Treatment with insulin is associated with worse outcome in patients with chronic heart failure and diabetes

TY - JOUR

T1 - Treatment with insulin is associated with worse outcome in patients with chronic heart failure and diabetes

AU - Cosmi, Franco

AU - Shen, Li

AU - Magnoli, Michela

AU - Abraham, William T.

AU - Anand, Inder S.

AU - Cleland, John G.

AU - Cohn, Jay N.

AU - Cosmi, Deborah

AU - De Berardis, Giorgia

AU - Dickstein, Kenneth

AU - Franzosi, Maria Grazia

AU - Gullestad, Lars

AU - Jhund, Pardeep S.

AU - Kjekshus, John

AU - Køber, Lars

AU - Lepore, Vito

AU - Lucisano, Giuseppe

AU - Maggioni, Aldo P.

AU - Masson, Serge

AU - McMurray, John J.V.

AU - Nicolucci, Antonio

AU - Petrarolo, Vito

AU - Robusto, Fabio

AU - Staszewsky, Lidia

AU - Tavazzi, Luigi

AU - Teli, Roberto

AU - Tognoni, Gianni

AU - Wikstrand, John

AU - Latini, Roberto

PY - 2018

Y1 - 2018

N2 - Aims: Up to one-third of patients with diabetes mellitus and heart failure (HF) are treated with insulin. As insulin causes sodium retention and hypoglycaemia, its use might be associated with worse outcomes. Methods and results: We examined two datasets: 24 012 patients with HF from four large randomized trials and an administrative database of 4 million individuals, 103 857 of whom with HF. In the former, survival was examined using Cox proportional hazards models adjusted for baseline variables and separately for propensity scores. Fine–Gray competing risk regression models were used to assess the risk of hospitalization for HF. For the latter, a case–control nested within a population-based cohort study was conducted with propensity score. Prevalence of diabetes mellitus at study entry ranged from 25.5% to 29.5% across trials. Insulin alone or in combination with oral hypoglycaemic drugs was prescribed at randomization to 24.4% to 34.5% of the patients with diabetes. The rates of death from any cause and hospitalization for HF were higher in patients with vs. without diabetes, and highest of all in patients prescribed insulin [propensity score pooled hazard ratio for all-cause mortality 1.27 (1.16–1.38), for HF hospitalization 1.23 (1.13–1.33)]. In the administrative registry, insulin prescription was associated with a higher risk of all-cause death [odds ratio (OR) 2.02, 95% confidence interval (CI) 1.87–2.19] and rehospitalization for HF (OR 1.42, 95% CI 1.32–1.53). Conclusions: Whether insulin use is associated with poor outcomes in HF should be investigated further with controlled trials, as should the possibility that there may be safer alternative glucose-lowering treatments for patients with HF and type 2 diabetes mellitus.

AB - Aims: Up to one-third of patients with diabetes mellitus and heart failure (HF) are treated with insulin. As insulin causes sodium retention and hypoglycaemia, its use might be associated with worse outcomes. Methods and results: We examined two datasets: 24 012 patients with HF from four large randomized trials and an administrative database of 4 million individuals, 103 857 of whom with HF. In the former, survival was examined using Cox proportional hazards models adjusted for baseline variables and separately for propensity scores. Fine–Gray competing risk regression models were used to assess the risk of hospitalization for HF. For the latter, a case–control nested within a population-based cohort study was conducted with propensity score. Prevalence of diabetes mellitus at study entry ranged from 25.5% to 29.5% across trials. Insulin alone or in combination with oral hypoglycaemic drugs was prescribed at randomization to 24.4% to 34.5% of the patients with diabetes. The rates of death from any cause and hospitalization for HF were higher in patients with vs. without diabetes, and highest of all in patients prescribed insulin [propensity score pooled hazard ratio for all-cause mortality 1.27 (1.16–1.38), for HF hospitalization 1.23 (1.13–1.33)]. In the administrative registry, insulin prescription was associated with a higher risk of all-cause death [odds ratio (OR) 2.02, 95% confidence interval (CI) 1.87–2.19] and rehospitalization for HF (OR 1.42, 95% CI 1.32–1.53). Conclusions: Whether insulin use is associated with poor outcomes in HF should be investigated further with controlled trials, as should the possibility that there may be safer alternative glucose-lowering treatments for patients with HF and type 2 diabetes mellitus.

KW - Diabetes mellitus

KW - Heart failure

KW - Insulin

U2 - 10.1002/ejhf.1146

DO - 10.1002/ejhf.1146

M3 - Journal article

C2 - 29488676

AN - SCOPUS:85042564501

SN - 1567-4215

VL - 20

SP - 888

EP - 895

JO - European Journal of Heart Failure, Supplement

JF - European Journal of Heart Failure, Supplement

IS - 5

ER -