Glycaemic control and mortality in older people with type 2 diabetes: The Fremantle Diabetes Study Phase II

Bruce, David; Davis, Wendy A.; Davis, Timothy

doi:10.1111/dom.13469

Cited by 20 publications

(21 citation statements)

References 40 publications

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“…However, unmeasured factors other than hypoglycaemia may be involved in the increased mortality in patients on treatment with agents causing hypoglycaemia, including poor adherence, depression, cognitive impairment, education, socio-economic status, etc. The results of our study are also consistent with the increased mortality reported in older people with type 2 diabetes from the Fremantle Diabetes Study Phase II who were treated with sulfonylurea and/or insulin and had HbA 1c levels < 7.0%, but not with the increased mortality observed in those who were treated with metformin and had HbA 1c levels < 6.5%, a finding which the authors attributed to confounding by indication [20]. Conversely, our data are in contrast with previous reports from the UK General Practice Research Database [21] and the Kaiser Permanente Diabetes Registry of Northwest [22] and Northern California [23] showing a U-shape relationship between achieved HbA 1c and mortality in diabetic individuals, with both higher and lower HbA 1c values associated with increased all-cause mortality.…”

Section: Discussionsupporting

confidence: 89%

Association between On-Treatment Haemoglobin A1c and All-Cause Mortality in Individuals with Type 2 Diabetes: Importance of Personalized Goals and Type of Anti-Hyperglycaemic Treatment

Orsi

Bonora

Solini

et al. 2020

JCM

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The increased mortality reported with intensive glycaemic control has been attributed to an increased risk of treatment-related hypoglycaemia. This study investigated the relationships of haemoglobin (Hb) A1c, anti-hyperglycaemic treatment, and potential risks of adverse effects with all-cause mortality in patients with type 2 diabetes. Patients (n = 15,773) were stratified into four categories according to baseline HbA1c and then assigned to three target categories, based on whether HbA1c was ≤0.5% below or above (on-target), >0.5% below (below-target) or >0.5% above (above-target) their HbA1c goal, personalized according to the number of potential risks among age > 70 years, diabetes duration > 10 years, advanced complication(s), and severe comorbidity (ies). The vital status was retrieved for 15,656 patients (99.26%). Over a 7.4-year follow-up, mortality risk was increased among patients in the highest HbA1c category (≥8.5%) (adjusted hazard ratio, 1.34 (95% confidence interval, 1.22–1.47), p < 0.001) and those above-target (1.42 (1.29–1.57), p < 0.001). Risk was increased among individuals in the lowest HbA1c category (<6.5%) and those below-target only if treated with agents causing hypoglycaemia (1.16 (1.03–1.29), p = 0.01 and 1.10 (1.01–1.22), p = 0.04, respectively). These data suggest the importance of setting both upper and lower personalized HbA1c goals to avoid overtreatment in high-risk individuals with type 2 diabetes treated with agents causing hypoglycaemia.

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Section: Discussionsupporting

confidence: 89%

Association between On-Treatment Haemoglobin A1c and All-Cause Mortality in Individuals with Type 2 Diabetes: Importance of Personalized Goals and Type of Anti-Hyperglycaemic Treatment

Orsi

Bonora

Solini

et al. 2020

JCM

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“…Instead of a reduced risk of cardiovascular diseases, a growing risk of severe hypoglycemia was reported in patients with a number of coexisting diseases and long-term diabetes [9]. This supports the need for early diagnosis followed by intensive therapy of diabetes, but also indicates that the benefits of such treatment are limited in the older population of patients with a long-term disease and short expected survival [10, 11]. Therefore in recent years, there have been discussions among diabetes associations with regard to the target levels of glycemic control, especially in the older population.…”

Section: Introductionmentioning

confidence: 95%

A retrospective cross-sectional study of type 2 diabetes overtreatment in patients admitted to the geriatric ward

Wojszel

Kasiukiewicz

2019

BMC Geriatr

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Background Glycemic control targets in older patients should be individualized according to functional status and comorbidities. The aim of the study was to identify high-risk patients who had evidence of tight glycemic control and thus at risk of serious hypoglycemia. Methods Retrospective cross-sectional study of type 2 diabetes patients admitted to the geriatric ward receiving diabetes medications. Patients’ hospital records were analyzed. The high risk of hypoglycemia group constituted patients who were aged 80+ years, diagnosed with dementia, with end- stage renal disease, or with a history of macrovascular complications. The primary outcome measure was hemoglobin A 1C (HbA 1C ) ≤ 7.0% [53 mmol/mol]. Results Two hundred thirteen patients were included (77.5% women; 49.3% 80+ year-old). 65.3% received sulfonylurea, 39,4%- metformin, 32.9%- insulin, and 4.2%- acarbose (in 61.5% as monotherapy, and in 38.5% combination therapy). We identified 130 patients (60%) as the denominator for the primary outcome measure; 73.1% had a HbA 1C value ≤7.0% [53.3 mmol/mol], but 55.4% ≤6,5% [48.8 mmol/mol], and 40.8% ≤6.0% [42 mmol/mol]. Conclusions The results show a very high rate of tight glycemic control in older patients admitted to the geriatric ward, for whom higher HbA 1C targets are recommended. This indicates the high probability of diabetes overtreatment in this group, associated with a high risk of recurrent hypoglycemia. This is all the more likely because most of them received medications known to cause hypoglycemia. This points to the need of paying more attention to specific difficulties in diabetes treatment in older people, especially those suffering from various geriatric syndromes and diseases worsening their prognosis.

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“…They reported that approximately 50% of patients aged 75 years or older, who were treated with insulin and/or sulphonylureas, had an HbA 1c <53 mmol/mol (<7%) 12 . Similarly, results from The Fremantle Diabetes Cohort Study, which included 367 patients over the age of 75 with type 2 diabetes showed that approximately three of five (61%) of the patients had an HbA 1c <53 mmol/mol (<7%) 37 . As treatment needs to be individualized according to a patient's preferences and resources as well as life expectancy it is of interest that in our cohort dementia was registered as a diagnosis for 16% and non-skin malignancy for 19% of the included patients.…”

Section: Discussionmentioning

confidence: 93%

“…Other studies on glycemic control in older people, including the mentioned studies of nursing home residents and larger cohort studies report a much higher proportion of patients treated with glucose-lowering medication. Thus, between 85-100% of the patients received glucose-lowering medication in other cohort studies of a general population with type 2 diabetes 12,23,37 , and up to 86% were pharmacologically treated in studies investigating glycemic control in nursing home residents 24,39,40 . Our lower treatment prevalence is most likely due to the fact that many patients in our cohort did not meet the criteria for type 2 diabetes at the time of study.…”

Section: Discussionmentioning

confidence: 99%

Glycemic control and use of glucose-lowering medications in hospital-admitted type 2 diabetes patients over 80 years

Gotfredsen

Vinther

Petersen

et al. 2020

Sci Rep

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Treatment guidelines for type 2 diabetes (T2D) recommend avoidance of hypoglycemia and less stringent glycemic control in older patients. We examined the relation of glycemic control to glucoselowering medications use in a cohort of patients aged>80 years with a diagnosis of T2D and a hospital admission in the Capital Region of Denmark in 2012-2016. We extracted data on medication use, diagnoses, and biochemistry from the hospitals' records. We identified 5,172 T2D patients with high degree of co-morbidity and where 17% had an HbA 1c in the range recommended for frail, comorbid, older patients with type 2 diabetes (58-75 mmol/mol (7.5-9%)). Half of the patients (n = 2,575) had an HbA 1c <48 mmol/mol (<6.5%), and a majority of these (36% of all patients) did not meet the diagnostic criteria for T2D. Of patients treated with one or more glucose-lowering medications (n = 1,758), 20% had HbA 1c -values <42 mmol/mol (<6%), and 1% had critically low Hba 1c values <30 mmol/mol (<4.9%), In conclusion, among these hospitalized T2D patients, few had an HbA 1c within the generally recommended glycemic targets. One third of patients did not meet the diagnostic criteria for T2D, and of the patients who were treated with glucose-lowering medications, one-fifth had HbA 1c -values suggesting overtreatment.For patients with type 2 diabetes, it is important to maintain blood glucose levels as close to normal as possible in order to reduce the risk of micro-and macrovascular complications 1-4 . Treatment should, however, be individualized according to comorbidities, disease duration, risk of adverse events and in particular hypoglycemia, life expectancy as well as the patient's own preferences, resources and support system 1 . Elderly people with type 2 diabetes will generally have co-existing illness and relatively few resources 5 . Life expectancy will often be shorter than the time it takes for micro-and macrovascular disease complications to develop and manifest 6,7 . This is in contrast to the potential adverse effects of glucose-lowering medications that often appear in the short term. Hypoglycemia is the most important example of an acute and potentially fatal adverse effect to which elderly are particularly vulnerable [8][9][10][11][12][13][14][15] . Less effective counterregulatory mechanisms, decreased drug elimination, motor and cognitive impairment as well as unspecific/uncharacteristic symptoms all contribute to the heightened risk in elderly patients 16 . Thus, the overall goal with treatment individualization should be to weigh the typically long-term benefits vs. therapy burden and risk of adverse events on the shorter term 7,15,17,18 . Available evidence from the few clinical trials enrolling elderly patients with type 2 diabetes support that the benefits of intensive glycemic control targeting near-normal glycemia may not outweigh potential risks in this population 8,[19][20][21][22] . This is also reflected in several international guidelines which generally advocate a less stringent treatment approach for older ...

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Glycaemic control and mortality in older people with type 2 diabetes: The Fremantle Diabetes Study Phase II

Abstract: Tight glycaemic control may be hazardous in older people with type 2 diabetes when achieved with pharmacotherapy with metformin, and especially with insulin or sulphonylureas. These data confirm that overtreatment is likely to be an important clinical problem in this vulnerable population.

Cited by 20 publications

References 40 publications

Association between On-Treatment Haemoglobin A1c and All-Cause Mortality in Individuals with Type 2 Diabetes: Importance of Personalized Goals and Type of Anti-Hyperglycaemic Treatment

Association between On-Treatment Haemoglobin A1c and All-Cause Mortality in Individuals with Type 2 Diabetes: Importance of Personalized Goals and Type of Anti-Hyperglycaemic Treatment

A retrospective cross-sectional study of type 2 diabetes overtreatment in patients admitted to the geriatric ward

Glycemic control and use of glucose-lowering medications in hospital-admitted type 2 diabetes patients over 80 years

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