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Effect of glitazones on cancer mortality in type 2 diabetes
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CANADIAN JOURNAL OF DIABETES
D-0996 Decreasing stroke rates among albertans with and without diabetes, 2003-2007 S.H. Simpson1, M.D. Hill2, S.U. Balko3, G. Hugel3, J.A. Johnson4 1 University of Alberta, Faculty of Pharmacy & Pharmaceutical Sciences, Edmonton, Canada 2 University of Calgary, Faculty of Medicine, Calgary, Canada 3 Institute of Health Economics, Alberta Diabetes Surveillance System, Edmonton, Canada 4 University of Alberta, School of Public Health Sciences, Edmonton, Canada aim: Stroke has a major impact on the individual and our health care system. Diabetes is an established risk factor for ischemic stroke and also appears to increase the risk of hemorrhagic stroke. This time-series analysis compared population-based rates of acute ischemic strokes (AIS), transient ischemic attacks (TIA), and hemorrhagic strokes between Alberta residents with and without diabetes. Methods: Administrative databases from Alberta Health and Wellness were used to identify hospitalizations with a most responsible diagnosis of stroke for all Alberta residents >=20 years old between 2003 and 2007. Alberta is one of ten provincial jurisdictions in Canada with a population of approximately 3.4 million people living in diverse regions. The Canadian National Diabetes Surveillance System algorithm was used to identify people with diabetes. The pathological type of stroke was grouped into three categories: AIS (ICD-9 codes 362.3, 433, 434 & 436 [excluding 433.X0 and 434.X0]; ICD-10 codes H34.1, I63 & I64), TIA (ICD-9 code 435; ICD-10 codes G45, G45.0, G45.1-G45.3, G45.8 & G45.9), and hemorrhagic stroke (ICD-9 codes 430 or 431; ICD-10 codes I60 or I61). Annual age- and sex-standardized rates for each stroke type were compared between Albertans with and without diabetes across the observation period (2003-2007). results: The annual age- and sex-standardized rates (per 10,000 people) by type and diabetes status are presented in the following table. 2003
2004
2005
2006
2007
AIS Diabetes No Diabetes
18.3 7.1
15.2 6.9
15.5 6.6
15.9 6.4
13.1 6.6
TIA Diabetes No Diabetes
6.3 3.5
6.2 3.6
6.5 3.4
5.1 2.9
5.4 2.7
3.0 1.6
1.9 1.4
2.5 1.5
2.0 1.4
2.0 1.4
Hemorrhagic Stroke Diabetes No Diabetes
information, however, exploring the effect of the glitazones and cancer mortality in T2DM. We hypothesized a decreased risk of cancer mortality associated with glitazones use, compared to sulfonylurea monotherapy use. Methods: This was a population-based retrospective cohort study using administrative data from Saskatchewan Health. We identified new users of metformin or sulfonylureas from January 1, 2000 to December 31, 2005, with follow-up until death, departure from the province, or December 31, 2006. We compared cancer mortality between glitazone users (plus metformin), metformin and sulfonylurea combination users, metformin monotherapy users, and sulfonylurea monotherapy users (reference group). A time-varying Cox analysis was used to estimate the hazard ratio (HR) of cancer mortality, accounting for oral antidiabetic therapy, insulin therapy, age, sex, and chronic disease score (CDS). Exposure to oral antidiabetic therapies was defined by use of each agent (i.e., yes/no) within 1-year time windows. We examined the dose-response gradient for insulin exposure. Firstly, we created a count of insulin dispensations for each 1-year time window. Cumulative insulin exposure/year was then calculated by summing insulin counts at the end of each year and dividing by the person years of insulin use since insulin index. We stratified the cumulative insulin exposure level into high, low, and no exposure to insulin. results: We identified 20,448 new users of metformin or sulfonylureas during the index period, with an average (SD) follow-up of 3.5 (1.8) years. The mean age for the cohort was 61.3 (14.3) years and 53.8% were men. Unadjusted cancer mortality was 9.8% (154/1,577) for sulfonylurea monotherapy users and 1.3% (43/3,365) for glitazone (plus metformin) users (p < 0.0001). After adjusting for age, sex, CDS, and insulin use, glitazone (plus metformin) users had a significantly lower risk of cancer mortality compared with the sulfonylurea monotherapy cohort (HR: 0.42, 95% CI: 0.24 – 0.72; p=0.002). The adjusted HRs (95% CI) for insulin use were 1.33 (0.83 – 2.13) and 7.08 (5.27 – 9.51) for <12 and =12 cumulative insulin dispensations/ year, respectively, compared to those using no insulin. conclusion: These findings add further support that antidiabetic therapies may play a role in the relationship between type 2 diabetes and cancer outcomes. Our results suggest that patients with type 2 diabetes exposed to glitazones had a significantly decreased risk of cancer mortality compared to patients exposed to sulfonylurea monotherapy. It is uncertain whether this decreased risk is related to a protective effect of glitazones or a toxic effect of sulfonylureas. Epidemiology
The age- and sex-standardized rate ratio between diabetes and no diabetes fell from 2.59 in 2003 to 1.99 in 2007 for AIS and from 1.96 in 2003 to 1.39 in 2007 for hemorrhagic stroke. The rate ratio for TIA increased from 1.80 in 2003 to 2.04 in 2007. Discussion: Stroke rates declined for all Albertans over the observation period of 2003-2007. Within all stroke types, people with diabetes had consistently higher rates compared to those without diabetes. This difference appears to be slowly closing over time for AIS and hemorrhagic stroke; however, it appears to be widening for TIAs. Epidemiology No conflict of interest D-1000 Effect of glitazones on cancer mortality in type 2 diabetes S. Bowker1, Y. Yasui1, P. Veugelers1, S.H. Simpson2, J.A. Johnson1 University of Alberta, School of Public Health, Edmonton, Canada 2 University of Alberta, Department of Pharmacy, Edmonton, Canada
1
aims: Numerous studies have observed an association between type 2 diabetes (T2DM) and cancer, with recent reports suggesting a modulating role of antidiabetic therapy. There is little epidemiologic
No conflict of interest D-1005 an evidence informed diabetes curriculum to prepare exercise professionals for delivering culturally relevant pre-diabetes physical activity interventions C. Rowan1, M. Riddell1, V. Jamnik1, P. Ritvo1, A. Salmon2, N. Gledhill1 York University, Physical Activity and Chronic Disease Unit Diabetes Section Faculty of Health School of Kinesiology and Health Science, Toronto, Canada 2 Ontario Ministry of Health Promotion, Toronto, Canada
1
aims: In preparation for a pre-diabetes detection and physical activity (PA) intervention program, we developed a curriculum to prepare fitness professionals to deliver culturally relevant pre-diabetes PA interventions to high-risk target populations. The curriculum is a comprehensive resource on diabetes, pre-diabetes detection, behaviour change methods and culturally relevant PA options to reduce the incidence of type 2 diabetes. Methods: The curriculum was developed after careful review of scientific literature and clinical recommendations from prominent diabetes associations throughout North America. It is targeted at highly qualified fitness professionals - Certified Exercise Physiologists. The following populations are known to have an elevated risk for type 2
CANADIAN JOURNAL OF DIABETES
D-0996 Decreasing stroke rates among albertans with and without diabetes, 2003-2007 S.H. Simpson1, M.D. Hill2, S.U. Balko3, G. Hugel3, J.A. Johnson4 1 University of Alberta, Faculty of Pharmacy & Pharmaceutical Sciences, Edmonton, Canada 2 University of Calgary, Faculty of Medicine, Calgary, Canada 3 Institute of Health Economics, Alberta Diabetes Surveillance System, Edmonton, Canada 4 University of Alberta, School of Public Health Sciences, Edmonton, Canada aim: Stroke has a major impact on the individual and our health care system. Diabetes is an established risk factor for ischemic stroke and also appears to increase the risk of hemorrhagic stroke. This time-series analysis compared population-based rates of acute ischemic strokes (AIS), transient ischemic attacks (TIA), and hemorrhagic strokes between Alberta residents with and without diabetes. Methods: Administrative databases from Alberta Health and Wellness were used to identify hospitalizations with a most responsible diagnosis of stroke for all Alberta residents >=20 years old between 2003 and 2007. Alberta is one of ten provincial jurisdictions in Canada with a population of approximately 3.4 million people living in diverse regions. The Canadian National Diabetes Surveillance System algorithm was used to identify people with diabetes. The pathological type of stroke was grouped into three categories: AIS (ICD-9 codes 362.3, 433, 434 & 436 [excluding 433.X0 and 434.X0]; ICD-10 codes H34.1, I63 & I64), TIA (ICD-9 code 435; ICD-10 codes G45, G45.0, G45.1-G45.3, G45.8 & G45.9), and hemorrhagic stroke (ICD-9 codes 430 or 431; ICD-10 codes I60 or I61). Annual age- and sex-standardized rates for each stroke type were compared between Albertans with and without diabetes across the observation period (2003-2007). results: The annual age- and sex-standardized rates (per 10,000 people) by type and diabetes status are presented in the following table. 2003
2004
2005
2006
2007
AIS Diabetes No Diabetes
18.3 7.1
15.2 6.9
15.5 6.6
15.9 6.4
13.1 6.6
TIA Diabetes No Diabetes
6.3 3.5
6.2 3.6
6.5 3.4
5.1 2.9
5.4 2.7
3.0 1.6
1.9 1.4
2.5 1.5
2.0 1.4
2.0 1.4
Hemorrhagic Stroke Diabetes No Diabetes
information, however, exploring the effect of the glitazones and cancer mortality in T2DM. We hypothesized a decreased risk of cancer mortality associated with glitazones use, compared to sulfonylurea monotherapy use. Methods: This was a population-based retrospective cohort study using administrative data from Saskatchewan Health. We identified new users of metformin or sulfonylureas from January 1, 2000 to December 31, 2005, with follow-up until death, departure from the province, or December 31, 2006. We compared cancer mortality between glitazone users (plus metformin), metformin and sulfonylurea combination users, metformin monotherapy users, and sulfonylurea monotherapy users (reference group). A time-varying Cox analysis was used to estimate the hazard ratio (HR) of cancer mortality, accounting for oral antidiabetic therapy, insulin therapy, age, sex, and chronic disease score (CDS). Exposure to oral antidiabetic therapies was defined by use of each agent (i.e., yes/no) within 1-year time windows. We examined the dose-response gradient for insulin exposure. Firstly, we created a count of insulin dispensations for each 1-year time window. Cumulative insulin exposure/year was then calculated by summing insulin counts at the end of each year and dividing by the person years of insulin use since insulin index. We stratified the cumulative insulin exposure level into high, low, and no exposure to insulin. results: We identified 20,448 new users of metformin or sulfonylureas during the index period, with an average (SD) follow-up of 3.5 (1.8) years. The mean age for the cohort was 61.3 (14.3) years and 53.8% were men. Unadjusted cancer mortality was 9.8% (154/1,577) for sulfonylurea monotherapy users and 1.3% (43/3,365) for glitazone (plus metformin) users (p < 0.0001). After adjusting for age, sex, CDS, and insulin use, glitazone (plus metformin) users had a significantly lower risk of cancer mortality compared with the sulfonylurea monotherapy cohort (HR: 0.42, 95% CI: 0.24 – 0.72; p=0.002). The adjusted HRs (95% CI) for insulin use were 1.33 (0.83 – 2.13) and 7.08 (5.27 – 9.51) for <12 and =12 cumulative insulin dispensations/ year, respectively, compared to those using no insulin. conclusion: These findings add further support that antidiabetic therapies may play a role in the relationship between type 2 diabetes and cancer outcomes. Our results suggest that patients with type 2 diabetes exposed to glitazones had a significantly decreased risk of cancer mortality compared to patients exposed to sulfonylurea monotherapy. It is uncertain whether this decreased risk is related to a protective effect of glitazones or a toxic effect of sulfonylureas. Epidemiology
The age- and sex-standardized rate ratio between diabetes and no diabetes fell from 2.59 in 2003 to 1.99 in 2007 for AIS and from 1.96 in 2003 to 1.39 in 2007 for hemorrhagic stroke. The rate ratio for TIA increased from 1.80 in 2003 to 2.04 in 2007. Discussion: Stroke rates declined for all Albertans over the observation period of 2003-2007. Within all stroke types, people with diabetes had consistently higher rates compared to those without diabetes. This difference appears to be slowly closing over time for AIS and hemorrhagic stroke; however, it appears to be widening for TIAs. Epidemiology No conflict of interest D-1000 Effect of glitazones on cancer mortality in type 2 diabetes S. Bowker1, Y. Yasui1, P. Veugelers1, S.H. Simpson2, J.A. Johnson1 University of Alberta, School of Public Health, Edmonton, Canada 2 University of Alberta, Department of Pharmacy, Edmonton, Canada
1
aims: Numerous studies have observed an association between type 2 diabetes (T2DM) and cancer, with recent reports suggesting a modulating role of antidiabetic therapy. There is little epidemiologic
No conflict of interest D-1005 an evidence informed diabetes curriculum to prepare exercise professionals for delivering culturally relevant pre-diabetes physical activity interventions C. Rowan1, M. Riddell1, V. Jamnik1, P. Ritvo1, A. Salmon2, N. Gledhill1 York University, Physical Activity and Chronic Disease Unit Diabetes Section Faculty of Health School of Kinesiology and Health Science, Toronto, Canada 2 Ontario Ministry of Health Promotion, Toronto, Canada
1
aims: In preparation for a pre-diabetes detection and physical activity (PA) intervention program, we developed a curriculum to prepare fitness professionals to deliver culturally relevant pre-diabetes PA interventions to high-risk target populations. The curriculum is a comprehensive resource on diabetes, pre-diabetes detection, behaviour change methods and culturally relevant PA options to reduce the incidence of type 2 diabetes. Methods: The curriculum was developed after careful review of scientific literature and clinical recommendations from prominent diabetes associations throughout North America. It is targeted at highly qualified fitness professionals - Certified Exercise Physiologists. The following populations are known to have an elevated risk for type 2