Early glycaemic changes after initiation of oral antidiabetic medication and risk of major adverse cardiovascular events: results from a large primary care population of patients with type 2 diabetes

2020 ◽  
Author(s):  
Jonas Ghouse ◽  
Paul Blanche ◽  
Morten W Skov ◽  
Bent Lind ◽  
Allan Vaag ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Cardiovascular Events ◽  
Major Adverse Cardiovascular Events ◽  
Short Term ◽  
Oral Antidiabetic ◽  
Steep Decline ◽  
Pre Treatment ◽  
First Time

Abstract Aims To determine the risk of major adverse cardiovascular events (MACE) and death, associated with an early large and rapid decline in glycated haemoglobin (HbA1C) following first time initiation of an oral antidiabetic drug (OAD). Methods and results We included 10 518 primary care patients with type 2 diabetes, who initiated an OAD for the first time. For each individual, we measured a decline in HbA1C, as the difference between the pre-treatment HbA1C (within 3 months before OAD initiation) and the post-treatment HbA1C (within 1.5–4.5 months after OAD initiation), divided by the time between the two measurements. The decline was reported in mmol/mol change per 3 months in HbA1C and categorized by the median decline into levels of steep [≥9 mmol/mol (≥0.8%)] and flat decline [<9 mmol/mol per 3 months (<0.8%)]. Pre-treatment HbA1C was categorized by the median, into levels of low (48–62 mmol/mol) and high (>62 mmol/mol). Multiple Cox regression was used to study the effect of decline (steep vs. flat) on the outcome hazard rates separately for patients with low and high pre-treatment HbA1C. Analyses were adjusted for age, sex, traditional cardiovascular risk factors, severe comorbidities, and concomitant medication treatment. During a median follow-up time of 7.7 years, 1625 developed MACE and 2323 died. We found that a steep decline vs. a flat decline was significantly associated with a decreased hazard for MACE, both in individuals with high [hazard ratio (HR) 0.81; 95% confidence interval (CI) 0.69–0.94; P = 0.005] and low pre-treatment HbA1C (HR 0.79; 95% CI 0.66–0.96; P = 0.015). The hazard of MACE was more pronounced on the short-term vs. long-term in individuals with high pre-treatment HbA1C. We found no significant association between combinations of pre-treatment HbA1C and decline categories and hazard of all-cause mortality. However, a combination of a low pre-treatment HbA1C and steep decline was associated with increased 1-year mortality (HR 1.52; 95% CI 1.00–2.29; P = 0.048) and hypoglycaemia (HR 1.82; 95% CI 1.11–2.98; P = 0.017). Conclusion A combination of a high pre-treatment HbA1C and a steep decline in HbA1C was associated with a decreased short-term risk of MACE. A low pre-treatment HbA1C and a steep decline was associated with a long-term reduced risk of MACE, but a short-term increased risk of death and hypoglycaemia.

P6269Early glycemic changes after initiation of oral anti-diabetic medication and risk of major adverse cardiovascular events: results from a large primary care population of patients with type 2 diabetes

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Ghouse ◽  
M W Skov ◽  
M S Olesen ◽  
A G Holst ◽  
J B Nielsen
Keyword(s):  
Primary Care ◽  
P Value ◽  
Short Term ◽  
Primary Care Population ◽  
All Cause Mortality ◽  
Pre Treatment ◽  
First Time ◽  
Large Decline

Abstract Background Results from randomized trials in patients with type 2 diabetes have led to concerns regarding the safety and efficacy of aiming for normoglycemia. Purpose To determine the risk of major cardiovascular events (MACE) and death, associated with a large and rapid decline in HbA1C following first time initiation of an oral antidiabetic drug (OAD). Methods We included 10,518 primary care patients with T2D, who initiated an OAD for the first time. For each individual, we measured a decline in HbA1C, as the difference between the pre-treatment HbA1C (within 3 months before OAD initiation) and the post-treatment HbA1C (within 1.5–4.5 months after OAD initiation), divided by the time between the two measurements. The decline was reported in mmol/mol change per 3 months in HbA1C and categorized by the median decline into levels of steep (≤−9 mmol/mol [≤−0.8%]) and flat decline (>−11 mmol/mol per 3 mo. [> −1%]). Pre-treatment HbA1C was categorized by the median, into levels of low (48–70 mmol/mol) and high (>70 mmol/mol). Multiple Cox regression was used to study the effect of decline (steep vs. flat) on the outcome hazard rates separately for patients with low and high pre-treatment HbA1C, adjusted for age, sex, traditional cardiovascular risk factors, severe comorbidities, and concomitant medication treatment. Results During a median follow-up time of 7.7 years, 1,625 developed MACE and 2,323 died. We found that a steep decline vs. a flat decline was significantly associated with a decreased hazard for MACE, both in individuals high (Figure A; HR 0.81; 95% CI 0.69–0.94; P-value = 0.005) and low pre-treatment HbA1C (Figure A; HR 0.79; 95% CI 0.66–0.96; P-value = 0.015). The hazard of MACE was more pronounced on the short-term vs. long-term in individuals with high pre-treatment HbA1C (Figure A). We found no significant long-term association between combinations of pre-treatment HbA1C and decline categories and hazard of all-cause mortality. However, in patients with a low pre-treatment HbA1C, a steep slope was associated with an increased hazard of 1-year mortality (Figure B; HR 1.52; 95% CI 1.00–2.29; P-value = 0.048). Conclusions Using a primary-care population with T2D initiating an OAD for the first time, a combination of a high pre-treatment HbA1C and a large decline in HbA1C observed 3 months post-initiation, was associated with a decreased short-term risk of MACE, while a low pre-treatment HbA1C and a large decline was associated with an increased short-term risk of all-cause mortality. Although observational data have important limitations, our data indicate that clinicians might need to differentiate treatment with OADs based on the level of pre-treatment glycemia and be attentive to the magnitude of the HbA1C lowering observed three months post-initiation. Acknowledgement/Funding The Research Foundation at Copenhagen University Hospital, Rigshospitalet

Abstract #238: Improved Short Term and Long Term Outcomes of Early Insulin Initiation in Type 2 Diabetes Over 10 Years

2017 ◽  
Vol 23 ◽  
pp. 50
Author(s):  
Jothydev Kesavadev ◽  
Shashank Joshi ◽  
Banshi Saboo ◽  
Hemant Thacker ◽  
Arun Shankar ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Insulin Initiation ◽  
Long Term Outcomes ◽  
Short Term

scholarly journals NHS Health Checks for people with mental ill-health 2013–2017: an observational study

2020 ◽  
Vol 29 ◽  
Author(s):  
C. Garriga ◽  
J. Robson ◽  
C. Coupland ◽  
J. Hippisley-Cox
Keyword(s):  
Type 2 Diabetes ◽  
Cardiovascular Events ◽  
Health Check ◽  
Health Checks ◽  
Hazard Ratios ◽  
Nationally Representative ◽  
Nhs Health Checks ◽  
Nhs Health Check

Abstract Aims People living with serious mental ill-health experience adverse cardiovascular outcomes causing some of the greatest health inequality gaps in England, UK. We describe uptake of the NHS Health Check programme in people with mental ill-health, and rates of new diagnoses and management of cardiovascular risk factors in those who attend NHS Health Checks in comparison to those people without mental ill-health. Methods We used a large nationally representative database of people registered with general practitioners in England (QResearch). Between 2013 and 2017, we analysed attendance at NHS Health Checks and outcomes in the succeeding 12 months, in people with serious mental illness (SMI) including psychoses and in people prescribed long-term antidepressant medications (LTAD), with comparison to attendees who did not have these conditions. Hazard ratios (HR) were used to describe the association between outcomes and SMI and LTAD adjusting for sociodemographic variables. Results In those eligible for the NHS Health Check programme, we found a higher percentage of people with SMI attended an NHS Health Check (65 490, 19.8%) than those without SMI (524 728, 16.6%); adjusted HR 1.05 [95% confidence interval 1.02–1.08]. We also observed a higher percentage of attendance in people on LTAD (46 437, 20.1%) compared to people who were not prescribed LTAD (543 781, 16.7%); adjusted HR 1.10 (1.08–1.13). People with SMI were more likely to be identified with chronic kidney disease (CKD, HR 1.23, 1.12–1.34) and type 2 diabetes (HR 1.14, 1.03–1.25) within the 12 months following their NHS Health Check compared with those without SMI. People on LTAD were more likely to be identified with CKD (HR 1.55, 1.42–1.70) and type 2 diabetes (HR 1.45, 1.31–1.60) and also hypertension, cardiovascular disease, non-diabetic hyperglycaemia, familial hypercholesterolemia and dementia within the 12 months following their NHS Health Check. Statins were more likely to be prescribed to NHS Health Check attendees with SMI and those on LTAD than those without these conditions; HR 1.31 (1.25–1.38) and 1.91 (1.82–2.01), respectively. Antihypertensives were more likely to be prescribed to those on LTAD; HR 1.21 (1.14–1.29). Conclusions We found evidence that people with SMI or on LTAD treatment were 5–10% more likely to access NHS Health Checks than people without these conditions. People with SMI or on LTAD treatment who attended NHS Health Checks had higher rates of diagnosis of CKD, type 2 diabetes and some other relevant co-morbidities and increased treatment with statins and also anti-hypertensive medication in people on LTAD. This is likely to contribute to equitable reduction in adverse cardiovascular events for people with mental ill-health.

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