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Quenneville S, Labouèbe G, Basco D, Metref S, Viollet B, Foretz M, Thorens B. Hypoglycemia-Sensing Neurons of the Ventromedial Hypothalamus Require AMPK-Induced Txn2 Expression but Are Dispensable for Physiological Counterregulation. Diabetes 2020; 69:2253-2266. [PMID: 32839348 PMCID: PMC7576557 DOI: 10.2337/db20-0577] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/18/2020] [Indexed: 12/23/2022]
Abstract
The ventromedial nucleus of the hypothalamus (VMN) is involved in the counterregulatory response to hypoglycemia. VMN neurons activated by hypoglycemia (glucose-inhibited [GI] neurons) have been assumed to play a critical although untested role in this response. Here, we show that expression of a dominant negative form of AMPK or inactivation of AMPK α1 and α2 subunit genes in Sf1 neurons of the VMN selectively suppressed GI neuron activity. We found that Txn2, encoding a mitochondrial redox enzyme, was strongly downregulated in the absence of AMPK activity and that reexpression of Txn2 in Sf1 neurons restored GI neuron activity. In cell lines, Txn2 was required to limit glucopenia-induced reactive oxygen species production. In physiological studies, absence of GI neuron activity after AMPK suppression in the VMN had no impact on the counterregulatory hormone response to hypoglycemia or on feeding. Thus, AMPK is required for GI neuron activity by controlling the expression of the antioxidant enzyme Txn2. However, the glucose-sensing capacity of VMN GI neurons is not required for the normal counterregulatory response to hypoglycemia. Instead, it may represent a fail-safe system in case of impaired hypoglycemia sensing by peripherally located glucose detection systems that are connected to the VMN.
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Affiliation(s)
- Simon Quenneville
- Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
| | - Gwenaël Labouèbe
- Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
| | - Davide Basco
- Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
| | - Salima Metref
- Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
| | - Benoit Viollet
- Université de Paris, Institut Cochin, CNRS, INSERM, Paris, France
| | - Marc Foretz
- Université de Paris, Institut Cochin, CNRS, INSERM, Paris, France
| | - Bernard Thorens
- Center for Integrative Genomics, University of Lausanne, Lausanne, Switzerland
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102
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Lontchi-Yimagou E, Aleksic S, Hulkower R, Gospin R, Goyal A, Kuo B, Mitchell WG, You JY, Upadhyay L, Carey M, Sandu OA, Gabriely I, Shamoon H, Hawkins M. Plasma Epinephrine Contributes to the Development of Experimental Hypoglycemia-Associated Autonomic Failure. J Clin Endocrinol Metab 2020; 105:5903847. [PMID: 32915987 PMCID: PMC7678732 DOI: 10.1210/clinem/dgaa539] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/04/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recurrent hypoglycemia blunts counter-regulatory responses to subsequent hypoglycemic episodes, a syndrome known as hypoglycemia-associated autonomic failure (HAAF). Since adrenergic receptor blockade has been reported to prevent HAAF, we investigated whether the hypoglycemia-associated rise in plasma epinephrine contributes to pathophysiology and reported interindividual differences in susceptibility to HAAF. METHODS To assess the role of hypoglycemia-associated epinephrine responses in the susceptibility to HAAF, 24 adult nondiabetic subjects underwent two 2-hour hyperinsulinemic hypoglycemic clamp studies (nadir 54 mg/dL; 0-2 hours and 4-6 hours) on Day 1, followed by a third identical clamp on Day 2. We challenged an additional 7 subjects with two 2-hour infusions of epinephrine (0.03 μg/kg/min; 0-2 hours and 4-6 hours) vs saline on Day 1 followed by a 200-minute stepped hypoglycemic clamp (90, 80, 70, and 60 mg/dL) on Day 2. RESULTS Thirteen out of 24 subjects developed HAAF, defined by ≥20% reduction in average epinephrine levels during the final 30 minutes of the third compared with the first hypoglycemic episode (P < 0.001). Average epinephrine levels during the final 30 minutes of the first hypoglycemic episode were 2.3 times higher in subjects who developed HAAF compared with those who did not (P = 0.006).Compared to saline, epinephrine infusion on Day 1 reduced the epinephrine responses by 27% at the 70 and 60 mg/dL glucose steps combined (P = 0.04), with a parallel reduction in hypoglycemic symptoms (P = 0.03) on Day 2. CONCLUSIONS Increases in plasma epinephrine reproduce key features of HAAF in nondiabetic subjects. Marked interindividual variability in epinephrine responses to hypoglycemia may explain an individual's susceptibility to developing HAAF.
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Affiliation(s)
| | | | | | | | - Akankasha Goyal
- New York University Langone Medical Center, New York, New York
| | - Bryan Kuo
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Jee Young You
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Michelle Carey
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Oana A Sandu
- Albert Einstein College of Medicine, Bronx, New York
| | - Ilan Gabriely
- Albert Einstein College of Medicine, Bronx, New York
| | - Harry Shamoon
- Albert Einstein College of Medicine, Bronx, New York
| | - Meredith Hawkins
- Albert Einstein College of Medicine, Bronx, New York
- Correspondence and Reprint Requests: Dr. Meredith Hawkins, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA. E-mail:
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103
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Lin YK, Fisher SJ, Pop‐Busui R. Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies. J Diabetes Investig 2020; 11:1388-1402. [PMID: 32403204 PMCID: PMC7610104 DOI: 10.1111/jdi.13290] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022] Open
Abstract
Impaired awareness of hypoglycemia (IAH) is a reduction in the ability to recognize low blood glucose levels that would otherwise prompt an appropriate corrective therapy. Identified in approximately 25% of patients with type 1 diabetes, IAH has complex pathophysiology, and might lead to serious and potentially lethal consequences in patients with diabetes, particularly in those with more advanced disease and comorbidities. Continuous glucose monitoring systems can provide real-time glucose information and generate timely alerts on rapidly falling or low blood glucose levels. Given their improvements in accuracy, affordability and integration with insulin pump technology, continuous glucose monitoring systems are emerging as critical tools to help prevent serious hypoglycemia and mitigate its consequences in patients with diabetes. This review discusses the current knowledge on IAH and effective diagnostic methods, the relationship between hypoglycemia and cardiovascular autonomic neuropathy, a practical approach to evaluating cardiovascular autonomic neuropathy for clinicians, and recent evidence from clinical trials assessing the effects of the use of CGM technologies in patients with type 1 diabetes with IAH.
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Affiliation(s)
- Yu Kuei Lin
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Simon J Fisher
- Division of Endocrinology, Metabolism and DiabetesDepartment of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Rodica Pop‐Busui
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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104
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de Heide LJM, van den Broek M, van Dijk G, Emous M, van Beek AP. Diminished Counterregulatory Responses to Meal-Induced Hypoglycemia 4 Years After RYGB. Obes Surg 2020; 31:597-602. [PMID: 33063157 DOI: 10.1007/s11695-020-05035-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/01/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Post-bariatric hypoglycemia is a complication of bariatric surgery, especially Roux-en-Y gastric bypass (RYGB). The counterregulatory hormonal and sympathetic neural responses were measured during a previously reported meal test in which 48% had an almost asymptomatic hypoglycemic event. MATERIALS AND METHODS Forty-four randomly selected patients 4 years after RYGB. A liquid meal test (MMT) after overnight fasting. Based on the glucose nadir during the MMT, patients were divided in a hypo group (glucose < 3.3 mmol/L) and a non-hypo group (glucose ≥ 3.3 mmol/L). Cortisol, epinephrine, norepinephrine, blood pressure, and heart rate were measured up to 180 min after ingestion of the meal. Incremental areas under the curve (iAUC), peak, and delta hormone responses after the glucose nadir were calculated. Parameters were compared between the hypo and non-hypo groups. RESULTS A total of 21/44 (48%) had an almost asymptomatic hypoglycemic event. Cortisol and epinephrine responses in the hypo group were not increased compared to the non-hypo group, and there were no signs of increased sympathetic nerve activity. Peak and delta cortisol were lower in the hypo compared to the non-hypo group. Norepinephrine was higher in the hypo group especially in the time frame 60-120 and 120-180 min after start of the meal. CONCLUSION No increase in epinephrine and a lower cortisol response to hypoglycemia were observed compared to normoglycemia during a meal test in patients after RYGB. Norepinephrine levels were higher in the hypo group. These findings may suggest that possible recurrent hypoglycemia after RYGB results in blunting of counterregulatory responses indicative of hypoglycemia-induced autonomic failure. CLIN TRIAL REGISTER ID ISRCTN 11738149.
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Affiliation(s)
- Loek J M de Heide
- Center for Obesity North-Netherlands (CON), Medical Center Leeuwarden, H. Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
| | - Merel van den Broek
- Center for Obesity North-Netherlands (CON), Medical Center Leeuwarden, H. Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Gertjan van Dijk
- GELIFES-Neurobiology, Department of Behavioral Neuroscience, University of Groningen, Groningen, The Netherlands
| | - Marloes Emous
- Center for Obesity North-Netherlands (CON), Medical Center Leeuwarden, H. Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - André P van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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105
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Direct Effects of D-Chiro-Inositol on Insulin Signaling and Glucagon Secretion of Pancreatic Alpha Cells. Biomolecules 2020; 10:biom10101404. [PMID: 33020399 PMCID: PMC7601246 DOI: 10.3390/biom10101404] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/18/2020] [Accepted: 10/02/2020] [Indexed: 02/06/2023] Open
Abstract
The insulin resistance state of pancreatic α-cells seems to be related to glucagon hypersecretion in type 2 diabetes. Treatment that can improve the insulin sensitivity of α-cells could control glucagon levels in patients with diabetes mellitus. The aim of this study was to investigate the preventive role of D-chiro-inositol (DCI), which has insulin receptor-sensitizer effects on insulin signaling pathways and glucagon secretion in pancreatic α-TC1 clone 6 cells. Cells were chronically treated with palmitate to induce insulin resistance in the presence/absence of DCI. DCI treatment improved the insulin signaling pathway and restored insulin-mediated glucagon suppression in α-TC1-6 cells exposed to palmitate. These results indicate that DCI treatment prevents the insulin resistance of α-TC1-6 cells chronically exposed to palmitate. Our data provide evidence that DCI could be useful to improve the insulin sensitivity of pancreatic α-cells in diabetes treatment.
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106
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Dagogo-Jack S. Role of the HPA Axis in the Metabolic and Baroreflex Components of Hypoglycemia-Associated Autonomic Failure. J Clin Endocrinol Metab 2020; 105:5863390. [PMID: 32589741 PMCID: PMC7425998 DOI: 10.1210/clinem/dgaa391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/22/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Sam Dagogo-Jack
- Division of Endocrinology, Diabetes & Metabolism, University of Tennessee Health Science Center, Memphis, TN, US
- Correspondence and Reprint Requests: Sam Dagogo-Jack, MD, DSc, Division of Endocrinology, Diabetes & Metabolism, University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN 38163. E-mail:
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Nair GG, Tzanakakis ES, Hebrok M. Emerging routes to the generation of functional β-cells for diabetes mellitus cell therapy. Nat Rev Endocrinol 2020; 16:506-518. [PMID: 32587391 PMCID: PMC9188823 DOI: 10.1038/s41574-020-0375-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2020] [Indexed: 02/07/2023]
Abstract
Diabetes mellitus, which affects more than 463 million people globally, is caused by the autoimmune ablation or functional loss of insulin-producing β-cells, and prevalence is projected to continue rising over the next decades. Generating β-cells to mitigate the aberrant glucose homeostasis manifested in the disease has remained elusive. Substantial advances have been made in producing mature β-cells from human pluripotent stem cells that respond appropriately to dynamic changes in glucose concentrations in vitro and rapidly function in vivo following transplantation in mice. Other potential avenues to produce functional β-cells include: transdifferentiation of closely related cell types (for example, other pancreatic islet cells such as α-cells, or other cells derived from endoderm); the engineering of non-β-cells that are capable of modulating blood sugar; and the construction of synthetic 'cells' or particles mimicking functional aspects of β-cells. This Review focuses on the current status of generating β-cells via these diverse routes, highlighting the unique advantages and challenges of each approach. Given the remarkable progress in this field, scalable bioengineering processes are also discussed for the realization of the therapeutic potential of derived β-cells.
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Affiliation(s)
- Gopika G Nair
- Diabetes Center, University of California San Francisco, San Francisco, CA, USA
| | - Emmanuel S Tzanakakis
- Chemical and Biological Engineering, Tufts University, Medford, MA, USA
- Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, USA
| | - Matthias Hebrok
- Diabetes Center, University of California San Francisco, San Francisco, CA, USA.
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108
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Leung JH, Bayomy OF, Bonyhay I, Celli J, White J, Freeman R, Adler GK. ACTH Infusion Impairs Baroreflex Sensitivity-Implications for Cardiovascular Hypoglycemia-Associated Autonomic Failure. J Clin Endocrinol Metab 2020; 105:5827417. [PMID: 32353115 PMCID: PMC7255850 DOI: 10.1210/clinem/dgaa221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/27/2020] [Indexed: 01/22/2023]
Abstract
CONTEXT Hypoglycemia attenuates cardiovascular homeostatic autonomic control. This attenuation, known as the cardiovascular component of hypoglycemia-associated autonomic failure (HAAF), is characterized most notably by decreased baroreflex sensitivity (BRS) that begins during hypoglycemia and persists until at least the next day, despite return to euglycemia. Understanding the mechanisms underlying this reduction in BRS is important because BRS attenuation is associated with increased morbidity and mortality. OBJECTIVE The objective of this work is to investigate the role of the adrenocorticotropin (ACTH)-adrenal axis in decreasing BRS. We tested the hypothesis that infusion of ACTH 1-24 (cosyntropin), as compared to placebo, would acutely suppress BRS, and that this decrease in BRS would be present the next day. DESIGN A double-blind, placebo-controlled, random-order, cross-over study was conducted. SETTING This study took place in a clinical research center. PARTICIPANTS Participants included healthy men and women. INTERVENTIONS Interventions included an intravenous infusion of cosyntropin (70 μg/hour for 2.5 hours in the morning and again in the early afternoon) vs normal saline placebo. MAIN OUTCOME MEASURES Outcome measures included BRS during and 16 hours after cosyntropin vs placebo infusions. RESULTS Cosyntropin infusion attenuated BRS (mm Hg/ms) as compared to placebo (baseline 17.8 ± 1.38 vs 17.0 ± 2.07; during 14.4 ± 1.43 vs 17.3 ± 1.65; and next day 14.8 ± 1.42 vs 18.9 ± 2.04; P < .05, time by treatment, analysis of variance). BRS was decreased during the final 30 minutes of the morning cosyntropin infusion as compared to baseline (P < .01) and remained suppressed the next day (16 hours after afternoon infusion) (P < .025). Placebo infusion did not significantly change BRS. Corrected QT interval was not affected. CONCLUSIONS ACTH attenuates BRS, raising the possibility that hypoglycemia-induced increases in ACTH may contribute to the cardiovascular component of HAAF.
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Affiliation(s)
- Janet H Leung
- Division of Endocrinology and Diabetes, Virginia Mason Medical Center, Seattle, Washington
| | - Omar F Bayomy
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Istvan Bonyhay
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Johanna Celli
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jeffrey White
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Gail K Adler
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Gail K. Adler, MD, PhD, FAHA, Brigham and Women’s Hospital, Division of Endocrinology, Diabetes and Hypertension, 221 Longwood Avenue, Boston, MA 02115. E-mail:
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109
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Gradel AKJ, Kildegaard J, Ludvigsen TP, Porsgaard T, Schou-Pedersen AMV, Fels JJ, Lykkesfeldt J, Refsgaard HHF. The counterregulatory response to hypoglycaemia in the pig. Basic Clin Pharmacol Toxicol 2020; 127:278-286. [PMID: 32343047 DOI: 10.1111/bcpt.13422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 01/31/2023]
Abstract
The domestic pig is commonly used as animal model in the pharmaceutical development of new therapeutics for treatment of diabetes. Since a formal definition of hypoglycaemia only exists in humans, the purpose of this study was to assess the counterregulatory response in the domestic pig at glucose levels known to induce symptoms of hypoglycaemia in humans. Six pigs were included in hyperinsulinaemic glucose clamps with plasma glucose targets of 2, 3 and 5 mmol/L in a cross-over design, and the associated glucose counterregulatory response was assessed by measuring glucose kinetics and levels of glucagon, c-peptide, catecholamines, cortisol and growth hormone. Results showed that the 2 and 3 vs 5 mmol/L clamps significantly decreased and increased the secretion of c-peptide and glucagon, respectively (P < .05). This finding was associated with increased rate of glucose appearance (Ra ) and decreased rate of glucose disappearance (Rd ) (P < .001). No marked differences in the catecholamine, growth hormone or cortisol response were observed. Consequently, like humans, pigs respond to hypoglycaemia by decreasing the pancreatic output of insulin while increasing that of glucagon, with increased glucose mobilization and decreased glucose disposal as a result. The hypoglycaemic clamps did not result in a marked secretion of the other counterregulatory hormones.
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Affiliation(s)
- Anna Katrina J Gradel
- Department of Veterinary and Animal Sciences, Section for Experimental Animal Models, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Global Drug Discovery, Novo Nordisk A/S, Måløv, Denmark
| | | | | | | | - Anne Marie V Schou-Pedersen
- Department of Veterinary and Animal Sciences, Section for Experimental Animal Models, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Jens Lykkesfeldt
- Department of Veterinary and Animal Sciences, Section for Experimental Animal Models, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Davis TME, Dwyer P, England M, Fegan PG, Davis WA. Efficacy of Intermittently Scanned Continuous Glucose Monitoring in the Prevention of Recurrent Severe Hypoglycemia. Diabetes Technol Ther 2020; 22:367-373. [PMID: 31724878 DOI: 10.1089/dia.2019.0331] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: People with diabetes experiencing hypoglycemia are at increased risk of recurrence because of attenuated autonomic warning. We assessed the efficacy of intermittently scanned continuous glucose monitoring (isCGM; FreeStyle Libre™, Abbott) compared with usual-care self-monitoring of blood glucose (SMBG) in reducing this risk in type 1 and insulin-treated type 2 diabetes. Methods: Insulin-treated adults with diabetes and an episode of clinically significant biochemical hypoglycemia (blood glucose [BG] <3.0 mM) or symptomatic hypoglycemia and BG <4.0 mM were randomized to 6 months of isCGM (intensive group) or SMBG (control group) against a background of usual care. The primary outcome was hypoglycemia requiring second-party assistance for recovery. Prespecified secondary outcomes included other hypoglycemic episodes (self-reported, and BG <3.0, 3.0-3.9, <4.0 mM) and change in HbA1c at 24 weeks. Results: Of 59 participants (mean age 53.6 years, 44.1% males, median HbA1c 61.8 mmol/mol or 7.8%), 30 were allocated to isCGM and 29 to SMBG. The incidence of severe hypoglycemia was not significantly different between the two groups (incident rate ratio [95% confidence interval]: 1.49 [0.46-5.56], P = 0.47). The incidence of other recorded hypoglycemic episodes in the intervention group was double that in the control group (P < 0.001). There was no difference in the change in HbA1c between the two groups (P = 0.74). There were seven serious adverse events and none was considered related to the intervention. Conclusions: Although isCGM is safe, it does not appear to have a role in preventing recurrent severe hypoglycemia in at-risk individuals with diabetes.
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Affiliation(s)
- Timothy M E Davis
- Medical School, Fremantle Hospital, University of Western Australia, Fremantle, Australia
| | - Penny Dwyer
- Medical School, Fremantle Hospital, University of Western Australia, Fremantle, Australia
| | - Michelle England
- Medical School, Fremantle Hospital, University of Western Australia, Fremantle, Australia
| | - P Gerry Fegan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Australia
| | - Wendy A Davis
- Medical School, Fremantle Hospital, University of Western Australia, Fremantle, Australia
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111
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Aitken ML, Szkudlinska MA, Boyko EJ, Ng D, Utzschneider KM, Kahn SE. Impaired counterregulatory responses to hypoglycaemia following oral glucose in adults with cystic fibrosis. Diabetologia 2020; 63:1055-1065. [PMID: 31993716 PMCID: PMC7150633 DOI: 10.1007/s00125-020-05096-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/20/2019] [Indexed: 02/01/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to determine the mechanism(s) for hypoglycaemia occurring late following oral glucose loading in patients with cystic fibrosis (CF). METHODS A 3 h 75 g OGTT was performed in 27 non-diabetic adults with CF who were classified based on this test as experiencing hypoglycaemia (glucose <3.3 mmol/l with or without symptoms or glucose <3.9 mmol/l with symptoms, n = 14) or not (n = 13). Beta cell function, incretin (glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic peptide [GIP]) and counterregulatory hormone responses (glucagon, catecholamines, growth hormone and cortisol) were assessed. RESULTS The two groups did not differ in age, weight or BMI. There were more male participants and individuals with pancreatic exocrine insufficiency in the hypoglycaemia group. Fasting plasma glucose did not differ between the two groups (5.3 ± 0.16 vs 5.3 ± 0.10 mmol/l). Both fasting insulin (20.7 ± 2.9 vs 36.5 ± 4.8 pmol/l; p = 0.009) and C-peptide (0.38 ± 0.03 vs 0.56 ± 0.05 nmol/l; p = 0.002) were lower in those who experienced hypoglycaemia. Following glucose ingestion, glucose concentrations were significantly lower in the hypoglycaemia group from 135 min onwards, with a nadir of 3.2 ± 0.2 vs 4.8 ± 0.3 mmol/l at 180 min (p < 0.001). The test was terminated early in three participants because of a glucose level <2.5 mmol/l. Insulin and C-peptide concentrations were also lower in the hypoglycaemia group, while incretin hormone responses were not different. Modelling demonstrated that those experiencing hypoglycaemia were more insulin sensitive (439 ± 17.3 vs 398 ± 13.1 ml min-1 m-2, p = 0.074 based on values until 120 min [n = 14]; 512 ± 18.9 vs 438 ± 15.5 ml min-1 m-2, p = 0.006 based on values until 180 min [n = 11]). In line with their better insulin sensitivity, those experiencing hypoglycaemia had lower insulin secretion rates (ISRfasting: 50.8 ± 3.2 vs 74.0 ± 5.9 pmol min-1 m-2, p = 0.002; ISROGTT: 44.9 ± 5.0 vs 63.4 ± 5.2 nmol/m2, p = 0.018) and beta cell glucose sensitivity (47.4 ± 4.5 vs 79.2 ± 7.5 pmol min-1 m-2 [mmol/l]-1, p = 0.001). Despite the difference in glucose concentrations, there were no significant increases in glucagon, noradrenaline, cortisol or growth hormone levels. Adrenaline increased by only 66% and 61% above baseline at 165 and 180 min when glucose concentrations were 3.8 ± 0.2 and 3.2 ± 0.2 mmol/l, respectively. CONCLUSIONS/INTERPRETATION Hypoglycaemia occurring late during an OGTT in people with CF was not associated with the expected counterregulatory hormone response, which may be a consequence of more advanced pancreatic dysfunction/destruction.
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Affiliation(s)
- Moira L Aitken
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Magdalena A Szkudlinska
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - Edward J Boyko
- Division of General Internal Medicine, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, WA, USA
| | - Debbie Ng
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kristina M Utzschneider
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
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113
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Thieu VT, Mitchell BD, Varnado OJ, Frier BM. Treatment and prevention of severe hypoglycaemia in people with diabetes: Current and new formulations of glucagon. Diabetes Obes Metab 2020; 22:469-479. [PMID: 31820562 PMCID: PMC7079012 DOI: 10.1111/dom.13941] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/22/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
Some therapies for diabetes increase the risk of hypoglycaemia, in particular all insulins and insulin secretagogues, including the glinides and sulfonylureas. Hypoglycaemia remains a major limiting factor to successful glycaemic management, despite the availability of prevention options such as insulin analogues, continuous glucose monitoring, insulin pumps, and dogs that have been trained to detect hypoglycaemia. Non-severe (self-treated) and severe (requiring assistance for recovery) hypoglycaemia rates are higher in people with type 1 diabetes, but those with insulin-treated type 2 diabetes are also at risk. Education and regular review are essential between people with diabetes and their caregivers and healthcare professionals about symptoms, prevention and treatment. Awareness of the potential dangers of hypoglycaemia is fundamental to the optimal management of diabetes. When therapy is intensified to achieve glycaemic targets, it is important that people at risk of severe hypoglycaemia, and particularly their caregivers, have ready access to effective treatment for hypoglycaemia emergencies. The current and potential formulations of glucagon available for treatment of severe hypoglycaemia are reviewed.
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Affiliation(s)
| | | | | | - Brian M. Frier
- The Queen's Medical Research InstituteUniversity of EdinburghEdinburghUK
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114
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Long C, Dungan K. Hypoglycemia awareness and burden among hospitalized patients at high risk for hypoglycemia. J Diabetes Complications 2020; 34:107521. [PMID: 31937469 DOI: 10.1016/j.jdiacomp.2019.107521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/13/2019] [Accepted: 12/30/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hypoglycemia, a common complication of insulin therapy in patients with diabetes, is associated with increased hospital morbidity and mortality. Hypoglycemia may be underrecognized in hospitalized patients due to impaired counter regulation or reduced recognition. Beta blocker (BB) use may also affect hypoglycemia recognition. AIM To characterize hypoglycemia unawareness and patient perceived hypoglycemia burden in hospitalized patients. MATERIALS AND METHODS Over a 2-month period, we prospectively identified non-critically ill cognitively intact hospitalized insulin-requiring patients who were undergoing bedside glucose monitoring. Participants were included if they reported any episode of hypoglycemia in the 30 days prior to admission and either had no BB use or were on stable BB for 90 days. Hypoglycemia unawareness was assessed using the Clarke score and burden of hypoglycemia was assessed with the (TRIM-HYPO) score. RESULTS Of the 46 participants, 20 were not taking a BB and 26 were taking a BB. Predictors of hypoglycemia during admission included glucose coefficient of variation and hospital length of stay. Nine participants (20%) had hypoglycemia unawareness (Clarke score ≥4). Participants with a history of coronary artery disease were less likely to have impaired awareness. Burden of hypoglycemia was associated with more hypoglycemia and longer hospital length of stay. There were no differences in measures of hypoglycemia unawareness or burden according to BB use. CONCLUSIONS BB use was not related to hypoglycemia unawareness, or burden in hospitalized high risk patients. Hypoglycemia burden may identify patients at higher risk of hypoglycemia during admission.
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Affiliation(s)
- Clarine Long
- The Ohio State University College of Medicine, United States of America
| | - Kathleen Dungan
- The Ohio State University, Division of Endocrinology, Diabetes & Metabolism, United States of America.
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115
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Freeman R, Illigens BMW, Lapusca R, Campagnolo M, Abuzinadah AR, Bonyhay I, Sinn DI, Miglis M, White J, Gibbons CH. Symptom Recognition Is Impaired in Patients With Orthostatic Hypotension. Hypertension 2020; 75:1325-1332. [PMID: 32223377 DOI: 10.1161/hypertensionaha.119.13619] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Failure to recognize symptoms of orthostatic hypotension (OH) may result in falls, syncope, and injuries. The relationship between orthostatic changes in blood pressure and symptom occurrence and severity is not known. The goal of the present study was to define the relationship between the occurrence and severity of the symptoms of orthostatic hypotension (OH) and (1) the upright systolic blood pressure (SBP) and (2) the fall in SBP after tilting in patients with OH. We prospectively studied 89 patients with OH. Reported BP values include the lowest BP in the first 3 minutes of tilt and the change in blood pressure during tilt. Subjects were queried about symptoms of orthostatic intolerance while supine and during the first 3 minutes of tilt testing using Question 1 of the Orthostatic Hypotension Questionnaire. Mean tilted SBP was 101.6±26.1 mm Hg and mean SBP fall 47.9±18.1 mm Hg. Mean symptom scores when upright were: light-headedness (2.3/10±2.7), dizziness (1.6/10±2.5), and impending blackout (0.8/10±1.9). The majority of patients were asymptomatic or mildly symptomatic and no discrete cutoff for symptoms was observed. The magnitude of the SBP fall (r=-0.07, P=NS) and the lowest upright SBP (r=0.08, P=NS) did not correlate with any reported symptom. These results suggest a poor relationship between the magnitude of the orthostatic BP fall, the upright orthostatic BP, and symptoms. Many patients are asymptomatic despite substantial SBP falls and low orthostatic blood pressures. These findings have implications for clinical care of patients with OH and clinical trials to treat patients with OH.
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Affiliation(s)
- Roy Freeman
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.F., B.M.W.I., I.B., C.H.G.)
| | - Ben M W Illigens
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.F., B.M.W.I., I.B., C.H.G.)
| | - Razvan Lapusca
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Germany (R.L.)
| | | | - Ahmad R Abuzinadah
- Department of Internal Medicine, King Abdulaziz University Hospital, College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia (A.R.A.)
| | - Istvan Bonyhay
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.F., B.M.W.I., I.B., C.H.G.)
| | - Dong-In Sinn
- Department of Neurology, Stanford Medical Center, Palo Alto, CA (D.-I.S., M.M.)
| | - Mitchell Miglis
- Department of Neurology, Stanford Medical Center, Palo Alto, CA (D.-I.S., M.M.)
| | - Jeffrey White
- University of Virginia School of Medicine, Charlottesville (J.W.)
| | - Christopher H Gibbons
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.F., B.M.W.I., I.B., C.H.G.)
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116
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Abstract
Treatment of type 1 diabetes with exogenous insulin often results in unpredictable daily glucose variability and hypoglycemia, which can be dangerous. Automated insulin delivery systems can improve glucose control while reducing burden for people with diabetes. One approach to improve treatment outcomes is to incorporate the counter-regulatory hormone glucagon into the automated delivery system to help prevent the hypoglycemia that can be induced by the slow pharmacodynamics of insulin action. This article explores the advantages and disadvantages of incorporating glucagon into dual-hormone automated hormone delivery systems.
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Affiliation(s)
- Leah M Wilson
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA.
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Mail Code: CH13B, 3303 Southwest Bond Avenue, Portland, OR 97239, USA
| | - Jessica R Castle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA
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117
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Aklan I, Sayar Atasoy N, Yavuz Y, Ates T, Coban I, Koksalar F, Filiz G, Topcu IC, Oncul M, Dilsiz P, Cebecioglu U, Alp MI, Yilmaz B, Davis DR, Hajdukiewicz K, Saito K, Konopka W, Cui H, Atasoy D. NTS Catecholamine Neurons Mediate Hypoglycemic Hunger via Medial Hypothalamic Feeding Pathways. Cell Metab 2020; 31:313-326.e5. [PMID: 31839488 PMCID: PMC9017597 DOI: 10.1016/j.cmet.2019.11.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 09/22/2019] [Accepted: 11/18/2019] [Indexed: 02/07/2023]
Abstract
Glucose is the essential energy source for the brain, whose deficit, triggered by energy deprivation or therapeutic agents, can be fatal. Increased appetite is the key behavioral defense against hypoglycemia; however, the central pathways involved are not well understood. Here, we describe a glucoprivic feeding pathway by tyrosine hydroxylase (TH)-expressing neurons from nucleus of solitary tract (NTS), which project densely to the hypothalamus and elicit feeding through bidirectional adrenergic modulation of agouti-related peptide (AgRP)- and proopiomelanocortin (POMC)-expressing neurons. Acute chemogenetic inhibition of arcuate nucleus (ARC)-projecting NTSTH neurons or their target, AgRP neurons, impaired glucoprivic feeding induced by 2-Deoxy-D-glucose (2DG) injection. Neuroanatomical tracing results suggested that ARC-projecting orexigenic NTSTH neurons are largely distinct from neighboring catecholamine neurons projecting to parabrachial nucleus (PBN) that promotes satiety. Collectively, we describe a circuit organization in which an ascending pathway from brainstem stimulates appetite through key hunger neurons in the hypothalamus in response to hypoglycemia.
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Affiliation(s)
- Iltan Aklan
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA
| | - Nilufer Sayar Atasoy
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA
| | - Yavuz Yavuz
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA; Department of Physiology, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Tayfun Ates
- Department of Physiology, School of Medicine, Regenerative and Restorative Medical Research Center (REMER), Istanbul Medipol University, Istanbul, Turkey
| | - Ilknur Coban
- Department of Physiology, School of Medicine, Regenerative and Restorative Medical Research Center (REMER), Istanbul Medipol University, Istanbul, Turkey
| | - Fulya Koksalar
- Department of Physiology, School of Medicine, Regenerative and Restorative Medical Research Center (REMER), Istanbul Medipol University, Istanbul, Turkey
| | - Gizem Filiz
- Department of Physiology, School of Medicine, Regenerative and Restorative Medical Research Center (REMER), Istanbul Medipol University, Istanbul, Turkey
| | - Iskalen Cansu Topcu
- Department of Physiology, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Merve Oncul
- Department of Physiology, School of Medicine, Regenerative and Restorative Medical Research Center (REMER), Istanbul Medipol University, Istanbul, Turkey
| | - Pelin Dilsiz
- Department of Physiology, School of Medicine, Regenerative and Restorative Medical Research Center (REMER), Istanbul Medipol University, Istanbul, Turkey
| | - Utku Cebecioglu
- Department of Physiology, School of Medicine, Regenerative and Restorative Medical Research Center (REMER), Istanbul Medipol University, Istanbul, Turkey
| | - Muhammed Ikbal Alp
- Department of Physiology, School of Medicine, Regenerative and Restorative Medical Research Center (REMER), Istanbul Medipol University, Istanbul, Turkey
| | - Bayram Yilmaz
- Department of Physiology, School of Medicine, Yeditepe University, Istanbul, Turkey
| | - Deborah R Davis
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA
| | - Karolina Hajdukiewicz
- Laboratory of Animal Models, Neurobiology Center, Nencki Institute of Experimental Biology, Warsaw, Poland
| | - Kenji Saito
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA
| | - Witold Konopka
- Laboratory of Animal Models, Neurobiology Center, Nencki Institute of Experimental Biology, Warsaw, Poland
| | - Huxing Cui
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA
| | - Deniz Atasoy
- Department of Neuroscience and Pharmacology, Roy J. and Lucille A. Carver College of Medicine, Iowa Neuroscience Institute, University of Iowa, Iowa City, Iowa, USA.
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118
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Hu X, Xu W, Lin S, Zhang C, Ling C, Chen M. Development and Validation of a Hypoglycemia Risk Model for Intensive Insulin Therapy in Patients with Type 2 Diabetes. J Diabetes Res 2020; 2020:7292108. [PMID: 33015194 PMCID: PMC7525304 DOI: 10.1155/2020/7292108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/16/2020] [Accepted: 08/28/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS To develop a simple hypoglycemic prediction model to evaluate the risk of hypoglycemia during hospitalization in patients with type 2 diabetes treated with intensive insulin therapy. METHODS We performed a cross-sectional chart review study utilizing the electronic database of the Third Affiliated Hospital of Sun Yat-sen University, and included 257 patients with type 2 diabetes undergoing intensive insulin therapy in the Department of Endocrinology and Metabolism. Logistic regression analysis was used to derive the clinical prediction rule with hypoglycemia (blood glucose ≤ 3.9 mmol/L) as the main result, and internal verification was performed. RESULTS In the derivation cohort, the incidence of hypoglycemia was 51%. The final model selected included three variables: fasting insulin, fasting blood glucose, and total treatment time. The area under the curve (AUC) of this model was 0.666 (95% CI: 0.594-0.738, P < 0.001). CONCLUSIONS The model's hypoglycemia prediction and the actual occurrence are in good agreement. The variable data was easy to obtain and the evaluation method was simple, which could provide a reference for the prevention and treatment of hypoglycemia and screen patients with a high risk of hypoglycemia.
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Affiliation(s)
- Xiling Hu
- Department of Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Weiran Xu
- School of Nursing, Sun Yat-sen University, Guangzhou 510085, China
| | - Shuo Lin
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Cang Zhang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Cong Ling
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Miaoxia Chen
- Nursing Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
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119
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Khanimov I, Shimonov M, Wainstein J, Leibovitz E. Hypoglycemia, Malnutrition and Body Composition. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:71-84. [PMID: 32329027 DOI: 10.1007/5584_2020_526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hypoglycemia is one of the most significant factors to affect prognosis, and is detrimental to patients regardless of diabetes mellitus (DM) status. The classical paradigms dictate that hypoglycemia is a result of overtreatment with glucose lowering agents (iatrogenic hypoglycemia), or, as among patients without DM, this condition is attributed to disease severity. New information shows that hypoglycemia occurs among patients that have a tendency for it. Incident hypoglycemia is very prevalent in the hospital setting, occurring in 1:6 patients with DM and in 1:17 patients without DM (Leibovitz E, Khanimov I, Wainstein J, Boaz M; Diabetes Metab Syndr Clin Res Rev. 13:222-226, 2019).One of the major factors associated with incidence of hypoglycemia is the nutritional status on hospital admission and during the hospitalization. Assessment of nutritional status using questionnaires and biomarkers might be helpful in determining risk of hypoglycemia. Moreover, administration of oral nutritional supplements was shown to decrease this risk.It is also well known that a high burden of comorbidities is associated with an increased risk of hypoglycemia. For example, kidney disease, whether acute or chronic, was shown to increase the risk for hypoglycemia, as well as some endocrine disorders.In this review we elaborate on specific findings that are characteristic of patients at risk for developing hypoglycemia, as well as treatment aimed at preventing its occurrence.
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Affiliation(s)
- I Khanimov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Shimonov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Diabetes Unit, Edith Wolfson Medical Center, Holon, Israel
| | - J Wainstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Surgery "A", Edith Wolfson Medical Center, Holon, Israel
| | - Eyal Leibovitz
- Department of Internal Medicine "A", Yoseftal Hospital, Eilat, Israel.
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120
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Severe Hypoglycemia and Risk of Subsequent Cardiovascular Events: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cardiol Rev 2019; 28:244-249. [PMID: 31868770 DOI: 10.1097/crd.0000000000000276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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121
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Noguchi GM, Huising MO. Integrating the inputs that shape pancreatic islet hormone release. Nat Metab 2019; 1:1189-1201. [PMID: 32694675 PMCID: PMC7378277 DOI: 10.1038/s42255-019-0148-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023]
Abstract
The pancreatic islet is a complex mini organ composed of a variety of endocrine cells and their support cells, which together tightly control blood glucose homeostasis. Changes in glucose concentration are commonly regarded as the chief signal controlling insulin-secreting beta cells, glucagon-secreting alpha cells and somatostatin-secreting delta cells. However, each of these cell types is highly responsive to a multitude of endocrine, paracrine, nutritional and neural inputs, which collectively shape the final endocrine output of the islet. Here, we review the principal inputs for each islet-cell type and the physiological circumstances in which these signals arise, through the prism of the insights generated by the transcriptomes of each of the major endocrine-cell types. A comprehensive integration of the factors that influence blood glucose homeostasis is essential to successfully improve therapeutic strategies for better diabetes management.
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Affiliation(s)
- Glyn M Noguchi
- Department of Neurobiology, Physiology & Behavior, College of Biological Sciences, University of California, Davis, Davis, CA, USA
| | - Mark O Huising
- Department of Neurobiology, Physiology & Behavior, College of Biological Sciences, University of California, Davis, Davis, CA, USA.
- Department of Physiology & Membrane Biology, School of Medicine, University of California, Davis, Davis, CA, USA.
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122
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Abstract
PURPOSE OF REVIEW The effects of hypoglycemia can result in injury, including at work. Our goal was to review the recent medical literature regarding hypoglycemia and occupational injuries and provide guidance to clinicians asked to render opinions regarding fitness for work duties in individuals with diabetes. RECENT FINDINGS Recent studies contain conflicting conclusions regarding the occupational risks posed by workers with diabetes. However, the US Federal Motor Carrier Safety Administration concluded there was sufficient evidence to change the rule that previously disqualified commercial drivers with insulin-treated diabetes. Blanket employment policies that disqualify workers with diabetes are unnecessary in many occupational fields. In assessing occupational risks and fitness for duty in workers with diabetes, it is important to perform an individualized assessment of the worker and consider the risk factors for hypoglycemia, information from the treating clinician, essential functions of the job, and, if needed, availability of reasonable accommodations.
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Affiliation(s)
- Robert M Gerbo
- Department of Occupational and Environmental Sciences, Section of Occupational Medicine, West Virginia University School of Public Health, 3860 Health Sciences Center, Morgantown, WV, 26506-9145, USA.
| | - Chuan Fang Jin
- Department of Occupational and Environmental Sciences, Section of Occupational Medicine, West Virginia University School of Public Health, 3860 Health Sciences Center, Morgantown, WV, 26506-9145, USA
| | - Karen Clark
- Department of Medicine, Section of General Internal Medicine, West Virginia University School of Medicine, Morgantown, WV, USA
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123
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Rich LR, Harris W, Brown AM. The Role of Brain Glycogen in Supporting Physiological Function. Front Neurosci 2019; 13:1176. [PMID: 31749677 PMCID: PMC6842925 DOI: 10.3389/fnins.2019.01176] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/17/2019] [Indexed: 01/08/2023] Open
Abstract
Glycogen is present in the mammalian brain but occurs at concentrations so low it is unlikely to act as a conventional energy reserve. Glycogen has the intriguing feature of being located exclusively in astrocytes, but its presence benefits neurones, suggesting that glycogen is metabolized to a conduit that is transported between the glia and neural elements. In the rodent optic nerve model glycogen supports axon conduction in the form of lactate to supplement axonal metabolism during aglycemia, hypoglycemia and during periods of increased energy demand under normoglycemic conditions. In the hippocampus glycogen plays a vital role in supplying the neurones with lactate during memory formation. The physiological processes that glycogen supports, such as learning and memory, imply an inclusive and vital role in supporting physiological brain functions.
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Affiliation(s)
- Laura R Rich
- School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - William Harris
- School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Angus M Brown
- School of Life Sciences, University of Nottingham, Nottingham, United Kingdom.,Department of Neurology, University of Washington, Seattle, WA, United States
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124
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Wiegers EC, Rooijackers HM, Tack CJ, Philips BW, Heerschap A, van der Graaf M, de Galan BE. Effect of lactate administration on brain lactate levels during hypoglycemia in patients with type 1 diabetes. J Cereb Blood Flow Metab 2019; 39:1974-1982. [PMID: 29749805 PMCID: PMC6775588 DOI: 10.1177/0271678x18775884] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Administration of lactate during hypoglycemia suppresses symptoms and counterregulatory responses, as seen in patients with type 1 diabetes and impaired awareness of hypoglycemia (IAH), presumably because lactate can substitute for glucose as a brain fuel. Here, we examined whether lactate administration, in a dose sufficient to impair awareness of hypoglycemia, affects brain lactate levels in patients with normal awareness of hypoglycemia (NAH). Patients with NAH (n = 6) underwent two euglycemic-hypoglycemic clamps (2.8 mmol/L), once with sodium lactate infusion (NAH w|lac) and once with saline infusion (NAH w|placebo). Results were compared to those obtained during lactate administration in patients with IAH (n = 7) (IAH w|lac). Brain lactate levels were determined continuously with J-difference editing 1H-MRS. During lactate infusion, symptom and adrenaline responses to hypoglycemia were considerably suppressed in NAH. Infusion of lactate increased brain lactate levels modestly, but comparably, in both groups (mean increase in NAH w|lac: 0.12 ± 0.05 µmol/g and in IAH w|lac: 0.06 ± 0.04 µmol/g). The modest increase in brain lactate may suggest that the excess of lactate is immediately metabolized by the brain, which in turn may explain the suppressive effects of lactate on awareness of hypoglycemia observed in patients with NAH.
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Affiliation(s)
- Evita C Wiegers
- Department of Radiology and Nuclear Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Hanne M Rooijackers
- Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Cees J Tack
- Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Bart Wj Philips
- Department of Radiology and Nuclear Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Arend Heerschap
- Department of Radiology and Nuclear Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Marinette van der Graaf
- Department of Radiology and Nuclear Medicine, Radboud university medical center, Nijmegen, The Netherlands.,Department of Pediatrics, Radboud university medical center, Nijmegen, The Netherlands
| | - Bastiaan E de Galan
- Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
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125
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Mao Y, Wen S, Zhou M, Zhu S, Zhou L. The hypoglycemia associated autonomic failure triggered by exercise in the patients with "brittle" diabetes and the strategy for prevention. Endocr J 2019; 66:753-762. [PMID: 31406090 DOI: 10.1507/endocrj.ej19-0153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Exercise is a fundamental component of diabetes management. However, choosing inappropriate type or timing of exercise is associated with mild or severe hypoglycemia either during exercise or several hours after exercise. Several studies have shown that impaired counterregulatory responses triggers hypoglycemia. Therefore, in this investigation, we explored the appropriate intensity and time of exercise in patients with diabetes. The mechanisms of counterregulatory responses and hypoglycemia associated autonomic failure (HAAF), as well as the strategies for preventing episodes of hypoglycemia after exercise were also investigated. In this study, we obtained the following results: 1) High intensity interval exercise is more suitable for diabetic patients. 2) Morning exercise reduces nocturnal hypoglycemia risks compared with midday, afternoon and evening exercise. 3) Hypoglycemia can be prevented by dietary approach, reduction or suspension of insulin dose, use of mini dose glucagon, caffeine, mitigation methods, prediction algorithm, autonomic feedback controlled close-loop insulin delivery, real time continuous glucose monitoring. Based on these results we concluded that exercise may cause severe hypoglycemia or induce blunted response in patients with diabetes. For Diabetes Mellitus (DM) patients, the intensity and time of exercise influence the occurrence of hypoglycemia. This review summarizes the clinical characteristics of different types of exercises and time of exercise that can be potentially used to educate and guide patients regarding the role of exercise in standard of care.
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Affiliation(s)
- Yilun Mao
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai 201399, China
| | - Song Wen
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai 201399, China
| | - Mingyue Zhou
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, USA
| | - Shifei Zhu
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai 201399, China
| | - Ligang Zhou
- Department of Endocrinology, Shanghai Pudong Hospital, Fudan University, Shanghai 201399, China
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126
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Yamamoto K, Ito T, Nagasato T, Shinnakasu A, Kurano M, Arimura A, Arimura H, Hashiguchi H, Deguchi T, Maruyama I, Nishio Y. Effects of glycemic control and hypoglycemia on Thrombus formation assessed using automated microchip flow chamber system: an exploratory observational study. Thromb J 2019; 17:17. [PMID: 31496922 PMCID: PMC6717975 DOI: 10.1186/s12959-019-0206-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/26/2019] [Indexed: 01/13/2023] Open
Abstract
Background Thrombus formation is an important factor affecting cardiovascular events and venous thromboembolism in type 2 diabetes. However, it is unclear whether glycemic control reduces thrombogenicity. We investigated the effect of short-term glycemic control (STUDY 1) and hypoglycemia (STUDY 2) on thrombus formation using an automated microchip flow chamber system. Methods For STUDY 1, we recruited 10 patients with type 2 diabetes. Before and after 2 weeks of treatment, blood glucose was analyzed with a continuous glucose monitoring system, and thrombogenicity was analyzed with an automated microchip flow chamber system. For STUDY 2, we recruited 10 subjects without diabetes who underwent an insulin tolerance test. We evaluated the change in thrombogenic potential with hypoglycemia. Results STUDY1: The mean blood glucose level reduced from 10.1 ± 2.6 to 6.9 ± 0.97 mM (P < 0.01). T10, an indicator of thrombogenicity, significantly attenuated after glycemic control (338 ± 65 vs. 425 ± 117 s, P < 0.05). The attenuation in T10 was significantly correlated with changes in mean blood glucose level after treatment (r = - 0.718, P < 0.05). STUDY 2: Platelet function was enhanced with decreasing blood glucose; increased platelet function was strongly correlated with an increase in epinephrine. Conclusions We demonstrated attenuation in thrombogenicity with short-term comprehensive diabetes care and enhancement in thrombogenicity with hypoglycemia, using a new flow chamber system. Trial registration UMIN-CTR UMIN 000019899, registered 26-Jan-2015 (STUDY 2).
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Affiliation(s)
- Kiyoaki Yamamoto
- 1Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Takashi Ito
- 2Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Tomoka Nagasato
- 2Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan.,3Fujimori Kogyo Co., Research Institute, 1-10-1, Yokohama, Kanagawa, 236-0003 Japan
| | - Atsushi Shinnakasu
- 1Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Mihoko Kurano
- 1Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Aiko Arimura
- 1Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Hiroshi Arimura
- 1Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Hiroshi Hashiguchi
- 1Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Takahisa Deguchi
- 1Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Ikuro Maruyama
- 2Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
| | - Yoshihiko Nishio
- 1Department of Diabetes and Endocrine Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544 Japan
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Ren H, Vieira-de-Abreu A, Yan S, Reilly AM, Chan O, Accili D. Altered Central Nutrient Sensing in Male Mice Lacking Insulin Receptors in Glut4-Expressing Neurons. Endocrinology 2019; 160:2038-2048. [PMID: 31199472 PMCID: PMC6691683 DOI: 10.1210/en.2019-00341] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/08/2019] [Indexed: 12/20/2022]
Abstract
Insulin signaling in the central nervous system influences satiety, counterregulation, and peripheral insulin sensitivity. Neurons expressing the Glut4 glucose transporter influence peripheral insulin sensitivity. Here, we analyzed the effects of insulin receptor (IR) signaling in hypothalamic Glut4 neurons on glucose sensing as well as leptin and amino acid signaling. By measuring electrophysiological responses to low glucose conditions, we found that the majority of Glut4 neurons in the ventromedial hypothalamus (VMH) were glucose excitatory neurons. GLUT4-Cre-driven insulin receptor knockout mice with a combined ablation of IR in Glut4-expressing tissues showed increased counterregulatory response to either 2-deoxyglucose-induced neuroglycopenia or systemic insulin-induced hypoglycemia. The latter response was recapitulated in mice with decreased VMH IR expression, suggesting that the effects on the counterregulatory response are likely mediated through the deletion of IRs on Glut4 neurons in the VMH. Using immunohistochemistry in fluorescently labeled hypothalamic Glut4 neurons, we showed that IR signaling promoted hypothalamic cellular signaling responses to the rise of insulin, leptin, and amino acids associated with feeding. We concluded that hypothalamic Glut4 neurons modulated the glucagon counterregulatory response and that IR signaling in Glut4 neurons was required to integrate hormonal and nutritional cues for the regulation of glucose metabolism.
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Affiliation(s)
- Hongxia Ren
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, Indiana
- Correspondence: Hongxia Ren, PhD, Indiana University School of Medicine, 635 Barnhill Drive, MS2031, Indianapolis, Indiana 46202. E-mail: ; or Owen Chan, PhD, Department of Internal Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Utah, 15 North 2030 East, EIHG Building 533, Room 2420B, Salt Lake City, Utah 84112. E-mail:
| | - Adriana Vieira-de-Abreu
- Department of Internal Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Utah, Salt Lake City, Utah
| | - Shijun Yan
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | - Austin M Reilly
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | - Owen Chan
- Department of Internal Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Utah, Salt Lake City, Utah
- Correspondence: Hongxia Ren, PhD, Indiana University School of Medicine, 635 Barnhill Drive, MS2031, Indianapolis, Indiana 46202. E-mail: ; or Owen Chan, PhD, Department of Internal Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Utah, 15 North 2030 East, EIHG Building 533, Room 2420B, Salt Lake City, Utah 84112. E-mail:
| | - Domenico Accili
- Department of Medicine and Berrie Diabetes Center, Columbia University College of Physicians & Surgeons, New York, New York
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Rickels MR. Hypoglycemia-associated autonomic failure, counterregulatory responses, and therapeutic options in type 1 diabetes. Ann N Y Acad Sci 2019; 1454:68-79. [PMID: 31389033 DOI: 10.1111/nyas.14214] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/06/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
Hypoglycemia remains a major barrier to the achievement of target levels of glycemic control for most individuals with insulin-dependent type 1 diabetes (T1D). Both the loss of β cells and an accompanying defect in the α cell response to hypoglycemia predispose patients with T1D to the development of low blood glucose. Increased glucose variability, exposure to hypoglycemia, and impaired awareness of hypoglycemia all contribute to increased risk of experiencing severe hypoglycemia, which is explained by progressive impairment in epinephrine secretion and autonomic symptom generation in response to hypoglycemia leading to defective glucose counterregulation and hypoglycemia unawareness that characterize hypoglycemia-associated autonomic failure (HAAF). Interruption of HAAF requires interfering with the mechanisms of brain adaptation to low blood glucose that affect central glucose sensing and the autonomic response to hypoglycemia, or avoidance of hypoglycemia that may allow for eventual recovery of counterregulatory and autonomic symptom responses. Strategies for hypoglycemia avoidance that include continuous glucose monitoring may reduce, but do not eliminate, clinically significant hypoglycemia, with ongoing counterregulatory defects and impaired awareness of hypoglycemia. Complete avoidance of hypoglycemia can be achieved following pancreatic islet transplantation and allows for the restoration of counterregulatory and autonomic symptom responses that evidences the potential for reversing HAAF in T1D.
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Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Institute for Diabetes, Obesity and Metabolism, the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Cell Autonomous Dysfunction and Insulin Resistance in Pancreatic α Cells. Int J Mol Sci 2019; 20:ijms20153699. [PMID: 31357734 PMCID: PMC6695724 DOI: 10.3390/ijms20153699] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 12/23/2022] Open
Abstract
To date, type 2 diabetes is considered to be a "bi-hormonal disorder" rather than an "insulin-centric disorder," suggesting that glucagon is as important as insulin. Although glucagon increases hepatic glucose production and blood glucose levels, paradoxical glucagon hypersecretion is observed in diabetes. Recently, insulin resistance in pancreatic α cells has been proposed to be associated with glucagon dysregulation. Moreover, cell autonomous dysfunction of α cells is involved in the etiology of diabetes. In this review, we summarize the current knowledge about the physiological and pathological roles of glucagon.
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Garla V, Kanduri S, Yanes-Cardozo L, Lién LF. Management of diabetes mellitus in chronic kidney disease. MINERVA ENDOCRINOL 2019; 44:273-287. [DOI: 10.23736/s0391-1977.19.03015-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hermanns N, Heinemann L, Freckmann G, Waldenmaier D, Ehrmann D. Impact of CGM on the Management of Hypoglycemia Problems: Overview and Secondary Analysis of the HypoDE Study. J Diabetes Sci Technol 2019; 13:636-644. [PMID: 30841740 PMCID: PMC6610605 DOI: 10.1177/1932296819831695] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hypoglycemia remains the limiting factor of near-normal glucose control in people with diabetes using insulin therapy. Continuous glucose monitoring (CGM) may be able to avoid hypoglycemia and support the management of hypoglycemia problems in clinical care. Real-time continuous glucose monitoring (rtCGM) systems provide alerts if certain predetermined hypo- or hyperglycemic thresholds are exceeded. The combination of rtCGM systems with insulin pumps allows insulin delivery to be suspended if glucose falls below certain predefined thresholds. This might also support avoidance of hypoglycemia. More sophisticated closed-loop systems allow a semiautomatic insulin dosage, which also have the potential for the prevention of hypoglycemia. In this overview, we discuss and illustrate (1) the efficacy of CGM for intervention in people with hypoglycemia problems and for the avoidance of biochemical as well as clinical hypoglycemia; (2) the potential of CGM technology for the identification of people with diabetes who are at risk for hypoglycemia problems; and (3) the implications of the current state of the art for future research regarding CGM and hypoglycemia. As an example, how rtCGM data can facilitate identification of people with diabetes and an elevated risk of hypoglycemia, a secondary analysis of the HypoDE data is presented. We conclude that CGM technology can assist in the reliable identification of people with diabetes who are at risk for hypoglycemia problems, is a powerful intervention for the avoidance of mild as well as severe hypoglycemia, and can also stimulate research on the course of hypoglycemia problems.
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Affiliation(s)
- Norbert Hermanns
- Research Institute Diabetes Academy
Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and
Psychotherapy, Bamberg, Germany
- Diabetes Clinic Mergentheim,
Germany
- Norbert Hermanns, PhD, Research Institute
Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str 24, 97980 Bad
Mergentheim, Germany.
| | - Lutz Heinemann
- Science-Consulting in Diabetes GmbH,
Düsseldorf, Germany
| | - Guido Freckmann
- IDT-Institut für Diabetes-Technologie,
Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm,
Germany
| | - Delia Waldenmaier
- IDT-Institut für Diabetes-Technologie,
Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm,
Germany
| | - Dominic Ehrmann
- Research Institute Diabetes Academy
Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and
Psychotherapy, Bamberg, Germany
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Justinussen T, Madsbad S, Holst JJ, Bojsen-Møller KN. Pros and cons of Roux en-Y gastric bypass surgery in obese patients with type 2 diabetes. Expert Rev Endocrinol Metab 2019; 14:243-257. [PMID: 31215828 DOI: 10.1080/17446651.2019.1628639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 06/04/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The worldwide prevalence of obesity and type 2 diabetes (T2D) constitutes an epidemic that is a threat to public health. Bariatric surgery, including Roux en-Y gastric bypass (RYGB), is currently the most effective treatment to induce long-term weight loss and remission of co-morbid conditions. Surgery, however, comes with an added risk of complications, highlighting the need to understand the comparative effectiveness and risks of surgical versus conventional approaches to the treatment of obesity and T2D. AREAS COVERED Positive and negative outcomes of RYGB surgery in patients with T2D are assessed, with a primary focus on RYGB surgery versus standard non-surgical treatment of obese patients with T2D in randomized clinical trials or high-quality observational cohorts. Searches were conducted in the PubMed database up to 11 April 2019 for relevant studies. EXPERT OPINION High-level evidence reveals that RYGB ameliorates the clinical manifestations of T2D to a significantly higher degree than medical therapy. Postoperative incidence of beneficial effects and complications, however, differ across subgroups of patients with different preoperative characteristics. Key knowledge gaps, particularly on long-term complications, microvascular- and macrovascular events, and mortality should be addressed, so treatment with RYGB can be applied in an individualized approach to maximize benefits and minimize complications.
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Affiliation(s)
- Tummas Justinussen
- a Department of Endocrinology , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
- b Novo Nordisk Foundation Centre for Basic Metabolic Research , University of Copenhagen , Copenhagen , Denmark
| | - Sten Madsbad
- a Department of Endocrinology , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
- b Novo Nordisk Foundation Centre for Basic Metabolic Research , University of Copenhagen , Copenhagen , Denmark
| | - Jens Juul Holst
- b Novo Nordisk Foundation Centre for Basic Metabolic Research , University of Copenhagen , Copenhagen , Denmark
- c Department of Biomedical Sciences, Faculty of Health , University of Copenhagen , Copenhagen , Denmark
| | - Kirstine Nyvold Bojsen-Møller
- a Department of Endocrinology , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
- b Novo Nordisk Foundation Centre for Basic Metabolic Research , University of Copenhagen , Copenhagen , Denmark
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GhavamiNejad A, Li J, Lu B, Zhou L, Lam L, Giacca A, Wu XY. Glucose-Responsive Composite Microneedle Patch for Hypoglycemia-Triggered Delivery of Native Glucagon. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1901051. [PMID: 31165524 DOI: 10.1002/adma.201901051] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/14/2019] [Indexed: 06/09/2023]
Abstract
Insulin-dependent patients with diabetes mellitus require multiple daily injections of exogenous insulin to combat hyperglycemia. However, administration of excess insulin can lead to hypoglycemia, a life-threatening condition characterized by abnormally low blood glucose levels (BGLs). To prevent hypoglycemia associated with intensive insulin therapy, a "smart" composite microneedle (cMN) patch is developed, which releases native glucagon at low glucose levels. The cMN patch is composed of a photo-crosslinked methacrylated hyaluronic acid (MeHA) microneedle array with embedded multifunctional microgels. The microgels incorporate zwitterionic moieties that stabilize loaded glucagon and phenylboronic acid moieties that provide glucose-dependent volume change to facilitate glucagon release. Hypoglycemia-triggered release of structurally unchanged glucagon from the cMN patch is demonstrated in vitro and in a rat model of type 1 diabetes (T1D). Transdermal application of the patch prevented insulin-induced hypoglycemia in the diabetic rats. This work is the first demonstration of a glucose-responsive glucagon-delivery MN patch for the prevention of hypoglycemia, which has a tremendous potential to reduce the dangers of intensive insulin therapy and improve the quality of life of patients with diabetes and their caregivers.
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Affiliation(s)
- Amin GhavamiNejad
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, M5S 3M2, Canada
| | - Jason Li
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, M5S 3M2, Canada
| | - Brian Lu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, M5S 3M2, Canada
| | - Liwei Zhou
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, M5S 1A8, Canada
| | - Loretta Lam
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, M5S 1A8, Canada
| | - Adria Giacca
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, M5S 1A8, Canada
| | - Xiao Yu Wu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, M5S 3M2, Canada
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Turner G, Quigg S, Davoren P, Basile R, McAuley SA, Coombes JS. Resources to Guide Exercise Specialists Managing Adults with Diabetes. SPORTS MEDICINE - OPEN 2019; 5:20. [PMID: 31161377 PMCID: PMC6546780 DOI: 10.1186/s40798-019-0192-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 05/10/2019] [Indexed: 12/16/2022]
Abstract
Exercise is an important element to optimize health and well-being, though navigating exercise safely can be challenging for exercise specialists working with people with diabetes. Measuring glucose levels before an exercise session assists in the determination of whether exercise is safe for a person with diabetes. A number of organizations have recently developed guidelines to provide exercise and diabetes recommendations based on glucose levels and other relevant factors. However, there are limited easy-to-use resources to assist exercise specialists to determine whether exercise should be started and continued by people with diabetes. The type of diabetes, pre-exercise glucose level, medications and their timing, recent food intake and general sense of wellness all warrant consideration when determining the approach to each exercise session. An expert group was convened to review the published literature and develop resources to guide exercise specialists in assessing the safety of an adult with diabetes starting exercise, and indications to cease exercise, based upon glucose levels and other factors. Contraindications to people with diabetes starting or continuing exercise are (1) glucose < 4.0 mmol/L; (2) glucose > 15.0 mmol/L with symptoms of weakness/tiredness, or with ketosis; (3) hypoglycaemic event within the previous 24 h that required assistance from another person to treat and (4) feeling unwell. To optimize diabetes and exercise safety, recommendations (stratified by pre-exercise glucose level) are provided regarding carbohydrate ingestion, glucose monitoring and medication adjustment.
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Affiliation(s)
- Grant Turner
- Chronic Disease and Post Acute Programs, Diagnostic, Emergency and Medical Services, Gold Coast Health, Queensland Health, Robina, Australia
| | - Scott Quigg
- Metro North Hospital and Health Service, Community, Indigenous and Subacute Service, Diabetes Service, North Lakes Health Precinct, Queensland Health, North Lakes, Australia
| | - Peter Davoren
- Division Medicine, Gold Coast Health, Queensland Health, Robina, Australia
| | - Renata Basile
- Diabetes Centre, Gold Coast University Hospital, Southport, Australia
| | - Sybil A McAuley
- Department of Medicine, University of Melbourne, Melbourne, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, 4072, Australia.
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Rhyu YA, Jang JY, Park S, An JH, Kim DL, Kim SK, Song KH. Impaired Cortisol and Growth Hormone Counterregulatory Responses among Severe Hypoglycemic Patients with Type 2 Diabetes Mellitus. Endocrinol Metab (Seoul) 2019; 34:187-194. [PMID: 31257746 PMCID: PMC6599906 DOI: 10.3803/enm.2019.34.2.187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 04/11/2019] [Accepted: 04/16/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Elevated levels of cortisol and growth hormone are critical counterregulatory responses to severe hypoglycemia. However, the proportion and clinical characteristics of patients with type 2 diabetes mellitus (DM) who fail to show appropriate cortisol and/or growth hormone secretion in response to severe hypoglycemia have not been investigated. METHODS We measured plasma cortisol and growth hormone levels in type 2 DM patients with severe hypoglycemia who visited the emergency department between 2006 and 2015. RESULTS Of 112 hypoglycemic patients, 23 (20.5%) had an impaired cortisol response (<18 μg/dL) and 82 patients (73.2%) had an impaired growth hormone response (<5 ng/mL). Nineteen patients (17.0%) had impaired responses to both cortisol and growth hormone. The patients with impaired responses of cortisol, growth hormone, and both hormones were significantly older and more likely to be female, and had higher admission rates, lower growth hormone levels, and lower adrenocorticotropic hormone levels than the patients with a normal hormonal response. Multivariate logistic regression analysis indicated that an impaired growth hormone response was significantly associated with advanced age, shorter DM duration, a higher admission rate, and a higher body mass index (BMI). An impaired cortisol response was significantly associated with growth hormone levels. Patients with an impaired growth hormone response had higher admission rates than patients with a normal response. CONCLUSION A considerable number of type 2 DM patients had impaired cortisol and/or growth hormone responses to severe hypoglycemia. Advanced age, shorter DM duration, and higher BMI were independently associated with an abnormal growth hormone response.
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Affiliation(s)
- Young A Rhyu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Ju Young Jang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Sooyoun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jee Hyun An
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dong Lim Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Suk Kyeong Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Kee Ho Song
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.
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Quirós C, Viñals C, Giménez M, Roca D, Conget I. Assessment of the effectiveness of long-term insulin pump therapy using a combined goal of HbA 1c decrease and absence of severe hypoglycemia. ACTA ACUST UNITED AC 2019; 66:534-539. [PMID: 31133475 DOI: 10.1016/j.endinu.2019.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 03/14/2019] [Accepted: 03/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Less than one third of patients with type 1 diabetes mellitus (T1DM) achieve the cut-off value proposed as good metabolic control by most guidelines, HbA1c<7%. However, HbA1c reductions and prevention of severe hypoglycemia (SH) have shown clinically relevant benefits. The study objective therefore was to assess the effectiveness of continuous subcutaneous insulin infusion (CSII) therapy at 5 years of follow-up in a cohort of patients attending a specialized unit using HbA1c reduction and abscence of SH as combined goals. METHODS A retrospective, observational study on 178 patients with T1DM who started CSII treatment at Hospital Clinic of Barcelona between 2003 and 2008. HbA1c levels at baseline and after 5 years of treatment with CSII and presence or absence of SH were recorded. The combined variables calculated included: a) HbA1c reduction by≥0.5 points and absence of SH in the last 2 years; b) HbA1c at 5 years<7.5% and no SH in the last 2 years; c) HbA1c<8.5% and no HG in the last 2 years, and d) HbA1c reduction by≥0.5 points and/or HbA1c<7.5% at 5 years with no SH in the last 2 years of follow-up. RESULTS Twenty-seven of the 178 patients were excluded due to loss to follow-up or CSII discontinuation. A total of 151 patients (aged 37.4±10.5 years, 64% women, diabetes duration of 19.2±10.7 years) were therefore analyzed. The 2 main reasons for starting CSII were suboptimal metabolic control (60.9%) and severe hypoglycemia/hypoglycemia unawareness (28.5%). HbA1c levels in the total cohort and in patients with suboptimal metabolic control were 8.0±1.2 and 8.4±1.1% at CSII start and 7.8±1.2 and 8.0±1.3% at 5 years of treatment (P=.104 and P=.016) respectively. In the overall cohort, 55.5% of patients achieved at 5 years the combined goal of HbA1c<7.5% and/or HbA1c reductions≥0.5% without SH. CONCLUSIONS After 5 years of CSII therapy, more than half of the patients achieved the combined goal of significant HbA1c reduction and absence of SH. The use of combined goals offers the opportunity to assess the effectiveness of T1DM treatment from a clinically more meaningful point of view.
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Affiliation(s)
- Carmen Quirós
- Servicio de Endocrinología y Nutrición, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España.
| | - Clara Viñals
- Unidad de Diabetes, Servicio de Endocrinología y Nutrición, Hospital Clínic de Barcelona, Barcelona, España
| | - Marga Giménez
- Unidad de Diabetes, Servicio de Endocrinología y Nutrición, Hospital Clínic de Barcelona, Barcelona, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, España
| | - Daria Roca
- Unidad de Diabetes, Servicio de Endocrinología y Nutrición, Hospital Clínic de Barcelona, Barcelona, España
| | - Ignacio Conget
- Unidad de Diabetes, Servicio de Endocrinología y Nutrición, Hospital Clínic de Barcelona, Barcelona, España; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, España
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Shah M, Addison A, Wang P, Zhu W, Chan O. Recurrent glucose deprivation leads to the preferential use of lactate by neurons in the ventromedial hypothalamus. Am J Physiol Endocrinol Metab 2019; 316:E948-E955. [PMID: 30888861 PMCID: PMC6580165 DOI: 10.1152/ajpendo.00468.2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Increased GABAergic output in the ventromedial hypothalamus (VMH) contributes to counterregulatory failure in recurrently hypoglycemic (RH) rats, and lactate, an alternate fuel source in the brain, contributes to this phenomenon. The current study assessed whether recurring bouts of glucose deprivation enhanced neuronal lactate uptake and, if so, whether this influenced γ-aminobutyric acid (GABA) output and the counterregulatory responses. Glucose deprivation was induced using 5-thioglucose (5TG). Control rats received an infusion of artificial extracellular fluid. These groups were compared with RH animals. Subsequently, the rats underwent a hypoglycemic clamp with microdialysis. To test whether 5TG affected neuronal lactate utilization, a subgroup of 5TG-treated rats was microinjected with a lactate transporter inhibitor [cyano-4-hydroxycinnamate (4CIN)] just before the start of the clamp. Both RH and 5TG raised VMH GABA levels, and this was associated with impaired counterregulatory responses. 4CIN reduced VMH GABA levels and restored the hormone responses in the 5TG group. We then evaluated [14C]lactate uptake in hypothalamic neuronal cultures. Recurring exposure to low glucose increased monocarboxylate transporter-2 mRNA expression and augmented lactate uptake. Taken together, our data suggest that glucose deprivation, per se, enhances lactate utilization in hypothalamic neurons, and this may contribute to suppression of the counterregulatory responses to hypoglycemia.
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Affiliation(s)
- Maitreyee Shah
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine , New Haven, Connecticut
| | - Augustina Addison
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine , New Haven, Connecticut
| | - Peili Wang
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine , New Haven, Connecticut
| | - Wanling Zhu
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine , New Haven, Connecticut
| | - Owen Chan
- Division of Endocrinology, Metabolism and Diabetes, Department of Internal Medicine, University of Utah School of Medicine , Salt Lake City, Utah
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138
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Rickels MR, Robertson RP. Pancreatic Islet Transplantation in Humans: Recent Progress and Future Directions. Endocr Rev 2019; 40:631-668. [PMID: 30541144 PMCID: PMC6424003 DOI: 10.1210/er.2018-00154] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/26/2018] [Indexed: 12/11/2022]
Abstract
Pancreatic islet transplantation has become an established approach to β-cell replacement therapy for the treatment of insulin-deficient diabetes. Recent progress in techniques for islet isolation, islet culture, and peritransplant management of the islet transplant recipient has resulted in substantial improvements in metabolic and safety outcomes for patients. For patients requiring total or subtotal pancreatectomy for benign disease of the pancreas, isolation of islets from the diseased pancreas with intrahepatic transplantation of autologous islets can prevent or ameliorate postsurgical diabetes, and for patients previously experiencing painful recurrent acute or chronic pancreatitis, quality of life is substantially improved. For patients with type 1 diabetes or insulin-deficient forms of pancreatogenic (type 3c) diabetes, isolation of islets from a deceased donor pancreas with intrahepatic transplantation of allogeneic islets can ameliorate problematic hypoglycemia, stabilize glycemic lability, and maintain on-target glycemic control, consequently with improved quality of life, and often without the requirement for insulin therapy. Because the metabolic benefits are dependent on the numbers of islets transplanted that survive engraftment, recipients of autoislets are limited to receive the number of islets isolated from their own pancreas, whereas recipients of alloislets may receive islets isolated from more than one donor pancreas. The development of alternative sources of islet cells for transplantation, whether from autologous, allogeneic, or xenogeneic tissues, is an active area of investigation that promises to expand access and indications for islet transplantation in the future treatment of diabetes.
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Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - R Paul Robertson
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
- Division of Endocrinology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Pacific Northwest Diabetes Research Institute, Seattle, Washington
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139
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Hemoglobin A1c and Permissive Hyperglycemia in Patients in the Intensive Care Unit with Diabetes. Crit Care Clin 2019; 35:289-300. [DOI: 10.1016/j.ccc.2018.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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140
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Lin YK, Hung M, Sharma A, Chan O, Varner MW, Staskus G, Fisher SJ. IMPAIRED AWARENESS OF HYPOGLYCEMIA CONTINUES TO BE A RISK FACTOR FOR SEVERE HYPOGLYCEMIA DESPITE THE USE OF CONTINUOUS GLUCOSE MONITORING SYSTEM IN TYPE 1 DIABETES. Endocr Pract 2019; 25:517-525. [PMID: 30865520 DOI: 10.4158/ep-2018-0527] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective: Impaired awareness of hypoglycemia (IAH) is a risk factor for severe hypoglycemia in patients with type 1 diabetes (T1D) not using a continuous glucose monitoring (CGM) system. The current study investigated the prevalence of IAH and its relationship with severe hypoglycemia in T1D patients using CGM systems. Methods: This cross-sectional observational study enrolled 135 patients with T1D and ongoing real-time CGM use. A survey was conducted to assess hypoglycemia awareness with the Gold, Clarke, and Pedersen-Bjergaard questionnaires and the 6-month history of severe hypoglycemia. Other diabetes histories and the CGM glucose data were collected. Results: The Gold, Clarke, and Pedersen-Bjergaard questionnaires demonstrated the overall prevalence of IAH/abnormal awareness to be 33.3%, 43.7%, and 77.0%, respectively. Participant age and duration of T1D were consistently related to IAH or hypoglycemia unawareness with all three questionnaires (P<.05). Amongst the patients using CGM for >6 months, 24.5% were found to have at least one episode of severe hypoglycemia in the preceding 6 months. IAH identified by the Gold and Clarke questionnaires and hypoglycemia unawareness identified by the Pedersen-Bjergaard questionnaire were related to 6-, 4.63-, and 5.83-fold increased risk of severe hypoglycemia (P = .001, .004, and .013), respectively. IAH identified by the Gold/Clarke questionnaires was associated with a longer duration of CGM glucose <54 mg/dL and higher glucose coefficients of variation (P<.05). Conclusion: IAH is highly prevalent and related to a higher risk for severe hypoglycemia in T1D patients using CGM. Abbreviations: CGM = continuous glucose monitoring; CI = confidence interval; HAAF = hypoglycemia-associated autonomic failure; HbA1c = hemoglobin A1C; IAH = impaired awareness of hypoglycemia; T1D = type 1 diabetes.
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141
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Navigating Two Roads to Glucose Normalization in Diabetes: Automated Insulin Delivery Devices and Cell Therapy. Cell Metab 2019; 29:545-563. [PMID: 30840911 DOI: 10.1016/j.cmet.2019.02.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 12/23/2022]
Abstract
Incredible strides have been made since the discovery of insulin almost 100 years ago. Insulin formulations have improved dramatically, glucose levels can be measured continuously, and recently first-generation biomechanical "artificial pancreas" systems have been approved by regulators around the globe. However, still only a small fraction of patients with diabetes achieve glycemic goals. Replacement of insulin-producing cells via transplantation shows significant promise, but is limited in application due to supply constraints (cadaver-based) and the need for chronic immunosuppression. Over the past decade, significant progress has been made to address these barriers to widespread implementation of a cell therapy. Can glucose levels in people with diabetes be normalized with artificial pancreas systems or via cell replacement approaches? Here we review the road ahead, including the challenges and opportunities of both approaches.
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142
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Cefalo CMA, Cinti F, Moffa S, Impronta F, Sorice GP, Mezza T, Pontecorvi A, Giaccari A. Sotagliflozin, the first dual SGLT inhibitor: current outlook and perspectives. Cardiovasc Diabetol 2019; 18:20. [PMID: 30819210 PMCID: PMC6393994 DOI: 10.1186/s12933-019-0828-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 02/19/2019] [Indexed: 12/12/2022] Open
Abstract
Sotagliflozin is a dual sodium-glucose co-transporter-2 and 1 (SGLT2/1) inhibitor for the treatment of both type 1 (T1D) and type 2 diabetes (T2D). Sotagliflozin inhibits renal sodium-glucose co-transporter 2 (determining significant excretion of glucose in the urine, in the same way as other, already available SGLT-2 selective inhibitors) and intestinal SGLT-1, delaying glucose absorption and therefore reducing post prandial glucose. Well-designed clinical trials, have shown that sotagliflozin (as monotherapy or add-on therapy to other anti-hyperglycemic agents) improves glycated hemoglobin in adults with T2D, with beneficial effects on bodyweight and blood pressure. Similar results have been obtained in adults with T1D treated with either continuous subcutaneous insulin infusion or multiple daily insulin injections, even after insulin optimization. A still ongoing phase 3 study is currently evaluating the effect of sotagliflozin on cardiovascular outcomes (ClinicalTrials.gov NCT03315143). In this review we illustrate the advantages and disadvantages of dual SGLT 2/1 inhibition, in order to better characterize and investigate its mechanisms of action and potentialities.
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Affiliation(s)
- Chiara Maria Assunta Cefalo
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Cinti
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Moffa
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Flavia Impronta
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gian Pio Sorice
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Teresa Mezza
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Pontecorvi
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Giaccari
- Center for Endocrine and Metabolic Diseases, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy. .,Istituto di Patologia Speciale Medica e Semeiotica Clinica, Università Cattolica del Sacro Cuore, Rome, Italy.
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143
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Castle JR, Elander M. Long-Term Safety and Tolerability of Dasiglucagon, a Stable-in-Solution Glucagon Analogue. Diabetes Technol Ther 2019; 21:94-96. [PMID: 30707621 DOI: 10.1089/dia.2018.0363] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jessica R Castle
- 1 Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
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144
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Yardley JE, Rees JL, Funk DR, Toghi-Eshghi SR, Boulé NG, Senior PA. Effects of Moderate Cycling Exercise on Blood Glucose Regulation Following Successful Clinical Islet Transplantation. J Clin Endocrinol Metab 2019; 104:493-502. [PMID: 30403817 DOI: 10.1210/jc.2018-01498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/31/2018] [Indexed: 12/26/2022]
Abstract
CONTEXT Islet transplantation is effective in preventing hypoglycemia in patients with type 1 diabetes (T1D). However, it is unknown whether transplanted islets regulate plasma glucose concentrations appropriately during and after exercise in human islet transplant recipient (ITxs). OBJECTIVE To determine the effect of exercise on plasma glucose, insulin, and glucagon concentrations in ITxs compared with control subjects (CONs) without diabetes. INTERVENTION Participants completed two conditions in random order: 45 minutes of aerobic exercise (60% VO2peak) and 45 minutes of seated rest. Blood samples were drawn at baseline, immediately after exercise or rest, and every 15 minutes throughout a 60-minute recovery period. Postexercise (24 hours) interstitial glucose was monitored with continuous glucose monitoring (CGM). RESULTS Twenty-four participants (12 ITxs, 12 CONs) completed the protocol. Plasma glucose decreased more over time with exercise in ITxs compared with CONs [main effects of treatment (P = 0.019), time (P = 0.001), and group (P = 0.012)]. Plasma glucose was lower during exercise vs rest in ITxs but not CONs [treatment by group interaction (P = 0.028)]. Plasma glucose decreased more during exercise than during rest [treatment by time interaction (P = 0.001)]. One ITx and one CON experienced plasma glucose concentrations <3.5 mmol/L at the end of exercise, both of whom returned above that threshold within 15 minutes. Nocturnal CGM glucose <3.5 mmol/L was detected in two CONs but no ITxs. CONCLUSION Despite a greater plasma glucose decline during exercise in ITxs, hypoglycemia risk was similar during and after exercise in ITxs compared with CONs.
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Affiliation(s)
- Jane E Yardley
- Augustana Faculty, University of Alberta, Camrose, Alberta, Canada
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Jordan L Rees
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Deanna R Funk
- Augustana Faculty, University of Alberta, Camrose, Alberta, Canada
| | - Saeed Reza Toghi-Eshghi
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Normand G Boulé
- Alberta Diabetes Institute, Edmonton, Alberta, Canada
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Peter A Senior
- Alberta Diabetes Institute, Edmonton, Alberta, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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145
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Klaprat N, MacIntosh A, McGavock JM. Gaps in Knowledge and the Need for Patient-Partners in Research Related to Physical Activity and Type 1 Diabetes: A Narrative Review. Front Endocrinol (Lausanne) 2019; 10:42. [PMID: 30787908 PMCID: PMC6372552 DOI: 10.3389/fendo.2019.00042] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022] Open
Abstract
Regular physical activity (PA) is a cornerstone in the management of complications associated with type 1 diabetes (T1D). Most national guidelines advocate for regular PA for persons living with T1D, however the evidence to support these recommendations has not be reviewed recently. Additionally, in an era of patient-centered care and patient oriented research, the role of patient partners in the area of PA and T1D interventions has never been explored. The purpose of this narrative review is to overcome these two gaps in the literature. Here we review selected epidemiological evidence and identify gaps in research that would add important information to guide practitioners and future guidelines. We also provide an overview of patient-oriented research projects co-developed with persons living with T1D. Significant gaps in the field include: (1) a lack of adequately powered prospective cohort studies using serial measures of PA and hard chronic disease end-points; (2) no multi-centered, highly powered, randomized controlled trials of PA, and long-term health outcomes; (3) little data on the role of new technologies to support PA-related behavior change, and (4) no trials that involved patients in the design and execution of PA-based clinical trials. This review provides a template for scientists and patient partners to develop future research priorities and agendas in the field.
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Affiliation(s)
- Nika Klaprat
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Diabetes Research Envisioned and Accomplished in Manitoba (DREAM) Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Andrea MacIntosh
- Diabetes Research Envisioned and Accomplished in Manitoba (DREAM) Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
- Department of Pediatrics and Child Health, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jonathan M. McGavock
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
- Diabetes Research Envisioned and Accomplished in Manitoba (DREAM) Theme, Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
- Department of Pediatrics and Child Health, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Diabetes Action Canada SPOR Network, Toronto, ON, Canada
- *Correspondence: Jonathan M. McGavock
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146
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Henriksen MM, Andersen HU, Thorsteinsson B, Pedersen-Bjergaard U. Asymptomatic hypoglycaemia in Type 1 diabetes: incidence and risk factors. Diabet Med 2019; 36:62-69. [PMID: 30368899 DOI: 10.1111/dme.13848] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2018] [Indexed: 01/24/2023]
Abstract
AIM The epidemiology of asymptomatic (silent) hypoglycaemia is not well-described. We investigated incidence and risk factors for asymptomatic hypoglycaemia in Type 1 diabetes. METHODS A cohort of 153 people with Type 1 diabetes participated in 6 days of blinded continuous glucose monitoring (CGM) and recording of hypoglycaemia symptoms. At entry, hypoglycaemia awareness was classified (by three different methods) and HbA1c and C-peptide were measured. Hypoglycaemic episodes were defined as interstitial glucose ≤ 3.9 mmol/l (IG3.9 ) or ≤ 3.0 mmol/l (IG3.0 ) for ≥ 15 min, and were considered asymptomatic if no hypoglycaemic symptoms were reported. RESULTS At thresholds IG3.9 and IG3.0 , the incidence rates of hypoglycaemic episodes were 5.0 (7.9) [median (IQR)] and 1.3 (3.4) episodes/person-week, respectively. Three-quarters of episodes were asymptomatic. In total, 77% and 52% of participants experienced one or more episode of asymptomatic hypoglycaemia at IG3.9 and IG3.0 [3.0 (6.2) and 1.0 (2.3) asymptomatic episodes/person-week]. At multivariate analysis, reduced awareness was positively associated with asymptomatic hypoglycaemia, particularly nocturnal events, and negatively with symptomatic hypoglycaemia. High insulin dose was associated with increased risk of both asymptomatic and symptomatic hypoglycaemia, whereas low HbA1c and long diabetes duration were risk factors only for symptomatic hypoglycaemia. CONCLUSIONS Asymptomatic hypoglycaemia constitutes the majority of hypoglycaemic events in Type 1 diabetes. Reduced hypoglycaemia awareness and high insulin dose are risk factors for asymptomatic hypoglycaemia but other conventional risk factors for severe hypoglycaemia do not correlate with risk of asymptomatic episodes.
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Affiliation(s)
- M M Henriksen
- Department of Endocrinology and Nephrology, Nordsjaellands Hospital, Hillerød
| | | | - B Thorsteinsson
- Department of Endocrinology and Nephrology, Nordsjaellands Hospital, Hillerød
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - U Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjaellands Hospital, Hillerød
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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147
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Beck RW, Bergenstal RM, Riddlesworth TD, Kollman C. The Association of Biochemical Hypoglycemia with the Subsequent Risk of a Severe Hypoglycemic Event: Analysis of the DCCT Data Set. Diabetes Technol Ther 2019; 21:1-5. [PMID: 30575408 PMCID: PMC6909677 DOI: 10.1089/dia.2018.0362] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the association of biochemical hypoglycemia with subsequent severe hypoglycemia (SH) events using the Diabetes Control and Complications Trial (DCCT) data set. RESEARCH DESIGN AND METHODS The frequency of biochemical hypoglycemia (percentage of values <70 and <54 mg/dL [3.9 and 3.0 mmol/L) was assessed using DCCT blood glucose concentrations measured at a central laboratory from seven finger-stick samples (7-point testing: pre- and 90-min postmeals and at bedtime) collected during 1 day every 3 months. SH events required a change in mental status necessitating the involvement of another individual to provide treatment. A Poisson model accounting for repeated measures from each participant was used to assess the association of biochemical hypoglycemia frequency, computed from the 7-point finger-stick data, with the development of SH events. RESULTS The risk of SH during a 3-month period was substantially higher (P < 0.001) when there was at least one hypoglycemic blood glucose value in the preceding 7-point profile, with similar results seen for both the 70 mg/dL (rate ratio = 3.0 [95% confidence interval: 2.6-3.3]) and 54 mg/dL (rate ratio = 2.7 [95% confidence interval: 2.4-3.1]) thresholds. CONCLUSIONS The occurrence of biochemical hypoglycemia <70 or <54 mg/dL is associated with an increased risk of SH. For this reason as well as the deleterious effects of hypoglycemia on glucose counter-regulation and hypoglycemia awareness, cognition, quality of life, and arrhythmias, it is important in diabetes management to avoid hypoglycemic glucose levels as much as possible.
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Affiliation(s)
- Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida
- Address correspondence to: Roy W. Beck, MD, PhD, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647
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148
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In vitro differentiation of human multilineage differentiating stress-enduring (Muse) cells into insulin producing cells. J Genet Eng Biotechnol 2018; 16:433-440. [PMID: 30733757 PMCID: PMC6354004 DOI: 10.1016/j.jgeb.2018.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/09/2018] [Indexed: 12/30/2022]
Abstract
Mesenchymal stem cells (MSCs) is a heterogeneous population. Muse cells is a rare pluripotent subpopulation within MSCs. This study aims to evaluate the pulirpotency and the ability of Muse cells to generate insulin producing cells (IPCs) after in vitro differentiation protocol compared to the non-Muse cells. Muse cells were isolated by FACSAria III cell sorter from adipose-derived MSCs and were evaluated for its pluripotency. Following in vitro differentiation, IPCs derived from Muse and non-Muse cells were evaluated for insulin production. Muse cells comprised 3.2 ± 0.7% of MSCs, approximately 82% of Muse cells were positive for anti stage-specific embryonic antigen-3 (SSEA-3). Pluripotent markers were highly expressed in Muse versus non-Muse cells. The percentage of generated IPCs by flow cytometric analysis was higher in Muse cells. Under confocal microscopy, Muse cells expressed insulin and c-peptide while it was undetected in non-Muse cells. Our results introduced Muse cells as a new adult pluripotent subpopulation, which is capable to produce higher number of functional IPCs.
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149
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Lucidi P, Porcellati F, Bolli GB, Fanelli CG. Real-time continuous glucose monitoring decreases the risk of severe hypoglycemia in people with type 1 diabetes and impaired awareness of hypoglycemia. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:S97. [PMID: 30740418 DOI: 10.21037/atm.2018.11.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Paola Lucidi
- Department of Medicine, Section of Endocrinology & Metabolism, Perugia University School of Medicine, Perugia, Italy
| | - Francesca Porcellati
- Department of Medicine, Section of Endocrinology & Metabolism, Perugia University School of Medicine, Perugia, Italy
| | - Geremia B Bolli
- Department of Medicine, Section of Endocrinology & Metabolism, Perugia University School of Medicine, Perugia, Italy
| | - Carmine G Fanelli
- Department of Medicine, Section of Endocrinology & Metabolism, Perugia University School of Medicine, Perugia, Italy
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150
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Faber CL, Matsen ME, Velasco KR, Damian V, Phan BA, Adam D, Therattil A, Schwartz MW, Morton GJ. Distinct Neuronal Projections From the Hypothalamic Ventromedial Nucleus Mediate Glycemic and Behavioral Effects. Diabetes 2018; 67:2518-2529. [PMID: 30257978 PMCID: PMC6245222 DOI: 10.2337/db18-0380] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 09/17/2018] [Indexed: 01/03/2023]
Abstract
The hypothalamic ventromedial nucleus (VMN) is implicated both in autonomic control of blood glucose and in behaviors including fear and aggression, but whether these divergent effects involve the same or distinct neuronal subsets and their projections is unknown. To address this question, we used an optogenetic approach to selectively activate the subset of VMN neurons that express neuronal nitric oxide synthase 1 (VMNNOS1 neurons) implicated in glucose counterregulation. We found that photoactivation of these neurons elicits 1) robust hyperglycemia achieved by activation of counterregulatory responses usually reserved for the physiological response to hypoglycemia and 2) defensive immobility behavior. Moreover, we show that the glucagon, but not corticosterone, response to insulin-induced hypoglycemia is blunted by photoinhibition of the same neurons. To investigate the neurocircuitry by which VMNNOS1 neurons mediate these effects, and to determine whether these diverse effects are dissociable from one another, we activated downstream VMNNOS1 projections in either the anterior bed nucleus of the stria terminalis (aBNST) or the periaqueductal gray (PAG). Whereas glycemic responses are fully recapitulated by activation of VMNNOS1 projections to the aBNST, freezing immobility occurred only upon activation of VMNNOS1 terminals in the PAG. These findings support previous evidence of a VMN→aBNST neurocircuit involved in glucose counterregulation and demonstrate that activation of VMNNOS1 neuronal projections supplying the PAG robustly elicits defensive behaviors.
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Affiliation(s)
- Chelsea L Faber
- UW Medicine Diabetes Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Miles E Matsen
- UW Medicine Diabetes Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Kevin R Velasco
- UW Medicine Diabetes Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Vincent Damian
- UW Medicine Diabetes Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Bao Anh Phan
- UW Medicine Diabetes Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Daniel Adam
- School of Medicine, Creighton University, Omaha, NE
| | | | - Michael W Schwartz
- UW Medicine Diabetes Institute, Department of Medicine, University of Washington, Seattle, WA
| | - Gregory J Morton
- UW Medicine Diabetes Institute, Department of Medicine, University of Washington, Seattle, WA
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