After an average of 27 years’ follow-up of patients with type 1 diabetes, 6.5 years of initial intensive diabetes therapy was associated with a modestly lower all-cause rate of death, compared with conventional therapy, according to a study in the January 6 issue of JAMA.
Based on the demonstrated reductions in illness, intensive diabetes therapy is now the recommended standard of care; however, it has not been established whether mortality in type 1 diabetes mellitus is affected following a period of intensive diabetes therapy. In type 2 diabetes treatment, reducing glycemia (blood sugar) closer to the nondiabetic range has not consistently reduced mortality, according to background information in the article.
Trevor J. Orchard, M.D., of the University of Pittsburgh, and colleagues examined whether mortality differed between the original intensive and conventional treatment groups in the long-term follow-up of the Diabetes Control and Complications Trial (DCCT) cohort. The DCCT (1983-1993) randomly assigned 1,441 healthy volunteers with type 1 diabetes mellitus between the ages of 13 and 39 years to intensive or conventional therapy, with the goal of studying the effects of near-normal blood sugars on long-term diabetes complications. After the DCCT ended, participants were followed up in a multisite (27 U.S. and Canadian academic clinical centers) observational study (Epidemiology of Diabetes Interventions and Complications; EDIC) until December 31, 2012.
During the initial clinical trial, participants were randomly assigned to receive intensive therapy (n = 711) aimed at achieving blood sugar control as close to the nondiabetic range as safely possible, or conventional therapy (n = 730) with the goal of avoiding symptomatic hypoglycemia (abnormally low blood sugar) and hyperglycemia (abnormally high blood sugar). At the end of the DCCT, after an average of 6.5 years, intensive therapy was taught and recommended to all participants and diabetes care was returned to personal physicians.
Vital status was ascertained for 1,429 (99.2 percent) participants. Of the 107 (7.4 percent) deaths, 43 (6.0 percent) were in the intensive treatment group and 64 (8.8 percent) were in the conventional treatment group. Overall mortality risk in the intensive group was lower than that in the conventional group, although the absolute risk reduction was small.
Primary causes of death were cardiovascular disease, cancer, acute diabetes complications, and accidents or suicide. Higher levels of glycated hemoglobin (a common lab test that gauges overall blood sugar control) were associated with all-cause mortality, as well as the development of albuminuria (the presence of excessive protein in the urine).
The authors write that intensive therapy is associated with increased hypoglycemic risk, which in turn has been associated with increased mortality. “The current data suggest net mortality benefit from intensive therapy. These results provide reassurance that adoption of 6.5 years of intensive therapy in type 1 diabetes does not incur increased risk of overall mortality.”
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Association Between 7 Years of Intensive Treatment of Type 1 Diabetes and Long-term Mortality FREE. 33% Reduced Mortality
ABSTRACT
Importance Mortality in type 1 diabetes mellitus is affected following intensive glycemic therapy has been established.
Objective To determine whether mortality differed between the original intensive and conventional treatment groups in the long-term follow-up of the Diabetes Control and Complications Trial (DCCT) cohort.
Design, Setting, and Participants After the DCCT (1983-1993) ended, participants were followed up in a multisite (27 US and Canadian academic clinical centers) observational study (Epidemiology of Diabetes Control and Complications [EDIC]) until December 31, 2012. Participants were 1441 healthy volunteers with diabetes mellitus who, at baseline, were 13 to 39 years of age with 1 to 15 years of diabetes duration and no or early microvascular complications, and without hypertension, preexisting cardiovascular disease, or other potentially life-threatening disease.
Interventions and Exposures During the clinical trial, participants were randomly assigned to receive intensive therapy (n = 711) aimed at achieving glycemia as close to the nondiabetic range as safely possible, or conventional therapy (n = 730) with the goal of avoiding symptomatic hypoglycemia and hyperglycemia. At the end of the DCCT, after a mean of 6.5 years, intensive therapy was taught and recommended to all participants and diabetes care was returned to personal physicians.
Main Outcomes and Measures Total and cause-specific mortality was assessed through annual contact with family and friends and through records over 27 years’ mean follow-up.
Results Vital status was ascertained for 1429 (99.2%) participants. There were 107 deaths, 64 in the conventional and 43 in the intensive group. The absolute risk difference was −109 per 100 000 patient-years (95% CI, −218 to −1), with lower all-cause mortality risk in the intensive therapy group (hazard ratio [HR] = 0.67 [95% CI, 0.46-0.99]; P = .045). Primary causes of death were cardiovascular disease (24 deaths; 22.4%), cancer (21 deaths; 19.6%), acute diabetes complications (19 deaths; 17.8%), and accidents or suicide (18 deaths; 16.8%). Higher levels of glycated hemoglobin (HbA1c) were associated with all-cause mortality (HR = 1.56 [95% CI, 1.35-1.81 per 10% relative increase in HbA1c]; P < .001), as well as the development of albuminuria (HR = 2.20 [95% CI, 1.46-3.31]; P < .001).
Conclusions and Relevance After a mean of 27 years’ follow-up of patients with type 1 diabetes, 6.5 years of initial intensive diabetes therapy was associated with a modestly lower all-cause mortality rate when compared with conventional therapy.
Trial Registration clinicaltrials.gov Identifiers: NCT00360815 and NCT00360893
JAMA
Scottish Study Finds Substantially Shorter Life Expectancy for Patients with Type 1 Diabetes. The better HbA1c The Longer Survival Rate
For patients with type 1 diabetes in Scotland, at age 20 years, the average man has an estimated life expectancy loss of about 11 years; for women, it is 13 years, compared with the general Scottish population without type 1 diabetes, according to a study in the January 6 issue of JAMA.
Major advances in treatment of type 1 diabetes have occurred in the past three decades. Accurate contemporary estimates of life expectancy would be useful as a measure of the current effect of diabetes and as a benchmark for assessing changes in diabetes care through time. Although there are many reports of the standardized mortality ratios for type 1 diabetes, few studies have provided life expectancy data, according to background information in the article.
Shona J. Livingstone, M.Sc., of the University of Dundee, Dundee, Scotland, and colleagues used a large national registry of patients with type 1 diabetes living in Scotland to provide contemporary comparisons of life expectancy with the general population without type 1 diabetes. The analysis included individuals who were 20 years of age or older from 2008 through 2010 (n = 24,691) with type 1diabetes.
Life expectancy at an attained age of 20 years was an additional 46.2 years among men with type 1 diabetes and 57.3 years among men without it, an estimated loss in life expectancy with diabetes of 11.1 years. Life expectancy from age 20 years was an additional 48.l years among women with type 1 diabetes and 61.0 years among women without it, an estimated loss with diabetes of 12.9 years. In the general population without type 1 diabetes, 76 percent of men and 83 percent of women survived to age 70 years compared with 47 percent of men and 55 percent of women with type 1 diabetes.
Even among patients with type 1 diabetes and preserved kidney function, life expectancy was reduced, with an estimated loss from age 20 years of 8.3 years for men and 7.9 years for women. Overall, the largest percentage of the estimated loss in life expectancy was related to ischemic heart disease, but death from diabetic coma or the condition ketoacidosis was associated with the largest percentage of the estimated loss occurring before age 50 years.
The authors note that whether their findings are generalizable internationally cannot be directly assessed because there are no large contemporary or historical nationally representative studies from other countries. “Therefore, it would be of interest to see contemporary larger scale data from the United States and other countries too.”
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Estimated Life Expectancy in a Scottish Cohort With Type 1 Diabetes, 2008-2010
Shona J. Livingstone, MSc1; Daniel Levin, MSc1; Helen C. Looker, MBBS1; Robert S. Lindsay, FRCP2; Sarah H. Wild, FRCP3; Nicola Joss, MD4; Graham Leese, MD5; Peter Leslie, MD6; Rory J. McCrimmon, FRCP5; Wendy Metcalfe, MD7; John A. McKnight, FRCP3,8; Andrew D. Morris, FRCP3; Donald W. M. Pearson, FRCP9; John R. Petrie, MD2; Sam Philip, MD9; Naveed A. Sattar, FRCP2; Jamie P. Traynor, MD7; Helen M. Colhoun, MD1; for the Scottish Diabetes Research Network epidemiology group and the Scottish Renal Registry
ABSTRACT
Importance Type 1 diabetes has historically been associated with a significant reduction in life expectancy. Major advances in treatment of type 1 diabetes have occurred in the past 3 decades. Contemporary estimates of the effect of type 1 diabetes on life expectancy are needed.
Objective To examine current life expectancy in people with and without type 1 diabetes in Scotland. We also examined whether any loss of life expectancy in patients with type 1 diabetes is confined to those who develop kidney disease.
Design, Setting, and Participants Prospective cohort of all individuals alive in Scotland with type 1 diabetes who were aged 20 years or older from 2008 through 2010 and were in a nationwide register (n=24 691 contributing 67 712 person-years and 1043 deaths).
Main Outcomes and Measures Differences in life expectancy between those with and those without type 1 diabetes and the percentage of the difference due to various causes.
Results Life expectancy at an attained age of 20 years was an additional 46.2 years among men with type 1 diabetes and 57.3 years among men without it, an estimated loss in life expectancy with diabetes of 11.1 years (95% CI, 10.1-12.1). Life expectancy from age 20 years was an additional 48.1 years among women with type 1 diabetes and 61.0 years among women without it, an estimated loss with diabetes of 12.9 years (95% CI, 11.7-14.1). Even among those with type 1 diabetes with an estimated glomerular filtration rate of 90 mL/min/1.73 m2 or higher, life expectancy was reduced (49.0 years in men, 53.1 years in women) giving an estimated loss from age 20 years of 8.3 years (95% CI, 6.5-10.1) for men and 7.9 years (95% CI, 5.5-10.3) for women. Overall, the largest percentage of the estimated loss in life expectancy was related to ischemic heart disease (36% in men, 31% in women) but death from diabetic coma or ketoacidosis was associated with the largest percentage of the estimated loss occurring before age 50 years (29.4% in men, 21.7% in women).
Conclusions and Relevance Estimated life expectancy for patients with type 1 diabetes in Scotland based on data from 2008 through 2010 indicated an estimated loss of life expectancy at age 20 years of approximately 11 years for men and 13 years for women compared with the general population without type 1 diabetes.