Associations of HbA1c and educational level with risk of cardiovascular events in 32 871 drug‐treated patients with Type 2 diabetes: a cohort study in primary care

Aims

To explore the association of HbA_1c and educational level with risk of cardiovascular events and mortality in patients with Type 2 diabetes.

Methods

A cohort of 32 871 patients with Type 2 diabetes aged 35 years and older identified by extracting data from electronic patient records for all patients who had a diagnosis of Type 2 diabetes and had glucose‐lowering agents prescribed between 1999 and 2009 at 84 primary care centres in Sweden. Associations of mean HbA_1c levels and educational level with risks of cardiovascular events and all‐cause mortality were analysed.

Results

The associations of HbA_1c with risk of all‐cause and cardiovascular mortality were J‐shaped, with the lowest risk observed for cardiovascular mortality at an HbA_1c level of 51 mmol/mol (6.8%) for subjects on oral agents and 56 mmol/mol (7.3%) in insulin‐treated patients. The lowest risk observed for all‐cause mortality was at an HbA_1c level of 51 mmol/mol (6.8%) for subjects on oral agents and 56 mmol/mol (7.3%) in insulin‐treated patients. There was an increased risk for cardiovascular death [hazard ratio 1.6 (1.2–2.1), P = 0.0008] at the lowest HbA_1c decile for subjects in the low education category. For subjects with higher education there was no evident J curve for cardiovascular death [hazard ratio 1.2 (0.8–1.6), P = 0.3873].

Conclusions

Our results lend support to the recent American Diabetes Association/ European Association for the Study of Diabetes position statement that emphasizes the importance of additional factors, including the propensity for hypoglycaemia, which should influence HbA_1c targets and treatment choices for individual patients. (Clinical Trials Registry No; NCT 01121315)     

Hemoglobin A1c Levels and the Risk of Cardiovascular Disease in People Without Known Diabetes: A Population-Based Cohort Study in Japan

High hemoglobin A_1c (HbA_1c) levels are strongly associated with an increased risk of cardiovascular disease (CVD) in people with and without diabetes. However, information regarding the relationship between low HbA_1c levels and the risk of CVD among people without known diabetes is limited. The aim of this large-scale, prospective, population-based cohort study was to clarify the association between HbA_1c levels and CVD risk among people without known diabetes.We followed-up 10,980 men and 18,079 women (46–80 years old and free of CVD and cancer at baseline) in the Japan Public Health Center-based Prospective Study. Using Cox models, we estimated the hazard ratios for CVD risk with adjustments for age, sex, geographic areas, body mass index, smoking status, sports and physical exercise, alcohol intake, systolic blood pressure, non-high-density lipoprotein cholesterol, and high-density lipoprotein cholesterol.During the median follow-up of 9.4 years, 935 CVD events (770 strokes and 165 coronary heart diseases) occurred. We observed a nonlinear association between HbA_1c levels and CVD risk in participants without known diabetes. Compared with HbA_1c levels of 5.0 to 5.4% (31–36 mmol/mol), the hazard ratios for CVD in participants without known diabetes were 1.50 (95% confidence interval: 1.15–1.95), 1.01 (0.85–1.20), 1.04 (0.82–1.32), and 1.77 (1.32–2.38) for HbA_1c levels of <5.0% (<31 mmol/mol), 5.5 to 5.9% (37–41 mmol/mol), 6.0 to 6.4% (42–47 mmol/mol), and ≥6.5% (≥48 mmol/mol), respectively (P value for nonlinear trend: <0.001). In addition, the hazard ratio for CVD was 1.81 (1.43–2.29) in patients with known diabetes compared with participants with HbA_1c levels of 5.0 to 5.4% and without known diabetes. This nonlinear relation persisted after excluding people with kidney dysfunction, liver dysfunction, anemia, body mass index <18.5 kg/m², or early events within 3 years of follow-up (P value for nonlinear trend: <0.01 for all tests).In conclusion, both low and high levels of HbA_1c were associated with a higher risk of CVD in a Japanese general population without known diabetes.     

Hemoglobin A1c,comorbid conditions and all-cause mortality in older patients with diabetes: A retrospective 9-year cohort study

AimsTo examine whether hemoglobin A_1c levels and comorbid conditions are related to all-cause mortality in a cohort of patients with type 1 or 2 diabetes receiving continuous care for 9 years. In patients with comorbid congestive heart failure (CHF), we test for ‘reverse epidemiology,’ or whether greater HbA_1c values are associated with lower risk of mortality.MethodsThe population for this longitudinal cohort study was 8820 Group Health enrollees in the Seattle area with type 1 or 2 diabetes in 1997 and enrolled continuously from 1997 to 2006. Comorbid conditions were hypertension, coronary artery disease, congestive heart failure, depression, and chronic pulmonary disease. Mistimed HbA_1c scores were addressed by multiple imputation, and Cox proportional hazards models estimated associations controlling for other risk factors.ResultsAbout 30% of the enrollees died in 1998–2006. CHF had the strongest association with all-cause mortality. Compared to enrollees with HbA_1c ≥ 7.1% (54 mmol/mol) and <7.5% (58 mmol/mol; 5th decile), enrollees with HbA_1c < 6.4% (46 mmol/mol) had a significantly greater risk of death (HR range: 1.28–2.26). HbA_1c > 7.5% had HR < 1.0 but were not significant. For enrollees with diabetes and CHF at baseline, HbA_1c scores ≥ 8.7% (72 mmol/mol) had a significantly lower risk of death (HR range: 0.64–0.69).ConclusionsIn our patient population, HbA_1c scores < 6.4% have significantly higher all-cause mortality. CHF is a major determinant of all-cause mortality. Adults with comorbid CHF and high HbA_1c scores have lower all-cause mortality.     

The impact of structured self-monitoring of blood glucose on glycaemic variability in non-insulin treated type 2 diabetes: The SMBG study,a 12-month randomised controlled trial

Background and AimsThere is inconsistent evidence supporting the self-monitoring of blood glucose (SMBG) in people with non-insulin treated type 2 diabetes (T2D). Structured SMBG protocols have a greater impact on glycaemic control than unstructured SMBG and may improve measures of glycaemic variability (GV), though few previous studies have reported on specific GV outcomes. Our aim was to determine the impact of structured SMBG on simple measures of GV in people with T2D.MethodsParticipants undertook structured SMBG over 12 months, with HbA_1c recorded at baseline and at 3-monthly follow-up. For each participant, the mean blood glucose (MBG), fasting blood glucose (FBG), standard deviation BG (SD-BG), coefficient of variation of BG (CV-BG), mean absolute glucose change (MAG) and HbA_1c were determined for each 3-month period. Responders were participants with an improvement in HbA_1c of ≥5 mmol/mol (0.5%) over 12 months.ResultsData from two hundred and thirty-one participants were included for analysis. Participants had a baseline median [interquartile range] HbA_1c 68.0 [61.5–75.5] mmol/mol (8.4%). Participants demonstrated significant improvements in the MBG (−1.25 mmol/L), FBG (−0.97 mmol/L), SD-BG (−0.44 mmol/L), CV-BG (−1.43%), MAG (−0.97 mmol/L), and HbA_1c (−7.0 mmol/mol) (all p < 0.001) at 12 months compared to these measures collected within the first 3 months of SMBG. Responders had a significantly higher baseline median [interquartile range] HbA_1c of 70.0 [63.0–78.0] mmol/mol compared to 61.0 [56.5–66.0] mmol/mol in non-responders (P < 0.001).ConclusionsStructured SMBG improved all the observed measures of GV. These results support the use of structured SMBG in people with non-insulin treated T2D.     

Fasting plasma glucose and HbA1c as risk factors for Type 2 diabetes

Aims We examined the value of combining fasting plasma glucose (FPG) and glycated haemoglobin (HbA_1c) as a predictor of diabetes, using the new American Diabetes Association (ADA) criteria of FPG and lower cut‐off point of HbA_1c. Methods A retrospective cohort study was conducted from 1998 to 2006, inclusive, in 10 042 persons (55 884 person‐years), with a mean age of 53.0 years at baseline. The cumulative incidence of diabetes (defined either as an FPG ≥ 7.0 mmol/l or as clinically diagnosed diabetes) was measured. Results The cumulative incidence and incidence density of diabetes were 3.7% (368 cases) and 6.6/1000 person‐years over a mean follow‐up period of 5.5 years. The cumulative incidence of diabetes in subjects with impaired fasting glucose (IFG) and HbA_1c 5.5–6.4% was 24.8% (172/694 persons) compared with 0.4% (25/6698 persons), 2.5% (15/605 persons), 7.6% (156/2045 persons) in those with normal fasting glucose (NFG) and HbA_1c < 5.5%, NFG and HbA_1c 5.5–6.4% and IFG and HbA_1c < 5.5%, respectively. The hazard ratio for diabetes, adjusted for possible confounders, was 7.4 (95% confidence interval, 4.70 to 11.74) for those with NFG and HbA_1c 5.5–6.4%, 14.4 (11.93 to 27.79) for those with IFG and HbA_1c < 5.5% and 38.4 (24.63 to 59.88) for those with IFG and HbA_1c 5.5–6.4%. Conclusions The combination of FPG and HbA_1c identifies individuals who are at risk of progression to Type 2 diabetes at the new ADA criteria of FPG and a lower cut‐off point of HbA_1c than previous studies.     

Residual dysglycemia when at target HbA1c of 7% (53 mmol/mol) in persons with type 2 diabetes

Aims

To understand the composition of the residual dysglycemia when HbA_1c is between 6.5% (48 mmol/mol) and 7% (53 mmol/mol), representing the definition of diabetes and the recommended treatment goal, respectively.

Methods

One hundred persons with type 2 diabetes and a HbA_1c < 7% (53 mmol/mol), treated with diet alone and/or oral hypoglycemic agents underwent continuous glucose monitoring (CGM) and were further divided into two subgroups 1 (n = 50) and 2 (n = 50) according to whether the HbA_1c was <6.5% (48 mmol/mol) or 6.5–6.9% (48–52 mmol/mol), respectively. A similar analysis was performed in those on diet alone: subgroups A (n = 34, HbA_1c < 6.5%, 48 mmol/mol) and B (n = 10, HbA_1c 6.5–6.9%, 48–52 mmol/mol). The residual dysglycemia determined from the CGM was assessed using glucose exposures defined as areas under curves (AUCs) and mean glucose values.

Results

Averaged 2-h postprandial glucose value (averaged PPG, mmol/L, mean ± SD) and postprandial glucose exposure (AUCpp, mean ± SD, mmol·L⁻¹·h) were significantly higher in subgroup 2 (mean HbA_1c = 6.7%, 50 mmol/mol) than in subgroup 1 (mean HbA_1c = 6.0%, 42 mmol/mol): averaged PPG = 8.1 ± 1.3 versus 7.3 ± 1.3 mmol/L (p < 0.002); AUCpp = 23.5 ± 8.6 versus 16.2 ± 8.6 (p < 0.0001). The percentages of persons with averaged PPG ≥ 7.8 mmol/L were 52% and 24% (p < 0.01) in subgroups 2 and 1, respectively. Similar results were observed in those (subgroups A and B) who were on diet alone.

Conclusions

The residual dysglycemia in type 2 diabetes with HbA_1c between 6.5 and 6.9% (48–52 mmol/mol) inclusive is mainly due to remnant abnormal postprandial glucose excursions. Consequently, HbA_1c < 6.5% (48 mmol/mol) is an achievable goal with therapeutic measures aimed at reducing postmeal glucose when the HbA_1c is at 7% (53 mmol/mol).     

Fasting plasma glucose and HbA1c in cardiovascular risk prediction: a sex-specific comparison in individuals without diabetes mellitus

Aims/hypothesis

This study aimed to assess the cardiovascular risk of individuals with fasting plasma glucose (FPG)- and/or HbA_1c-defined prediabetes (5.6–6.9 mmol/l and 39–47 mmol/mol [5.7–6.4%], respectively) or manifest diabetes mellitus and to evaluate whether FPG or HbA_1c can improve risk prediction beyond that estimated by the Systematic Coronary Risk Evaluation (SCORE) chart in individuals without diabetes mellitus.

Methods

Cox regression was employed to estimate HRs for primary incident cardiovascular events (CVEs) in a cohort of 8,365 individuals aged 50–74 years. Furthermore, HbA_1c and FPG were added individually to the variables of the SCORE and measures of model discrimination and reclassification were assessed.

Results

During 8 years of follow-up, 702 individuals had a primary CVE. After adjusting for conventional cardiovascular risk factors, HRs were attenuated close to one for the prediabetes groups (especially for women), whereas a 1.7- and a 1.9-fold increased risk persisted for men and women with diabetes, respectively. Extension of the SCORE variables by either FPG or HbA_1c did not improve its predictive abilities in individuals without diabetes. There was a non-significant net reclassification improvement for men when HbA_1c was added (2.2%, p?=?0.16).

Conclusions/interpretation

The increased cardiovascular risk of individuals with FPG- or HbA_1c-defined prediabetes can mainly be explained by other cardiovascular risk factors. Adding FPG or HbA_1c did not significantly improve CVE risk prediction by the SCORE variables in individuals without diabetes mellitus.     

Progression rates from HbA1c 6.0–6.4% and other prediabetes definitions to type 2 diabetes: a meta-analysis

Aims/hypothesis

Precise estimates of progression rates from ‘prediabetes’ to type 2 diabetes are needed to optimise prevention strategies for high-risk individuals. There is acceptance of prediabetes defined by impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), but there is some controversy surrounding HbA_1c-defined prediabetes ranges, with some favouring 6.0–6.4% (42–46 mmol/mol). Comparing progression rates between groups might aid this issue, thus we aimed to accurately estimate progression rates to diabetes from different prediabetes categories.

Methods

Meta-analysis of prospective observational studies in which participants had prediabetes at baseline (ADA-defined IFG [5.6–6.9 mmol/l], WHO-defined IFG [6.1–6.9 mmol/l], IGT (7.8–11.0 mmol/l) or raised HbA_1c [6.0–6.4%/42–46 mmol/mol]) and were followed up for incident diabetes. Incidence rates were combined using Bayesian random effects models.

Results

Overall, 70 studies met the inclusion criteria. In the six studies that used raised HbA_1c, the pooled incidence rate (95% credible interval) of diabetes was 35.6 (15.1, 83.0) per 1,000 person-years. This rate was most similar to that for ADA-defined IFG (11 studies; 35.5 [26.6, 48.0]) and was non-significantly lower than WHO-defined IFG (34 studies; 47.4 [37.4, 59.8]), IGT (46 studies, 45.5 [37.8, 54.5]) and IFG plus IGT (15 studies, 70.4 [53.8, 89.7]). Similar results were seen when the data were analysed by the criteria used to diagnose diabetes.

Conclusions/interpretation

This study provides evidence that progression rates differ by prediabetes definition, which has implications for the planning and implementation of diabetes prevention programmes. HbA_1c 6.0–6.4% might identify people at a lower diabetes risk than other prediabetes definitions, but further research is needed.     

Differences in HbA1C at the time of diabetes diagnosis in the adult population of Ontario,Canada

AimsTo determine the proportion of adults with HbA_1c ≥ 8.0% (64 mmol/mol) at diabetes diagnosis, as an indicator of delayed diagnosis or less intensive screening.MethodsWe conducted a cross-sectional population-level study using clinical, administrative and immigration data from Ontario, Canada. We identified all individuals diagnosed with diabetes between June 2012 and June 2015, and determined the HbA_1c between 60 days prior to and 30 days after diagnosis. Individuals were stratified based on many sociodemographic, clinical and primary care characteristics, and the proportion with HbA_1c ≥ 8.0% (64 mmol/mol) was determined.ResultsMean HbA_1c at diabetes diagnosis in the population was 7.3 ± 1.9% (56 ± 21 mmol/mol), and 21.1% had HbA_1c ≥ 8.0% (64 mmol/mol) at diagnosis. Factors for which there were important differences in the proportion with HbA_1c ≥ 8.0% (64 mmol/mol) included age, sex, ethnicity, comorbidities, frequency of primary care and primary care rostering.ConclusionsIn a real-world population-level setting, more than one-fifth of individuals diagnosed with diabetes have HbA_1c levels ≥8.0% (64 mmol/mol), suggesting a delay in diagnosis due to inadequate screening. Differences were found based on age, sex and clinical factors, but not based on socioeconomic or immigration factors.     

Relationship between number of contacts between previous dropouts with type 2 diabetes and health care professionals on glycaemic control: A cohort study in public primary health care

AimPrevious study findings have shown that more frequent contacts with the diabetes care team predict better diabetes control. It is unknown whether this is true also for previous dropouts with type 2 diabetes (T2D). The aim of this study was to evaluate if those previous dropouts with T2D who succeeded to improve their glycaemic control had more frequent contacts with health care professionals in the public primary diabetes health care system than those dropouts who did not show improvement.MethodsIn this “real life” retrospective cohort study, we identified 115 dropouts with T2D who were contacted by trained diabetes nurses and who returned to a public T2D-care system. Those previous dropouts who had baseline haemoglobin A_1c ≥53 mmol/mol (7%) and had a reduction in HbA_1c ≥ 6 mmol/mol (0.5%) during the follow-up were compared with those with unsatisfactory change in HbA_1c (baseline HbA_1c ≥ 53 mmol/mol and change <6 mmol/mol, or HbA_1c < 53 mmol/mol at the baseline measurement but above that in the end of the study period) or with those who remained at good glycaemic control over the study period. Trained diabetes nurses collected quantitative data from the patient records about visits and contacts during the follow-up.ResultsPrevious dropouts showing improvement had more visits to the diabetes nurse (p = 0.003) and other nurses (p < 0.001) than those with no improvement or those with satisfactory glycaemic control. Telephone calls not focusing on diabetes (p < 0.001) were also more frequent among previous dropouts with improvement than among the others.ConclusionsEspecially previous dropouts with T2D who had poor glycaemic control, may benefit from more frequent contacts including visits and telephone calls. Recalling dropouts does not seem to lead to overuse of the T2D care-system by those recalled patients whose glycaemic control does not require special care.     

Diagnostic value of glycated haemoglobin (HbA1c) for the early detection of diabetes in high‐risk subjects

Objective The aim of this study was to assess the validity of fasting plasma glucose (FPG) and/or glycated haemoglobin (HbA_1c) as screening tests for the early detection of diabetes in high‐risk subjects. Methods A total of 392 subjects (149 male and 243 female) with risk factors for diabetes were included. All subjects underwent a 75‐g oral glucose tolerance test and HbA_1c measurement. Receiver operating characteristic curve analysis was used to examine the sensitivity and specificity of FPG and HbA_1c for detecting diabetes, which was defined as a FPG ≥ 7.0 mmol/l or a post‐challenge 2‐h plasma glucose ≥ 11.1 mmol/l. Results The prevalence of newly diagnosed diabetes was 22.4% (n = 88). The current guideline of FPG ≥ 7.0 mmol/l for diabetes screening detected only 55.7% of diabetic subjects. The optimal cut‐off points of HbA_1c and FPG for the diagnosis of diabetes were 6.1% (sensitivity 81.8%, specificity 84.9%) and 6.1 mmol/l (sensitivity 85.2%, specificity 88.5%), respectively. The screening model using FPG ≥ 6.1 mmol/l and/or HbA_1c ≥ 6.1% had sensitivities of 71.6–95.5% and specificities of 77.6–95.7% for detecting undiagnosed diabetes. Conclusions The current American Diabetes Association diagnostic criteria, based only on FPG, are relatively insensitive in the detection of diabetes in high‐risk subjects. The simultaneous measurement of FPG and HbA_1c might be a more sensitive screening tool for identifying high‐risk individuals with diabetes at an early stage.     

Modelling incremental benefits on complications rates when targeting lower HbA1c levels in people with Type 2 diabetes and cardiovascular disease

Aim

Glucose‐lowering interventions in Type 2 diabetes mellitus have demonstrated reductions in microvascular complications and modest reductions in macrovascular complications. However, the degree to which targeting different HbA_1c reductions might reduce risk is unclear.

Methods

Participant‐level data for Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS) participants with established cardiovascular disease were used in a Type 2 diabetes‐specific simulation model to quantify the likely impact of different HbA_1c decrements on complication rates. Ten‐year micro‐ and macrovascular rates were estimated with HbA_1c levels fixed at 86, 75, 64, 53 and 42 mmol/mol (10%, 9%, 8%, 7% and 6%) while holding other risk factors constant at their baseline levels. Cumulative relative risk reductions for each outcome were derived for each HbA_1c decrement.

Results

Of 5717 participants studied, 72.0% were men and 74.2% White European, with a mean (sd ) age of 66.2 (7.9) years, systolic blood pressure 134 (16.9) mmHg, LDL‐cholesterol 2.3 (0.9) mmol/l, HDL‐cholesterol 1.13 (0.3) mmol/l and median Type 2 diabetes duration 9.6 (5.1–15.6) years. Ten‐year cumulative relative risk reductions for modelled HbA_1c values of 75, 64, 53 and 42 mmol/mol, relative to 86 mmol/mol, were 4.6%, 9.3%, 15.1% and 20.2% for myocardial infarction; 6.0%, 12.8%, 19.6% and 25.8% for stroke; 14.4%, 26.6%, 37.1% and 46.4% for diabetes‐related ulcer; 21.5%, 39.0%, 52.3% and 63.1% for amputation; and 13.6%, 25.4%, 36.0% and 44.7 for single‐eye blindness.

Conclusions

These simulated complication rates might help inform the degree to which complications might be reduced by targeting particular HbA_1c reductions in Type 2 diabetes.     

Patients newly diagnosed with clinical type 2 diabetes mellitus but presenting with HbA1c within normal range: 19-Year mortality and clinical outcomes

AimsTo investigate whether long-term mortality or clinical outcomes differed between patients diagnosed with type 2 diabetes mellitus and presenting with HbA_1c within or above normal range at time of diagnosis.MethodsData were from a population-based sample of 1136 individuals with newly diagnosed type 2 diabetes mellitus. The diagnosis was confirmed with a single fasting whole blood/plasma glucose ≥7.0/8.0 mmol/l. The median time from day of diagnosis until end of follow up was 18.8 years. Patients were grouped according to normal HbA_1c and elevated HbA_1c at diagnosis. The effect of elevated HbA_1c on a number of clinical outcomes and all-cause mortality was assessed in Cox regression models.ResultsAt diagnosis, 97 patients (8.5%) had an HbA_1c level within normal range. Age (mean (SD)) at diagnosis was 64.5 (11.5) years. Both unadjusted and adjusted hazard ratios for the effect of HbA_1c on mortality and other outcomes were not statistically significant.ConclusionsPatients who are diagnosed with type 2 diabetes mellitus by means of elevated fasting whole blood/plasma glucose but have HbA_1c within reference range at diagnosis do not seem to have a relatively benign long-term clinical course. Therefore new diagnostic procedures should preferably be able to identify these individuals.     

The role of childhood BMI in predicting early adulthood dysglycemia: Tehran lipid and glucose study

Background and AimIncreased adiposity is associated with insulin resistance and glycemic disturbances. We aimed to determine whether childhood overweight or obesity are independent factors in predicting adulthood dysglycemia (prediabetes or type 2 diabetes).Methods and ResultsIn this population-based cohort study, 1290 normoglycemic subjects aged 3–11 years were followed for incidence of dysglycemia. Cox-proportional hazard models were employed to evaluate the association of obesity and overweight with incidence of dysglycemia by adjustments for age, sex, parental risk factors and baseline individual risk factors.The participants, with a mean age of 7.7 ± 2.5 years, were followed for a median of 14.9 years. During follow up, 158 subjects developed dysglycemia (18 type 2 diabetes, 140 prediabetes), contributing to a total cumulative incidence of 24.7%. The unadjusted HR for developing adult dysglycemia were 1.6 (95% CI; 1.0–2.4) and 1.7 (95% CI; 1.0–3.0) in overweight and obese children, respectively. Further adjustments for age, sex, parental risk factors and baseline individual risk factors changed the results in both overweight and obese children.ConclusionThese findings show that overweight or obesity in childhood have no independent role for developing adulthood dysglycemia.     

Assessing the economic value of maintained improvements in Type 1 diabetes management,in terms of HbA1c,weight and hypoglycaemic event incidence

Aims

Insulin therapy is indicated for people with Type 1 diabetes mellitus; however, treatment‐related weight gain and hypoglycaemia represent barriers to optimal glycaemic management. This study assessed the health economic value of maintained reductions in HbA_1c, BMI and hypoglycaemia incidence among the UK Type 1 diabetes population.

Methods

The Cardiff Type 1 Diabetes Model was used to estimate lifetime costs, life‐years and quality‐adjusted life‐years (QALYs) for individuals with Type 1 diabetes at different baseline HbA_1c, BMI and hypoglycaemic event rates. Results were discounted at 3.5%, and the net monetary benefit associated with improving Type 1 diabetes management was derived at £20 000/QALY gained. Per‐person outputs were inflated to national levels using UK Type 1 diabetes prevalence estimates.

Results

Modelled subjects with an HbA_1c of 86 mmol/mol (10.0%) were associated with discounted lifetime per‐person costs of £23 795; £12 649 of which may be avoided by maintaining an HbA_1c of 42 mmol/mol (6.0%). Combined with estimated QALY gains of 2.80, an HbA_1c of 42 mmol/mol (6.0%) vs. 86 mmol/mol (10.0%) was associated with a £68 621 per‐person net monetary benefit. Over 1 year, unit reductions in BMI produced £120 per‐person net monetary benefit, and up to £197 for the avoidance of one non‐severe hypoglyceamic event.

Conclusions

Maintained reductions in HbA_1c significantly alleviate the burden associated with Type 1 diabetes in the UK. Given the influence of weight and hypoglycaemia on health economic outcomes, they must also be key considerations when assessing the value of Type 1 diabetes technologies in clinical practice.     

Effect of HbA1c combined FPG on screening diabetes in health check-up

ObjectiveTo appraise the effectiveness of HbA_1c and fasting plasma glucose (FPG) on screening diabetes in health check-up.MethodsA total of 1 337 individuals (male 850, female 487), aged 27 to 91 years with HbA_1c test were included. Participates with HbA_1c ?6.0% or FPG?6.1 mmol/L underwent oral glucose tolerance test (OGTT). Diabetes mellitus was diagnosed according to the criteria of WHO in 1999, FPG?7.0 mmol/L and/or OGTT 2 h-postload plasm glucose (2 h-PG)?11.1 mmol/L. The sensitivity and specificity of HbA_1c thresholds and FPG or combination test on screening of diabetes were analyzed.ResultsA total of 842 subjects had HbA_1c <6.0%, in which 32 had isolated FPG?6.1 mmol/L, of 495 had HbA_1c?6.0%. Subjects with HbA_1c?6.0% had significant increased disorder indexes than those with HbA_1c<6.0%. 527 subjects who had HbA_1c?6.0% or FPG?6.1 mmol/L underwent OGTT. A total of 234 subjects were newly diagnosed diabetes, including 123 (123/234, 52.56%) with FPG?7.0 mmol/L, and 111 subjects (111/234, 47.43%) with isolated 2 h-PG?11.1 mmol/L. Among 234 new diabetes, 91.88% (215 subjects) had HbA_1c?6.3%, and 77.40% (181 subjects) had HbA_1c?6.5%. HbA_1c?6.3% combined FPG ?7.0 mmol/L increased the positive rate of newly diagnosed diabetes from 91.88% to 96.58%.ConclusionsHbA_1c is a practical and convenient tool for screening undiagnosed diabetes in routine health check-up of a large population. Combined use of HbA_1c?6.3% and/or FPG?7.0 mmol/L is efficient for early detection of diabetes.     

Short-term impact of HbA1c on morbidity and all-cause mortality in people with type 2 diabetes: a Danish population-based observational study

Aims/hypothesis  

In a population-based setting, we investigated whether diabetes-related morbidity and all-cause mortality within 2 years of HbA_1c measurement were associated with that HbA_1c level in individuals with type 2 diabetes. The main objective was to compare outcomes in those with HbA_1c ≥ and <7% (53 mmol/mol).     

Factors associated with reaching or not reaching target HbA1c after initiation of basal or premixed insulin in patients with type 2 diabetes

AimsTo evaluate factors associated with reaching or not reaching target glycated haemoglobin (HbA_1c) levels by analysing the respective contributions of fasting hyperglycaemia (FHG), also referred to as basal hyperglycaemia, vs postprandial hyperglycaemia (PHG) before and after initiation of a basal or premixed insulin regimen in patients with type 2 diabetes.MethodsThis post-hoc analysis of insulin-naïve patients in the DURABLE study randomised to receive either insulin glargine or insulin lispro mix 25 evaluated the percentages of patients achieving a target HbA_1c of < 7.0% (< 53 mmol/mol) per baseline HbA_1c quartiles, and the effect of each insulin regimen on the relative contributions of PHG and FHG to overall hyperglycaemia.ResultsPatients had comparable demographic characteristics and similar HbA_1c and FHG values at baseline in each HbA_1c quartile regardless of whether they reached the target HbA_1c. The higher the HbA_1c quartile, the greater was the decrease in HbA_1c, but also the smaller the percentage of patients achieving the target HbA_1c. HbA_1c and FHG decreased more in patients reaching the target, resulting in significantly lower values at endpoint in all baseline HbA_1c quartiles with either insulin treatment. Patients not achieving the target HbA_1c had slightly higher insulin doses, but lower total hypoglycaemia rates.ConclusionSmaller decreases in FHG were associated with not reaching the target HbA_1c, suggesting a need to increase basal or premixed insulin doses to achieve targeted fasting plasma glucose and improve patient response before introducing more intensive prandial insulin regimens.     

Type 2 diabetes care in North Karelia Finland: Do area-level socio-economic factors affect processes and outcomes?

AimsThis research assessed the impact of area-level socio-economic factors on the prevalence and outcomes of type 2 diabetes in North Karelia, Finland.MethodsAll type 2 diabetes patients (n = 10,204) were analyzed from the regional electronic patient database during the years 2011 and 2012. The patient's individual laboratory data was used to assess whether hemoglobin A_1c (HbA_1c) was measured and whether the recommended level of HbA_1c <7% (<53 mmol/l) was achieved. The variables describing socio-economic characteristics of postal code areas were retrieved from the database of Statistics Finland. Linear and logistic regression analyses were used to determine associations.ResultsHbA_1c had been measured in 83% of patients. Over 70% of those with HbA_1c measured reached the recommended level of HbA_1c. The worse the area-level socio-economic status, the more probably HbA_1c was not measured. Achieving the recommended HbA_1c level was associated with being female and having a better area-level socio-economic status. The age-adjusted prevalence of type 2 diabetes was not linearly dependent on the socio-economic circumstances of the postal code areas.ConclusionsThis study shows that socio-economic factors at the small area-level are associated with treatment outcomes. The information from the regional electronic patient database linked with area-level socio-economic information could be effectively utilized to improve diabetes care.     

Real-world safety and effectiveness of iGlarLixi in people with type 2 diabetes who fast during Ramadan: The SoliRam observational study

Background and aimsTo evaluate the safety and effectiveness of iGlarLixi in adults with type 2 diabetes (T2D) fasting during Ramadan.MethodsSoliRam was a multinational, prospective, single-arm, real-world observational study conducted during Ramadan 2020 and 2021 in adults with T2D treated with iGlarLixi ≥3 months at study entry. The primary endpoint was the percentage of participants experiencing ≥1 episode of severe and/or symptomatic documented hypoglycemia (<70 mg/dL [<3.9 mmol/L]).ResultsAmong the 409 eligible participants followed during Ramadan, 96.8% fasted for ≥25 days and 92.4% did not break fasting during Ramadan. Four participants broke their fast due to hypoglycemia. Minimal adjustments were seen in antihyperglycemic therapies from pre to during Ramadan. Documented symptomatic hypoglycemia was experienced by 1.0%, 2.3%, and 0.3% of participants, respectively, during the last month of pre-Ramadan, Ramadan, and first month post-Ramadan. Mean change in HbA_1c from pre-to post-Ramadan periods was ?0.75% (?8.2 mmol/mol), and participants with HbA_1c <7% (<53 mmol/mol) increased from 7.9% pre-Ramadan to 28.6% post-Ramadan.ConclusionsiGlarLixi is an effective and well-tolerated therapy for people with T2D, including those who intend to fast during Ramadan, and is associated with a low risk of hypoglycemia; benefits were observed both during and after Ramadan.