T2DM Screening in COPD Patients a Must in Primary Care

Results from a recent study published in the July issue of NPJ Primary Care Respiratory Medicine, suggest that primary care patients with chronic obstructive pulmonary disease (COPD) may be at increased risk of type 2 diabetes mellitus (T2DM), especially if they have frequent exacerbations and are treated with inhaled corticosteroids (ICS).1 “We have shown that incidence and prevalence of type 2 diabetes in the COPD population is high, suggesting an opportunity to identify patients at high risk of type 2 diabetes within a primary care setting early in order to optimize management of comorbid disease,” first author Alicia Gayle, senior epidemiologist at Boehringer Ingelheim Ltd. in Bracknell, United Kingdom, told Patient Care Online via email. In the study, the prevalence of T2DM among primary care patients with COPD was 9%, which corresponds to 111 240 people among the 1.2 million patients with COPD in the UK. “Patients with prior exposure to ICS or a history of exacerbations had an increased risk of developing comorbid type 2 diabetes,” Gayle added. “These characteristics along with comorbid cardiac conditions and high body mass index should help direct targeted interventions to prevent the high burden of illness that comorbid disease has in a primary care setting.” Past studies have linked COPD with increased risk for T2DM, but the underlying mechanism remains unclear. ICS, which are commonly prescribed for COPD exacerbations, may contribute to metabolic dysregulation and diabetes. But there may be more going on than that. A 2012 meta-analysis of 26 clinical trials in COPD patients failed to find a significant association between the ICS budesonide and new onset diabetes.2 Some scientists hypothesize that other factors related to COPD itself (eg, smoking, systemic inflammation, hypoxia, decreased ability to exercise, obesity) may also contribute. NEXT: Study Methods and Results In the recent cohort study, researchers analyzed data from the Clinical Practice Research Datalink, a database with clinical record data from 689 primary care practices in the UK, covering 3.9 million people. The analysis included data from 220 971 adults aged ≥35 years, who were already diagnosed with COPD and were current or former smokers. Researchers used a nested case control design to match cases to controls from the same cohort in a 1 to 5 fashion by age, gender, and primary care practice. Results were adjusted for ICS dose, COPD exacerbations, smoking status, economic deprivation, body mass index, hypertension, coronary heart disease, heart failure, and duration of COPD. Between January 2010 and December 2016, the cumulative prevalence of T2DM among patients with COPD was 9.3% (n=20 488); incidence rate was 1.26 per 100 patient years (95% CI: 1.24–1.28). Men had higher rates of T2DM vs women (1.32 vs 1.18 per 100 patient years, respectively). Patients with ≥2 COPD exacerbations per year were 47% more likely to develop T2DM vs patients with less frequent exacerbations (adjusted OR 1.47; 95% CI: 1.36–1.60). Those on high-dose ICS (>800 µg budesonide equivalent dose) were almost twice as likely to develop T2DM as those who were not on ICSs (adjusted OR 1.73; 95% CI: 1.65–1.82). However, analyses that excluded patients with comorbid asthma showed increased risk for T2DM across all categories of ICS dosage. Compared to no ICS, low-dose ICS was tied to 47% increased risk of T2DM, (adjusted OR 1.47; 95% CI: 1.36–1.59), and as high as a 58% increased risk for very high-dose ICS (adjusted OR 1.58; 95% CI: 1.47–1.68). The results suggest increased risk for T2DM regardless of ICS dose, but further research is needed to confirm these findings, according to the authors. “This observational study adds to the growing body of literature that recommend use of ICS should be considered with caution. Further work is needed to understand whether optimal treatment of patients with COPD results in a lower incidence of type 2 diabetes,” Gayle concluded. The study was limited by reliance on an electronic database, which did not contain information on physical activity, alcohol consumption, or diet. References: 1. Gayle A, Dickinson S, Poole C, et al. Incidence of type II diabetes in chronic obstructive pulmonary disease: a nested case-control study. NPJ Prim Care Respir Med. 2019;29:28. 2. O'Byrne PM, Rennard S, Gerstein H, et al. Risk of new onset diabetes mellitus in patients with asthma or COPD taking inhaled corticosteroids. Respir Med. 2012;106:1487-1493.