All-cause mortality of insulin plus dipeptidyl peptidase-4 inhibitors in persons with type 2 diabetes.

BACKGROUND: Dipeptidyl peptidase-4 (DPP-4) inhibitors could effectively reduce HbA1C and postprandial hyperglycemia and could incur only minimal danger of hypoglycemia. Patients with uncontrolled diabetes might be treated by the complementary action of insulin plus DPP-4 inhibitors. Here, we compared the all-cause mortality risk between DPP-4 inhibitor users and nonusers with underlying insulin therapy. METHODS: Using the population-based National Health Insurance Research Database of Taiwan, we conducted an 11-year retrospective cohort study. A total of 3120 patients undergoing insulin therapy for type 2 diabetes mellitus (T2DM) during 2000-2010 were enrolled. The overall incidence rates for all-cause mortality of 1560 DPP-4 inhibitor users and 1560 matched DPP-4 inhibitor nonusers were compared. RESULTS: No significant difference was found in the baseline demographic and clinical variables of the two groups of patients. Median follow-up period for the matched cohort was 1.67 years. All-cause mortality was observed in 93 (6.0%) of 1560 DPP-4 inhibitor nonusers and 36 (2.3%) of 1560 DPP-4 users. The incidence rate of mortality was 11.72 for DPP-4 inhibitor users and 38.16 per 1000 person-years for DPP-4 inhibitor nonusers. After multivariate adjustment, DPP-4 inhibitor users ran a reduced mortality risk (adjusted hazard ratio 0.32, 95% CI 0.22-0.47; p < 0.0001) than did the nonusers. CONCLUSION: Risk of all-cause mortality may be reduced when using insulin plus DPP-4 inhibitors than when using insulin plus non-DPP-4 inhibitors.

[From Monologue to Dialogue: The Evolution of Diabetes Self-Management Education].

Diabetes is a chronic disease. Patients with diabetes must actively change their eating and exercise habits and cannot rely solely on medication. Moreover, these patients need to control high blood glucose, high blood pressure, and high blood cholesterol, commonly known as control of the "three highs". As the current state of diabetes control is not ideal in the United States and Taiwan, disease-related complications such as blindness and the need for dialysis is expected to continue to increase in these countries in the future. This article highlights the possible factors of poor control of the "three highs" such as the therapeutic inertia of physicians (also known as clinical inertia), patient adherence, and current challenges in diabetes self-management education. In the past, courses in health education at our institution have been frequently delivered in monologue format. In recent years, we have tried a form of group therapy known as shared medical appointment (SMA) in order to encourage dialogue among patients and minimize didactic teaching. The preliminary results have been promising. In recent weeks, we began to discuss targeting SMA therapy on the topics of food metabolism and the typical effects and side effects of new and old drugs. We hope this will ease our introduction of shared decision making (SDM) in the near future. Promoting time-consuming procedures such as SDM is difficult in Taiwan because national-insurance health insurance payments to the healthcare provider are based on volume rather than value. We hope that the Health Insurance Bureau begins to recognize and appreciate the contribution of nurse educators and dietitians in the care of patients with diabetes and approve compensation for their hard work.

Mortality trends in patients with diabetes in Taiwan: a nationwide survey in 2000-2009.

BACKGROUND/PURPOSE: Medical systems and care for diabetes have changed greatly in Taiwan in recent years. This study investigated mortality trends in patients with diabetes in Taiwan from 2000 to 2009. METHODS: We linked the National Health Insurance (NHI) claims database, which contains data on 99% of the population of Taiwan, to the National Death Registry and Cancer Registry. Patients were classified as having diabetes if they had at least one hospital admission or three or more outpatient visits with a diabetes diagnostic code in each calendar year. Mortality data from the Collaboration Center of Health Information Application were used to estimate age- and sex-specific mortality rates, all-cause mortality, and life expectancy (LE). RESULTS: The mortality of patients with diabetes in Taiwan decreased continuously from 2000 to 2009 for both sexes and all age groups; the mortality rate was generally higher for men than for women (3.92% vs. 3.29% in 2000; 3.64% vs. 3.11% in 2005, and 3.12% vs. 2.71% in 2009, all p < 0.05). Diabetic patients had a shorter LE than the entire population, although this difference decreased over time. The estimated loss of life due to diabetes was 6.1 years in women and 5.3 years in men in 2009, when diabetes was diagnosed at the age of 40. The four major causes of death were diabetes, malignancies, heart diseases, and cerebrovascular diseases. CONCLUSION: The mortality of diabetic patients in Taiwan decreased from 2000 to 2009. Although patients with diabetes had a shorter LE than the entire population, the difference decreased over time.

Prevalence of hypertension and dyslipidemia and their associations with micro- and macrovascular diseases in patients with diabetes in Taiwan: an analysis of nationwide data for 2000-2009.

BACKGROUND/PURPOSE: Cardiovascular complication is the leading cause of mortality in patients with diabetes. Dyslipidemia and hypertension are the major risk factors contributing to cardiovascular disease (CVD). This study was carried out to investigate the prevalence of dyslipidemia and hypertension and their associations with microvascular and macrovascular complications in patients with type 2 diabetes in Taiwan. METHODS: Health-care data and diagnostic codes were retrieved from the Taiwan Bureau of National Health Insurance claims files for the years 2000-2009. Based on these data the annual prevalences of dyslipidemia and hypertension were calculated and patients were stratified by age, gender, and diabetic complications. RESULTS: In patients with diabetes, the prevalence of dyslipidemia increased with age, with the highest rate recorded in adults (inclusive of both genders) between 40 and 65 years of age (p for trend <0.001). The prevalence of hypertension also increased with age with the highest rate seen in adults (inclusive of both genders) >65 years of age (p for trend <0.001). The prevalence of stroke and CVD decreased gradually (p for trend 0.025 and <0.001, respectively), while the prevalence of peripheral vascular disease (PVD) increased in patients with diabetes during the study period (p for trend <0.001). The prevalence of dyslipidemia increased in diabetic patients with eye diseases and in men with nephropathies, but decreased in women with nephropathies during the study period. In contrast, the prevalence of dyslipidemia decreased in patients with macrovascular complications, including CVD and cerebrovascular disease (cerebrovascular accident), but increased in those patients with PVD (p for all trends <0.05). In diabetic patients with various macrovascular complications, except PVD, there was a decrease in the prevalence of hypertension in the past 10 years. The prevalence of hypertension increased in patients with microvascular complications including retinopathy, patients on dialysis (inclusive of both genders), and in men with nephropathy. The prevalence of hypertension along with dyslipidemia increased in patients with microvascular complications including retinopathy, patients on dialysis (inclusive of both genders), and in men with nephropathy; however, the rate decreased in all macrovascular complications except in PVD. CONCLUSION: Although progressively increased prevalence of dyslipidemia and hypertension was observed in patients with diabetes in Taiwan, there was a decrease in the prevalence of stroke and CVD in the past 10 years. Among those with macrovascular diseases, except PVD, there was a trend of decreased prevalence of hypertension and dyslipidemia during the study period. In patients with microvascular diseases, prevalence of hypertension and dyslipidemia in patients with eye diseases increased in the past 10 years. More aggressive management of different risk factors is warranted in diabetic patients with various vascular diseases.

Cardiovascular outcomes of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes on insulin therapy.

AIMS: To compare the hazard of cardiovascular diseases between DPP-4 inhibitor users and non-users who were on insulin therapy. METHODS: We conducted a population-based cohort study. 2652 patients with type 2 diabetes mellitus (T2DM) under insulin therapy were enrolled during 1997-2010. The incidence rates per 1000 person-years (PYs) of stroke, coronary heart disease (CAD) and heart failure were compared between 1326 DPP-4 inhibitor users and 1326 propensity score matched non-users. Multivariable Cox proportional hazards model was used to evaluate excess risk of the DPP-4 inhibitor non-users. RESULTS: After adjustment of age, gender, comorbidities, drugs used and diabetes duration; the incidence rate per 1000 PYs were 21.70 and 9.88 in DPP-4 inhibitor non-users and users; DPP-4 inhibitor users had lower hazard ratio (HR) of stroke (adjusted HR: 0.59, 95% CI: 0.42-0.83, p value: 0.002) compared with non-users. The incidence rates per 1000 PYs of CAD and heart failure of control versus users were 19.85 versus 13.54 and 5.56 versus 4.78; the adjusted HRs of CAD and heart failure were 0.86 and 1.11. Both were non-significant. CONCLUSION: This nationwide study demonstrated that insulin plus DPP-4 inhibitor users had significantly lower risk of stroke as compared with non-users.

Impact of pay-for-performance on mortality in diabetes patients in Taiwan: A population-based study.

BACKGROUND: The impact of pay-for-performance (P4P) programs on long-term mortality for chronic illnesses, especially diabetes mellitus, has been rarely reported. Several studies described the favorable impact of P4P for diabetes mellitus on medical utilizations or intermediate outcomes. Therefore, this study aimed to investigate the impact of a P4P program on mortality in patients with type 2 diabetes. METHODS: The P4P group in this population-based cohort study was 2090 individuals with a primary diagnosis of type 2 diabetes who had been newly enrolled in the P4P program of Taiwan between January 1, 2004 and December 31, 2004. Matched by 1:1 ratio, patients in the non-P4P group were selected by propensity score matching (PSM) for sex, age, the first year of diagnosis as diabetes, and 32 other potential confounding factors. Mean (SD) age was 60.91 (12.04) years when diabetes was first diagnosed and mean (SD) duration of diabetes was 4.3 (1.9) years at baseline. The time-dependent Cox regression model was used to explore the impact of P4P on all-cause mortality. RESULTS: During a mean of 5.13 years (SD = 1.07 years) of follow-up, 206 and 263 subjects died in the P4P group and the non-P4P group, respectively. After adjusting for the potential confounding factors at baseline, survival was significantly longer in the P4P group than in the non-P4P group (hazard ratio, 0.76 [95% confidence interval, 0.64-0.92], P = 0.004, by log-rank test). This decrease in mortality is equivalent to one less death for every 37 patients who were treated in the P4P program for 5.13 years. In this study, the P4P program significantly increased the medical utilization of physician visits and diabetes-related examinations, improved the adherence of oral hypoglycemic drugs during the first 3 years and that of insulin during the second 3 years, and was negatively associated with risk of cancer and chronic kidney disease. In annual health expense, there was no significant difference between P4P and non-P4P groups, P = 0.430. CONCLUSIONS: As compared with control, pay-for-performance program significantly improved survival in patients with diabetes without increasing the medical cost. The P4P group had significantly lower risk of cancer and chronic kidney disease.

Efficacy and tolerability of acarbose in Asian patients with type 2 diabetes inadequately controlled with diet and sulfonylureas.

The objective of this study was to investigate the efficacy, tolerability, and safety of acarbose in the improvement of glycemic control in Asian patients with type 2 diabetes inadequately controlled by diet and sulfonylureas. A 24-week, double-blind, placebo-controlled multicenter group comparison study was conducted. Patients were randomized to receive acarbose titrated up to 100-mg tid (n=36) or matching placebo (n=33). Concomitant sulfonylurea treatment remained unchanged throughout the study. The primary efficacy parameter was the change in HbA(1c) from baseline to double-blind endpoint. Secondary efficacy variables consisted of the change from baseline to endpoint in blood glucose (fasting and 1-h postprandial), serum insulin (fasting and 1-h postprandial), and urinary glucose. In the intention-to-treat (ITT) analysis, acarbose treatment was associated with significantly greater reductions in glycated hemoglobin (HbA(1c)) (-0.91% vs. placebo 0.13%, P=.0018) and 1-h postprandial blood glucose levels (-2.84 mmol/l vs. placebo -0.28 mmol/l, P=.002) compared to placebo. There were no significant differences between the treatment groups regarding changes in fasting blood glucose, fasting or 1-h postprandial serum insulin, urinary glucose, or body weight. Adverse events occurred with similar frequency in both treatment arms except for drug-related gastrointestinal side-effects associated with acarbose (acarbose 48.5% and placebo 12.5%). This study has shown that the use of acarbose in Asian patients with type 2 diabetes inadequately controlled by diet and sulfonylureas is efficacious in improving metabolic control and that acarbose is safe and well tolerated.

ABC control of diabetes: survey data from National Diabetes Health Promotion Centers in Taiwan.

We undertook nationwide surveys to evaluate the status of diabetes control in 7541 diabetes subjects among 114 accredited Diabetes Health Promotion Centers in Taiwan in 2006, focusing on characteristics of those who attained the "ABC" goals (n=310). The mean age was 62.8+/-12.4 years (mean+/-SD), BMI 25.9+/-0.4 kg/m(2) and HbA1c levels 7.9+/-1.7%. The percentage of subjects whose HbA1c levels met ADA goals was less than 7% (A), and both SBP and DBP less than 130/80 mmHg (B), total cholesterol less than 160 mg/dl or LDL cholesterol levels less than 100mg/dl (C) were 32.4%, 30.9% and 35.3%, respectively. Overall, the percentage of examined diabetic subjects who fulfilled current recommended ABC goals was 4.1% (95% CI, 3.66-4.56%). Results of logistic regression analysis that indicated factors significantly associated with ABC goals are diagnosis of type 1 diabetes (p=0.025), BMI less than 23 kg/m(2) (p=0.022) and subjects not requiring insulin (p=0.006). In conclusion, only 4.1% of subjects reached all ABC goals. Diabetic individuals with diagnosis of type 1 diabetes, lesser BMI and those not using insulin were more likely to attain all ABC goals.

Obesity and changes in body weight related to 10-year diabetes incidence in women in Taiwan.

This study aimed to investigate the relation of obesity and changes in body weight through adulthood with risks of type 2 diabetes. This study of 954 middle-aged women free of diabetes (mean age, 37.1 +/- 9.6 years) was conducted in a hospital. The baseline and biannual health check-ups were performed from 1993 to 2003. The cumulative incidence rate of type 2 diabetes was 3.64 per 1000 person-years during the mean follow-up period of 10 years. 73.3% of subjects who developed type 2 diabetes were overweight (16.6%) or obese (56.7%). Obese subjects (body mass index more than 25 kg/m2) had a relative risk of type 2 diabetes of 10.4 (95% confidence interval 2.95-36.9) compared with subjects with an optimal body mass index (18-22.9 kg/m2). Long-term weight gain was strongly related to the risk of type 2 diabetes. Each 1 kg of weight gain was associated with a 16% increase in risk of developing diabetes. This study indicated that obesity at young adult and weight gain appreciably increase risk for type 2 diabetes. Maintaining a lean weight throughout adulthood seems to be beneficial in the primary prevention of type 2 diabetes.