easily accessible clinical data. The implementation of such a tool (http://www.hyporiskscore.com/) may facilitate improved recognition of, and education about, severe hypoglycaemia risk, potentially improving patient care.
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Affiliation(s)
- Simon Heller
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
| | - Ildiko Lingvay
- Department of Internal Medicine and Department of Population and Data SciencesUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Steven P. Marso
- HCA Midwest Health Heart and Vascular InstituteOverland ParkKansasUSA
| | | | - Thomas R. Pieber
- Department of Internal MedicineMedical University of GrazGrazAustria
| | - Neil R. Poulter
- Imperial Clinical Trials Unit, Imperial College LondonLondonUK
| | | | | | | | | | - Alan C. Moses
- Novo Nordisk A/SSøborgDenmark
- Independent ConsultantPortsmouthNew HampshireUSA
| | | | - John B. Buse
- University of North Carolina School of MedicineChapel HillNorth CarolinaUSA
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Woo V, Kvist K, Buse JB, Hachmann-Nielsen E, Alexopoulos AS. 117 - Diabetes Duration Did Not Moderate Severe Hypoglycemia Seen With Glargine U100 vs Degludec in DEVOTE. Can J Diabetes 2019. [DOI: 10.1016/j.jcjd.2019.07.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Pieber TR, Marso SP, McGuire DK, Zinman B, Poulter NR, Emerson SS, Pratley RE, Woo V, Heller S, Lange M, Brown-Frandsen K, Moses A, Barner Lekdorf J, Lehmann L, Kvist K, Buse JB. DEVOTE 3: temporal relationships between severe hypoglycaemia, cardiovascular outcomes and mortality. Diabetologia 2018; 61:58-65. [PMID: 28913543 PMCID: PMC6002964 DOI: 10.1007/s00125-017-4422-0] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 08/25/2017] [Indexed: 11/15/2022]
Abstract
AIMS/HYPOTHESIS The double-blind Trial Comparing Cardiovascular Safety of Insulin Degludec vs Insulin Glargine in Patients with Type 2 Diabetes at High Risk of Cardiovascular Events (DEVOTE) assessed the cardiovascular safety of insulin degludec. The incidence and rates of adjudicated severe hypoglycaemia, and all-cause mortality were also determined. This paper reports a secondary analysis investigating associations of severe hypoglycaemia with cardiovascular outcomes and mortality. METHODS In DEVOTE, patients with type 2 diabetes were randomised to receive either insulin degludec or insulin glargine U100 (100 units/ml) once daily (between dinner and bedtime) in an event-driven, double-blind, treat-to-target cardiovascular outcomes trial. The primary outcome was the first occurrence of an adjudicated major adverse cardiovascular event (MACE; cardiovascular death, non-fatal myocardial infarction or non-fatal stroke). Adjudicated severe hypoglycaemia was the pre-specified secondary outcome. In the present analysis, the associations of severe hypoglycaemia with both MACE and all-cause mortality was evaluated in the pooled trial population using time-to-event analyses, with severe hypoglycaemia as a time-dependent variable and randomised treatment as a fixed factor. An investigation with interaction terms indicated that the effect of severe hypoglycaemia on the risk of MACE and all-cause mortality were the same for both treatment arms, and so the temporal association for severe hypoglycaemia with subsequent MACE and all-cause mortality is reported for the pooled population. RESULTS There was a non-significant difference in the risk of MACE for individuals who had vs those who had not experienced severe hypoglycaemia during the trial (HR 1.38, 95% CI 0.96, 1.96; p = 0.080) and therefore there was no temporal relationship between severe hypoglycaemia and MACE. There was a significantly higher risk of all-cause mortality for patients who had vs those who had not experienced severe hypoglycaemia during the trial (HR 2.51, 95% CI 1.79, 3.50; p < 0.001). There was a higher risk of all-cause mortality 15, 30, 60, 90, 180 and 365 days after experiencing severe hypoglycaemia compared with not experiencing severe hypoglycaemia in the same time interval. The association between severe hypoglycaemia and all-cause mortality was maintained after adjustment for the following baseline characteristics: age, sex, HbA1c, BMI, diabetes duration, insulin regimen, hepatic impairment, renal status and cardiovascular risk group. CONCLUSIONS/INTERPRETATION The results from these analyses demonstrate an association between severe hypoglycaemia and all-cause mortality. Furthermore, they indicate that patients who experienced severe hypoglycaemia were particularly at greater risk of death in the short term after the hypoglycaemic episode. These findings indicate that severe hypoglycaemia is associated with higher subsequent mortality; however, they cannot answer the question as to whether severe hypoglycaemia serves as a risk marker for adverse outcomes or whether there is a direct causal effect. TRIAL REGISTRATION ClinicalTrials.gov NCT01959529.
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Affiliation(s)
- Thomas R Pieber
- Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, A-8036, Graz, Austria.
| | | | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Richard E Pratley
- Florida Hospital Translational Research Institute for Metabolism and Diabetes, Orlando, FL, USA
- Sanford Burnham Prebys Medical Discovery Institute, Orlando, FL, USA
| | - Vincent Woo
- University of Manitoba, Winnipeg, MB, Canada
| | - Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | | | | | | | | | | | | | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Zinman B, Marso SP, Poulter NR, Emerson SS, Pieber TR, Pratley RE, Lange M, Brown-Frandsen K, Moses A, Ocampo Francisco AM, Barner Lekdorf J, Kvist K, Buse JB. Day-to-day fasting glycaemic variability in DEVOTE: associations with severe hypoglycaemia and cardiovascular outcomes (DEVOTE 2). Diabetologia 2018; 61:48-57. [PMID: 28913575 PMCID: PMC6002963 DOI: 10.1007/s00125-017-4423-z] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/21/2017] [Indexed: 12/16/2022]
Abstract
AIMS/HYPOTHESIS The Trial Comparing Cardiovascular Safety of Insulin Degludec vs Insulin Glargine in Patients with Type 2 Diabetes at High Risk of Cardiovascular Events (DEVOTE) was a double-blind, randomised, event-driven, treat-to-target prospective trial comparing the cardiovascular safety of insulin degludec with that of insulin glargine U100 (100 units/ml) in patients with type 2 diabetes at high risk of cardiovascular events. This paper reports a secondary analysis investigating associations of day-to-day fasting glycaemic variability (pre-breakfast self-measured blood glucose [SMBG]) with severe hypoglycaemia and cardiovascular outcomes. METHODS In DEVOTE, patients with type 2 diabetes were randomised to receive insulin degludec or insulin glargine U100 once daily. The primary outcome was the first occurrence of an adjudicated major adverse cardiovascular event (MACE). Adjudicated severe hypoglycaemia was the pre-specified secondary outcome. In this article, day-to-day fasting glycaemic variability was based on the standard deviation of the pre-breakfast SMBG measurements. The variability measure was calculated as follows. Each month, only the three pre-breakfast SMBG measurements recorded before contact with the site were used to determine a day-to-day fasting glycaemic variability measure for each patient. For each patient, the variance of the three log-transformed pre-breakfast SMBG measurements each month was determined. The standard deviation was determined as the square root of the mean of these monthly variances and was defined as day-to-day fasting glycaemic variability. The associations between day-to-day fasting glycaemic variability and severe hypoglycaemia, MACE and all-cause mortality were analysed for the pooled trial population with Cox proportional hazards models. Several sensitivity analyses were conducted, including adjustments for baseline characteristics and most recent HbA1c. RESULTS Day-to-day fasting glycaemic variability was significantly associated with severe hypoglycaemia (HR 4.11, 95% CI 3.15, 5.35), MACE (HR 1.36, 95% CI 1.12, 1.65) and all-cause mortality (HR 1.58, 95% CI 1.23, 2.03) before adjustments. The increased risks of severe hypoglycaemia, MACE and all-cause mortality translate into 2.7-, 1.2- and 1.4-fold risk, respectively, when a patient's day-to-day fasting glycaemic variability measure is doubled. The significant relationships of day-to-day fasting glycaemic variability with severe hypoglycaemia and all-cause mortality were maintained after adjustments. However, the significant association with MACE was not maintained following adjustment for baseline characteristics with either baseline HbA1c (HR 1.19, 95% CI 0.96, 1.47) or the most recent HbA1c measurement throughout the trial (HR 1.21, 95% CI 0.98, 1.49). CONCLUSIONS/INTERPRETATION Higher day-to-day fasting glycaemic variability is associated with increased risks of severe hypoglycaemia and all-cause mortality. TRIAL REGISTRATION ClinicalTrials.gov NCT01959529.
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Affiliation(s)
- Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, 60 Murray St, Box 17, University of Toronto, Toronto, ON, M5T 3L9, Canada.
| | | | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | | | - Richard E Pratley
- Florida Hospital Translational Research Institute for Metabolism and Diabetes, Orlando, FL, USA
- Sanford Burnham Prebys Medical Discovery Institute, Orlando, FL, USA
| | | | | | | | | | | | | | - John B Buse
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Marso SP, McGuire DK, Zinman B, Poulter NR, Emerson SS, Pieber TR, Pratley RE, Haahr PM, Lange M, Brown-Frandsen K, Moses A, Skibsted S, Kvist K, Buse JB. Efficacy and Safety of Degludec versus Glargine in Type 2 Diabetes. N Engl J Med 2017; 377:723-732. [PMID: 28605603 PMCID: PMC5731244 DOI: 10.1056/nejmoa1615692] [Citation(s) in RCA: 384] [Impact Index Per Article: 54.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Degludec is an ultralong-acting, once-daily basal insulin that is approved for use in adults, adolescents, and children with diabetes. Previous open-label studies have shown lower day-to-day variability in the glucose-lowering effect and lower rates of hypoglycemia among patients who received degludec than among those who received basal insulin glargine. However, data are lacking on the cardiovascular safety of degludec. METHODS We randomly assigned 7637 patients with type 2 diabetes to receive either insulin degludec (3818 patients) or insulin glargine U100 (3819 patients) once daily between dinner and bedtime in a double-blind, treat-to-target, event-driven cardiovascular outcomes trial. The primary composite outcome in the time-to-event analysis was the first occurrence of an adjudicated major cardiovascular event (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke) with a prespecified noninferiority margin of 1.3. Adjudicated severe hypoglycemia, as defined by the American Diabetes Association, was the prespecified, multiplicity-adjusted secondary outcome. RESULTS Of the patients who underwent randomization, 6509 (85.2%) had established cardiovascular disease, chronic kidney disease, or both. At baseline, the mean age was 65.0 years, the mean duration of diabetes was 16.4 years, and the mean (±SD) glycated hemoglobin level was 8.4±1.7%; 83.9% of the patients were receiving insulin. The primary outcome occurred in 325 patients (8.5%) in the degludec group and in 356 (9.3%) in the glargine group (hazard ratio, 0.91; 95% confidence interval, 0.78 to 1.06; P<0.001 for noninferiority). At 24 months, the mean glycated hemoglobin level was 7.5±1.2% in each group, whereas the mean fasting plasma glucose level was significantly lower in the degludec group than in the glargine group (128±56 vs. 136±57 mg per deciliter, P<0.001). Prespecified adjudicated severe hypoglycemia occurred in 187 patients (4.9%) in the degludec group and in 252 (6.6%) in the glargine group, for an absolute difference of 1.7 percentage points (rate ratio, 0.60; P<0.001 for superiority; odds ratio, 0.73; P<0.001 for superiority). Rates of adverse events did not differ between the two groups. CONCLUSIONS Among patients with type 2 diabetes at high risk for cardiovascular events, degludec was noninferior to glargine with respect to the incidence of major cardiovascular events. (Funded by Novo Nordisk and others; DEVOTE ClinicalTrials.gov number, NCT01959529 .).
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Affiliation(s)
- Steven P Marso
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Darren K McGuire
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Bernard Zinman
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Neil R Poulter
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Scott S Emerson
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Thomas R Pieber
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Richard E Pratley
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Poul-Martin Haahr
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Martin Lange
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Kirstine Brown-Frandsen
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Alan Moses
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Simon Skibsted
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - Kajsa Kvist
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
| | - John B Buse
- From the Research Medical Center, Kansas City, MO (S.P.M.); University of Texas Southwestern Medical Center, Dallas (D.K.M.); Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto (B.Z.); Imperial Clinical Trials Unit, Imperial College London, London (N.R.P.); University of Washington, Seattle (S.S.E.); Medical University of Graz, Graz, Austria (T.R.P.); Florida Hospital Translational Research Institute for Metabolism and Diabetes and Sanford Burnham Prebys Medical Discovery Institute, Orlando (R.E.P.); Novo Nordisk, Søborg, Denmark (P.-M.H., M.L., K.B.-F., A.M., S.S., K.K.); and University of North Carolina School of Medicine, Chapel Hill (J.B.B.)
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Wysham C, Bhargava A, Chaykin L, de la Rosa R, Handelsman Y, Troelsen LN, Kvist K, Norwood P. Effect of Insulin Degludec vs Insulin Glargine U100 on Hypoglycemia in Patients With Type 2 Diabetes: The SWITCH 2 Randomized Clinical Trial. JAMA 2017; 318:45-56. [PMID: 28672317 PMCID: PMC5817473 DOI: 10.1001/jama.2017.7117] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 06/12/2017] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Hypoglycemia, a serious risk for insulin-treated patients with type 2 diabetes, negatively affects glycemic control. OBJECTIVE To test whether treatment with basal insulin degludec is associated with a lower rate of hypoglycemia compared with insulin glargine U100 in patients with type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, treat-to-target crossover trial including two 32-week treatment periods, each with a 16-week titration period and a 16-week maintenance period. The trial was conducted at 152 US centers between January 2014 and December 2015 in 721 adults with type 2 diabetes and at least 1 hypoglycemia risk factor who were previously treated with basal insulin with or without oral antidiabetic drugs. INTERVENTIONS Patients were randomized 1:1 to receive once-daily insulin degludec followed by insulin glargine U100 (n = 361) or to receive insulin glargine U100 followed by insulin degludec (n = 360) and randomized 1:1 to morning or evening dosing within each treatment sequence. MAIN OUTCOMES AND MEASURES The primary end point was the rate of overall symptomatic hypoglycemic episodes (severe or blood glucose confirmed [<56 mg/dL]) during the maintenance period. Secondary end points were the rate of nocturnal symptomatic hypoglycemic episodes (severe or blood glucose confirmed, occurring between 12:01 am and 5:59 am) and the proportion of patients with severe hypoglycemia during the maintenance period. RESULTS Of the 721 patients randomized (mean [SD] age, 61.4 [10.5] years; 53.1% male), 580 (80.4%) completed the trial. During the maintenance period, the rates of overall symptomatic hypoglycemia for insulin degludec vs insulin glargine U100 were 185.6 vs 265.4 episodes per 100 patient-years of exposure (PYE) (rate ratio = 0.70 [95% CI, 0.61-0.80]; P < .001; difference, -23.66 episodes/100 PYE [95% CI, -33.98 to -13.33]), and the proportions of patients with hypoglycemic episodes were 22.5% vs 31.6% (difference, -9.1% [95% CI, -13.1% to -5.0%]). The rates of nocturnal symptomatic hypoglycemia with insulin degludec vs insulin glargine U100 were 55.2 vs 93.6 episodes/100 PYE (rate ratio = 0.58 [95% CI, 0.46-0.74]; P < .001; difference, -7.41 episodes/100 PYE [95% CI, -11.98 to -2.85]), and the proportions of patients with hypoglycemic episodes were 9.7% vs 14.7% (difference, -5.1% [95% CI, -8.1% to -2.0%]). The proportions of patients experiencing severe hypoglycemia during the maintenance period were 1.6% (95% CI, 0.6%-2.7%) for insulin degludec vs 2.4% (95% CI, 1.1%-3.7%) for insulin glargine U100 (McNemar P = .35; risk difference, -0.8% [95% CI, -2.2% to 0.5%]). Statistically significant reductions in overall and nocturnal symptomatic hypoglycemia for insulin degludec vs insulin glargine U100 were also seen for the full treatment period. CONCLUSIONS AND RELEVANCE Among patients with type 2 diabetes treated with insulin and with at least 1 hypoglycemia risk factor, 32 weeks' treatment with insulin degludec vs insulin glargine U100 resulted in a reduced rate of overall symptomatic hypoglycemia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02030600.
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Affiliation(s)
- Carol Wysham
- Rockwood Clinic, University of Washington School of Medicine, Spokane
| | - Anuj Bhargava
- Iowa Diabetes and Endocrinology Research Center, Des Moines
| | | | | | | | | | - Kajsa Kvist
- Biostatistics Insulin and Diabetes Outcomes, Novo Nordisk, Søborg, Denmark
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Jaeckel E, Wysham C, Bhargava A, Chaykin L, de la Rosa R, Handelsman Y, Troelsen LN, Kvist K, Norwood P. Insulin degludec 100 E/ml (IDeg) zeigte gegenüber Insulin glargin 100 E/ml (IGlar) einen konsistenten Vorteil in Bezug auf Hypoglykämien bei Patienten mit T2D mit hohem Risiko für schwere Hypoglykämien: Eine randomisierte, doppelblinde Crossover-Studie. DIABETOL STOFFWECHS 2017. [DOI: 10.1055/s-0037-1601742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- E Jaeckel
- Medizinische Hochschule Hannover, Hannover, Germany
| | - C Wysham
- Rockwood Clinic, Spokane, United States
| | - A Bhargava
- Iowa Diabetes and Endocrinology Research Center, Des Moines, United States
| | - L Chaykin
- Meridien Research, Brandenton, United States
| | | | - Y Handelsman
- Metabolic Institute of America, Tarzana, United States
| | | | - K Kvist
- Novo Nordisk A/S, Søborg, Denmark
| | - P Norwood
- Valley Research, Fresno, United States
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Vilsbøll T, Vora J, Jarlov H, Kvist K, Blonde L. Type 2 Diabetes Patients Reach Target Glycemic Control Faster Using IDegLira than Either Insulin Degludec or Liraglutide Given Alone. Clin Drug Investig 2016; 36:293-303. [PMID: 26894800 PMCID: PMC4801992 DOI: 10.1007/s40261-016-0376-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The time-course when changes in glycemic control and body weight were first manifest in patients with type 2 diabetes mellitus (T2DM) treated with a combination of insulin degludec and liraglutide (IDegLira) was assessed, comparing IDegLira to its individual components. METHODS Data from weeks 0-12 from two studies were analyzed, one comparing IDegLira to each component (DUAL I), and one comparing IDegLira to insulin degludec titrated to a maximum 50 units (DUAL II). Efficacy endpoints included glycated hemoglobin (HbA1c) and fasting plasma glucose (FPG) reduction, proportion of patients achieving HbA1c [<7.0 % (<53.0 mmol/mol)] and FPG (≤7.2 mmol/L) targets, and proportion achieving HbA1c target without hypoglycemia and without hypoglycemia and weight gain. RESULTS Mean HbA1c was lower, and the proportion of patients reaching target HbA1c greater, with IDegLira versus comparators (both studies) at weeks 8 and 12. Proportions of patients reaching target HbA1c without hypoglycemia and without hypoglycemia and weight gain were higher for IDegLira versus insulin degludec, though not versus liraglutide. Mean FPG was lower with IDegLira, and the proportion achieving target FPG higher, versus components (both studies) from weeks 4-12. IDegLira was associated with mean weight reduction from weeks 4-12, although less than with liraglutide alone. Hypoglycemia occurred infrequently in weeks 0-12, with no difference in incidence between IDegLira and insulin degludec in either study. CONCLUSIONS IDegLira reduces plasma glucose to a greater extent than its components, measurable within the first 12 weeks of therapy, and without weight gain or an increased hypoglycemia risk versus insulin degludec.
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Affiliation(s)
- Tina Vilsbøll
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.
| | - Jiten Vora
- Diabetes and Endocrinology, Royal Liverpool University Hospitals, Liverpool, UK
| | | | | | - Lawrence Blonde
- Ochsner Diabetes Clinical Research Unit, Department of Endocrinology, Frank Riddick Diabetes Institute, Ochsner Medical Center, New Orleans, LA, USA
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Rodbard HW, Buse JB, Woo V, Vilsbøll T, Langbakke IH, Kvist K, Gough SCL. Benefits of combination of insulin degludec and liraglutide are independent of baseline glycated haemoglobin level and duration of type 2 diabetes. Diabetes Obes Metab 2016; 18:40-8. [PMID: 26343931 PMCID: PMC5063148 DOI: 10.1111/dom.12574] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 12/11/2022]
Abstract
AIM To evaluate, using post hoc analyses, whether the novel combination of a basal insulin, insulin degludec, and a glucagon-like peptide-1 receptor agonist, liraglutide (IDegLira), was consistently effective in patients with type 2 diabetes (T2D), regardless of the stage of T2D progression. METHODS Using data from the DUAL I extension [insulin-naïve patients uncontrolled on oral antidiabetic drugs (OADs), n = 1660, 52 weeks] and DUAL II (patients uncontrolled on basal insulin plus OADs, n = 398, 26 weeks) randomized trials, the efficacy of IDegLira was investigated with regard to measures of disease progression stage including baseline glycated haemoglobin (HbA1c), disease duration and previous insulin dose. RESULTS Across four categories of baseline HbA1c (≤7.5-9.0%), HbA1c reductions were significantly greater with IDegLira (1.1-2.5%) compared with IDeg or liraglutide alone in DUAL I. In DUAL II, HbA1c reductions were significantly greater with IDegLira (0.9-2.5%) than with IDeg in all but the lowest HbA1c category. In DUAL I, insulin dose and hypoglycaemia rate were lower across all baseline HbA1c categories for IDegLira versus IDeg, while hypoglycaemia was higher with IDegLira than liraglutide, irrespective of baseline HbA1c. In DUAL II, insulin dose and hypoglycaemia rate were similar with IDegLira and IDeg (maximum dose limited to 50 U) independent of baseline HbA1c. The reduction in HbA1c with IDegLira was independent of disease duration and previous insulin dose but varied depending on pre-trial OAD treatment. CONCLUSIONS IDegLira effectively lowered HbA1c across a range of measures, implying suitability for patients with either early or advanced T2D.
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Affiliation(s)
- H W Rodbard
- Endocrine and Metabolic Consultants, Rockville, MD, USA
| | - J B Buse
- Diabetes Care Center, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - V Woo
- Department of Endocrinology, University of Manitoba, Winnipeg, MB, Canada
| | - T Vilsbøll
- Diabetes Research Division, Gentofte Hospital, University of Copenhagen, Hellerup, Copenhagen, Denmark
| | | | - K Kvist
- Novo Nordisk A/S, Søborg, Denmark
| | - S C L Gough
- Oxford Centre for Diabetes Endocrinology and Metabolism, Academic Health Science Network, NIHR Oxford Biomedical Research Centre, Oxford, UK
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Freemantle N, Mamdani M, Vilsbøll T, Kongsø JH, Kvist K, Bain SC. IDegLira Versus Alternative Intensification Strategies in Patients with Type 2 Diabetes Inadequately Controlled on Basal Insulin Therapy. Diabetes Ther 2015; 6:573-591. [PMID: 26582052 PMCID: PMC4674480 DOI: 10.1007/s13300-015-0142-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION IDegLira is a once-daily combination of insulin degludec (IDeg) and liraglutide. Trials directly comparing IDegLira with alternative strategies for intensifying basal insulin are ongoing. While awaiting results, this analysis compared indirectly how different strategies affected glycated hemoglobin (HbA1c) and other outcomes. METHODS A pooled analysis of five completed Novo Nordisk randomized clinical trials in patients with type 2 diabetes inadequately controlled on basal insulin was used to compare indirectly IDegLira (N = 199) with: addition of liraglutide to basal insulin (N = 225) [glucagon-like peptide-1 receptor agonist (GLP-1RA) add-on strategy]; basal-bolus (BB) insulin [insulin glargine (IGlar) + insulin aspart] (N = 56); or up-titration of IGlar (N = 329). A supplementary analysis was performed with the BB arm including patients who received IGlar or IDeg as basal insulin in the relevant trial (N = 210). All trials had comparable inclusion/exclusion criteria and baseline characteristics. Individual patient-level data were analyzed using multivariable statistical models with potential baseline heterogeneity accounted for using explanatory variables. RESULTS At end of study, differences between IDegLira and BB or up-titrated IGlar, respectively, were as follows: reduction in HbA1c -0.30%, 95% confidence interval (-0.58; -0.01) and -0.65% (-0.83; -0.47); change in body weight -6.89 kg (-7.92; -5.86) and -4.04 kg (-4.69; -3.40) all in favor of IDegLira. Confirmed hypoglycemia rate was 122.8 (90.7; 166.1), 1060.8 (680.2; 1654.4), and 286.1 (231.1; 354.1) events/100 patient-years for IDegLira, BB, and up-titrated IGlar, respectively. Odds ratios for achieving HbA1c <7.0%, <7.0% without hypoglycemia, and <7.0% without hypoglycemia and no weight gain were greater with IDegLira versus up-titrated IGlar. The supplementary analysis yielded similar results to the main analysis. Results with IDegLira were similar to those for the 'GLP-1RA add-on' arm. CONCLUSION These results suggest that IDegLira may be more effective, with lower hypoglycemia rates and less weight gain, than up-titrated basal insulin or BB in patients uncontrolled on basal insulin.
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Affiliation(s)
- Nick Freemantle
- Department of Primary Care and Population Health, UCL Medical School, London, UK.
| | - Muhammad Mamdani
- Department of Health Policy, Management and Evaluation (Faculty of Medicine), University of Toronto, Ontario, Canada
| | - Tina Vilsbøll
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Stephen C Bain
- Diabetes and Endocrinology, Institute of Life Science, Swansea University, Swansea, UK
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Holst JJ, Buse JB, Rodbard HW, Linjawi S, Woo VC, Boesgaard TW, Kvist K, Gough SC. IDegLira Improves Both Fasting and Postprandial Glucose Control as Demonstrated Using Continuous Glucose Monitoring and a Standardized Meal Test. J Diabetes Sci Technol 2015; 10:389-97. [PMID: 26443290 PMCID: PMC4773967 DOI: 10.1177/1932296815610124] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE IDegLira is a novel, fixed-ratio combination of the long-acting basal insulin, insulin degludec, and the long-acting glucagon-like peptide-1 analog liraglutide. We studied the effect of IDegLira versus its components on postprandial glucose (PPG) in type 2 diabetes. METHODS In this substudy, 260 (15.6%) of the original 1663 patients with inadequate glycemic control participating in a 26-week, open-label trial (DUAL I) were randomized 2:1:1 to once-daily IDegLira, insulin degludec or liraglutide. Continuous glucose monitoring (CGM) for 72 hours and a meal test were performed. RESULTS At week 26, IDegLira produced a significantly greater decrease from baseline in mean PPG increment (normalized iAUC0-4h) than insulin degludec (estimated treatment difference [ETD] -12.79 mg/dl [95% CI: -21.08; -4.68], P = .0023) and a similar magnitude of decrease as liraglutide (ETD -1.62 mg/dl [95% CI: -10.09; 6.67], P = .70). CGM indicated a greater reduction in change from baseline in PPG increment (iAUC0-4h) for IDegLira versus insulin degludec over all 3 main meals (ETD -6.13 mg/dl [95% CI: -10.27, -1.98], P = .0047) and similar reductions versus liraglutide (ETD -1.80 mg/dl [95% CI: -2.52, 5.95], P = .4122). Insulin secretion ratio and static index were greater for IDegLira versus insulin degludec (P = .048 and P = .006, respectively) and similar to liraglutide (P = .45 and P = .895, respectively). CONCLUSIONS Once-daily IDegLira provides significantly better PPG control following a mixed meal test than insulin degludec. The improvement is at least partially explained by higher endogenous insulin secretion and improved beta cell function with IDegLira. The benefits of liraglutide on PPG control are maintained across all main meals in the combination.
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Affiliation(s)
- Jens J Holst
- NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - John B Buse
- University of North Carolina, Chapel Hill, NC, USA
| | | | | | | | | | | | - Stephen C Gough
- Oxford Centre for Diabetes, Endocrinology and Metabolism, and NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
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Jaeckel E, KIng A, Philis-Tsimikas A, Langbakke I, Kvist K, Vilsbøll T. IDegLira, eine Fixkombination aus Insulin degludec und Liraglutid, verbessert sowohl die prä- als auch die postprandiale Plasmaglucose bei Patienten mit Typ 2 Diabetes. DIABETOL STOFFWECHS 2015. [DOI: 10.1055/s-0035-1549744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
INTRODUCTION Previous research has shown that brain injury patients with Organic Personality Disorder (OPD) may display "borderline" traits due to prefrontal damage, and their personality structure may be unstable and close to a borderline personality organisation. They may have few general neuropsychological dysfunctions but specific executive deficits. Similar deficits have been found in patients with Borderline Personality Disorder (BPD). The objective of this study was to identify differences and similarities between the neuropsychological and personality profiles of BPD and OPD patients. METHODS Twenty BPD patients and 24 OPD patients were assessed with the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II), the Karolinska Psychodynamic Profile (KAPP), and a comprehensive neuropsychological test battery. RESULTS Very few neuropsychological differences were found between the two patient groups. However, the verbal fluency, verbal intelligence, verbal memory, and immediate auditory memory/attention of the BPD patients were significantly poorer than the OPD patients'. The KAPP profiles of the BPD patients showed significantly poorer functioning in three areas: frustration tolerance, the body as a factor of self-esteem, and overall personality organisation. CONCLUSIONS These results support our clinical experience and expectations concerning the severity of symptoms of both patient groups. We suggest considering in depth assessments of both neuropsychological and personality-related problems for each of these patients in order to inform treatment.
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Affiliation(s)
- Birgit B Mathiesen
- a Department of Psychology , University of Copenhagen , Copenhagen , Denmark
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Abstract
OBJECTIVE We investigated which factors can best predict relapse in older patients with major depressive disorder (MDD) who have achieved remission with escitalopram. METHODS A total of 405 patients who were 65 years or older with a primary diagnosis of MDD received 12 week, open-label escitalopram 10 or 20 mg/day. Patients in remission (MADRS ≤12) at Week 12 were randomized to 24 weeks of double-blind treatment with either placebo or escitalopram (fixed dose from Week 6). RESULTS After randomization of 312 patients in remission, patients whose dose had been increased to 20 mg escitalopram after 2 weeks of open-label treatment had a high escitalopram relapse rate (16.7%) and a placebo relapse rate of 32.5% with a hazard ratio (HR) of 2.2, whereas patients titrated to 20 mg escitalopram at Weeks 4 or 6 had a high placebo relapse rate (41.2%) and an escitalopram relapse rate of 5.7% with a HR = 8.9. A high placebo relapse rate was also observed for patients with a baseline MADRS below median, while low escitalopram relapse rates were characteristic of patients who had achieved remission by Week 6 or 8 (HR = 8.9), had a current depressive episode length below median, baseline MADRS below median (HR = 11.8), or received 10 mg for 12 weeks (HR = 6.3). A key limitation of the study was that some analyses were post-hoc and that none of the comparisons between complementary subgroups had nominal p-values <0.05. CONCLUSIONS In this post-hoc analysis of elderly patients with MDD, several factors, including female gender, early remission, low baseline MADRS score, major depressive episode (MDE) duration, and escitalopram dosage, significantly affected the relapse rate after randomization to escitalopram or placebo.
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Pedersen L, Parlar S, Kvist K, Whiteley P, Shattock P. Data mining the ScanBrit study of a gluten- and casein-free dietary intervention for children with autism spectrum disorders: behavioural and psychometric measures of dietary response. Nutr Neurosci 2013; 17:207-13. [PMID: 24075141 DOI: 10.1179/1476830513y.0000000082] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We previously reported results based on the examination of a gluten- and casein-free diet as an intervention for children diagnosed with an autism spectrum disorder as part of the ScanBrit collaboration. Analysis based on grouped results indicated several significant differences between dietary and non-dietary participants across various core and peripheral areas of functioning. Results also indicated some disparity in individual responses to dietary modification potentially indicative of responder and non-responder differences. Further examination of the behavioural and psychometric data garnered from participants was undertaken, with a view to determining potential factors pertinent to response to dietary intervention. Participants with clinically significant scores indicative of inattention and hyperactivity behaviours and who had a significant positive changes to said scores were defined as responders to the dietary intervention. Analyses indicated several factors to be potentially pertinent to a positive response to dietary intervention in terms of symptom presentation. Chronological age was found to be the strongest predictor of response, where those participants aged between 7 and 9 years seemed to derive most benefit from dietary intervention. Further analysis based on the criteria for original study inclusion on the presence of the urine compound, trans-indolyl-3-acryloylglycine may also merit further investigation. These preliminary observations on potential best responder characteristics to a gluten- and casein-free diet for children with autism require independent replication.
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Kvist K, Andersen PK, Angst J, Kessing LV. Event dependent sampling of recurrent events. Lifetime Data Anal 2010; 16:580-98. [PMID: 20526806 DOI: 10.1007/s10985-010-9172-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 05/24/2010] [Indexed: 05/07/2023]
Abstract
The effect of event-dependent sampling of processes consisting of recurrent events is investigated when analyzing whether the risk of recurrence increases with event count. We study the situation where processes are selected for study if an event occurs in a certain selection interval. Motivation comes from psychiatric epidemiology where repeated hospital admissions are studied for patients with affective disease, as seen in Kessing et al. (Acta Psychiatr Scand 109:339-344, 2004b). For the selected processes, either only disease course from selection and onwards is used in the analysis, or, both retrospective and prospective disease course histories are used. We examine two methods to correct for the selection depending on which data are used in the analysis. In the first case, the conditional distribution of the process given the pre-selection history is determined. In the second case, an inverse-probability-of-selection weighting scheme is suggested. The ability of the methods to correct for the bias due to selection is investigated with simulations. Furthermore, the methods are applied to affective disease data from a register-based study (Kessing et al. Br J Psychiatry 185:372-377, 2004a) and from a long-term clinical study (Kessing et al. Acta Psychiatr Scand 109:339-344, 2004b).
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Affiliation(s)
- Kajsa Kvist
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark.
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Brandt-Christensen M, Kvist K, Nilsson FM, Andersen PK, Kessing LV. Treatment with antiparkinson and antidepressant drugs: a register-based, pharmaco-epidemiological study. Mov Disord 2008; 22:2037-42. [PMID: 17853463 DOI: 10.1002/mds.21472] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Depressive symptoms and major depression are frequent in patients with Parkinson's disease (PD). However, a systematic knowledge about the treatment with antidepressant drugs among PD patients is missing. We estimated the frequency of antidepressant drug treatment in a national sample of persons treated with antiparkinson drugs (APDs). All persons treated with APDs were identified in the national Danish Prescription database. The subsequent risk of treatment with antidepressants was estimated and compared with the risks for two large control groups. The study period was 5 years. In total, 1,029,737 persons were included. Persons who got APDs had significantly increased rate ratios (RR) of subsequent antidepressant drug treatment compared with an unexposed control group (RR: 2.10 (95% CI: 2.04-2.16)) and with persons who got anti-diabetic drugs [RR: 1.58 (95% CI: 1.51-1.65)]. Persons treated with APDs have higher frequency of antidepressant drug treatment than have controls. With the reservation that data on drug consumption cannot be directly transferred into conclusions about specific diseases, the present study supports results from other population-based studies of an association between PD and depression.
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Kvist K, Gerster M, Andersen PK, Kessing LV. Non-parametric estimation and model checking procedures for marginal gap time distributions for recurrent events. Stat Med 2007; 26:5394-410. [DOI: 10.1002/sim.3135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
OBJECTIVES To estimate adherence to lithium in a nationwide sample of all patients treated with lithium and to characterize adherence according to gender and age. METHODS Adherence to lithium was estimated using data obtained by linking Medicinal Product Statistics with the Danish Medical Register on Vital Statistics, identifying all persons who received lithium among the 5.3 million persons living in Denmark during the period 1995 to 2000 inclusive. RESULTS The median time to discontinuation of lithium was 181.0 days [95% confidence interval (CI) 135.7-181.0] and 25% of patients stopped treatment with lithium within 45.2 days. Adherence to lithium was significantly poorer for women (135.7 days; 95% CI 90.5-135.7) than for men (316.7 days; 95% CI 271.4-407.1) and for younger (18-39 years) and older (>or=60 years) patients compared to middle-aged patients. CONCLUSIONS The results highlight the need for increased focus on long-term adherence to lithium with intensified psychological support, especially among younger and older female patients.
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Affiliation(s)
- Lars Vedel Kessing
- Department of Psychiatry, University Hospital of Copenhagen, Rigshospitalet, University of Copenhagen, Denmark.
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Avlund K, Vass M, Kvist K, Hendriksen C, Keiding N. Educational intervention toward preventive home visitors reduced functional decline in community-living older women. J Clin Epidemiol 2007; 60:954-62. [PMID: 17689812 DOI: 10.1016/j.jclinepi.2005.06.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Revised: 05/14/2005] [Accepted: 06/01/2005] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate whether immediate effects of a 3-year educational intervention in primary health care were confirmed 18 months after the end of the intervention. STUDY DESIGN AND SETTING A controlled 3-year intervention study in 34 Danish municipalities with randomization and intervention at municipality level. The 17 intervention municipality visitors received regular education, and GPs were introduced to a short assessment program. The effect was measured at the individual level by questions about functional ability at the end of the intervention period and 1(1/2) years later; 4,060 older adults living in the municipalities participated. We adopt the approach introduced by Dufouil et al. (2004) and treat dropouts due to death differently from dropouts from other reasons. RESULTS Educational intervention to primary care professionals was associated with better functional ability in surviving women at the end of the intervention (odds ratio [OR]: 1.24, 95% confidence interval [CI]=1.07-1.45), from the end of the intervention until 1(1/2) years later (OR: 1.21, 95% CI=1.03-1.44) and during the total study period (OR: 1.22, 95% CI=1.06-1.42). No effects were seen in men. CONCLUSION The effect of a brief, feasible educational intervention for primary care professionals is sustained in women 1(1/2) years after the end of the intervention.
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Affiliation(s)
- K Avlund
- Department of Social Medicine, Institute of Public Health, University of Copenhagen, Copenhagen K, Denmark.
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Søndergård L, Kvist K, Lopez AG, Andersen PK, Kessing LV. Temporal changes in suicide rates for persons treated and not treated with antidepressants in Denmark during 1995-1999. Acta Psychiatr Scand 2006; 114:168-76. [PMID: 16889587 DOI: 10.1111/j.1600-0447.2006.00796.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the temporal changes in suicide rate among patients treated with antidepressants with the change in suicide rate among persons who have not been treated with antidepressants during 1995-1999. METHOD In a historic prospective national pharmacoepidemiological register linkage study by using four Danish registers we included 438,625 patients who had purchased antidepressants, and compared them with 1,199,057 population based control persons. The annual rate of suicide was estimated using Poisson regression analyses. RESULTS The suicide rate decreased for persons treated with antidepressants as well as for persons not treated with antidepressants. The proportion of persons, who committed suicide and who had not been treated with antidepressants decreased. The reduction in suicide rate was more pronounced among persons treated with SSRIs or older antidepressants than among persons not treated with antidepressants. CONCLUSION Several factors contribute to the decreasing suicide rate. The most pronounced decrease in suicide rate was found among persons treated with antidepressants.
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Affiliation(s)
- L Søndergård
- Department of Psychiatry, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark.
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Abstract
As in many developed countries, the use of antidepressants in Denmark has been substantially increasing during recent years, coinciding with a decreasing suicide rate. We aimed to investigate the relationship between treatment with antidepressants and suicide on individualized data from a nationwide study comprising an observational cohort study with linkage of registers of all prescribed antidepressants and recorded suicides in Denmark during the period 1995-99. A total of 438 625 patients who purchased at least one prescription of antidepressants and 1073 862 individuals from the general population were included in the study. Patients who continued treatment with selective serotonin reuptake inhibitors (SSRIs) (i.e. who purchased SSRIs twice or more) had a decreased rate of suicide compared with patients who purchased SSRIs once only [rate ratio (RR)=0.63; 95% confidence interval (CI)=0.56-0.71]. Furthermore, the rate of suicide decreased consistently with the number of prescriptions. Similarly, among patients treated with newer antidepressants other than SSRIs, the rate of suicide was decreased compared with the rate for patients who purchased other newer antidepressants once only (RR=0.70; 95% CI=0.52-0.94). Continued antidepressant treatment with SSRIs or other newer antidepressants is found to be associated with a reduced risk of suicide.
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Affiliation(s)
- Lars Søndergård
- Department of Psychiatry, University Hospital of Copenhagen, Rigshospitalet, Copenhagen Ø, Denmark.
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Søndergård L, Kvist K, Andersen PK, Kessing LV. Do antidepressants precipitate youth suicide?: a nationwide pharmacoepidemiological study. Eur Child Adolesc Psychiatry 2006; 15:232-40. [PMID: 16502208 DOI: 10.1007/s00787-006-0527-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2006] [Indexed: 10/25/2022]
Abstract
The association between treatment with Selective serotonin reuptake inhibitors (SSRIs) and suicide in children and adolescents on the individual and ecological level were examined in a nationwide Danish pharmacoepidemiological register-linkage study including all persons aged 10-17 years treated with antidepressants during the period 1995-1999 (n=2,569) and a randomly selected control population (n=50,000). A tripartite approach was used. In Part 1, changes in youth suicide and use of antidepressants were examined. In Part 2, we made an assessment of youth suicide characteristics. In Part 3, we analysed the relative risk (RR) of suicide according to antidepressant treatment corrected for psychiatric hospital contact to minimize the problem of confounding by indication. The use of SSRIs among children and adolescents increased substantially during the study period, but the suicide rate remained stable (Part 1). Among 42 suicides nationally aged 10-17 years at death, none was treated with SSRIs within 2 weeks prior to suicide (Part 2). There was an increased rate of suicide associated with SSRIs (RR=4.47), however, not quite significant (95% CI: 0.95-20.96), when adjusted for severity of illness (Part 3). Conclusively, we were not able to identify an association between treatment with SSRIs and completed suicide among children and adolescents.
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Affiliation(s)
- Lars Søndergård
- Dept. of Psychiatry, University Hospital of Copenhagen, Rigshospitalet Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
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Brandt-Christensen M, Kvist K, Nilsson FM, Andersen PK, Kessing LV. Treatment with antidepressants and lithium is associated with increased risk of treatment with antiparkinson drugs: a pharmacoepidemiological study. J Neurol Neurosurg Psychiatry 2006; 77:781-3. [PMID: 16705201 PMCID: PMC2077439 DOI: 10.1136/jnnp.2005.083345] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Revised: 01/02/2006] [Accepted: 01/06/2006] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To estimate the risk for persons treated with antidepressants or lithium of subsequent treatment with antiparkinson drugs (APD). METHODS The Danish national prescription database supplied data on all persons who received antidepressants, lithium, or antidiabetics (first control group). A second control group was included comprising persons from the general population. Outcome was purchase of APD and the study period was 1995 to 1999. RESULTS In total, 1 293 789 persons were included. The rate ratio of treatment with APD after treatment with antidepressants was 2.27 (95% CI 2.14 to 2.42) for men and 1.50 (95% CI 1.43 to 1.58) for women. Figures for lithium were almost identical. CONCLUSION Persons treated with antidepressants or lithium are at increased risk of subsequently treatment with APD, showing an association between anxiety/affective disorder and Parkinson's disease.
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Affiliation(s)
- M Brandt-Christensen
- Department of Psychiatry, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, DK 2100 Copenhagen, Denmark.
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Brandt-Christensen M, Kvist K, Nilsson FM, Andersen PK, Kessing LV. Use of antiparkinsonian drugs in Denmark: Results from a nationwide pharmacoepidemiological study. Mov Disord 2006; 21:1221-5. [PMID: 16671076 DOI: 10.1002/mds.20907] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The objective of the present study was to record the use of antiparkinsonian drugs (APD) in Denmark and discuss estimates of the incidence and prevalence rates of Parkinson's disease (PD). The main indication for treatment with APD is idiopathic PD. The use of APD is, therefore, an indicator of the epidemiology of PD and Parkinsonism. We used a drug tracer design, which previously has been found applicable in estimating the frequency of PD. From a national prescription database, all persons who purchased APD from 1995 to 2002 could be identified on an individual level. Results show an age-standardized prevalence rate for APD purchase of 164.0 persons per 100,000, and an incidence rate of 55.9 persons per 100,000. The total number of persons purchasing APD was 11,656 per year on average. Our results showed higher figures of persons purchasing APD than the estimated prevalence of idiopathic PD in Denmark, which is approximately 100 persons per 100,000, corresponding to 5,000 to 6,000 persons. The differences might in part be explained by other indications for APD prescription in addition to PD and in part by misdiagnosis. However, the possibility of somewhat higher incidence and prevalence rates of PD than hitherto estimated should be considered.
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Kvist K, Thorup J, Byskov AG, Høyer PE, Møllgård K, Yding Andersen C. Cryopreservation of intact testicular tissue from boys with cryptorchidism. Hum Reprod 2005; 21:484-91. [PMID: 16210383 DOI: 10.1093/humrep/dei331] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Boys with cryptorchidism often face fertility problems in adult life despite having orchiopexy performed at a very young age. During this operation, a biopsy of the testis is normally taken in order to evaluate their infertility potential and the presence of malignant cells. This study evaluated the morphology and functional capacity of cryopreserved testes biopsies and their possible use in fertility preservation. METHODS Biopsies from 11 testes (eight boys) were obtained. Each biopsy was subdivided into six pieces and two pieces were frozen in each of two different cryoprotectants. One fresh and two cryopreserved pieces were cultured for 2 weeks. All pieces were prepared for histology. Used culture media were analysed for testosterone and inhibin B concentrations. RESULTS The morphology of the fresh and frozen-thawed samples was similar, with well-preserved seminiferous tubules and interstitial cells. A similar picture appeared after 2 weeks of culture, but a few of the cultured biopsies contained small necrotic areas. The presence of spermatogonia was verified by c-kit-positive immunostaining. Production of testosterone and inhibin B (ng/mm(3) testis tissue) in the frozen-thawed pieces was on average similar to that of the fresh samples. CONCLUSIONS Intact testicular tissue from young boys with non-descended testes tolerates cryopreservation with surviving spermatogonia and without significant loss of the ability to produce testis-specific hormones in vitro. It may be an option to freeze part of the testis biopsy, which is routinely removed during the operation for cryptorchidism, for fertility preservation in adult life.
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Affiliation(s)
- K Kvist
- Laboratory of Reproductive Biology, Section 5712, Department of Paediatric Surgery, Section 4072, University Hospital of Copenhagen, Rigshospitalet, DK-2100 Copenhagen, Denmark
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Abstract
CONTEXT Prior observational studies suggest that treatment with lithium may be associated with reduced risk of suicide in bipolar disorder. However, these studies are biased toward patients with the most severe disorders, and the relation to sex and age has seldom been investigated. OBJECTIVE To investigate whether treatment with lithium reduces the risk of suicide in a nationwide study. DESIGN An observational cohort study with linkage of registers of all prescribed lithium and recorded suicides in Denmark during a period from January 1, 1995, to December 31, 1999. SETTING All patients treated with lithium in Denmark, ie, within community psychiatry, private specialist practice settings, and general practice. PARTICIPANTS A total of 13 186 patients who purchased at least 1 prescription of lithium and 1.2 million subjects from the general population. MAIN OUTCOME MEASURE All suicides identified on the basis of death certificates completed by doctors at the time of death. RESULTS Patients who purchased lithium had a higher rate of suicide than persons who did not purchase lithium. Purchasing lithium at least twice was associated with a 0.44 reduced rate of suicide (95% confidence interval, 0.28-0.70) compared with the rate when purchasing lithium only once. Further, the rate of suicide decreased with the number of prescriptions of lithium. There was no significant interaction between continued lithium treatment and sex and age regarding the suicide rate. CONCLUSION In a nationwide study including all patients treated with lithium, it was found that continued lithium treatment was associated with reduced suicide risk regardless of sex and age.
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Affiliation(s)
- Lars Vedel Kessing
- Department of Psychiatry, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark.
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Vass M, Avlund K, Kvist K, Hendriksen C, Andersen CK, Keiding N. Structured home visits to older people. Are they only of benefit for women? A randomised controlled trial. Scand J Prim Health Care 2004; 22:106-11. [PMID: 15255491 DOI: 10.1080/02813430410005829] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To investigate whether education of primary care professionals improved functional ability in home-dwelling older people, with special focus on gender differences. DESIGN A prospective controlled three-year follow-up study (1999-2001) with randomisation and intervention at municipality level and outcomes measured at individual level. Intervention municipality visitors received regular education and GPs were introduced to a short assessment programme. Control municipalities received no education but conducted the preventive programme in their own way. SETTING Primary care, 34 municipalities. SUBJECTS 5788 home-dwelling 75- and 80-year-olds were invited. 4060 (70.1%) participated: 2104 in 17 intervention- and 1956 in 17 matched control-municipalities. The main outcome measure was obtained from 3383 (95.6%) of 3540 surviving participants. MAIN OUTCOME MEASURE Functional ability. RESULTS Municipality intervention in coordination with GPs was associated with better functional ability in women (OR: 1.26; CI95: 1.08-1.47, p=0.004), but not in men (OR: 1.04; CI95: 1.85-1.27). Accepting and receiving free preventive home visits was associated with better functional ability among women (OR: 1.36; CI95: 1.16-1.60, p=0.0002), but not among men (OR: 0.98; CI95: 0.80-1.21). CONCLUSION A brief, feasible educational intervention for primary care professionals and to accept and receive preventive home visits may have effect in older women, but not in older men.
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Affiliation(s)
- Mikkel Vass
- Department of General Practice and Central Research Unit for General Practice, Institute of Public Health, University of Copenhagen, Denmark.
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Abstract
A new design for estimating the distribution of time to pregnancy is proposed and investigated. The design is based on recording current durations in a cross-sectional sample of women, leading to statistical problems similar to estimating renewal time distributions from backward recurrence times. Non-parametric estimation is studied in some detail and a parametric approach is indicated. The results are illustrated on Monte Carlo simulations and on data from a recent European collaborative study. The role and applicability of this approach is discussed.
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Affiliation(s)
- Niels Keiding
- Department of Biostatistics, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark.
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Kvist K, Cortes D, Visfeldt J, Thorup JM. [Eosinophilic cystitis in children]. Ugeskr Laeger 1999; 161:6059-60. [PMID: 10778343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Eosinophilic cystitis is an inflammatory disorder of the urinary bladder, characterised by irritative voiding symptoms, negative urine cultures, and eosinophilic infiltration of the bladder wall. Since 1960 only about 20 cases have been described in the English scientific reports, making it a rather rare entity. In children the disease appears to be shortlived and self-limited, requiring no specific treatment. We present a case with a 7.5-year-old boy, who experienced spontaneous remission of all symptoms, following an acute attack of eosinophilic cystitis.
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Affiliation(s)
- K Kvist
- Børnekirurgisk klinik, H:S Rigshospitalet, København
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