Endocrine DOI 10.1007/s12020-017-1395-1

RESEARCH LETTER

Estimation of HbA1c in hospitalized patients with bronchial asthma Bayar Qasim

1

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Safer Haj1 Herish Ahmed2 ●

Received: 30 July 2017 / Accepted: 12 August 2017 © Springer Science+Business Media, LLC 2017

Introduction

Subjects and methods

Asthma is a chronic inflammatory respiratory disease. It can affect people of any age, but often starts in childhood. It is characterized by attacks (also known as exacerbations) of breathlessness and wheezing, with the severity and frequency of attacks varying from person to person [1]. Stress hormones like cortisol and catecholamine’s may increase in stressful conditions like asthma and expected to induce hyperglycemia. Some anti-asthma medications increase blood glucose levels e.g. Beta-agonist, while others are known hyperglycemic agent’s e.g. steroids. However, most medications are administered through the inhalation route and are less likely to cause systemic endocrinometabolic effects [2]. Hyperglycemia could represent a physiological response to stress associated with asthma. Excess stress hormones could ultimately induce insulin resistance. It has been hypothesized that insulin resistance may play a role in the development of asthma and allergy [3]. There is evidence that insulin modulates the inflammatory component of asthmatic responses mainly by influencing production/ release of tumor necrosis factor alpha (TNF-α), interluekin1beta (IL-1β), and others [4].

A case-control study conducted at the medical ward, department of internal medicine at Azadi Teaching Hospital in Duhok Governorate, Kurdistan Region, Iraq from 1st June 2016 to 30th January 2017. Seventy five patients and seventy five controls were enrolled in this study. HbA1c measurements were performed on blood samples of patients and controls. A pre-test questionnaire was administered to determine the demographic, clinical presentations and management of the patients with bronchial asthma and to assess the main risk factors. At admission venous blood sample was taken from patients, and following laboratory parameters were done including (complete blood count, random blood sugar, lipid profile, renal function test, liver function test, and serum HbA1c was measured by enzyme linked immunosorbent assay (ELISA) test. We used the following cut-off values based on values reported by the American Diabetes Association for diagnosing impaired glucose tolerance and diabetes after oral glucose tolerance tests [5]. For classifying HbA1c status as follow: ●

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* Bayar Qasim [email protected] 1

College of Medicine, University of Duhok, Duhok, Iraq

2

Azadi Teaching Hospital, Duhok, Iraq

A serum HbA1c level of less than 5.7% consider normal. A serum HbA1c between 5.7–6.4% consider prediabetes. A serum HbA1c 6.5% and higher consider diabetes.

The diagnosis of diabetes mellitus was made if patients with fasting glucose ≥7.0 mmol/L (126 mg/dl) or random glucose ≥ 11.1 mmol/L (199 mg/dl) or HbA1c > 6.5% according to the latest ADA recommendations [6]. Controls were matched to cases by age and gender and they should be free from previous respiratory diseases. Controls were

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recruited from attendants or relative of non-asthmatic patients from hospital wards. Bronchial asthma was diagnosed according to the 2016 NAEPP/USA guidelines [7]. Inclusion criteria for cases were patients admitted to medical ward, Azadi teaching hospital with diagnosis of bronchial asthma. While exclusion criteria of cases were; diabetes mellitus, sepsis, renal failure, liver failure, alcoholism, other respiratory diseases like COPD, current smoking, Anemia, and hyper-triglyceridemia. The Statistical Package for Social Sciences (IBM SPSS Statistics 21) was used for data analysis, and data were presented as mean ± standard deviation. Comparisons in categorical and continuous variables between the cases and control groups were analyzed using the chi-square test. P-values regarded significant when ≤0.05.

Table 1 Baseline characteristics of patients comparing to controls Character

Cases No. (%)

Controls No. (%)

Mean age

51.23 ± 14.647SD

50.04 ± 10.567SD

Male

26 (34.7)

27 (36)

Female

49 (65.3)

48 (64)

Total

75 (100)

75 (100)

Urban

40 (53.3)

48 (64.0)

Rural

35 (46.7)

27 (36.0)

Total

75 (100)

75 (100)

Sex

0.123

Family history Positive

42 (56)

0 (0.0)

Negative

33 (44)

75 (100)

Total

75 (100)

75 (100)

RBS <= 140

42 (56.0)

71 (94.7)

During the enrolment period of 8 months, 75 patients with bronchial asthma from medical word of internal medicine and 75 controls were included in this study. The patients mean age was 51.23 ± 14.64 ranged from 18–80 years, while the controls mean age was 50.04 ± 10.56 ranged from 31–69 years. Females were 97(64.7%) and males were 53 (35.3%). HbA1c level were elevated in 26(34.6%) of patients and in 4(5.3%) of controls.There was highly significant difference in distribution of herglycemia status among patients and controls (p = 0.001) as shown in Table 1. Levels of HbA1c was not significant in chronic use of corticosteroid both inhaler and oral type, salbutamol inhaler, current use of corticosteroid both intravenously and orally, and duration of bronchial asthma (p > 0.009).

141–199

18 (24.0)

4 (5.3)

≥200

15 (20.0)

0 (0.0)

Total

75 (100)

75 (100)

<5.7

49 (65.3)

79 (94.7)

5.7–6.4

13 (17.3)

4 (5.3)

≥6.5

13 (17.3)

0 (0.0)

Total

75 (100)

75 (100)

To the best of our knowledge, this is the first study to assess serum level of HbA1c among patients with bronchial asthma in Duhok, Iraq. The study revealed that the rate of hyperglycemia was higher in cases of bronchial asthma in comparison to healthy controls (P value < 0.001). Our data suggest that theHbA1c level were elevated in 26(34.6%) of patients and in 4(5.3%) of controls. A study from Sudan by Lutfi, M, et al. [8] found statistically significant difference in hyperglycemia between patients with bronchial asthma and control group. P.M. O’Byrnea, et al. [9] found similar to our data that the treatment with inhaled corticosteroids in patients with asthma or COPD was not associated with increased risk of new onset diabetes mellitus or hyperglycemia. In disagreement with our study Robert Schellenberg et al. [10] found that chronic use of oral corticosteroids can cause

0.50

Residency

Results

Discussion

P value

<0.001*

<0.001*

HbA1c <0.001*

P value comparison of data between cases and controls RBS random blood sugar, HbA1c glycated hemoglobin Significance level: *P <0.01

hyperglycemia. Besides, Lutfi, M, et al. [11] found that hyperglycemia is associated with bronchial asthma itself, rather than inhaler beta2 agonist medications. Al-Shawwa et al. [12] hypothesized that the proinflammatory state of insulin resistance may contribute to the pathogenesis of asthma in obese patients. Hyperglycemic effects of asthma treatments, namely beta agonists and steroids, are well documented in the literatures [13, 14] and should not be ignored when comparing blood glucose concentrations of control group with asthma group. However, in the present study, the higher values of HbA1c in asthmatic patients seemed not to be secondary to antiasthma medication. Absence of hyperglycemic effect of beta-2 agonists and steroids in patients taking these medications was probably attributable to the fact that most of these drugs were used in small doses and by the inhalation route [14, 15]. The present results regarding anti-asthma therapy are comparable with at least two previous studies on the endocrinometabolic effects of the aerosol therapy evaluated in asthmatic patients [14, 16]. Therefore, most of the findings in this study

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seemed to be associated with asthma itself rather than its treatments. Stress hormones like cortisol and catecholamine’s may increase in stressful conditions like asthma and are expected to antagonize insulin and therefore induce hyperglycemia. It has been hypothesized that insulin resistance may play a role in the development of asthma and allergy [17, 18]. In addition, insulin sensitivity was increased in asthmatic patients as a result of improvements in respiratory function noted following successful treatment [19]. Based on these studies and findings of the present data, insulin resistance [20] is likely to be involved in the patho-physiology of hyperglycemia of studied asthmatic patients. However, further studies are essential to determine whether concomitant insulin resistance is contributing factor of inflammation in asthmatic patients or it represents a physiological response to stress and/or anti-asthma medications. This study has some limitations, including small sample size, the single center experience. In summary, Hyperglycemic control might improve risk assessment in those patients with bronchial asthma. Hyperglycemia more probably is associated with bronchial asthma itself rather than its treatments. In patients admitted to a medical ward with acute bronchial asthma, glucose levels should be monitored closely. Bronchial asthma patients with hyperglycemia without prior history of diabetes should have further evaluation preferably by HbA1C. Acknowledgements Many thanks go to Dr. Yousif Ali Yaseen, Dr. Arten and Suzan Hussein for their help in completing this study. Compliance with ethical standards Conflict of interest interests.

The authors declare that they have no competing

Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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