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45 Int J Res Med. 2017; 6(3); 45-50 e ISSN:2320-2742 p ISSN: 2320-2734

Prevalence of Diabetes Mellitus in Stable COPD Patients

Srivastava A.B1, Garg Mini2*, Sharma Dinesh Kumar 3

1

MD, Professor, MBBS, 3rd year PG resident, 2,3MBBS, 3rd year PG resident, Department of Respiratory Medicine, R.N.T Medical College, Udaipur.

INTRODUCTION

The Chronic obstructive pulmonary

disease (COPD) is a disease with poorly reversible obstruction of airway that is progressive and associated with systemic inflammatory response (Alvarez-Sala, 2010)1. This proinflammatory state may lead to extra pulmonary manifestations in the majority of the patients with a negative effect on overall prognosis of the disease (Peces et al, 2008)3. The global burden of disease study projected that COPD, will became the fourth leading cause of death in 2030 which ranked sixth in 1990(GOLD 2015)2.The overall prevalence of COPD is 4-5% in India (Jindal SK et al 2006 And McKay AJ et al 2012)4,5. Co morbidities like coronary artery disease, congestive heart failure, hypertension, diabetes mellitus, osteoporosis, muscle weakness, lung cancer, depression, are common in

*Corresponding Author:

Dr Mini Garg

L-3/72 Jai Shree Colony, BohraGaneshji Road, Udaipur (Rajasthan)-313001

Contact No: 9829343317

Email: drmini43317@gmail.com

COPD (Manen et al 2001, Mapel et al 2000, Holguin et al 2000 and Mannino et al 2008 )6,7,9,27. The term "diabetes mellitus" describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances

of carbohydrate, fat and protein

metabolism resulting from defects in insulin secretion, insulin action or both. The effects of diabetes mellitus include

long–term damage, dysfunction and

failure of various organs (WHO 1999, American Diabetic Association 2012)20,11. In 2014 the global prevalence of diabetes is estimated to be 9% among adults aged more than eighteen years.

(Global status report on non

communicable disease, WHO

2012)18.There is higher prevalence of

diabetes in COPD patients, more so in stage 3 or 4 GOLD staging ( Mannino et al, Lexinton USA, 2008)27.Elevated levels of CRP, IL-6, and TNFα have been shown ( Festa et al 2002, Pradhan et al 2001, Hu et al 2004, Spranger et al 2003, Thorland

et al 2003, Hotamisligil et al

1999)13,14,15,22,24,26 to predict the

ORIGINAL ARTICLE

ABSTRACT

BACKGROUND AND OBJECTIVES: Presence of diabetes mellitus is frequent in COPD which is likely to impact the prognosis. In COPD patients treatment of diabetes mellitus may reduce pulmonary infections and exacerbations. To find out prevalence of diabetes mellitus in COPD patients and to correlate these with COPD related factors like severity, BMI etc. METHODS: The study was carried out in 77 stable COPD patients attending the department of Pulmonary Medicine at Chest and TB Hospital, Bari, RNT Medical College, Udaipur (Rajasthan), India in March 2015- December 2015 .The blood sugar of the patients was assessed and patients were classified according to severity of disease and their blood sugar level. Correlation of blood sugar with severity of COPD was done. RESULTS: 10.4% and 14.3% patients were diabetics and prediabetics respectively. There was positive correlations between fasting blood sugar (FBS) and smoking index (SI), body mass index (BMI), total duration of illness (TDI), severity of disease, exacerbation. None of them were statistically significant.

CONCLUSION: The majority of diabetics & prediabetics had moderate COPD. Fasting blood sugar increased with increase in age, smoking index (SI), body mass index (BMI), total duration of illness, severity of disease, exacerbation of COPD.

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46 Int J Res Med. 2017; 6(3); 45-50 e ISSN:2320-2742 p ISSN: 2320-2734 development of the insulin resistance,

supporting a role for inflammation in the pathogenesis of type two diabetes mellitus in COPD. Julie C Will et al, 200110 reported a dose response relationship between smoking and incidence of diabetes mellitus. Patients with poor glycaemic control who were hospitalized for acute COPD exacerbation have significantly higher mortality (Baker et al,2006)16, and even after discharge, diabetes remained a risk factor for mortality (Gudmundsson et al 2006 and Parappil et al 2010)17,21 .Both COPD and DM converge in a higher occurrence of coronary events and sudden death (Falk et al, 2008)19.

OBJECTIVES

 To find out prevalence of diabetes mellitus in COPD patients

 To correlate these with COPD related factors like severity, BMI etc

MATERIALS AND METHODS

The present study was carried out in 60 stable COPD patients admitted in TB & CHEST Hospital, Badi, Department of respiratory Medicine, R.N.T. Medical College, Udaipur, Rajasthan, India from November 2014 onwards. After informed consent about details and purpose of study these patients were evaluated as per the Performa including baseline data which included age, sex, years of exposure to cigarette/bidi smoking and biomass fuel, BMI and respiratory symptoms, drug

history, previous exacerbations,

investigations including previous

spirometry reports. Fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) were performed after overnight

fasting and withdrawal of known

diabetogenics, systemic glucocorticoids48 hrs & oral beta 2 agonists 12 hrs before the venous plasma sample was taken.ADA 201525 criteria is used to diagnose diabetes mellitus and pre diabetes. Diagnosis and assessment of severity of COPD will be done by spirometry as per GOLD guidelines 20152.

Exclusion criteria

1. COPD patients on long term

systemic glucocorticoids.

2. Patients with other systemic and cardiovascular illness not related to COPD.

3. Known case of diabetes mellitus and hepatic disease.

4. Patients with any other infective and/or inflammatory disease.

5. Pregnant women

Analysis of the data for prevalence and correlation with COPD related factors was

done using Pearson”s Correlation

Coefficient(r). Significance of

observations was done using Chi square test.

OBSERVATIONS

77 COPD Patients admitted at TB and Chest Hospital, Bari, RNT Medical College, Udaipur (Rajasthan), Indian were included in this study between March, 2015 to December, 2015 and following are the observations: There were 69 males and 8 females patients belonging to mean age of 59.87 ± 7.66 years.10.4% patients were

diabetics and 14.3% patients were

prediabetics (table 1).

Table 1: Distribution of patients according to blood sugar.

Blood sugar

Male (n=69) Female* (n=8) Total

No. % No. % No. %

Diabetic 7 10.1 1 12.5 8 10.4 Pre-diabetic 10 14.5 1 12.5 11 14.3 Normal 52 73.4 6 75.0 58 75.3 Total 69 89.6 8 10.4 77 51.9

P=0.971(NS)

In the study, 8% of patients were diabetic & 18% of patients were pre diabetic in ≤60 years age group while 14.8% patients were diabetic and 7.4% patients were pre diabetic in > 60 years age (table 2).

Table 2 Distribution of Blood Sugar with age

Blood Sugar

Age (in years) Total

40-60 (n=50) 61-80 (n=27)

No. % No. % No. %

Diabetic 4 8 4 14.8 8 10.4 Pre-diabetic 9 18 2 7.4 11 14.3 Normal 37 74 21 77.8 58 75.3

Total 50 100. 0

27 100. 0

77 100. 0

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47 Int J Res Med. 2017; 6(3); 45-50 e ISSN:2320-2742 p ISSN: 2320-2734 Majority of diabetic males (15.4%)

belongs to >60 years of age and majority of prediabetic males (18.6%) belong to <60 years of age. Maximum number of diabetics (62.5%) and pre diabetics

(81.8%) were undernourished. The

patients who were on inhaled

corticosteroids, beta 2 agonist and combination had diabetes. Majority of diabetics (75%) & prediabetics (54.5%) had moderate COPD. None of the Diabetics and prediabetic had very severe disease (table 3).

Table 3 Distribution of Diabetics and Prediabetics with COPD Severity

Blood Sugar

COPD Severity Mild Moderat

e

Severe Very Severe

Total

N o.

% N o.

% N o.

% N o.

% N o.

%

Diabeti c (n=8)

0 0 6 75 2 25 0 0.

0

8 42. 1 Prediab

etic (n=11)

3 27 .3

6 54 .5

2 18

.2

0 0. 0

11 57. 89

Total 3 15 .8

12 63 .1

4 21

.1

0 0. 0

19 100

P=0.274(NS)

Dyspnoea severity corelate with disease severity. Majority of diabetics (87.5%) &prediabetics (90%) belongs to smokers &ex smokers combined group (table 4).

Table 4 Distribution of Diabetic and Prediabetics with Smoking Status

Blood sugar Smoking status Total

Smoker& Ex-Smoker

Non-smoker

No. % No. % No.

Diabetic(n=8) 7 87.5 1 12.5 8 Pre-diabetic(n=11) 10 90 1 10 11

Total(n=19) 17 89.5 2 10.5 19

DISCUSSION

There were 69 males and 8 females patients belonging to 40 to 75 years of age. The mean age of the patients was 59.87 ± 7.66 years. The present study shows that 10.4% patients are diabetics and 14.3% patients are prediabetics respectively which is higher than prevalence of diabetes mellitus (3.9%) and prediabetes 6.6% in general tribal population of Rajasthan as reported by Bandana Sachdev et al, Churu, Sikar, Jhunjhunu, Rajasthan. Fumagalli et al, 2015, Italy30 found that prevalence of diabetes in COPD patients was 12.5% ± 2.8 which is comparable to our study. Mahishale et al. from Belgaun, Karnataka 201412 reported that 4.39%

COPD patients have diabetes mellitus. They also reported that 5.05% patients have deranged fasting blood sugar which is lower than prevalence of prediabetes in our study because Mahishale et al didn’t combined impaired glucose tolerance with impaired fasting glucose .In the present study 10.1% and 14.5% of males were diabetic & prediabetic respectively. 12.5% of females were diabetic and prediabetic each. Mannino et al, 2008, USA27 found higher risk of diabetes mellitus in males (13.5% ± 0.4) than females (12.0 % ±0.3) during analysis of 20296 cases. In the present study, 8% and 14.8% patients were COPD diabetic in ≤60 years of age &>60 years of age respectively. Majority of diabetics belongs to >60 years of age and majority of prediabetics belong to ≤60 years age. Katsura et al, Japan, 20118also found higher prevalence in higher age group 16.6% in 50-59 years age Vs 19.6% in 60-69 years of age. In present study maximum number of diabetics (62.5%)

and pre diabetics (81.8%) were

undernourished. 37.5% of diabetics and

54.5% of prediabetics had severe

undernutrition. Miguel et al,2014, Boston29 found that patients with higher BMI

(>30kg/m2) had increased

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48 Int J Res Med. 2017; 6(3); 45-50 e ISSN:2320-2742 p ISSN: 2320-2734 diabetes mellitus in all smokers, past or

current(relative risk 2.0,1.2-3.2).None of the patients who were on inhaled corticosteroids, beta 2 agonist and combination had diabetes. 33.3% patients on oral beta 2 and 25% of patients on oral

beta 2 agonist with ICS had

diabetes.33.3% patients on inhaled beta 2 agonist and 27.3% patients on combination of inhaled beta 2 agonist and ICS had prediabetes. Rogliani et al from Italy, 201423 using single, double & triple respiratory therapy for COPD observed that association between COPD and diabetes mellitus is regardless of use of

concomitant medication. She also

observed that there is slight association of inhaled corticosteroid use with the presence of diabetes mellitus in COPD, but the use of combination of inhaled corticosteroid and inhaled beta 2 agonist reduced this association. No studies regarding oral therapy was found.

CONCLUSION

There is positive correlations between fasting blood sugar (FBS) and age, smoking index (SI),Body mass index (BMI), total duration of index(TD)I, severity of disease, mMRC dyspnoea grade, exacerbation, i.e. FBS increased with increase in age, SI, BMI, TDI, severity of disease, mMRC and frequency of exacerbation but none of them were statistically significant.

LIMITATION:

1. Sample size was small to draw

statistically significant results.

2. Maximum patient in the sudy were

undernourished.None of the patient was overweight or obese.

3. Less number of patients in very

severe COPD.

4. No follow up study could be done

due to short study period.

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