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Mortality and other adverse outcomes in patients with type 2 diabetes mellitus admitted for COVID-19 in association with glucose-lowering drugs: a nationwide cohort study

Pérez-Belmonte et al., BMC Medicine, doi:10.1186/s12916-020-01832-2
Nov 2020  
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Mortality -10% Improvement Relative Risk Metformin  Pérez-Belmonte et al.  Prophylaxis Is prophylaxis with metformin beneficial for COVID-19? PSM retrospective 498 patients in Spain No significant difference in mortality c19early.org Pérez-Belmonte et al., BMC Medicine, Nov 2020 Favorsmetformin Favorscontrol 0 0.5 1 1.5 2+
Metformin for COVID-19
3rd treatment shown to reduce risk in July 2020, now with p < 0.00000000001 from 96 studies.
No treatment is 100% effective. Protocols combine treatments.
5,000+ studies for 104 treatments. c19early.org
Retrospective 2,666 type 2 diabetes COVID-19 patients in Spain, showing higher mortality with existing metformin use (not statistically significant).
risk of death, 10.4% higher, RR 1.10, p = 0.48, treatment 79 of 249 (31.7%), control 79 of 249 (31.7%), adjusted per study, odds ratio converted to relative risk, mixed effect logistic regression, propensity score matching.
Effect extraction follows pre-specified rules prioritizing more serious outcomes. Submit updates
Pérez-Belmonte et al., 16 Nov 2020, retrospective, propensity score matching, Spain, peer-reviewed, 26 authors.
This PaperMetforminAll
Mortality and other adverse outcomes in patients with type 2 diabetes mellitus admitted for COVID-19 in association with glucose-lowering drugs: a nationwide cohort study
Luis M Pérez-Belmonte, José David Torres-Peña, María D López-Carmona, M Mar. Ayala-Gutiérrez, Francisco Fuentes-Jiménez, Lucía Jorge Huerta, Jaime Alonso Muñoz, Manuel Rubio-Rivas, Manel Madrazo, Marcos Guzmán Garcia, Beatriz Vicente Montes, Joaquim Fernández Sola, Javier Ena, Ruth Gonzalez Ferrer, Carmen Mella Pérez, Carlos Jorge Ripper, Jose Javier Napal Lecumberri, Iris El Attar Acedo, Susana Plaza Canteli, Sara Fuente Cosío, Francisco Amorós Martínez, Begoña Cortés Rodríguez, Pablo Pérez-Martínez, José Manuel Ramos-Rincón, Ricardo Gómez-Huelgas
BMC Medicine, doi:10.1186/s12916-020-01832-2
Background: Limited evidence exists on the role of glucose-lowering drugs in patients with COVID-19. Our main objective was to examine the association between in-hospital death and each routine at-home glucose-lowering drug both individually and in combination with metformin in patients with type 2 diabetes mellitus admitted for COVID-19. We also evaluated their association with the composite outcome of the need for ICU admission, invasive and non-invasive mechanical ventilation, or in-hospital death as well as on the development of in-hospital complications and a long-time hospital stay.
Supplementary Information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12916-020-01832-2. Additional file 1: Table S1 . Pre-and post-propensity score matching of baseline sociodemographic and clinical characteristics of patients with type 2 diabetes mellitus admitted for coronavirus disease 2019 treated with metformin versus other glucose-lowering drugs. Additional file 2: Table S2 . Pre-and post-propensity score matching of baseline sociodemographic and clinical characteristics of patients with type 2 diabetes mellitus admitted for coronavirus disease 2019 treated with dipeptidyl peptidase-4 inhibitors versus other glucose-lowering drugs. Additional file 3: Table S3 . Pre-and post-propensity score matching of baseline sociodemographic and clinical characteristics of patients with type 2 diabetes mellitus admitted for coronavirus disease 2019 treated with insulin versus other glucose-lowering drugs. Additional file 4: Table S4 . Pre-and post-propensity score matching of baseline sociodemographic and clinical characteristics of patients with type 2 diabetes mellitus admitted for coronavirus disease 2019 treated with metformin plus dipeptidyl peptidase-4 inhibitors versus other glucose-lowering drugs. Additional file 5: Table S5 . Pre-and post-propensity score matching of baseline sociodemographic and clinical characteristics of patients with type 2 diabetes mellitus admitted for coronavirus disease 2019 treated with metformin plus..
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Our main ' 'objective was to examine the association between in-hospital death and each routine at-home ' 'glucose-lowering drug both individually and in combination with metformin in patients with ' 'type 2 diabetes mellitus admitted for COVID-19. We also evaluated their association with the ' 'composite outcome of the need for ICU admission, invasive and non-invasive mechanical ' 'ventilation, or in-hospital death as well as on the development of in-hospital complications ' 'and a long-time hospital ' 'stay.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We selected all ' 'patients with type 2 diabetes mellitus in the Spanish Society of Internal Medicine’s registry ' 'of COVID-19 patients (SEMI-COVID-19 Registry). It is an ongoing, observational, multicenter, ' 'nationwide cohort of patients admitted for COVID-19 in Spain from March 1, 2020. Each ' 'glucose-lowering drug user was matched with a user of other glucose-lowering drugs in a 1:1 ' 'manner by propensity scores. In order to assess the adequacy of propensity score matching, we ' 'used the standardized mean difference found in patient characteristics after matching. There ' 'was considered to be a significant imbalance in the group if a standardized mean difference ' '&gt;\u200910% was found. To evaluate the association between treatment and study outcomes, ' 'both conditional logit and mixed effect logistic regressions were used when the sample size ' 'was ≥\u2009100.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>A total ' 'of 2666 patients were found in the SEMI-COVID-19 Registry, 1297 on glucose-lowering drugs in ' 'monotherapy and 465 in combination with metformin. After propensity matching, 249 patients on ' 'metformin, 105 on dipeptidyl peptidase-4 inhibitors, 129 on insulin, 127 on ' 'metformin/dipeptidyl peptidase-4 inhibitors, 34 on metformin/sodium-glucose cotransporter 2 ' 'inhibitor, and 67 on metformin/insulin were selected. No at-home glucose-lowering drugs ' 'showed a significant association with in-hospital death; the composite outcome of the need of ' 'intensive care unit admission, mechanical ventilation, or in-hospital death; in-hospital ' 'complications; or long-time hospital ' 'stays.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>In patients ' 'with type 2 diabetes mellitus admitted for COVID-19, at-home glucose-lowering drugs showed no ' 'significant association with mortality and adverse outcomes. Given the close relationship ' 'between diabetes and COVID-19 and the limited evidence on the role of glucose-lowering drugs, ' 'prospective studies are needed.</jats:p></jats:sec>', 'DOI': '10.1186/s12916-020-01832-2', 'type': 'journal-article', 'created': { 'date-parts': [[2020, 11, 16]], 'date-time': '2020-11-16T02:03:53Z', 'timestamp': 1605492233000}, 'update-policy': 'http://dx.doi.org/10.1007/springer_crossmark_policy', 'source': 'Crossref', 'is-referenced-by-count': 41, 'title': [ 'Mortality and other adverse outcomes in patients with type 2 diabetes mellitus admitted for ' 'COVID-19 in association with glucose-lowering drugs: a nationwide cohort study'], 'prefix': '10.1186', 'volume': '18', 'author': [ {'given': 'Luis M.', 'family': 'Pérez-Belmonte', 'sequence': 'first', 'affiliation': []}, {'name': 'for the SEMI-COVID-19 Network', 'sequence': 'first', 'affiliation': []}, {'given': 'José David', 'family': 'Torres-Peña', 'sequence': 'additional', 'affiliation': []}, {'given': 'María D.', 'family': 'López-Carmona', 'sequence': 'additional', 'affiliation': []}, {'given': 'M. 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' 'COVID-19: consider cytokine storm syndromes and immunosuppression. ' 'Lancet. 2020;395:1033–4.', 'journal-title': 'Lancet'}, { 'key': '1832_CR28', 'doi-asserted-by': 'crossref', 'unstructured': 'Maddaloni E, Buzzetti R. Covid-19 and diabetes mellitus: unveiling the ' 'interaction of two pandemics. Diabetes Metab Res Rev. 2020:e33213321.', 'DOI': '10.1002/dmrr.3321'}, { 'issue': '3', 'key': '1832_CR29', 'doi-asserted-by': 'publisher', 'first-page': 'bnaa011', 'DOI': '10.1210/endrev/bnaa011', 'volume': '41', 'author': 'DJ Drucker', 'year': '2020', 'unstructured': 'Drucker DJ. Coronavirus infections and type 2 diabetes-shared pathways ' 'with therapeutic implications. Endocr Rev. 2020;41(3):bnaa011.', 'journal-title': 'Endocr Rev'}, { 'key': '1832_CR30', 'doi-asserted-by': 'publisher', 'first-page': '1417', 'DOI': '10.3390/jcm9051417', 'volume': '9', 'author': 'C Sardu', 'year': '2020', 'unstructured': 'Sardu C, Gambardella J, Morelli MB, Wang X, Marfella R, Santulli G. ' 'Hypertension, thrombosis, kidney failure, and diabetes: is COVID-19 an ' 'endothelial disease? A comprehensive evaluation of clinical and basic ' 'evidence. J Clin Med. 2020;9:1417.', 'journal-title': 'J Clin Med'}, { 'key': '1832_CR31', 'doi-asserted-by': 'publisher', 'DOI': '10.1161/JAHA.120.016948', 'volume': '9', 'author': 'C Sardu', 'year': '2020', 'unstructured': 'Sardu C, Maggi P, Messina V, Iuliano P, Sardu A, Iovinella V, et al. ' 'Could anti-hypertensive drug therapy affect the clinical prognosis of ' 'hypertensive patients with COVID-19 infection? Data from centers of ' 'southern Italy. J Am Heart Assoc. 2020;9:e016948.', 'journal-title': 'J Am Heart Assoc'}, { 'key': '1832_CR32', 'doi-asserted-by': 'publisher', 'DOI': '10.3390/jcm9103136', 'volume': '9', 'author': 'E Rodilla', 'year': '2020', 'unstructured': 'Rodilla E, Saura A, Jiménez I, Mendizábal A, Pineda-Cantero A, ' 'Lorenzo-Hernández E, et al. Association of hypertension with all-cause ' 'mortality among hospitalized patients with COVID-19. J Clin Med. ' '2020;9:E3136.', 'journal-title': 'J Clin Med'}, { 'key': '1832_CR33', 'doi-asserted-by': 'publisher', 'first-page': '405', 'DOI': '10.1016/j.dsx.2020.04.024', 'volume': '14', 'author': 'E Cure', 'year': '2020', 'unstructured': 'Cure E, Cumhur CM. Can dapagliflozin have a protective effect against ' 'COVID-19 infection? A hypothesis. Diabetes Metab Syndr. 2020;14:405–6.', 'journal-title': 'Diabetes Metab Syndr'}], 'container-title': ['BMC Medicine'], 'original-title': [], 'language': 'en', 'link': [ { 'URL': 'http://link.springer.com/content/pdf/10.1186/s12916-020-01832-2.pdf', 'content-type': 'application/pdf', 'content-version': 'vor', 'intended-application': 'text-mining'}, { 'URL': 'http://link.springer.com/article/10.1186/s12916-020-01832-2/fulltext.html', 'content-type': 'text/html', 'content-version': 'vor', 'intended-application': 'text-mining'}, { 'URL': 'http://link.springer.com/content/pdf/10.1186/s12916-020-01832-2.pdf', 'content-type': 'application/pdf', 'content-version': 'vor', 'intended-application': 'similarity-checking'}], 'deposited': { 'date-parts': [[2021, 4, 14]], 'date-time': '2021-04-14T09:04:58Z', 'timestamp': 1618391098000}, 'score': 1, 'subtitle': [], 'short-title': [], 'issued': {'date-parts': [[2020, 11, 16]]}, 'references-count': 33, 'journal-issue': {'issue': '1', 'published-print': {'date-parts': [[2020, 12]]}}, 'alternative-id': ['1832'], 'URL': 'http://dx.doi.org/10.1186/s12916-020-01832-2', 'relation': {}, 'ISSN': ['1741-7015'], 'issn-type': [{'value': '1741-7015', 'type': 'electronic'}], 'subject': ['General Medicine'], 'published': {'date-parts': [[2020, 11, 16]]}, 'assertion': [ { 'value': '31 August 2020', 'order': 1, 'name': 'received', 'label': 'Received', 'group': {'name': 'ArticleHistory', 'label': 'Article History'}}, { 'value': '29 October 2020', 'order': 2, 'name': 'accepted', 'label': 'Accepted', 'group': {'name': 'ArticleHistory', 'label': 'Article History'}}, { 'value': '16 November 2020', 'order': 3, 'name': 'first_online', 'label': 'First Online', 'group': {'name': 'ArticleHistory', 'label': 'Article History'}}, { 'value': 'Only patients who had previously given consent for their medical records to be ' 'used for medical research were included in this registry. Data confidentiality ' 'and patient anonymity were maintained at all times, in accordance with Spanish ' 'regulations on observational studies. Patient-identifying information was ' 'deleted before the database was analyzed. It is not possible to identify ' 'patients on an individual level either in this article or in the database. This ' 'study was also carried out in accordance with the Declaration of Helsinki and ' 'was approved by the Institutional Research Ethics Committee of Málaga on March ' '27, 2020 (Ethics Committee code: SEMI-COVID-19 27-03-20), as per the guidelines ' 'of the Spanish Agency of Medicines and Medical Products.', 'order': 1, 'name': 'Ethics', 'group': {'name': 'EthicsHeading', 'label': 'Ethics approval and consent to participate'}}, { 'value': 'Not applicable.', 'order': 2, 'name': 'Ethics', 'group': {'name': 'EthicsHeading', 'label': 'Consent for publication'}}, { 'value': 'The authors declare that they have no competing interests.', 'order': 3, 'name': 'Ethics', 'group': {'name': 'EthicsHeading', 'label': 'Competing interests'}}], 'article-number': '359'}
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