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Visser SAG, Kandala B, Fancourt C, Krug AW, Cho CR. A Model-Informed Drug Discovery and Development Strategy for the Novel Glucose-Responsive Insulin MK-2640 Enabled Rapid Decision Making. Clin Pharmacol Ther 2020; 107:1296-1311. [PMID: 31889297 PMCID: PMC7325312 DOI: 10.1002/cpt.1729] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/30/2019] [Indexed: 12/15/2022]
Abstract
A model‐informed drug discovery and development strategy played a key role in the novel glucose‐responsive insulin MK‐2640’s early clinical development strategy and supported a novel clinical trial paradigm to assess glucose responsiveness. The development and application of in silico modeling approaches by leveraging substantial published clinical insulin pharmacokinetic–pharmacodynamic (PKPD) data and emerging preclinical and clinical data enabled rapid quantitative decision making. Learnings can be applied to define PKPD properties of novel insulins that could become therapeutically meaningful for diabetic patients.
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Affiliation(s)
- Sandra A G Visser
- Department of Quantitative Pharmacology & Pharmacometrics (QP2) at Merck & Co. Inc., Kenilworth, New Jersey, USA
| | - Bhargava Kandala
- Department of Quantitative Pharmacology & Pharmacometrics (QP2) at Merck & Co. Inc., Kenilworth, New Jersey, USA
| | - Craig Fancourt
- Department of Quantitative Pharmacology & Pharmacometrics (QP2) at Merck & Co. Inc., Kenilworth, New Jersey, USA
| | - Alexander W Krug
- Department of Translational Pharmacology at Merck & Co. Inc., Kenilworth, New Jersey, USA
| | - Carolyn R Cho
- Department of Quantitative Pharmacology & Pharmacometrics (QP2) at Merck & Co. Inc., Kenilworth, New Jersey, USA
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Alghamdi EM, Alghubayshi LA, Alshamrani RA, Alnajashi RA, Alamoudi EA, Aljabarti AM, Zarif HA. Hypoglycemic Risk Factors Among Hospitalized Patients with Type 2 Diabetes Mellitus at King Abdulaziz Medical City, Jeddah. Cureus 2020; 12:e6742. [PMID: 32133264 PMCID: PMC7034734 DOI: 10.7759/cureus.6742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Hypoglycemia is a pathological condition in which the serum glucose level measures less than 3.0 mmol/L. It is a well-known complication in patients with diabetes mellitus. Age, body weight, gender, insulin usage, nutritional therapy, body mass index (BMI), the presence of diabetes complications, intensive care unit admission, and infection were reported as possible risk factors that may increase the risk of hypoglycemia. Therefore, this study aimed to analyze predisposing factors for hypoglycemia among hospitalized patients with type 2 diabetes in King Abdulaziz Medical City. Method This is a retrospective, case-control study design. The study included 326 hospitalized patients with type 2 diabetes; 152 experienced hypoglycemia (blood glucose <3.9) at least once during hospitalization and have been compared to 174 in the non-hypoglycemic group (blood glucose ≥3.9). Data were extracted from their electronic medical records (EMRs). Results This study reported that patients with lower BMI (28.80 ± 7 versus 31.20 ± 12.93) experienced hypoglycemia (P-value 0.044). Those hospitalized with infections or had acquired infections or required intensive care unit (ICU) admission during hospitalization had a higher risk to develop hypoglycemia (P-value 0.005, 0.003, and <0.001, respectively). Moreover, the use of multiple doses of insulin therapy or basal-plus insulin therapy was associated with a higher risk of hypoglycemia (P-value 0.012 and 0.028, respectively). Those on supplemental insulin were less likely to develop hypoglycemia (P-value <0.001). Patients on oral feeding had a lower chance of having a hypoglycemic attack (P-value 0.002) while those on tube feeding had double the odds (OR=2.37). Conclusions Infection, intensive care unit admission, lower body mass index, insulin regimen and nutritional therapy (enteral feeding and nothing-per-mouth (NPO)) were correlated with an elevated risk of having hypoglycemia in hospitalized patients with type 2 diabetes mellitus.
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Affiliation(s)
- Erada M Alghamdi
- Internal Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah Medical Research Center, Ministry of the National Guard, Jeddah, SAU
| | - Laila A Alghubayshi
- Internal Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah Medical Research Center, Ministry of the National Guard, Jeddah, SAU
| | - Reem A Alshamrani
- Internal Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah Medical Research Center, Ministry of the National Guard, Jeddah, SAU
| | | | | | | | - Hawazen A Zarif
- Medicine / Endocrinology, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, Jeddah, SAU
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153
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Huang MC, Hung CH, Chen CY, Hung WW, Liang HL. Factors associated with quality of life in patients with diabetic hypoglycaemia. J Clin Nurs 2020; 29:1704-1711. [PMID: 31944477 DOI: 10.1111/jocn.15183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 12/09/2019] [Accepted: 01/10/2020] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To identify determinants of quality of life among patients who had experienced hypoglycaemia and who were undergoing insulin treatment. BACKGROUND Patients with diabetes receiving insulin treatment are at high risk for hypoglycaemia, which tends to affect their quality of life. DESIGN With a cross-sectional and observational study design (see the STROBE checklist and Appendix S1). METHODS One hundred and fifty patients with type 2 diabetes who had received insulin treatment and had experienced hypoglycaemia (<70 mg/dl) in the last 6 months were recruited. Data were collected from May 2016-February 2018 using the Knowledge of Hypoglycaemia Scale, Fear of Hypoglycaemia Scale, Social Support Scale and the simplified Taiwanese version of the Quality of Life Scale developed by the World Health Organization. RESULTS Factors found to be associated with quality of life in patients with hypoglycaemia included having an educational level of senior high school or above, being on an insulin regimen only, engaging in regular exercise, diabetes complications, fear of hypoglycaemia and greater social support, which accounted for 28.5% of the total variance. CONCLUSIONS During the process of glycaemic control, patients inevitably experience hypoglycaemic episodes. Therefore, healthcare providers should assist patients with disease management to improve their quality of life. Future studies should also recruit patients who claim to have experienced hypoglycaemic symptoms, rather than considering only those with blood glucose levels below 70 mg/dl, to expand the generalisability of the findings. Future studies may also focus on the management of hypoglycaemia in patients on an insulin regimen, and on examining the effect of health education programmes on prevention of hypoglycaemia. RELEVANCE TO CLINICAL PRACTICE The present findings could provide a reference for healthcare providers to consolidate nursing care guidelines and to improve such patients' quality of life.
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Affiliation(s)
- Mei-Chuan Huang
- School of Nursing, National Tainan Junior College of Nursing, Tainan City, Taiwan
| | - Chich-Hsiu Hung
- School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | | | - Wei-Wen Hung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hsiu-Ling Liang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Kumar A, Sharma S, Gupta A, Dasgupta A, Asirvatham A, Talwalkar P, Das A, Mohan V. Indian reality of managing type 2 diabetes: an expert review of global and national guidelines for optimum insulin use. JOURNAL OF DIABETOLOGY 2020. [DOI: 10.4103/jod.jod_59_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Antidiabetic effect of Momordica charantia saponins in rats induced by high-fat diet combined with STZ. ELECTRON J BIOTECHN 2020. [DOI: 10.1016/j.ejbt.2019.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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156
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Secnik J, Schwertner E, Alvarsson M, Hammar N, Fastbom J, Winblad B, Garcia-Ptacek S, Religa D, Eriksdotter M. Cholinesterase inhibitors in patients with diabetes mellitus and dementia: an open-cohort study of ~23 000 patients from the Swedish Dementia Registry. BMJ Open Diabetes Res Care 2020; 8:8/1/e000833. [PMID: 31958305 PMCID: PMC7039592 DOI: 10.1136/bmjdrc-2019-000833] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/24/2019] [Accepted: 11/28/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Cholinesterase inhibitors (ChEIs) and memantine are the only approved pharmacological treatments for Alzheimer's disease (AD). Recent literature suggests reductions in cardiovascular burden and risk of stroke in ChEI users. However, the clinical effectiveness of these drugs in patients with diabetes mellitus (DM) and dementia has not been evaluated. RESEARCH DESIGN AND METHODS We conducted a registry-based open-cohort study of 22 660 patients diagnosed with AD and mixed-pathology dementia registered in the Swedish Dementia Registry until December 2015. Information on drug use, comorbidity and mortality was extracted using the linkage with the National Patient Registry, the Prescribed Drug Registry and the Cause of Death Registry. In total, 3176 (14%) patients with DM and 19 484 patients without DM were identified. Propensity-score matching, Cox-regression and competing-risk regression models were applied to produce HRs with 95% CIs for differences in all-cause, cardiovascular and diabetes-related mortality rates in ChEI users and non-users. RESULTS After matching the ChEI use in patients with DM was associated with 24% all-cause mortality reduction (HR 0.76 (95% CI 0.67 to 0.86)), compared with 20% reduction (0.80 (0.75 to 0.84)) in non-DM users. Donepezil and galantamine use were associated with a reduced mortality in both patients with DM (0.84 (0.74 to 0.96); 0.80 (0.66 to 0.97)) and patients without DM (0.85 (0.80 to 0.90); 0.93 (0.86 to 0.99)). Donepezil was further associated with reduction in cardiovascular mortality, however only in patients without DM (0.84 (0.75 to 0.94)). Rivastigmine lowered mortality only in the whole-cohort analysis and in patients without DM (0.82 (0.75 to 0.89)). Moreover, ChEI use was associated with 48% reduction in diabetes-related mortality (HR 0.52 (0.32 to 0.87)) in the whole-cohort analysis. Last, low and high doses were associated with similar benefit. CONCLUSIONS We found reductions in mortality in patients with DM and AD or mixed-pathology dementia treated with ChEIs, specifically donepezil and galantamine were associated with largest benefit. Future studies should evaluate whether ChEIs help maintain self-management of diabetes in patients with dementia.
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Affiliation(s)
- Juraj Secnik
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
| | - Emilia Schwertner
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
| | - Michael Alvarsson
- Growth and Metabolism, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Johan Fastbom
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Bengt Winblad
- Division of Neurogeriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Theme Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Sara Garcia-Ptacek
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
- Theme Aging, Karolinska University Hospital, Huddinge, Sweden
- Section for Neurology, Department of Internal Medicine, Södersjukhuset - Stockholm South General Hospital, Stockholm, Sweden
| | - Dorota Religa
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
- Theme Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Maria Eriksdotter
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
- Theme Aging, Karolinska University Hospital, Huddinge, Sweden
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Abstract
In health hypoglycaemia is rare and occurs only in circumstances like extreme sports. Hypoglycaemia in type 1 Diabetes (T1D) and advanced type 2 Diabetes (T2D) are the result of interplay between absolute or relative insulin access and defective glucose counterregulation. The basic mechanism is, failure of decreasing insulin and failure of the compensatory increasing counterregulatory hormones at the background of falling blood glucose. Any person with Diabetes on anti-diabetic medication who behaves oddly in any way whatsoever is hypoglycaemic until proven otherwise. Hypoglycaemia can be a terrifying experience for a patient with Diabetes. By definition, hypoglycaemic symptoms are subjective and vary from person to person and even episode to episode in same person. Fear of iatrogenic hypoglycaemia is a major barrier in achieving optimum glycaemic control and quality of life which limits the reduction of diabetic complications. Diabetes patients with comorbidities especially with chronic renal failure, hepatic dysfunction, major limb amputation, terminal illness, cognitive dysfunction etc. are more vulnerable to hypoglycaemia. In most cases, prompt glucose intake reverts hypoglycaemia. Exogenous insulin in T1D and insulin treated advanced T2D have no control by pancreatic regulation. Moreover, failure of increase of glucagon and attenuated secretion in epinephrine causes the defective glucose counterregulation. In this comprehensive review, I will try to touch all related topics for better understanding of hypoglycaemia.
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Stefenon P, Silveira ALMD, Giaretta LS, Leitão CB, Bauer AC. Hypoglycemia symptoms and awareness of hypoglycemia in type 1 diabetes mellitus: cross-cultural adaptation and validation of the Portuguese version of three questionnaires and evaluation of its risk factors. Diabetol Metab Syndr 2020; 12:15. [PMID: 32082423 PMCID: PMC7023738 DOI: 10.1186/s13098-020-0521-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/01/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND To adapt and validate the Clarke and Gold questionnaires and the Edinburgh Hypoglycemia Symptom Scale (EHSS) to Brazilian Portuguese and to determine the prevalence and risk factors associated with impaired awareness of hypoglycemia (IAH) in patients with type 1 diabetes mellitus (T1DM). METHODS The process of translation, cultural adaptation, and validation of the questionnaires followed the recommendations of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR)-Task Force for Translation and Cultural Adaptation. Patients with T1DM for a minimum of 12 months, aged 18 years or older, and with Brazilian nationality were selected to participate. RESULTS A total of 123 patients were enrolled. The Clarke and Gold questionnaires as well as the EHSS exhibited adequate internal consistency, test-retest reliability, and convergent validity. The prevalence of IAH was 38.3% with the Clarke questionnaire and 25.2% with the Gold questionnaire. The prevalence increased with longer duration of diabetes, lower HbA1c, and lower eGFR. CONCLUSIONS The validation and cross-cultural adaptation of the proposed questionnaires to Brazilian Portuguese were adequate. In this sample of T1DM, the prevalence of IAH was high and associated with a longer duration of T1DM, lower HbA1C and lower eGFR.
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Affiliation(s)
- Paula Stefenon
- Postgraduation Program in Endocrinology, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul Brazil
| | | | - Luana Seminotti Giaretta
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul Brazil
| | - Cristiane Bauermann Leitão
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350; Prédio 12; 4° andar, Porto Alegre, 90035-003 Brazil
| | - Andrea Carla Bauer
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul Brazil
- Endocrinology Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350; Prédio 12; 4° andar, Porto Alegre, 90035-003 Brazil
- Nephrology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul Brazil
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159
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Kennedy KE, Teng C, Patek TM, Frei CR. Hypoglycemia Associated with Antibiotics Alone and in Combination with Sulfonylureas and Meglitinides: An Epidemiologic Surveillance Study of the FDA Adverse Event Reporting System (FAERS). Drug Saf 2019; 43:363-369. [PMID: 31863282 DOI: 10.1007/s40264-019-00901-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Fluoroquinolones, clarithromycin, linezolid, tigecycline, cefditoren, doxycycline, and trimethoprim-sulfamethoxazole are known to be associated with hypoglycemia, but few studies have considered concomitant glucose-lowering medications. OBJECTIVE The objective of this study was to evaluate the association between hypoglycemia and antibiotics using the US Food and Drug Administration Adverse Event Reporting System (FAERS), while accounting for concomitant glucose-lowering medications including sulfonylureas and meglitinides. METHODS FAERS reports from 1 January 2004 to 31 December 2017 were included in the study. Reporting odds ratios (RORs) and corresponding 95% confidence intervals (CIs) for the association between antibiotics and hypoglycemia were calculated. An association was considered to be statistically significant when the lower limit of the 95% CI was > 1.0. RESULTS A total of 2,334,959 reports (including 18,466 hypoglycemia reports) were considered, after inclusion criteria were applied. Statistically significant hypoglycemia RORs (95% CI) for antibiotics were: cefditoren 14.03 (8.93-22.03), tigecycline 3.32 (1.95-5.65), clarithromycin 2.41 (1.89-3.08), ertapenem 2.07 (1.14-3.75), moxifloxacin 2.06 (1.59-2.65), levofloxacin 1.66 (1.37-2.01), and linezolid 1.54 (1.07-2.20). After adjusting for concomitant sulfonylureas and meglitinides, the following antibiotics were still significantly associated with hypoglycemia: cefditoren 14.25 (9.08-22.39), tigecycline 3.34 (1.96-5.68), ertapenem 1.93 (1.03-3.60), and clarithromycin 1.56 (1.15-2.11). CONCLUSION In many patients, antibiotics, including fluoroquinolones, are associated with hypoglycemia when they are also taking sulfonylureas or meglitinides. Cefditoren, tigecycline, ertapenem, and clarithromycin are associated with hypoglycemia even if not taken with sulfonylureas or meglitinides. The association between ertapenem and hypoglycemia has not been previously reported.
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Affiliation(s)
- Kaitlin E Kennedy
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, San Antonio, TX, USA
- Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA
| | - Chengwen Teng
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, San Antonio, TX, USA
- Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA
| | - Taylor M Patek
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, San Antonio, TX, USA
- Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA
| | - Christopher R Frei
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, San Antonio, TX, USA.
- Pharmacotherapy Education and Research Center, Long School of Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., MSC-6220, San Antonio, TX, 78229, USA.
- South Texas Veterans Health Care System, San Antonio, TX, USA.
- University Health System, San Antonio, TX, USA.
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Carbohydrate Intake in the Context of Exercise in People with Type 1 Diabetes. Nutrients 2019; 11:nu11123017. [PMID: 31835538 PMCID: PMC6950062 DOI: 10.3390/nu11123017] [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: 11/15/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 02/06/2023] Open
Abstract
Although the benefits of regular exercise on cardiovascular risk factors are well established for people with type 1 diabetes (T1D), glycemic control remains a challenge during exercise. Carbohydrate consumption to fuel the exercise bout and/or for hypoglycemia prevention is an important cornerstone to maintain performance and avoid hypoglycemia. The main strategies pertinent to carbohydrate supplementation in the context of exercise cover three aspects: the amount of carbohydrates ingested (i.e., quantity in relation to demands to fuel exercise and avoid hypoglycemia), the timing of the intake (before, during and after the exercise, as well as circadian factors), and the quality of the carbohydrates (encompassing differing carbohydrate types, as well as the context within a meal and the associated macronutrients). The aim of this review is to comprehensively summarize the literature on carbohydrate intake in the context of exercise in people with T1D.
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161
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Tang C, Ksiazek I, Siccardi N, Gapp B, Weber D, Wirsching J, Beck V, Reist M, Gaudet L, Stuber N, Surber SS, Mao X, Nicholson TB, Carbone W, Beibel M, Roma G, Gubser Keller C, Bassilana F. UTS2B Defines a Novel Enteroendocrine Cell Population and Regulates GLP-1 Secretion Through SSTR5 in Male Mice. Endocrinology 2019; 160:2849-2860. [PMID: 31556942 DOI: 10.1210/en.2019-00549] [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: 07/26/2019] [Accepted: 09/20/2019] [Indexed: 12/25/2022]
Abstract
The gut-pancreas axis plays a key role in the regulation of glucose homeostasis and may be therapeutically exploited to treat not only type 2 diabetes but also hypoglycemia and hyperinsulinemia. We identify a novel enteroendocrine cell type expressing the peptide hormone urotensin 2B (UTS2B). UTS2B inhibits glucagon-like peptide-1 (GLP-1) secretion in mouse intestinal crypts and organoids, not by signaling through its cognate receptor UTS2R but through the activation of the somatostatin receptor (SSTR) 5. Circulating UTS2B concentrations in mice are physiologically regulated during starvation, further linking this peptide hormone to metabolism. Furthermore, administration of UTS2B to starved mice demonstrates that it is capable of regulating blood glucose and plasma concentrations of GLP-1 and insulin in vivo. Altogether, our results identify a novel cellular source of UTS2B in the gut, which acts in a paracrine manner to regulate GLP-1 secretion through SSTR5. These findings uncover a fine-tuning mechanism mediated by a ligand-receptor pair in the regulation of gut hormone secretion, which can potentially be exploited to correct metabolic unbalance caused by overactivation of the gut-pancreas axis.
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Affiliation(s)
- Cong Tang
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Iwona Ksiazek
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Noemie Siccardi
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Berangere Gapp
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Delphine Weber
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - Valerie Beck
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Matthias Reist
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Laurent Gaudet
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Nathalie Stuber
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - Xiaohong Mao
- Novartis Institutes for BioMedical Research, Cambridge, Massachusetts
| | | | - Walter Carbone
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Martin Beibel
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Guglielmo Roma
- Novartis Institutes for BioMedical Research, Basel, Switzerland
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Fadini GP, Feher M, Hansen TK, de Valk HW, Koefoed MM, Wolden M, Zimmermann E, Jendle J. Switching to Degludec From Other Basal Insulins Is Associated With Reduced Hypoglycemia Rates: A Prospective Study. J Clin Endocrinol Metab 2019; 104:5977-5990. [PMID: 31397845 PMCID: PMC6812737 DOI: 10.1210/jc.2019-01021] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/05/2019] [Indexed: 01/10/2023]
Abstract
CONTEXT Observational studies of insulin degludec (degludec) with hypoglycemia events prospectively recorded are lacking. OBJECTIVE To evaluate the safety and effectiveness of degludec in patients with type 1 diabetes (T1D) or type 2 diabetes (T2D) switching from other basal insulins in routine care. DESIGN Results From Real-World Clinical Treatment With Tresiba® was a multinational, multicenter, prospective, observational, single-arm study comprising a 4-week baseline period (preswitch basal insulin) and 12-month follow-up (degludec). SETTING Routine clinical practice. PATIENTS OR OTHER PARTICIPANTS Insulin-treated patients (≥18 years) with T1D (n = 556) or T2D (n = 611) with treatment plans to initiate degludec. INTERVENTIONS Switching to degludec from other basal insulins. MAIN OUTCOME MEASURE Change from baseline in number of overall hypoglycemic events recorded in patient diaries. RESULTS In T1D, the 12-month follow-up/baseline rate ratios (95% CI) of overall [0.80 (0.74 to 0.88)], nonsevere [0.83 (0.76 to 0.91)], severe [0.28 (0.14 to 0.56)], and nocturnal [0.61 (0.50 to 0.73)] hypoglycemia suggested significantly lower hypoglycemia rates with degludec (all Ps < 0.001). At 12 months, HbA1c, fasting plasma glucose (FPG), and basal insulin dosage decreased significantly. Body weight increased, and treatment satisfaction improved significantly. In T2D, the hypoglycemia rate ratios were overall [0.46 (0.38 to 0.56)], nonsevere [0.53 (0.44 to 0.64)], and nocturnal [0.35 (0.20 to 0.62)] (all Ps < 0.001; too few events for analysis of severe hypoglycemia). At 12 months, HbA1c and FPG decreased significantly. Body weight and insulin dosages remained unchanged, and treatment satisfaction was significantly improved. CONCLUSIONS In a routine clinical care setting, switching to degludec from other basal insulins was associated with significantly lower rates of hypoglycemia, improved glycemic control, and treatment satisfaction in patients with T1D or T2D.
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Affiliation(s)
- Gian Paolo Fadini
- Department of Medicine, Division of Metabolic Diseases, University of Padova, Padova, Italy
- Correspondence and Reprint Requests: Gian Paolo Fadini, MD, PhD, Department of Medicine, Division of Metabolic Diseases, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy. E-mail:
| | - Michael Feher
- Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London, United Kingdom
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | | | - Harold W de Valk
- Department of Internal Medicine, University Medical Center Utrecht, CX Utrecht, Netherlands
| | | | | | | | - Johan Jendle
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
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Larkin ME, Nathan DM, Bebu I, Krause-Steinrauf H, Herman WH, Higgins JM, Tiktin M, Cohen RM, Lund C, Bergenstal RM, Johnson ML, Arends V. Rationale and Design for a GRADE Substudy of Continuous Glucose Monitoring. Diabetes Technol Ther 2019; 21:682-690. [PMID: 31393176 PMCID: PMC7207016 DOI: 10.1089/dia.2019.0202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: The Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) study has enrolled a racially and ethnically diverse population with type 2 diabetes, performed extensive phenotyping, and randomly assigned the participants to one of four second-line diabetes medications. The continuous glucose monitoring (CGM) substudy has been added to determine whether there are racial/ethnic differences in the relationship between average glucose (AG) and hemoglobin A1c (HbA1c). CGM will also be used to compare time in target range, glucose variability, and the frequency and duration of hypoglycemia across study groups. Methods: The observational CGM substudy will enroll up to 1800 of the 5047 GRADE study participants from the four treatment groups, including as many as 450 participants from each of 4 racial/ethnic minority groups to be compared: Hispanic White, non-Hispanic White, non-Hispanic African American, and non-Hispanic Other. CGM will be performed for 2 weeks in proximity to a GRADE annual visit, during which an oral glucose tolerance test will be performed and HbA1c and glycated albumin measured. Indicators of interindividual variation in red blood cell turnover, based on specialized erythrocyte measurements, will also be measured to explore the potential causes of interindividual HbA1c variations. Conclusions: The GRADE CGM substudy will provide new insights into whether differences exist in the relationship between HbA1c and AG among different racial/ethnic groups and whether glycemic profiles differ among frequently used diabetes medications and their potential clinical implications. Understanding such differences is important for clinical care and adjustment of diabetes medications in patients of different races or ethnicities.
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Affiliation(s)
- Mary E. Larkin
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, Massachusetts
- Address correspondence to: Mary Larkin, MS, RN, c/o GRADE Coordinating Center, The George Washington University Biostatistics Center, 6110 Executive Boulevard, Suite 750, Rockville, MD 20852
| | - David M. Nathan
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Ionut Bebu
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute of Public Health, The George Washington University, Rockville, Maryland
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute of Public Health, The George Washington University, Rockville, Maryland
| | - William H. Herman
- Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - John M. Higgins
- Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Margaret Tiktin
- Multidisciplinary Research, Case Western Reserve University, Cleveland, Ohio
| | - Robert M. Cohen
- Cincinnati VA Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Claire Lund
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute of Public Health, The George Washington University, Rockville, Maryland
| | | | - Mary L. Johnson
- Health Partners Institute, International Diabetes Center, Minneapolis, Minnesota
| | - Valerie Arends
- Advanced Research and Diagnostic Laboratory, University of Minnesota, Minneapolis, Minnesota
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164
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Ultrahigh performance liquid chromatography methods facilitate the development of glucose-responsive insulin therapeutics. Anal Bioanal Chem 2019; 412:377-388. [PMID: 31773226 DOI: 10.1007/s00216-019-02249-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/22/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
Insulin oligosaccharide conjugates hold promise as potential glucose-responsive insulins (GRIs), which can improve the therapeutic index of insulins and mitigate the risk of hypoglycemia. A key challenge for the analytical development of such molecules is finding an efficient method to characterize the purity and impurities of conjugated insulins. Using the S-Matrix Fusion QbD-ultrahigh performance liquid chromatography (UHPLC) integrated system, we were able to quickly screen and develop two short UHPLC methods. These methods were used to support process development, clinical batch drug substance (DS) release, and stability studies of MK-2640, an insulin oligosaccharide conjugate. Both methods used a Waters CSH C18 column, with a shallow gradient of acetonitrile to aqueous mobile phase containing 25 mM sodium perchlorate and 0.05% perchloric acid. The 10-min run time method was well suited for process development and monitoring as it was able to separate the main product, MK-2640, six oligosaccharide-substituted recombinant human insulin (RHI) impurities, A21 deamidated MK-2640, and the starting material RHI. The 13-min run time method provided improved separation of the major impurities and demonstrated good chromatographic reproducibility on different instruments or using columns from different lots of stationary phase, which made it ideal for the final DS release. Validation of the 13-min method demonstrated great linearity for both the MK-2640 main peak and its related impurities, low limit of detection (0.02%), and limit of quantitation (0.05%). The high specificity of the method allowed the separation of the degradation products from main peak, thus makes it suitable for stability monitoring. The major impurities in the DS were characterized by two-dimensional liquid chromatography-mass spectrometry (2D-LC-MS).
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165
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VanBaak KD, Nally LM, Finigan RT, Jurkiewicz CL, Burnier AM, Conrad BP, Khodaee M, Lipman GS. Wilderness Medical Society Clinical Practice Guidelines for Diabetes Management. Wilderness Environ Med 2019; 30:S121-S140. [PMID: 31753543 DOI: 10.1016/j.wem.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 10/11/2019] [Accepted: 10/11/2019] [Indexed: 11/18/2022]
Abstract
The Wilderness Medical Society convened an expert panel in 2018 to develop a set of evidence-based guidelines for the treatment of type 1 and 2 diabetes, as well as the recognition, prevention, and treatment of complications of diabetes in wilderness athletes. We present a review of the classifications, pathophysiology, and evidence-based guidelines for planning and preventive measures, as well as best practice recommendations for both routine and urgent therapeutic management of diabetes and glycemic complications. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each recommendation.
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Affiliation(s)
- Karin D VanBaak
- Department of Family Medicine and Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO.
| | - Laura M Nally
- Department of Pediatric Endocrinology, Yale University School of Medicine, New Haven, CT
| | | | - Carrie L Jurkiewicz
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
| | | | - Barry P Conrad
- Division of Endocrinology, Stanford Children's Hospital, Stanford, CA
| | - Morteza Khodaee
- Department of Family Medicine and Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Grant S Lipman
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
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166
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Loh HH, Lim L, Loh HS, Yee A. Safety of Ramadan fasting in young patients with type 1 diabetes: A systematic review and meta-analysis. J Diabetes Investig 2019; 10:1490-1501. [PMID: 30938074 PMCID: PMC6825934 DOI: 10.1111/jdi.13054] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/26/2019] [Accepted: 03/31/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS/INTRODUCTION Although patients with type 1 diabetes are medically exempt, many insist on fasting during Ramadan. Multiple daily insulin injections (MDI), premixed insulin and continuous subcutaneous insulin infusion (CSII) are commonly used. To date, little is known about the safety of Ramadan fasting in these patients. MATERIALS AND METHODS We pooled data from 17 observational studies involving 1,699 patients treated with either CSII or non-CSII (including premixed and MDI) regimen. The study outcomes were the frequencies of hypoglycemia, hyperglycemia and/or ketosis. Given the lack of patient-level data, separate analyses for premixed and MDI regimen were not carried out. RESULTS The CSII-treated group (n = 203) was older (22.9 ± 6.9 vs 17.8 ± 4.0 years), and had longer diabetes duration (116.7 ± 66.5 vs 74.8 ± 59.2 months) and lower glycated hemoglobin (7.8 ± 1.1% vs 9.1 ± 2.0%) at baseline than the non-CSII-treated group (n = 1,496). The non-CSII-treated group had less non-severe hypoglycemia than the CSII-treated group (22%, 95% CI 13-34 vs 35%, 95% CI 17-55). Of the non-CSII-treated group, 7.1% (95% CI 5.8-8.5) developed severe hypoglycemia, but none from the CSII-treated group did. The non-CSII-treated group was more likely to develop hyperglycemia (12%, 95% CI 3-25 vs 8.8%, 95% CI 0-31) and ketosis (2.5%, 95% CI 1.0-4.6 vs 1.6%, 95% CI 0.1-4.7), and discontinue fasting (55%, 95% CI 34-76 vs 31%, 95% CI 9-60) than the CSII-treated group. CONCLUSIONS The CSII regimen had lower rates of severe hypoglycemia and hyperglycemia/ketosis, but a higher rate of non-severe hyperglycemia than premixed/MDI regimens. These suggest that appropriate patient selection with regular, supervised fine-tuning of the basal insulin rate with intensive glucose monitoring might mitigate the residual hypoglycemia risk during Ramadan.
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Affiliation(s)
- Huai Heng Loh
- Faculty of Medicine and Health SciencesUniversity of Malaysia SarawakSarawakMalaysia
| | - Lee‐Ling Lim
- Department of MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
- Asia Diabetes FoundationShatin, Hong Kong SARChina
| | - Huai Seng Loh
- Clinical Academic UnitNewcastle University Medicine MalaysiaJohorMalaysia
| | - Anne Yee
- Department of Psychological MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
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167
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Lake A, Arthur A, Byrne C, Davenport K, Yamamoto JM, Murphy HR. The effect of hypoglycaemia during hospital admission on health-related outcomes for people with diabetes: a systematic review and meta-analysis. Diabet Med 2019; 36:1349-1359. [PMID: 31441089 PMCID: PMC7004204 DOI: 10.1111/dme.14115] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 12/15/2022]
Abstract
AIM To assess the health-related outcomes of hypoglycaemia for people with diabetes admitted to hospital; specifically, hospital length of stay and mortality. METHODS We conducted a systematic review and meta-analysis of studies relating to hypoglycaemia (< 4 mmol/l) for hospitalized adults (≥ 16 years) with diabetes reporting the primary outcomes of interest, hospital length of stay or mortality. Final papers for inclusion were reviewed in duplicate and the adjusted results of each were pooled, using a random effects model then undergoing further prespecified subgroup analysis. RESULTS In total, 15 studies were included in the meta-analysis. The pooled mean difference in length of stay for ward-based inpatients exposed to hypoglycaemia was 4.1 days longer [95% confidence interval (CI) 2.36 to 5.79; I² = 99%] compared with those without hypoglycaemia. This association remained robust across the pre-specified subgroup analyses. The pooled relative risk (RR) of in-hospital mortality was greater for those exposed to hypoglycaemia (RR 2.09, 95% CI 1.64 to 2.67; I² = 94%, n = 7 studies) but not in intensive care unit mortality (RR 0.75, 95% CI 0.49 to 1.16; I² =0%, n = 2 studies). CONCLUSION There is an association between inpatient hypoglycaemia and longer length of stay and greater in-hospital mortality. Studies examining this association were heterogenous in terms of both clinical populations and effect size, but the overall direction of the association was consistent. Therefore, glucose concentration should be considered a potential tool to aid the identification of inpatients at risk of poor health-related outcomes.
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Affiliation(s)
- A. Lake
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
- University of East AngliaNorwich Research ParkNorwichUK
| | - A. Arthur
- University of East AngliaNorwich Research ParkNorwichUK
| | - C. Byrne
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - K. Davenport
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - J. M. Yamamoto
- Departments of Medicine and Obstetrics and GynaecologyUniversity of CalgaryCalgaryAlbertaCanada
- Alberta Children's Hospital Research InstituteCalgaryAlbertaCanada
| | - H. R. Murphy
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
- University of East AngliaNorwich Research ParkNorwichUK
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168
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Qiu Y, Agrawal R, Chen D, Zheng N, Durupt G, Kim JH, Fisher SJ, Chou DH. Long‐Lasting Designer Insulin with Glucose‐Dependent Solubility Markedly Reduces Risk of Hypoglycemia. ADVANCED THERAPEUTICS 2019. [DOI: 10.1002/adtp.201900128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Yibo Qiu
- Department of BiochemistryUniversity of Utah Salt Lake City UT 84112 USA
| | - Rahul Agrawal
- Division of Endocrinology, Department of Internal MedicineUniversity of Utah Salt Lake City UT 84112 USA
| | - Diao Chen
- Department of BiochemistryUniversity of Utah Salt Lake City UT 84112 USA
| | - Nan Zheng
- Department of BiochemistryUniversity of Utah Salt Lake City UT 84112 USA
| | - Griffin Durupt
- Division of Endocrinology, Department of Internal MedicineUniversity of Utah Salt Lake City UT 84112 USA
| | - Jin Hwan Kim
- Department of BiochemistryUniversity of Utah Salt Lake City UT 84112 USA
| | - Simon J. Fisher
- Division of Endocrinology, Department of Internal MedicineUniversity of Utah Salt Lake City UT 84112 USA
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169
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Avari P, Ramli R, Reddy M, Oliver N, Fothergill R. Rationale and protocol for the Assessment of Impact of Real-time Continuous Glucose Monitoring on people presenting with severe Hypoglycaemia (AIR-CGM) study. BMC Endocr Disord 2019; 19:110. [PMID: 31655586 PMCID: PMC6815361 DOI: 10.1186/s12902-019-0439-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 10/09/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Severe hypoglycaemia carries a significant risk of morbidity and mortality for people with type 1 diabetes. Economic costs are also high, estimated at approximately £13 million annually in England, UK. Continuous glucose monitoring (CGM) has been shown to reduce hypoglycaemia and associated fear, improve overall glycaemia and quality of life, and is cost-effective. Despite effective pathways in place with high levels of resource utilization, it has been reported there are low levels of follow-up, therapy change and specialist intervention after severe hypoglycaemia. This study is designed to assess the impact of providing real-time CGM to people with type 1 diabetes, who have had a recent episode of severe hypoglycaemia (within 72 h), compared to standard care. METHODS/DESIGN Fifty-five participants with type 1 diabetes and a recent episode of severe hypoglycaemia, who are CGM naïve, will be recruited to the study. Participants will be randomised to CGM or standard care. The primary outcome is percentage time spent in hypoglycaemia (< 3.0 mmol/L, 55 mg/dL). Secondary outcomes include other measures of hypoglycaemia, time in euglycaemia, overall glucose status and patient reported qualitative measures. DISCUSSION This study assesses the impact of providing continuous glucose monitoring at the outset in individuals at highest risk of hypoglycaemia. Changing demand means that novel approaches need to be taken to healthcare provision. This study has the potential to shape future national standards. TRIAL REGISTRATION NCT03748433 , November 2018 (UK).
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Affiliation(s)
- Parizad Avari
- Division of Diabetes, Endocrinology and Metabolism, Faculty of Medicine, Imperial College, 7S7a, Commonwealth Building, Hammersmith Campus, Du Cane Road, W12 0HS, London, UK
| | - Rozana Ramli
- Division of Diabetes, Endocrinology and Metabolism, Faculty of Medicine, Imperial College, 7S7a, Commonwealth Building, Hammersmith Campus, Du Cane Road, W12 0HS, London, UK
| | - Monika Reddy
- Division of Diabetes, Endocrinology and Metabolism, Faculty of Medicine, Imperial College, 7S7a, Commonwealth Building, Hammersmith Campus, Du Cane Road, W12 0HS, London, UK
| | - Nick Oliver
- Division of Diabetes, Endocrinology and Metabolism, Faculty of Medicine, Imperial College, 7S7a, Commonwealth Building, Hammersmith Campus, Du Cane Road, W12 0HS, London, UK
| | - Rachael Fothergill
- Clinical Audit & Research Unit, London Ambulance Service NHS Trust, London, UK
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170
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Thewjitcharoen Y, Yenseung N, Malidaeng A, Butadej S, Chotwanvirat P, Krittiyawong S, Thammawiwat C, Himathongkam T. Effectiveness of Insulin Degludec in Thai Patients with Diabetes Mellitus: Real-World Evidence From a Specialized Diabetes Center. Exp Clin Endocrinol Diabetes 2019; 129:666-673. [PMID: 31597169 PMCID: PMC8416321 DOI: 10.1055/a-0899-5118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background
Insulin degludec, an ultra-long-acting insulin analogue, has been available in Thailand since October 2016. Although clinical trial results revealed less hypoglycemia, data from real-world settings is limited especially in Asian patients. This study aimed to evaluate prospectively the real-world effectiveness, safety, quality of life (QOL) and patient satisfaction with insulin degludec among Thai patients with diabetes mellitus (DM).
Methods
From October 2016 to September 2017, all patients who had started insulin degludec for at least 3 months were observed and evaluated at baseline, 3, 6, and 12 months. QOL was assessed using WHOQOL-BREF-THAI and level of satisfaction was measured by 7-point Likert scale. Glycemic fluctuation from paired iPro2 continuous glucose monitoring (CGM) obtained 4–6 weeks apart were also evaluated from a subset of patients with T1DM who switched from insulin glargine to insulin degludec.
Results
A total of 55 patients (T2DM 76.4%, females 54.5%, mean age 57.1±16.1 years, duration of diabetes 16.7±8.8 years, BMI 27.3±5.5 kg/m
2
, baseline A1C 9.3±2.3%, median duration of treatment 8 months) were included in the study. In T1DM patients (n=13), the overall mean A1C reduction at 12 months was 0.5% with minimal weight gain of 0.9 kgs at 12 months. In T2DM patients (n=42), the overall mean A1C reduction at 12 months was 0.8% with minimal weight loss of 0.4 kgs at 12 months. The proportion of T1DM patients who could achieve optimal glycemic control increased slightly from 14.3 to 18.2% but the proportion of T2DM patients who could achieve optimal glycemic control increased from 30.8 to 53.8%. Patient satisfaction showed a sustained improvement throughout the duration of study. In four T1DM patients who had paired CGM data, insulin degludec provided greater reductions in glycemic variability endpoints with increased time-in-range when compared with previous insulin glargine.
Discussion
Our data suggested that the effectiveness of insulin degludec was consistent with the results seen in clinical trials with lower risk of patients-reported hypoglycemia, and a significant improvement in glycemic control. Patients also reported higher treatment satisfaction. More long-term and cost-effectiveness data are needed to establish the role of this ultra-long-acting insulin in real-world settings.
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Affiliation(s)
| | - Nalin Yenseung
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
| | - Areeya Malidaeng
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
| | - Siriwan Butadej
- Diabetes and Thyroid Center, Theptarin Hospital, Bangkok, Thailand
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171
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Farngren J, Ahrén B. Incretin-based medications (GLP-1 receptor agonists, DPP-4 inhibitors) as a means to avoid hypoglycaemic episodes. Metabolism 2019; 99:25-31. [PMID: 31279738 DOI: 10.1016/j.metabol.2019.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/17/2019] [Accepted: 06/28/2019] [Indexed: 01/21/2023]
Abstract
Hypoglycaemia is common in both type 1 and type 2 diabetes and has both acute and long-term consequences. Therefore, a key to proper glucose-lowering therapy in diabetes is to avoid or prevent hypoglycaemia. Incretin therapy (DPP-4 inhibitors and GLP-1 receptor agonists) offers an advantage in this respect, because it reduces glucose with a low risk of hypoglycaemia, both in monotherapy and in combination with other therapies. The reason for this low risk of hypoglycaemia is the glucose dependency of action of incretin therapy and the sustainment of glucose counter-regulatory hormone responses to hypoglycaemia, in particular the glucagon response. Incretin therapy is also associated with a low risk of hypoglycaemia in patient groups which are especially vulnerable and susceptible for hypoglycaemia, e.g., subjects with renal impairment, elderly subjects and subjects with on-going insulin therapy. This review summarizes how incretin therapy may meet the challenges of hypoglycaemia and suggests that incretin therapy is a therapy of choice to avoid hypoglycaemia, both in the general diabetes population and in subjects with increased risk or vulnerability for hypoglycaemia.
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Affiliation(s)
- Johan Farngren
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Bo Ahrén
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
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172
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Bajpai SK, Cambron-Mellott MJ, Peck E, Poon JL, Wang Q, Mitchell BD, Babrowicz J, Child CJ, Raibulet NK, Beusterien K. Perceptions About Glucagon Delivery Devices for Severe Hypoglycemia: Qualitative Research With Patients, Caregivers, and Acquaintances. Clin Ther 2019; 41:2073-2089.e6. [DOI: 10.1016/j.clinthera.2019.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 08/13/2019] [Accepted: 08/15/2019] [Indexed: 02/06/2023]
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173
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PACAP stimulates insulin secretion by PAC1 receptor and ion channels in β-cells. Cell Signal 2019; 61:48-56. [DOI: 10.1016/j.cellsig.2019.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/28/2019] [Accepted: 05/06/2019] [Indexed: 01/02/2023]
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174
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Haynes A, Hermann JM, Clapin H, Hofer SE, Karges B, Jones TW, Davis EA, Holl RW. Decreasing Trends in Mean HbA 1c Are Not Associated With Increasing Rates of Severe Hypoglycemia in Children: A Longitudinal Analysis of Two Contemporary Population-Based Pediatric Type 1 Diabetes Registries From Australia and Germany/Austria Between 1995 and 2016. Diabetes Care 2019; 42:1630-1636. [PMID: 31213467 DOI: 10.2337/dc18-2448] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 05/28/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate temporal trends in glycemic control and severe hypoglycemia rates for pediatric patients with type 1 diabetes from 1995 to 2016 by analyzing data from the longitudinal, prospective, population-based German/Austrian (Diabetes Patient History Documentation [DPV]) and Western Australian (Western Australian Children's Diabetes Database [WACDD]) diabetes registries. RESEARCH DESIGN AND METHODS Patients diagnosed with type 1 diabetes aged <15 years were identified from the DPV (N = 59,883) and WACDD (N = 2,595) registries and data extracted for all clinic visits occurring between 1995 and 2016, inclusive. Mean HbA1c and severe hypoglycemia (self-reported loss of consciousness/convulsion) rates were calculated per 100 patient-years. RESULTS Between 1995 and 2016, the annual mean HbA1c decreased from 8.3 to 7.8% in the DPV cohort and from 9.2 to 8.3% in the WACDD cohort. Over the same period, the severe hypoglycemia rate decreased by an annual average of 2% (relative risk 0.983 [95% CI 0.981, 0.986]) in the DPV cohort and 6% (relative risk 0.935 [95% CI 0.934, 0.937]) in the WACDD cohort. Concomitant decreasing trends in both HbA1c and severe hypoglycemia rates were observed in boys and girls, all age-groups, and injection therapy/pump regimen groups. CONCLUSIONS Over the past two decades, there have been concurrent improvements in HbA1c and decreasing severe hypoglycemia rates in two contemporary, longitudinal, population-based pediatric cohorts of type 1 diabetes. Translation of these data into clinical practice and patient education may reduce fear of hypoglycemia and enable better glycemic control.
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Affiliation(s)
- Aveni Haynes
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Julia M Hermann
- Central Institution for Biomedical Engineering, Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany.,German Center for Diabetes Research, München-Neuherberg, Germany
| | - Helen Clapin
- Department of Diabetes and Endocrinology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Timothy W Jones
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Diabetes and Endocrinology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Elizabeth A Davis
- Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Diabetes and Endocrinology, Perth Children's Hospital, Perth, Western Australia, Australia
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175
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Hendrieckx C, Ivory N, Singh H, Frier BM, Speight J. Impact of severe hypoglycaemia on psychological outcomes in adults with Type 2 diabetes: a systematic review. Diabet Med 2019; 36:1082-1091. [PMID: 31271669 DOI: 10.1111/dme.14067] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2019] [Indexed: 12/25/2022]
Abstract
AIM Hypoglycaemia affects many people with Type 2 diabetes using insulin and other glucose-lowering therapies. This systematic review examined the impact of severe hypoglycaemia (episodes requiring external assistance) on psychological outcomes (e.g. emotional well-being, health status and quality of life) in adults with Type 2 diabetes. METHODS MEDLINE Complete, PsycINFO and CINAHL databases were searched for peer-reviewed empirical studies, published in English, reporting the occurrence and severity of hypoglycaemia and its relationship with patient-reported outcomes (PROs) in adults with Type 2 diabetes. Data were extracted from published reports and analysed. RESULTS Of 3756 potentially relevant abstracts, 29 studies met the inclusion criteria. Most reported cross-sectional data and sample sizes varied widely (N = 71 to 17 563). Although definitions of mild and severe hypoglycaemia were largely consistent between studies, additional non-standard categorizations (e.g. moderate, very severe) were apparent and recall periods varied. Overall, severe hypoglycaemia was associated with increased fear of hypoglycaemia and decreased emotional well-being, health status and diabetes-specific quality of life. Effect sizes show that the association with fear of hypoglycaemia was stronger than with general health status. CONCLUSIONS Notwithstanding the limitations of the empirical studies, these findings indicate that severe hypoglycaemia in adults with Type 2 diabetes (insulin- and non-insulin-treated) is associated with impaired psychological outcomes. Healthcare professionals should address the psychological impact of severe hypoglycaemia during clinical consultations, to support individuals to minimize exposure to, and the psychological consequences of, severe hypoglycaemia.
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Affiliation(s)
- C Hendrieckx
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - N Ivory
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - H Singh
- Mary & Dick Allen Diabetes Center, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - B M Frier
- The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - J Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
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Yun JS, Park YM, Han K, Cha SA, Ahn YB, Ko SH. Severe hypoglycemia and the risk of cardiovascular disease and mortality in type 2 diabetes: a nationwide population-based cohort study. Cardiovasc Diabetol 2019; 18:103. [PMID: 31412855 PMCID: PMC6694505 DOI: 10.1186/s12933-019-0909-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/07/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We investigated the association regarding severe hypoglycemia episodes with cardiovascular disease risk and all-cause mortality in patients with type 2 diabetes. METHODS Baseline and follow-up data (n = 1,568,097) from patients with type 2 diabetes were retrieved from the National Health Insurance System database (covering the entire Korean population). Type 2 diabetes, severe hypoglycemia, and major comorbidities were identified using International Classification of Diseases 10 codes and medication information. Individuals who were classified as type 2 diabetes in the year of 2009 were screened, and we counted severe hypoglycemia episodes from 2007 to 2009. The primary outcome was newly developed myocardial infarction (MI), stroke, heart failure, or all-cause mortality. Participants were followed from the baseline index date to the date of death or until December 31, 2015. RESULTS In total, 19,660 (1.2%) patients developed at least one severe hypoglycemia event during the period from 2007 to 2009. Mean follow-up was 5.7 years. After adjustment for confounding factors, the hazard ratio (HR) of MI significantly and sequentially increased: 0 vs. 1 episode, HR 1.56, 95% CI 1.46-1.64; 0 vs. 2 episodes, HR 1.86, 95% CI 1.61-2.15; 0 vs. 3 or more episodes, HR 1.86, 95% CI 1.48-2.35, P for trend < 0.001. Similar findings were noted regarding the relationship of severe hypoglycemia episodes with stroke, heart failure, and all-cause mortality. Risks for all outcomes were highest within 1 year from the index date and showed decreasing trends with follow-up. Sensitivity analyses of the data from the subgroup population and 797,544 subjects who received a national health examination did not change the significance of the main findings. CONCLUSION Among adult Korean patients with type 2 diabetes, a severe hypoglycemia episode is associated with increased risk for cardiovascular outcomes and all-cause mortality. Significant results from dose-response, temporal, and sensitivity analyses may suggest the possibility of direct causality between severe hypoglycemia and cardiovascular outcomes and mortality.
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Affiliation(s)
- Jae-Seung Yun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yong-Moon Park
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, USA
| | - Kyungdo Han
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seon-Ah Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yu-Bae Ahn
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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177
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Shariff A, Sridhar SB, Bittar HR, Hamad A, Ahmed R, Kadour G. Frequency and Predisposing Factors for Drug-Induced Hypoglycemia in Patients with Type-2 Diabetes Mellitus. J Res Pharm Pract 2019; 8:64-68. [PMID: 31367640 PMCID: PMC6636422 DOI: 10.4103/jrpp.jrpp_18_58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: Hypoglycemia is the most common complication of the treatment for diabetes mellitus. Various factors predispose an individual for drug-induced hypoglycemia. The aim of this study was to explore the relative frequency and likely predisposing factors for drug-induced hypoglycemia among type-2 diabetic patients in the United Arab Emirates (UAE). Methods: In this cross-sectional survey-based study which was conducted from February to April 2018 in two local community pharmacies in the UAE, diabetic patients underwent a structured interview on their diabetes mellitus status and management and specific open-ended questions related to hypoglycemic symptoms that they might have experienced and the occurrence of symptoms. Collected data were used to estimate the relative frequency of drug-induced hypoglycemia and to identify the probable predisposing factors and their contribution in causing hypoglycemia using relative risk, Chi-square test, and Fisher's exact test. Findings: The relative frequency of drug-induced hypoglycemia in our study was 46.25%. Patients' age of ≥65 years, duration of diabetes mellitus for more than 1 year, patients with more than one comorbid condition, and patients using more than one antidiabetic medication were predisposing for developing drug-induced hypoglycemia. Conclusion: The relative frequency of drug-induced hypoglycemia in a nontrial environment which lacks the special cares routinely provided in drug development clinical trials is high. We suggest that more attention should be paid to identify, prevent, and manage drug-induced hypoglycemia in type-2 diabetic patients who have more than 1 year of diabetes, more than one comorbidity, using more than one antidiabetic medication, and elderly.
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Affiliation(s)
- Atiqulla Shariff
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
| | - Sathvik Belagodu Sridhar
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
| | - Hana Rami Bittar
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
| | - Ahed Hamad
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
| | - Reem Ahmed
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
| | - Ghaidaa Kadour
- Department of Clinical Pharmacy and Pharmacology, RAK College of Pharmaceutical Sciences, RAK Medical and Health Sciences University, Ras Al Khaimah, United Arab Emirates
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Iatrogenic hypoglycemia–related hospital admissions identified through databases: economic burden and causes. Int J Clin Pharm 2019; 41:1159-1165. [DOI: 10.1007/s11096-019-00877-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 06/27/2019] [Indexed: 11/25/2022]
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179
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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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180
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Knudsen ST, Lapolla A, Schultes B, Tentolouris N, Catarig A, Wolden ML, Siegmund T. Clinical benefits of switching to insulin degludec irrespective of previous basal insulin therapy in people with Type 1 or Type 2 diabetes: evidence from a European, multicentre, retrospective, non-interventional study (EU-TREAT). Diabet Med 2019; 36:868-877. [PMID: 31001865 PMCID: PMC6618263 DOI: 10.1111/dme.13976] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 11/26/2022]
Abstract
AIMS To investigate whether the benefits of switching to insulin degludec observed in the European retrospective chart review study EU-TREAT were dependent on the previous basal insulin used. METHODS People with Type 1 or Type 2 diabetes were switched to insulin degludec from other basal insulins ≥6 months before data collection. Participants were stratified into three groups based on their previous basal insulin: insulin glargine 100 units/ml (Type 1: n=888; Type 2: n=259); insulin detemir (Type 1: n=726; Type 2: n=415); and neutral protamine Hagedorn (Type 1: n=53; Type 2: n=95). Their glycaemic control and hypoglycaemia incidence at 6 and 12 months post-switch vs pre-switch was then evaluated. RESULTS Significant HbA1c reductions were achieved in all previous basal insulin groups for participants with Type 1 diabetes [insulin glargine 100 units/ml: -2.08 mmol/mol (-0.19%); insulin detemir: -2.40 mmol/mol (-0.22%)] and those with Type 2 diabetes [insulin glargine 100 units/ml: -5.90 mmol/mol (-0.54%); insulin detemir: -6.01 mmol/mol (-0.55%); neutral protamine Hagedorn: -2.73 mmol/mol (-0.25%)] at 6 months, except for the relatively small neutral protamine Hagedorn group in those with Type 1 diabetes [-1.75 mmol/mol (-0.16%)], where statistical significance was not reached. At 6 months in the Type 1 diabetes group, switching to insulin degludec from insulin glargine 100 units/ml resulted in significantly lower hypoglycaemia rates across all hypoglycaemia categories; for the insulin detemir group, this significance was also observed for severe and nocturnal non-severe hypoglycaemia, while the low number of people in the neutral protamine Hagedorn group resulted in nonsignificant reductions in hypoglycaemia rates. At 6 months in the people with Type 2 diabetes, switching to insulin degludec resulted in significantly lower rates of hypoglycaemia across all categories for all groups. Similar outcomes were observed at 12 months. CONCLUSIONS Switching to insulin degludec from other basal insulins can improve glycaemic control and/or reduce hypoglycaemia risk in people with diabetes (although there was a nonsignificant reduction in HbA1c and hypoglycaemia rates for the neutral protamine Hagedorn group in Type 1 diabetes) under routine care.
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Affiliation(s)
- S. T. Knudsen
- Steno Diabetes Centre AarhusAarhus University HospitalAarhusDenmark
| | - A. Lapolla
- Department of MedicinePadova UniversityPadovaItaly
| | - B. Schultes
- eSwiss Medical and Surgical CentreSt GallenSwitzerland
| | - N. Tentolouris
- First Department of Propaedeutic Internal MedicineMedical SchoolNational and Kapodistrian University of AthensAthensGreece
| | | | | | - T. Siegmund
- Department of Endocrinology, Diabetes and MetabolismISAR Klinikum München GmbHMunichGermany
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Frier BM, Ratzki‐Leewing A, Harris SB. Reporting of hypoglycaemia in clinical trials of basal insulins: A need for consensus. Diabetes Obes Metab 2019; 21:1529-1542. [PMID: 30924567 PMCID: PMC6767397 DOI: 10.1111/dom.13732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/13/2019] [Accepted: 03/26/2019] [Indexed: 12/31/2022]
Abstract
Hypoglycaemia is a common side-effect of diabetes therapies, particularly insulin, and imposes a substantial burden on individuals and healthcare systems. Consequently, regulatory approval of newer basal insulin (BI) therapies has relied on demonstration of a balance between achievement of good glycaemic control and less hypoglycaemia. Randomized controlled trials (RCTs) are the gold standard for assessing efficacy and safety, including hypoglycaemia risk, of BIs and are invaluable for obtaining regulatory approval. However, their highly selected patient populations and their conditions lead to results that may not be representative of real-life situations. Real-world evidence (RWE) studies are more representative of clinical practice, but they also have limitations. As such, data both from RCTs and RWE studies provide a fuller picture of the hypoglycaemia risk with BI therapies. However, substantial differences exist in the way hypoglycaemia is reported across these studies, which confounds comparisons of hypoglycaemia frequency among different BIs. This problem is ongoing and persists in recent trials of second-generation BI analogues. Although they provide a lower risk of hypoglycaemia when compared with earlier BIs, they do not eliminate it. This review describes differences in the way hypoglycaemia is reported across RCTs and RWE studies of second-generation BI analogues and examines potential reasons for these differences. For studies of BIs, there is a need to standardize aspects of design, analysis and methods of reporting to better enable interpretation of the efficacy and safety of such insulins among studies; such aspects include length of follow-up, glycaemic targets, hypoglycaemia definitions and time intervals for determining nocturnal events.
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Affiliation(s)
- Brian M. Frier
- British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research Institute, University of EdinburghEdinburghUK
| | - Alexandria Ratzki‐Leewing
- Department of Epidemiology and BiostatisticsSchulich School of Medicine and Dentistry, Western UniversityLondonOntario, Canada
| | - Stewart B. Harris
- Department of Family MedicineSchulich School of Medicine and Dentistry, Western UniversityLondonOntario, Canada
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182
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Martin CT, Criego AB, Carlson AL, Bergenstal RM. Advanced Technology in the Management of Diabetes: Which Comes First-Continuous Glucose Monitor or Insulin Pump? Curr Diab Rep 2019; 19:50. [PMID: 31250124 PMCID: PMC6597598 DOI: 10.1007/s11892-019-1177-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW In this article, we consider advanced technologies for the management of diabetes. RECENT FINDINGS Specifically, we pose the question of which should come first: an insulin pump (CSII) or a continuous glucose monitor (CGM)? Historical perspective on both insulin delivery and glucose measurement is provided. Recently published clinical trials are reviewed. Practical issues including quality of life, patient education, and out-of-pocket cost are discussed. Based on available evidence and clinical experience, we favor CGM as a first-line technology recommendation for the treatment of type 1 diabetes (T1D).
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Affiliation(s)
| | - Amy B. Criego
- International Diabetes Center, Park Nicollet Pediatric Endocrine, Minneapolis, MN 55416 USA
| | - Anders L. Carlson
- International Diabetes Center, HealthPartners Endocrinology, Minneapolis, MN 55416 USA
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183
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Hermanns N, Ehrmann D, Kulzer B. Continuous glucose monitoring-based technologies in hypoglycaemia-prone patients with type 1 diabetes. Lancet Diabetes Endocrinol 2019; 7:419-421. [PMID: 31047900 DOI: 10.1016/s2213-8587(19)30146-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/23/2022]
Affiliation(s)
- Norbert Hermanns
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim 97980, Germany.
| | - Dominic Ehrmann
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim 97980, Germany
| | - Bernhard Kulzer
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim 97980, Germany
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184
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Languren G, Montiel T, Ramírez-Lugo L, Balderas I, Sánchez-Chávez G, Sotres-Bayón F, Bermúdez-Rattoni F, Massieu L. Recurrent moderate hypoglycemia exacerbates oxidative damage and neuronal death leading to cognitive dysfunction after the hypoglycemic coma. J Cereb Blood Flow Metab 2019; 39:808-821. [PMID: 29047291 PMCID: PMC6501509 DOI: 10.1177/0271678x17733640] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Moderate recurrent hypoglycemia (RH) is frequent in Type 1 diabetes mellitus (TIDM) patients who are under intensive insulin therapy increasing the risk for severe hypoglycemia (SH). The consequences of RH are not well understood and its repercussions on neuronal damage and cognitive function after a subsequent episode of SH have been poorly investigated. In the current study, we have addressed this question and observed that previous RH during seven consecutive days exacerbated oxidative damage and neuronal death induced by a subsequent episode of SH accompanied by a short period of coma, in the parietal cortex, the striatum and mainly in the hippocampus. These changes correlated with a severe decrease in reduced glutathione content (GSH), and a significant spatial and contextual memory deficit. Administration of the antioxidant, N-acetyl-L-cysteine, (NAC) reduced neuronal death and prevented cognitive impairment. These results demonstrate that previous RH enhances brain vulnerability to acute hypoglycemia and suggests that this effect is mediated by the decline in the antioxidant defense and oxidative damage. The present results highlight the importance of an adequate control of moderate hypoglycemic episodes in TIDM.
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Affiliation(s)
- Gabriela Languren
- División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Ciudad de México, México
| | - Teresa Montiel
- División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Ciudad de México, México
| | - Leticia Ramírez-Lugo
- División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Ciudad de México, México
| | - Israela Balderas
- División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Ciudad de México, México
| | - Gustavo Sánchez-Chávez
- División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Ciudad de México, México
| | - Francisco Sotres-Bayón
- División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Ciudad de México, México
| | - Federico Bermúdez-Rattoni
- División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Ciudad de México, México
| | - Lourdes Massieu
- División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México (UNAM), Ciudad Universitaria, Ciudad de México, México
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185
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Insulin-Treated Diabetes and Driving: Legal Jeopardy and Consequences of Hypoglycemia. Can J Diabetes 2019; 43:221-223. [DOI: 10.1016/j.jcjd.2018.08.201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/16/2018] [Accepted: 08/30/2018] [Indexed: 11/17/2022]
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186
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Interest and challenges of pharmacoepidemiology for the study of drugs used in diabetes. Therapie 2019; 74:255-260. [DOI: 10.1016/j.therap.2018.09.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/17/2018] [Indexed: 11/21/2022]
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187
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Pettus J, Roussel R, Liz Zhou F, Bosnyak Z, Westerbacka J, Berria R, Jimenez J, Eliasson B, Hramiak I, Bailey T, Meneghini L. Rates of Hypoglycemia Predicted in Patients with Type 2 Diabetes on Insulin Glargine 300 U/ml Versus First- and Second-Generation Basal Insulin Analogs: The Real-World LIGHTNING Study. Diabetes Ther 2019; 10:617-633. [PMID: 30767173 PMCID: PMC6437256 DOI: 10.1007/s13300-019-0568-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The LIGHTNING study applied conventional and advanced analytic approaches to model, predict, and compare hypoglycemia rates of people with type 2 diabetes (T2DM) on insulin glargine 300 U/ml (Gla-300) with those on first-generation (insulin glargine 100 U/ml [Gla-100]; insulin detemir [IDet]) or second-generation (insulin degludec [IDeg]) basal-insulin (BI) analogs, utilizing a large real-world database. METHODS Data were collected between 1 January 2007 and 31 March 2017 from the Optum Humedica US electronic health records [EHR] database. Patient-treatments, the period during which a patient used a specific BI, were analyzed for patients who switched from a prior BI or those who newly initiated BI therapy. Data were analyzed using two approaches: propensity score matching (PSM) and a predictive modeling approach using machine learning. RESULTS A total of 831,456 patients with T2DM receiving BI were included from the EHR data set. Following selection, 198,198 patient-treatments were available for predictive modeling. The analysis showed that rates of severe hypoglycemia (using a modified definition) were approximately 50% lower with Gla-300 than with Gla-100 or IDet in insulin-naïve individuals, and 30% lower versus IDet in BI switchers (all p < 0.05). Similar rates of severe hypoglycemia were predicted for Gla-300 and IDeg, regardless of prior insulin experience. Similar results to those observed in the overall cohorts were seen in analyses across subgroups at a particularly high risk of hypoglycemia. PSM (performed on 157,573 patient-treatments) revealed comparable reductions in HbA1c with Gla-300 versus first- and second-generation BI analogs, alongside lower rates of severe hypoglycemia with Gla-300 versus first-generation BI analogs (p < 0.05) and similar rates versus IDeg in insulin-naïve and BI-switcher cohorts. CONCLUSIONS Based on real-world data, predicted rates of severe hypoglycemia with Gla-300 tended to be lower versus first-generation BI analogs and similar versus IDeg in a wide spectrum of patients with T2DM. FUNDING Sanofi, Paris, France.
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Affiliation(s)
- Jeremy Pettus
- School of Medicine, University of California, San Diego, CA, USA
| | - Ronan Roussel
- Inserm U1138, Centre de Recherche Des Cordeliers, Paris, France
- University Paris Diderot, Sorbonne Paris Cite, Paris, France
- Diabetology, Endocrinology and Nutrition Department, DHU FIRE, Hopital Bichat, AP-HP, Paris, France
| | | | | | | | | | | | - Björn Eliasson
- Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Irene Hramiak
- Lawson Research Institute, University of Western Ontario, London, ON, Canada
| | | | - Luigi Meneghini
- Division of Endocrinology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- Global Diabetes Program, Parkland Health & Hospital System, Dallas, TX, USA.
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188
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Halama A, Kahal H, Bhagwat AM, Zierer J, Sathyapalan T, Graumann J, Suhre K, Atkin SL. Metabolic and proteomic signatures of hypoglycaemia in type 2 diabetes. Diabetes Obes Metab 2019; 21:909-919. [PMID: 30525282 DOI: 10.1111/dom.13602] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/20/2018] [Accepted: 12/01/2018] [Indexed: 12/31/2022]
Abstract
AIMS To determine the biochemical changes that underlie hypoglycaemia in a healthy control group and in people with type 2 diabetes (T2D). MATERIALS AND METHODS We report a hypoglycaemic clamp study in seven healthy controls and 10 people with T2D. Blood was withdrawn at four time points: at baseline after an overnight fast; after clamping to euglycaemia at 5 mmol/L; after clamping to hypoglycaemia at 2.8 mmol/L; and 24 hours later, after overnight fast. Deep molecular phenotyping using non-targeted metabolomics and the SomaLogic aptamer-based proteomics platform was performed on collected samples. RESULTS A total of 955 metabolites and 1125 proteins were identified, with significant alterations in >90 molecules. A number of metabolites significantly increased during hypoglycaemia, but only cortisol, adenosine-3',5'-cyclic monophosphate (cyclic AMP), and pregnenolone sulphate, were independent of insulin. By contrast, identified protein changes were triggered by hypoglycaemia rather than insulin. The T2D group had significantly higher levels of fatty acids including 10-nonadecenoate, linolenate and dihomo-linoleate during hypoglycaemia compared with the control group. Molecules contributing to cardiovascular complications such as fatty-acid-binding protein-3 and pregnenolone sulphate were altered in the participants with T2D during hypoglycaemia. Almost all molecules returned to baseline at 24 hours. CONCLUSIONS The present study provides a comprehensive description of molecular events that are triggered by insulin-induced hypoglycaemia. We identified deregulated pathways in T2D that may play a role in the pathophysiology of hypoglycaemia-induced cardiovascular complications.
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Affiliation(s)
- Anna Halama
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
| | - Hassan Kahal
- Academic Endocrinology, Diabetes and Metabolism, Hull York Medical School, Hull, UK
| | - Aditya M Bhagwat
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
| | - Jonas Zierer
- Caryl and Israel Englander Institute for Precision Medicine, Institute for Computational Biomedicine, Sandra and Edward Meyer Cancer Center, Weill Cornell Medicine, New York, New York
| | | | - Johannes Graumann
- Proteomics Core, Weill Cornell Medicine-Qatar, Education City, Doha, Qatar
- Scientific Service Group Biomolecular Mass Spectrometry, Max Planck Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Karsten Suhre
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
| | - Stephen L Atkin
- Department of Physiology and Biophysics, Weill Cornell Medicine Qatar, Education City, Doha, Qatar
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DeVries JH, Bailey TS, Bhargava A, Gerety G, Gumprecht J, Heller S, Lane W, Wysham CH, Zinman B, Bak BA, Hachmann‐Nielsen E, Philis‐Tsimikas A. Day-to-day fasting self-monitored blood glucose variability is associated with risk of hypoglycaemia in insulin-treated patients with type 1 and type 2 diabetes: A post hoc analysis of the SWITCH Trials. Diabetes Obes Metab 2019; 21:622-630. [PMID: 30362250 PMCID: PMC6587774 DOI: 10.1111/dom.13565] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/15/2018] [Accepted: 10/21/2018] [Indexed: 12/17/2022]
Abstract
AIMS To investigate the association between day-to-day fasting self-monitored blood glucose (SMBG) variability and risk of hypoglycaemia in type 1 (T1D) and type 2 diabetes (T2D), and to compare day-to-day fasting SMBG variability between treatments with insulin degludec (degludec) and insulin glargine 100 units/mL (glargine U100). MATERIALS AND METHODS Data were retrieved from two double-blind, randomized, treat-to-target, two-period (32 weeks each) crossover trials of degludec vs glargine U100 in T1D (SWITCH 1, n = 501) and T2D (SWITCH 2, n = 720). Available fasting SMBGs were used to determine the standard deviation (SD) of day-to-day fasting SMBG variability for each patient and the treatment combination. The association between day-to-day fasting SMBG variability and overall symptomatic, nocturnal symptomatic and severe hypoglycaemia was analysed for the pooled population using linear regression, with fasting SMBG variability included as a three-level factor defined by population tertiles. Finally, day-to-day fasting SMBG variability was compared between treatments. RESULTS Linear regression showed that day-to-day fasting SMBG variability was significantly associated with overall symptomatic, nocturnal symptomatic and severe hypoglycaemia risk in T1D and T2D (P < 0.05). Day-to-day fasting SMBG variability was significantly associated (P < 0.01) with all categories of hypoglycaemia risk, with the exception of severe hypoglycaemia in T2D when analysed within tertiles. Degludec was associated with 4% lower day-to-day fasting SMBG variability than glargine U100 in T1D (P = 0.0082) and with 10% lower day-to-day fasting SMBG variability in T2D (P < 0.0001). CONCLUSIONS Higher day-to-day fasting SMBG variability is associated with an increased risk of overall symptomatic, nocturnal symptomatic and severe hypoglycaemia. Degludec has significantly lower day-to-day fasting SMBG variability vs glargine U100.
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Affiliation(s)
- J. Hans DeVries
- University of AmsterdamAmsterdamThe Netherlands
- Profil Institute for Metabolic ResearchNeussGermany
| | | | - Anuj Bhargava
- Iowa Diabetes and Endocrinology Research CenterDes MoinesIowa
| | | | | | | | - Wendy Lane
- Mountain Diabetes and Endocrine CenterAshevilleNorth Carolina
| | | | - Bernard Zinman
- Lunenfeld‐Tanenbaum Research Institute, Mount Sinai HospitalUniversity of TorontoTorontoOntarioCanada
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190
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Marathe CS, Marathe JA, Rayner CK, Kar P, Jones KL, Horowitz M. Hypoglycaemia and gastric emptying. Diabetes Obes Metab 2019; 21:491-498. [PMID: 30378748 DOI: 10.1111/dom.13570] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/15/2018] [Accepted: 10/26/2018] [Indexed: 02/06/2023]
Abstract
Hypoglycaemia is arguably the most important complication of insulin therapy in type 1 and type 2 diabetes. Counter-regulation of hypoglycaemia is dependent on autonomic function and frequent hypoglycaemia may lead to reductions in both autonomic warning signals and the catecholamine response, the so-called "impaired awareness of hypoglycaemia". It is now appreciated that gastric emptying is a major determinant of the glycaemic response to carbohydrate-containing meals in both health and diabetes, that disordered (especially delayed) gastric emptying occurs frequently in diabetes, and that acute hypoglycaemia accelerates gastric emptying substantially. However, the potential relevance of gastric emptying to the predisposition to, and counter-regulation of, hypoglycaemia has received little attention. In insulin-treated patients, the rate of gastric emptying influences the timing of the postprandial insulin requirement, and gastroparesis is likely to predispose to postprandial hypoglycaemia. Conversely, the marked acceleration of gastric emptying induced by hypoglycaemia probably represents an important counter-regulatory response to increase the rate of carbohydrate absorption. This review summarizes the current knowledge of the inter-relationships between hypoglycaemia and gastric emptying, with a focus on clinical implications.
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Affiliation(s)
- Chinmay S Marathe
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- NHMRC Centre of Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, University of Adelaide, Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jessica A Marathe
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Christopher K Rayner
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- NHMRC Centre of Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Palash Kar
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karen L Jones
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- NHMRC Centre of Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, University of Adelaide, Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael Horowitz
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- NHMRC Centre of Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, University of Adelaide, Adelaide, South Australia, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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191
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Abstract
PURPOSE OF REVIEW Older adults often live with chronic disease including diabetes and its complications. In this review, we examine the complexity and heterogeneity of older adults with diabetes and chronic kidney disease, explore the nuances in their diabetes-related monitoring, and discuss their best diabetes management. RECENT FINDINGS Although there remains an overall lack of studies in older adults with diabetes and chronic kidney disease, recent reports have highlighted their vulnerabilities. These individuals face an increased risk of cognitive impairment and dementia, frailty, dysglycemia, polypharmacy, declining kidney function, and acute kidney injury. Their diabetes management should focus upon safer antihyperglycemic medications, close monitoring, and care individualization. Older adults with diabetes and chronic kidney disease are a complex population who requires careful diabetes management and monitoring. Research efforts might focus on improving the care and outcomes of these patients.
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Affiliation(s)
- Kristin K Clemens
- Department of Medicine, Division of Endocrinology, Western University, London, Ontario, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.
- St. Joseph's Health Care London, London, Ontario, Canada.
- Institute for Clinical Evaluative Sciences, Ontario, Canada.
- Lawson Health Research Institute, London, Ontario, Canada.
| | - Niamh O'Regan
- St. Joseph's Health Care London, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
- Department of Medicine, Division of Geriatric Medicine, Western University, London, Ontario, Canada
| | - Jinnie J Rhee
- Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, CA, USA
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192
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Hu C, Jia W. Therapeutic medications against diabetes: What we have and what we expect. Adv Drug Deliv Rev 2019; 139:3-15. [PMID: 30529309 DOI: 10.1016/j.addr.2018.11.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/01/2018] [Accepted: 11/27/2018] [Indexed: 02/06/2023]
Abstract
Diabetes has become one of the largest global health and economic burdens, with its increased prevalence and high complication ratio. Stable and satisfactory blood glucose control are vital to reduce diabetes-related complications. Therefore, continuous attempts have been made in antidiabetic drugs, treatment routes, and traditional Chinese medicine to achieve better disease control. New antidiabetic drugs and appropriate combinations of these drugs have increased diabetes control significantly. Besides, novel treatment routes including oral antidiabetic peptide delivery, nanocarrier delivery system, implantable drug delivery system are also pivotal for diabetes control, with its greater efficiency, increased bioavailability, decreased toxicity and reduced dosing frequency. Among these new routes, nanotechnology, artificial pancreas and islet cell implantation have shown great potential in diabetes therapy. Traditional Chinese medicine also offer new options for diabetes treatment. Our paper aim to overview these therapeutic methods for diabetes therapy. Proper combinations of these existing anti-diabetic medications and searching for novel routes are both necessary for better diabetes control.
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Affiliation(s)
- Cheng Hu
- Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, People's Republic of China; Shanghai Jiao Tong University Affiliated Sixth People's Hospital South Campus, 6600 Nanfeng Road, Shanghai 200433, People's Republic of China
| | - Weiping Jia
- Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Key Clinical Center for Metabolic Diseases, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai 200233, People's Republic of China.
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193
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Mohr GH, Søndergaard KB, Pallisgaard JL, Møller SG, Wissenberg M, Karlsson L, Hansen SM, Kragholm K, Køber L, Lippert F, Folke F, Vilsbøll T, Torp-Pedersen C, Gislason G, Rajan S. Survival of patients with and without diabetes following out-of-hospital cardiac arrest: A nationwide Danish study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:599-607. [PMID: 30632777 DOI: 10.1177/2048872618823349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Research regarding out-of-hospital cardiac arrest (OHCA) survival of diabetes patients is sparse and it remains unknown whether initiatives to increase OHCA survival benefit diabetes and non-diabetes patients equally. We therefore examined overall and temporal survival in diabetes and non-diabetes patients following OHCA. METHODS Adult presumed cardiac-caused OHCAs were identified from the Danish Cardiac Arrest Registry (2001-2014). Associations between diabetes and return of spontaneous circulation upon hospital arrival and 30-day survival were estimated with logistic regression adjusted for patient- and OHCA-related characteristics. RESULTS In total, 28,955 OHCAs were included of which 4276 (14.8%) had diabetes. Compared with non-diabetes patients, diabetes patients had more comorbidities, same prevalence of bystander-witnessed arrests (51.7% vs. 52.7%) and bystander cardiopulmonary resuscitation (43.2% vs. 42.0%), more arrests in residential locations (77.3% vs. 73.0%) and were less likely to have shockable heart rhythm (23.5% vs. 27.9%). Temporal increases in return of spontaneous circulation and 30-day survival were seen for both groups (return of spontaneous circulation: 8.8% in 2001 to 22.3% in 2014 (diabetes patients) vs. 7.8% in 2001 to 25.7% in 2014 (non-diabetes patients); and 30-day survival: 2.8% in 2001 to 9.7% in 2014 vs. 3.5% to 14.8% in 2014, respectively). In adjusted models, diabetes was associated with decreased odds of return of spontaneous circulation (odds ratio 0.74 (95% confidence interval 0.66-0.82)) and 30-day survival (odds ratio 0.56 (95% confidence interval 0.48-0.65)) (interaction with calendar year p=0.434 and p=0.243, respectively). CONCLUSION No significant difference in temporal survival was found between the two groups. However, diabetes was associated with lower odds of return of spontaneous circulation and 30-day survival.
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Affiliation(s)
- Grímur Høgnason Mohr
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Kathrine B Søndergaard
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Jannik L Pallisgaard
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Sidsel Gamborg Møller
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
| | - Mads Wissenberg
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark.,Emergency Medical Services Copenhagen, University of Copenhagen, Denmark
| | - Lena Karlsson
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark.,Emergency Medical Services Copenhagen, University of Copenhagen, Denmark
| | - Steen Møller Hansen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Denmark
| | - Kristian Kragholm
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Denmark.,Department of Cardiology, Hjørring Regional Hospital, Denmark.,Department of Cardiology, Aalborg University Hospital, Denmark
| | - Lars Køber
- The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark
| | - Freddy Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Denmark
| | - Fredrik Folke
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark.,Emergency Medical Services Copenhagen, University of Copenhagen, Denmark
| | - Tina Vilsbøll
- Clinical Metabolic Physiology, Steno Diabetes Centre Copenhagen, University of Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Denmark.,Department of Cardiology, Aalborg University Hospital, Denmark.,Department of Health Science and Technology, Aalborg University, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.,National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark
| | - Shahzleen Rajan
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Gentofte, Denmark
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194
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Gagliardino JJ, Chantelot JM, Domenger C, Ramachandran A, Kaddaha G, Mbanya JC, Shestakova M, Chan J. Impact of diabetes education and self-management on the quality of care for people with type 1 diabetes mellitus in the Middle East (the International Diabetes Mellitus Practices Study, IDMPS). Diabetes Res Clin Pract 2019; 147:29-36. [PMID: 30218744 DOI: 10.1016/j.diabres.2018.09.008] [Citation(s) in RCA: 20] [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] [Received: 05/09/2018] [Accepted: 09/10/2018] [Indexed: 11/27/2022]
Abstract
AIMS Self-management (self-monitoring of blood glucose, plus self-adjustment of insulin dose) is important in diabetes care, but its complexity presents a barrier to wider implementation, which hinders attainment and maintenance of glycemic targets. More evidence on self-management is needed to increase its implementation and improve metabolic outcomes. METHODS Data from 1316 participants with type 1 diabetes mellitus who were enrolled from Middle East countries into the International Diabetes Management Practices Study (IDMPS), a multinational observational survey, were analyzed to assess the impact of education on disease management and outcomes. RESULTS A majority (78%) of participants failed to achieve glycemic target (HbA1c < 7.0% [<53 mmol/mol]). Participants who had received diabetes education (59%) were more likely to practice self-management than those who had not (odds ratio [OR]: 2.51; 95% confidence interval [CI]: 1.7-3.69; p < 0.001), and those who practiced self-management were more likely to attain target HbA1c than those who did not (OR: 1.49; 95% CI: 1.06-2.09; p = 0.023). CONCLUSIONS These relationships between diabetes education, self-management and glycemic control suggest that diabetes education provides knowledge and skills to optimize self-management, favoring HbA1c target attainment. Middle East health authorities should search for ways to facilitate access to diabetes education to optimize treatment outcomes.
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Affiliation(s)
- Juan José Gagliardino
- CENEXA Center of Experimental and Applied Endocrinology (La Plata National University - La Plata National Scientific and Technical Research Council), La Plata, Argentina.
| | | | | | - Ambady Ramachandran
- India Diabetes Research Foundation, Dr. A. Ramachandran's Diabetes Hospitals, Chennai, India.
| | - Ghaida Kaddaha
- Diabetology Unit, Government of Dubai, Dubai Health Authority, Dubai, United Arab Emirates
| | - Jean Claude Mbanya
- Biotechnology Center, Doctoral School of Life Sciences, Health and Environment, and Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Marina Shestakova
- Endocrinology Research Center, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
| | - Juliana Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, The Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region.
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195
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Pujante Alarcón P, Rodríguez Escobedo R, García Urruzola F, Ares J, Manjón L, Sanchez Ragnarson C, Cacho L, Delgado E, Menéndez Torre EL. Experience after switching from insulin glargine U100 to glargine U300 in patients with type 1 diabetes mellitus. A study after one year of treatment in real life. ACTA ACUST UNITED AC 2018; 66:210-216. [PMID: 30559088 DOI: 10.1016/j.endinu.2018.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/06/2018] [Accepted: 09/08/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Current treatment of type 1 diabetes mellitus (T1DM) does not always achieve metabolic control because, among other things, the ocurrence of hypoglycemic events associated to insulin use. MATERIAL AND METHODS A descriptive real life study of 247 T1DM patients, 55.5% male, aged 46.53 ± 16.23 years, and with a mean diabetes duration of 21.89 ± 11.99 years, who were switched from basal insulin glargine U100 to glargine U300. The primary endpoints were changes in Hba1c and number of hypoglycemic events, while secondary endpoints included changes in weight and insulin dose after 6 and 12 months. RESULTS After one year, no changes were seen in HbA1c, but the proportion of patients with HbA1c values <7.5% increased at 6 months (33.5 vs. 40.5%; P<0.05) and remained stable during one year of follow-up. Hypoglycemic events significantly decreased after one year of treatment in patients with previous hypoglycemic events. No changes were seen in body weight. Total insulin dose (U/kg) increased 7.24% at 6 months of treatment and by 8.69% at one year, mainly due to basal insulin. No changes were seen between the doses given at 6 and 12 months. These changes were similar in the different metabolic control groups and in patients with or without hypoglycemia. This increase was not related with prior basal insulin dose, baseline HbA1c level, number of hypoglycemic events or baseline weight. DISCUSSION Glargine U300 is a good basal insulin alternative to treat T1DM, improving metabolic control in patients with HbA1c levels >7,5 and decreasing hypoglycemic events in patients with history of hypoglycemia without increasing body weight.
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Affiliation(s)
- Pedro Pujante Alarcón
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España.
| | - Raúl Rodríguez Escobedo
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - Fernando García Urruzola
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - Jessica Ares
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - Laura Manjón
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - Cecilia Sanchez Ragnarson
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - Laura Cacho
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - Elías Delgado
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - Edelmiro L Menéndez Torre
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
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196
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Heald AH, Livingston M, Fryer A, Cortes G, Anderson SG, Gadsby R, Laing I, Lunt M, Young RJ, Stedman M. Real-world practice level data analysis confirms link between variability within Blood Glucose Monitoring Strip (BGMS) and glycosylated haemoglobin (HbA1c) in Type 1 Diabetes. Int J Clin Pract 2018; 72:e13252. [PMID: 30168887 PMCID: PMC6766879 DOI: 10.1111/ijcp.13252] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/13/2018] [Accepted: 07/31/2018] [Indexed: 01/06/2023] Open
Abstract
AIMS/HYPOTHESIS Our aim was to quantify the impact of Blood Glucose Monitoring Strips variability (BGMSV) at GP practice level on the variability of reported glycated haemoglobin (HbA1cV) levels. METHODS Overall GP Practice BGMSV and HbA1cV were calculated from the quantity of main types of BGMS being prescribed combined with the published accuracy, as % results within ±% bands from reference value for the selected strip type. The regression coefficient between the BGMSV and HbA1cV was calculated. To allow for the aggregation of estimated three tests/day over 13 weeks (ie, 300 samples) of actual Blood Glucose (BG) values up to the HbA1c, we multiplied HbA1cV coefficient by √300 to estimate an empirical value for impact of BGMSV on BGV. RESULTS Four thousand five hundred and twenty-four practice years with 159 700 T1DM patient years where accuracy data were available for more than 80% of strips prescribed were included, with overall BGMSV 6.5% and HbA1c mean of 66.9 mmol/mol (8.3%) with variability of 13 mmol/mol equal to 19% of the mean. At a GP practice level, BGMSV and HbA1cV as % of mean HbA1c (in other words, the spread of HbA1c) were closely related with a regression coefficient of 0.176, P < 0.001. Thus, greater variability in the BGMS at a GP practice level resulted in a greater spread of HbA1C readings in T1DM patients. Applying this factor for BGMS to the national ISO accepted standard where 95% results must be ≤±15% from reference, revealed that for BG, 95% results would be ≤±45% from the reference value. Thus, the variation in BG is three times that of the BGMS. For a patient with BG target @10 mmol/L using the worst performing ISO standard strips, on 1/20 occasions (average 1/week) actual blood glucose value could be >±4.5 mmol/L from target, compared with the best performing BGMS with BG >±2.2 mmol/L from reference on 1/20 occasions. CONCLUSION Use of more variable/less accurate BGMS is associated both theoretically and in practice with a larger variability in measured BG and HbA1c, with implications for patient confidence in their day-to-day monitoring experience.
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Affiliation(s)
- Adrian H. Heald
- The School of Medicine and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
- Department of Diabetes and EndocrinologySalford Royal HospitalSalfordUK
| | | | - Anthony Fryer
- Institute for Applied Clinical SciencesKeele UniversityKeeleUK
| | - Gabriela Cortes
- Head of Medical DepartmentHigh Speciality Regional Hospital of IxtapalucaMexico CityMexico
| | - Simon G. Anderson
- Institute of Cardiovascular SciencesUniversity of ManchesterManchesterUK
| | - Roger Gadsby
- Warwick Medical SchoolUniversity of WarwickWiltshireUK
| | - Ian Laing
- Department of Diabetes and EndocrinologySalford Royal HospitalSalfordUK
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
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197
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Dementia and Atrial Fibrillation: Pathophysiological Mechanisms and Therapeutic Implications. Am J Med 2018; 131:1408-1417. [PMID: 30076825 DOI: 10.1016/j.amjmed.2018.06.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 11/23/2022]
Abstract
Atrial fibrillation increases the risk of stroke by a factor of four- to fivefold, and dementia is a common consequence of stroke. However, atrial fibrillation has been associated with cognitive impairment and dementia, even in patients without prior overt stroke. Nonischemic mechanisms include cerebral hypoperfusion, vascular inflammation, brain atrophy, genetic factors, and shared risk factors such as age or hypertension. Critical appraisal of studies evaluating the association between atrial fibrillation and dementia in stroke-free patients reveals that several suffer from methodological issues, such as not including silent stroke or anticoagulation therapy in multivariate analyses. Some studies show a close relationship between atrial fibrillation and dementia due to silent stroke, in the absence of overt stroke. Evidence is accumulating that anticoagulation may be effective to decrease the risk of dementia in atrial fibrillation patients. Overall, the pathogenesis linking atrial fibrillation to dementia is likely multifactorial. Cerebral infarctions, including silent stroke, play a central role. These findings underscore the importance of stroke prevention measures in atrial fibrillation patients.
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198
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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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Tooke BP, Yu H, Adams JM, Jones GL, Sutton-Kennedy T, Mundada L, Qi NR, Low MJ, Chhabra KH. Hypothalamic POMC or MC4R deficiency impairs counterregulatory responses to hypoglycemia in mice. Mol Metab 2018; 20:194-204. [PMID: 30503832 PMCID: PMC6358536 DOI: 10.1016/j.molmet.2018.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 11/15/2022] Open
Abstract
Objective Life-threatening hypoglycemia is a major limiting factor in the management of diabetes. While it is known that counterregulatory responses to hypoglycemia are impaired in diabetes, molecular mechanisms underlying the reduced responses remain unclear. Given the established roles of the hypothalamic proopiomelanocortin (POMC)/melanocortin 4 receptor (MC4R) circuit in regulating sympathetic nervous system (SNS) activity and the SNS in stimulating counterregulatory responses to hypoglycemia, we hypothesized that hypothalamic POMC as well as MC4R, a receptor for POMC derived melanocyte stimulating hormones, is required for normal hypoglycemia counterregulation. Methods To test the hypothesis, we induced hypoglycemia or glucopenia in separate cohorts of mice deficient in either POMC or MC4R in the arcuate nucleus (ARC) or the paraventricular nucleus of the hypothalamus (PVH), respectively, and measured their circulating counterregulatory hormones. In addition, we performed a hyperinsulinemic-hypoglycemic clamp study to further validate the function of MC4R in hypoglycemia counterregulation. We also measured Pomc and Mc4r mRNA levels in the ARC and PVH, respectively, in the streptozotocin-induced type 1 diabetes mouse model and non-obese diabetic (NOD) mice to delineate molecular mechanisms by which diabetes deteriorates the defense systems against hypoglycemia. Finally, we treated diabetic mice with the MC4R agonist MTII, administered stereotaxically into the PVH, to determine its potential for restoring the counterregulatory response to hypoglycemia in diabetes. Results Stimulation of epinephrine and glucagon release in response to hypoglycemia or glucopenia was diminished in both POMC- and MC4R-deficient mice, relative to their littermate controls. Similarly, the counterregulatory response was impaired in association with decreased hypothalamic Pomc and Mc4r expression in the diabetic mice, a phenotype that was not reversed by insulin treatment which normalized glycemia. In contrast, infusion of an MC4R agonist in the PVH restored the counterregulatory response in diabetic mice. Conclusion In conclusion, hypothalamic Pomc as well as Mc4r, both of which are reduced in type 1 diabetic mice, are required for normal counterregulatory responses to hypoglycemia. Therefore, enhancing MC4R function may improve hypoglycemia counterregulation in diabetes. Hypothalamic POMC as well as MC4R is necessary to counteract hypoglycemia. Type 1 diabetic mice exhibit a reduced Pomc and Mc4r expression in the hypothalamus. Insulin treatment does not restore Pomc and Mc4r expression in diabetic mice. MC4R agonist improves hypoglycemia counterregulation in diabetic mice.
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Affiliation(s)
- Benjamin P Tooke
- Case Western Reserve University, Cleveland, OH, USA; Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hui Yu
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jessica M Adams
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Graham L Jones
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA; Neuroscience Graduate Program, University of Michigan, Ann Arbor, MI, USA
| | - Talisha Sutton-Kennedy
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lakshmi Mundada
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nathan R Qi
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Malcolm J Low
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Kavaljit H Chhabra
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Reddy M, Jugnee N, Anantharaja S, Oliver N. Switching from Flash Glucose Monitoring to Continuous Glucose Monitoring on Hypoglycemia in Adults with Type 1 Diabetes at High Hypoglycemia Risk: The Extension Phase of the I HART CGM Study. Diabetes Technol Ther 2018; 20:751-757. [PMID: 30265562 PMCID: PMC6208158 DOI: 10.1089/dia.2018.0252] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The I HART CGM study showed that real-time continuous glucose monitoring (RT-CGM) has greater beneficial impact on hypoglycemia than intermittent flash glucose monitoring (flash) in adults with type 1 diabetes (T1D) at high risk. The impact of continuing RT-CGM or switching from flash to RT-CGM for another 8 weeks was then evaluated. METHODS Prospective randomized parallel group study with an extension phase. After a 2-week run-in with blinded CGM, participants were randomized to either RT-CGM or flash for 8 weeks. All participants were then given the option to continue with RT-CGM for another 8 weeks. Glycemic outcomes at 8 weeks are compared with the 16-week endpoint. RESULTS Forty adults with T1D on intensified multiple daily insulin injections and with impaired awareness of hypoglycemia or a recent episode of severe hypoglycemia were included (40% female, median [IQR] age 49.5 [37.5-63.5] years, diabetes duration 30.0 [21.0-36.5] years, HbA1c 56 [48-63] mmol/mol, and Gold Score 5 [4-5]), of whom 36 completed the final 16-week extension. There was a significant reduction in percentage time in hypoglycemia (<3.0 mmol/L) in the group switching from flash to RT-CGM (from 5.0 [3.7-8.6]% to 0.8 [0.4-1.9]%, P = 0.0001), whereas no change was observed in the RT-CGM group continuing with the additional 8 weeks of RT-CGM (1.3 [0.4-2.8] vs. 1.3 [0.8-2.5], P = 0.82). Time in target (3.9-10 mmol/L) increased in the flash group after switching to RT-CGM (60.0 [54.5-67.8] vs. 67.4 [56.3-72.4], P = 0.02) and remained the same in the RT-CGM group that continued with RT-CGM (65.9 [54.1-74.8] vs. 64.9 [49.2-73.9], P = 0.64). CONCLUSIONS Our data suggest that switching from flash to RT-CGM has a significant beneficial impact on hypoglycemia outcomes and that continued use of RT-CGM maintains hypoglycemia risk benefit in this high-risk population.
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Affiliation(s)
- Monika Reddy
- Division of Diabetes, Endocrinology and Metabolism, Imperial College, London, United Kingdom
- Address correspondence to: Monika Reddy, MBChB, MRCP, Division of Diabetes, Endocrinology and Metabolism, Imperial College, Ground Floor, Medical School Building, St. Mary's Campus, Norfolk Place, London W2 1PG, United Kingdom
| | - Narvada Jugnee
- Division of Diabetes, Endocrinology and Metabolism, Imperial College, London, United Kingdom
| | - Sinthuka Anantharaja
- Division of Diabetes, Endocrinology and Metabolism, Imperial College, London, United Kingdom
| | - Nick Oliver
- Division of Diabetes, Endocrinology and Metabolism, Imperial College, London, United Kingdom
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