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Bortolotti S, Zarantonello L, Uliana A, Vitturi N, Schiff S, Bisiacchi P, Avogaro A, Amodio P, Maran A. Impaired cognitive processing speed in type 1 diabetic patients who had severe/recurrent hypoglycaemia. J Diabetes Complications 2018; 32:1040-1045. [PMID: 30121207 DOI: 10.1016/j.jdiacomp.2018.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/16/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
Abstract
AIMS To detect whether adults with type 1 diabetes mellitus (T1DM) have lower cognitive performance than healthy individuals and to detect risk factors for low cognitive performance. METHODS Twenty-six adults with T1DM and twenty-six healthy subjects matched for age, gender and educational level were compared for cognitive performance by a chronometric computerized test measuring visuo-spatial working memory (N-Back) and by two validated neuropsychological tests (Mini Mental State Examination, Animal Naming Test). Clinical data about diabetes duration, average daily insulin dosage, glycated haemoglobin, retinopathy, urine albumin-creatinine ratio, previous hypoglycaemic coma and awareness of hypoglycaemia were obtained from medical records. Basal pre-test glycemia and blood pressure were measured for each patient. RESULTS No differences were found between patients (n = 26) and healthy controls (n = 26) in neuropsychological tests. Within diabetic patients, those with impaired awareness of hypoglycaemia (n = 7) or history of coma in the recent 1-3 years (n = 5) had psychomotor slowing at the N-Back test (592 ± 35 vs. 452 ± 21 ms and 619 ± 40 vs. 462 ± 19 ms, respectively; both p < 0.01). The variables related to diabetic severity did not show a relationship with reaction times of the N-Back test. CONCLUSION Psychomotor speed slowing is detectable in patients with T1DM who have a history of previous hypoglycaemic episodes or coma.
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Affiliation(s)
- Stefano Bortolotti
- Unit of Internal Medicine 5, Department of Medicine, University of Padova, Padova 35128, Italy
| | - Lisa Zarantonello
- Unit of Internal Medicine 5, Department of Medicine, University of Padova, Padova 35128, Italy
| | - Ambra Uliana
- Unit of Metabolic Disease, Department of Medicine, University of Padova, Padova 35128, Italy
| | - Nicola Vitturi
- Unit of Metabolic Disease, Department of Medicine, University of Padova, Padova 35128, Italy
| | - Sami Schiff
- Unit of Internal Medicine 5, Department of Medicine, University of Padova, Padova 35128, Italy
| | - Patrizia Bisiacchi
- Department General Psychology and CIRMANMEC, University of Padova, Padova 35128, Italy
| | - Angelo Avogaro
- Unit of Metabolic Disease, Department of Medicine, University of Padova, Padova 35128, Italy
| | - Piero Amodio
- Unit of Internal Medicine 5, Department of Medicine, University of Padova, Padova 35128, Italy.
| | - Alberto Maran
- Unit of Metabolic Disease, Department of Medicine, University of Padova, Padova 35128, Italy
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202
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Krug AW, Visser SA, Tsai K, Kandala B, Fancourt C, Thornton B, Morrow L, Kaarsholm NC, Bernstein HS, Stoch SA, Crutchlow M, Kelley DE, Iwamoto M. Clinical Evaluation of
MK
‐2640: An Insulin Analog With Glucose‐Responsive Properties. Clin Pharmacol Ther 2018; 105:417-425. [DOI: 10.1002/cpt.1215] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/05/2018] [Indexed: 12/27/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | - Harold S. Bernstein
- Merck & Co., Inc. Kenilworth New Jersey USA
- Vertex Pharmaceuticals Boston MA USA
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203
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Doggrell SA. Do glucagon-like peptide-1 receptor (GLP-1R) agonists have potential as adjuncts in the treatment of type 1 diabetes? Expert Opin Pharmacother 2018; 19:1655-1661. [PMID: 30234389 DOI: 10.1080/14656566.2018.1519547] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Glucagon-like peptide-1 (GLP-1) is produced by the gut, stimulates insulin secretion from the pancreatic β-cells, and inhibits glucagon secretion from the α-cells. The GLP-1 receptor (GLP-1R) agonists are used in the treatment of type 2 diabetes (T2DM). AREAS COVERED This review covers the clinical trials of the GLP-1R agonists (exenatide and liraglutide) and their potential as adjunct treatment in type 1 diabetes mellitus (T1DM). EXPERT OPINION GLP-1R agonists are unable to increase insulin secretion, in subjects with T1DM, who are C-peptide negative. Also, the GLP-1R agonists either have no effect or cause a small inhibition of glucagon secretion in subjects with T1DM. There is no evidence that the GLP-1R agonists cause a major reduction in HbA1c, or have a major effect on hypo- or hyperglycemia in subjects with TD1M. The main beneficial effect of the GLP-1R agonists is probably the modest weight loss, which may underlie the reduction in dose of insulin used. Given that the GLP-1R agonists cause gastrointestinal adverse effects, and with reduced insulin doses, increase the risk of ketosis, it seems to me that the risk with these agents may outweigh any benefit in T1DM, and that they have little potential as adjuncts in the treatment of T1DM.
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Affiliation(s)
- Sheila A Doggrell
- a Faculty of Health , Queensland University of Technology , Brisbane , Australia
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204
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Riyaphan J, Jhong CH, Lin SR, Chang CH, Tsai MJ, Lee DN, Sung PJ, Leong MK, Weng CF. Hypoglycemic Efficacy of Docking Selected Natural Compounds against α-Glucosidase and α-Amylase. Molecules 2018; 23:E2260. [PMID: 30189596 PMCID: PMC6225388 DOI: 10.3390/molecules23092260] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 08/31/2018] [Accepted: 09/03/2018] [Indexed: 11/16/2022] Open
Abstract
The inhibition of α-glucosidase and α-amylase is a clinical strategy for the treatment of type II diabetes, and herbal medicines have been reported to credibly alleviate hyperglycemia. Our previous study has reported some constituents from plant or herbal sources targeted to α-glucosidase and α-amylase via molecular docking and enzymatic measurement, but the hypoglycemic potencies in cell system and mice have not been validated yet. This study was aimed to elucidate the hypoglycemic efficacy of docking selected compounds in cell assay and oral glucose and starch tolerance tests of mice. All test compounds showed the inhibition of α-glucosidase activity in Caco-2 cells. The decrease of blood sugar levels of test compounds in 30 min and 60 min of mice after OGTT and OSTT, respectively and the decreased glucose levels of test compounds were significantly varied in acarbose. Taken altogether, in vitro and in vivo experiments suggest that selected natural compounds (curcumin, antroquinonol, HCD, docosanol, tetracosanol, rutin, and actinodaphnine) via molecular docking were confirmed as potential candidates of α-glucosidase and α-amylase inhibitors for treating diabetes.
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Affiliation(s)
- Jirawat Riyaphan
- Department of Life Science and Institute of Biotechnology, National Dong-Hwa University, Hualien 97401, Taiwan.
| | - Chien-Hung Jhong
- Department of Life Science and Institute of Biotechnology, National Dong-Hwa University, Hualien 97401, Taiwan.
| | - Shian-Ren Lin
- Department of Life Science and Institute of Biotechnology, National Dong-Hwa University, Hualien 97401, Taiwan.
| | - Chia-Hsiang Chang
- Department of Life Science and Institute of Biotechnology, National Dong-Hwa University, Hualien 97401, Taiwan.
| | - May-Jwan Tsai
- Neural Regeneration Laboratory, Neurological Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
| | - Der-Nan Lee
- Department of Biotechnology and Animal Science, National Ilan University, Ilan 26047, Taiwan.
| | - Ping-Jyun Sung
- National Museum of Marine Biology and Aquarium, Pingtung 94450, Taiwan.
- Graduate Institute of Marine Biotechnology, National Dong Hwa University, Pingtung 94450, Taiwan.
| | - Max K Leong
- Department of Life Science and Institute of Biotechnology, National Dong-Hwa University, Hualien 97401, Taiwan.
- Department of Chemistry, National Dong Hwa University, Hualien 97401, Taiwan.
| | - Ching-Feng Weng
- Department of Life Science and Institute of Biotechnology, National Dong-Hwa University, Hualien 97401, Taiwan.
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205
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Qian D, Zhang T, Tan X, Zheng P, Liang Z, Xie J, Jiang J, Situ B. Comparison of antidiabetic drugs added to sulfonylurea monotherapy in patients with type 2 diabetes mellitus: A network meta-analysis. PLoS One 2018; 13:e0202563. [PMID: 30148851 PMCID: PMC6110472 DOI: 10.1371/journal.pone.0202563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/06/2018] [Indexed: 12/23/2022] Open
Abstract
AIMS This study aimed to investigate the efficacy and safety of dual therapy comprising sulfonylurea (SU) plus antidiabetic drugs for the treatment of type 2 diabetes mellitus (T2DM). METHODS We searched the PubMed, Cochrane library, and Embase databases for randomized clinical trials (≥24 weeks) published up to December 28, 2017. Subsequently, we conducted pairwise and network meta-analyses to calculate the odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) of the outcomes. RESULTS The final analyses included 24 trials with a total of 10,032 patients. Compared with placebo, all treatment regimens were associated with a significantly higher risk of hypoglycemia, except the combinations of SU plus sodium-glucose co-transporter-2 inhibitor (SGLT-2i) [OR, 1.35 (95% CI: 0.81 to 2.25)] or alpha-glucosidase inhibitor (AGI) [OR, 1.16 (95% CI: 0.55 to 2.44)]. Notably, the combination of SU plus glucagon-like peptide-1 receptor agonist (GLP-1RA) was associated with the most significant increase in the risk of hypoglycemia. Furthermore, all SU-based combination regimens reduced the glycated hemoglobin (HbA1c) and fasting plasma glucose levels (FPG). However, only combinations containing SGLT-2i [MD, -1.00 kg (95% CI: -1.73 to -0.27)] and GLP-1RA [MD, -0.56 kg (95% CI: -1.10 to -0.02)] led to weight loss. CONCLUSIONS Our findings highlight the importance of considering the risk of hypoglycemia when selecting antidiabetic drugs to be administered concomitantly with SU. Although all classes of antidiabetic drugs improved glucose control when administered in combination with SU, SGLT-2i might be the best option with respect to factors such as hypoglycemia and body weight.
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Affiliation(s)
- Dan Qian
- Department of Pharmacy, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | | | - Xiangping Tan
- Department of Pharmacy, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Peiying Zheng
- Department of Pharmacy, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhuoru Liang
- College of Pharmacy, Jinan University, Guangzhou, China
| | - Jingmei Xie
- College of Pharmacy, Jinan University, Guangzhou, China
| | - Jie Jiang
- College of Pharmacy, Jinan University, Guangzhou, China
- * E-mail: (BS); (JJ)
| | - Bing Situ
- Department of Pharmacy, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- * E-mail: (BS); (JJ)
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Nutritional and Bioenergetic Considerations in Critically Ill Patients with Acute Neurological Injury. Neurocrit Care 2018; 27:276-286. [PMID: 28004327 DOI: 10.1007/s12028-016-0336-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The brain, due to intensive cellular processes and maintenance of electrochemical gradients, is heavily dependent on a constant supply of energy. Brain injury, and critical illness in general, induces a state of increased metabolism and catabolism, which has been proven to lead to poor outcomes. Of all the biochemical interventions undertaken in the ICU, providing nutritional support is perhaps one of the most undervalued, but potentially among the safest, and most effective interventions. Adequate provisions of calories and protein have been shown to improve patient outcomes, and guidelines for the nutritional support of the critically ill patient are reviewed. However, there are no such specific guidelines for the critically ill patient with neurological injury. Patients with primary or secondary neurological disorders are frequently undernourished, while data suggest this population would benefit from early and adequate nutritional support, although comprehensive clinical evidence is lacking. We review the joint recommendations from the Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, as they pertain to neurocritical care, and assess the recommendations for addressing nutrition in this patient population.
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207
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Malkov A, Ivanov AI, Buldakova S, Waseem T, Popova I, Zilberter M, Zilberter Y. Seizure-induced reduction in glucose utilization promotes brain hypometabolism during epileptogenesis. Neurobiol Dis 2018; 116:28-38. [DOI: 10.1016/j.nbd.2018.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022] Open
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Abstract
IN BRIEF Older adults with diabetes present unique challenges and require considerations that are not traditionally associated with diabetes management. In this review, we focus on issues that are unique to the older population and provide practical guidance for clincians who care for them.
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Affiliation(s)
- Erika Leung
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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209
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Farngren J, Persson M, Ahrén B. Effects on the glucagon response to hypoglycaemia during DPP-4 inhibition in elderly subjects with type 2 diabetes: A randomized, placebo-controlled study. Diabetes Obes Metab 2018; 20:1911-1920. [PMID: 29645341 DOI: 10.1111/dom.13316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/28/2018] [Accepted: 04/01/2018] [Indexed: 12/19/2022]
Abstract
AIMS Maintainance of glucagon response to hypoglycaemia is important as a safeguard against hypoglycaemia during glucose-lowering therapy in type 2 diabetes. During recent years, DPP-4 (dipeptidyl peptidase-4) inhibition has become more commonly used in elderly patients. However, whether DPP-4 inhibition affects the glucagon response to hypoglycaemia in the elderly is not known and was the aim of this study. METHODS In a single-centre, double-blind, randomized, placebo-controlled crossover study, 28 subjects with metformin-treated type 2 diabetes (17 male, 11 female; mean age, 74 years [range 65-86]; mean HbA1c, 51.5 mmol/mol [6.9%]) received sitagliptin (100 mg once daily) as add-on therapy or placebo for 4 weeks with a 4-week washout period in between. After each treatment period, the subjects underwent a standard breakfast test, followed by a 2-step hyperinsulinaemic hypoglycaemic clamp (target 3.5 and 3.0 mmol/L), followed by lunch. RESULTS Glucagon levels after breakfast and lunch, and the glucagon response at 3.5 mmol/L, were lower after sitagliptin than after placebo. However, the glucagon response to hypoglycaemia at 3.1 mmol/L did not differ significantly between the two. Similarly, the noradrenaline, adrenaline and cortisol responses were lower with sitagliptin than with placebo at 3.5 mmol/L, but not at 3.1 mmol/L glucose. Responses in pancreatic polypeptide did not differ between the two. CONCLUSIONS Elderly subjects with metformin-treated type 2 diabetes have lower glucagon levels at 3.5 mmol/L glucose, but maintain the glucagon response to hypoglycaemia at 3.1 mmol/L during DPP-4 inhibition, which safeguards against hypoglycaemia and may contribute to decreasing the risk of hypoglycaemia by DPP-4 inhibition in this age group.
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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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210
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Douros A, Dell'Aniello S, Yu OHY, Filion KB, Azoulay L, Suissa S. Sulfonylureas as second line drugs in type 2 diabetes and the risk of cardiovascular and hypoglycaemic events: population based cohort study. BMJ 2018; 362:k2693. [PMID: 30021781 PMCID: PMC6050517 DOI: 10.1136/bmj.k2693] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess whether adding or switching to sulfonylureas is associated with an increased risk of myocardial infarction, ischaemic stroke, cardiovascular death, all cause mortality, and severe hypoglycaemia, compared with remaining on metformin monotherapy in patients with type 2 diabetes. DESIGN Population based cohort study. SETTING General practices contributing data to the UK Clinical Practice Research Datalink. PARTICIPANTS Patients with type 2 diabetes initiating metformin monotherapy between 1998 and 2013. MAIN OUTCOME MEASURES Using the prevalent new-user cohort design we matched 1:1 patients adding or switching to sulfonylureas with those remaining on metformin monotherapy on high-dimensional propensity score, haemoglobin A1c, and number of previous metformin prescriptions. The two groups were compared using Cox proportional hazards models to estimate adjusted hazard ratios and 95% confidence intervals for the study outcomes. RESULTS Among 77 138 metformin initiators, 25 699 added or switched to sulfonylureas during the study period. During a mean follow-up of 1.1 years, sulfonylureas were associated with an increased risk of myocardial infarction (incidence rate 7.8 v 6.2 per 1000 person years, hazard ratio 1.26, 95% confidence interval 1.01 to 1.56), all cause mortality (27.3 v 21.5, 1.28, 1.15 to 1.44), and severe hypoglycaemia (5.5 v 0.7, 7.60, 4.64 to 12.44) compared with continuing metformin monotherapy. There was a trend towards increased risks of ischaemic stroke (6.7 v 5.5, 1.24, 0.99 to 1.56) and cardiovascular death (9.4 v 8.1, 1.18, 0.98 to 1.43). Compared with adding sulfonylureas, switching to sulfonylureas was associated with an increased risk of myocardial infarction (hazard ratio 1.51, 95% confidence interval, 1.03 to 2.24) and all-cause mortality (1.23, 1.00 to 1.50). No differences were observed for ischaemic stroke, cardiovascular death, or severe hypoglycaemia. CONCLUSIONS Sulfonylureas as second line drugs are associated with an increased risk of myocardial infarction, all cause mortality, and severe hypoglycaemia, compared with remaining on metformin monotherapy. Continuing metformin when introducing sulfonylureas appears to be safer than switching.
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Affiliation(s)
- Antonios Douros
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
| | - Oriana Hoi Yun Yu
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Division of Endocrinology, Jewish General Hospital, Montréal, QC, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Division of Clinical Epidemiology, Department of Medicine, McGill University, Montréal, QC, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montréal, QC, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, H-461 Montréal, QC H3T 1E2, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Division of Clinical Epidemiology, Department of Medicine, McGill University, Montréal, QC, Canada
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Li NX, Brown S, Kowalski T, Wu M, Yang L, Dai G, Petrov A, Ding Y, Dlugos T, Wood HB, Wang L, Erion M, Sherwin R, Kelley DE. GPR119 Agonism Increases Glucagon Secretion During Insulin-Induced Hypoglycemia. Diabetes 2018; 67:1401-1413. [PMID: 29669745 PMCID: PMC6014553 DOI: 10.2337/db18-0031] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/10/2018] [Indexed: 01/08/2023]
Abstract
Insulin-induced hypoglycemia in diabetes is associated with impaired glucagon secretion. In this study, we tested whether stimulation of GPR119, a G-protein-coupled receptor expressed in pancreatic islet as well as enteroendocrine cells and previously shown to stimulate insulin and incretin secretion, might enhance glucagon secretion during hypoglycemia. In the study, GPR119 agonists were applied to isolated islets or perfused pancreata to assess insulin and glucagon secretion during hypoglycemic or hyperglycemic conditions. Insulin infusion hypoglycemic clamps were performed with or without GPR119 agonist pretreatment to assess glucagon counterregulation in healthy and streptozotocin (STZ)-induced diabetic rats, including those exposed to recurrent bouts of insulin-induced hypoglycemia that leads to suppression of hypoglycemia-induced glucagon release. Hypoglycemic clamp studies were also conducted in GPR119 knockout (KO) mice to evaluate whether the pharmacological stimulatory actions of GPR119 agonists on glucagon secretion during hypoglycemia were an on-target effect. The results revealed that GPR119 agonist-treated pancreata or cultured islets had increased glucagon secretion during low glucose perfusion. In vivo, GPR119 agonists also significantly increased glucagon secretion during hypoglycemia in healthy and STZ-diabetic rats, a response that was absent in GPR119 KO mice. In addition, impaired glucagon counterregulatory responses were restored by a GPR119 agonist in STZ-diabetic rats that were exposed to antecedent bouts of hypoglycemia. Thus, GPR119 agonists have the ability to pharmacologically augment glucagon secretion, specifically in response to hypoglycemia in diabetic rodents. Whether this effect might serve to diminish the occurrence and severity of iatrogenic hypoglycemia during intensive insulin therapy in patients with diabetes remains to be established.
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Affiliation(s)
- Nina Xiaoyan Li
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | | | - Tim Kowalski
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | - Margaret Wu
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | - Liming Yang
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | - Ge Dai
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | - Aleksandr Petrov
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | | | | | - Harold B Wood
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | - Liangsu Wang
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | - Mark Erion
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
| | | | - David E Kelley
- Discovery, Preclinical and Early Development, Merck & Co., Inc., Kenilworth, NJ
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Abstract
PURPOSE OF REVIEW This article provides an overview of endocrine emergencies with potentially devastating neurologic manifestations that may be fatal if left untreated. Pituitary apoplexy, adrenal crisis, myxedema coma, thyroid storm, acute hypercalcemia and hypocalcemia, hyperglycemic emergencies (diabetic ketoacidosis and hyperglycemic hyperosmolar state), and acute hypoglycemia are discussed, with an emphasis on identifying the signs and symptoms as well as diagnosing and managing these clinical entities. RECENT FINDINGS To identify the optimal management of endocrine emergencies, using formal clinical diagnostic criteria and grading scales such as those recently proposed for pituitary apoplexy will be beneficial in future prospective studies. A 2015 prospective study in patients with adrenal insufficiency found a significant number of adrenal crisis-related deaths despite all study patients receiving standard care and being educated on crisis prevention strategies, highlighting that current prevention strategies and medical management remain suboptimal. SUMMARY Early diagnosis and prompt treatment of endocrine emergencies are essential but remain challenging because of a lack of objective diagnostic tools. The optimal management is also unclear as prospective and randomized studies are lacking. Additional research is needed for these clinical syndromes that can be fatal despite intensive medical intervention.
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213
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Lu CL, Chang YH, Sun Y, Li CY. A population-based study of epilepsy incidence in association with type 2 diabetes and severe hypoglycaemia. Diabetes Res Clin Pract 2018; 140:97-106. [PMID: 29608979 DOI: 10.1016/j.diabres.2018.03.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/27/2018] [Accepted: 03/15/2018] [Indexed: 11/21/2022]
Abstract
AIMS This study was conducted to investigate potential link between type 2 diabetes mellitus (T2DM) and epilepsy, and the role of severe hypoglycaemia (SH) might play in the relationship. METHODS This was a cohort study based on Taiwan's National Health insurance claims. Totally 751,792 people with T2DM and 824,253 matched controls were identified in 2002-2003 and followed to incidence of epilepsy or end of 2011. We used Cox proportional hazard model to relate epilepsy incidence to separate and joint effects of T2DM and SH. A possible mediation effect of SH on the association between T2DM and epilepsy was analyzed. RESULTS Over a 10-year follow-up, patients with T2DM had a higher incidence rate of epilepsy than controls (35.0 vs 21.9 per 10,000 person-years). After controlling for potential confounders including SH, T2DM increased the hazard of epilepsy by some 50%. The stratified analysis further indicated that T2DM (hazard ratio (HR)=1.44, 95% confidence interval (CI) = 1.40-1.47), and SH (HR = 2.22, 95% CI = 1.76-2.81) were both independent risk factors for epilepsy. SH did not modify but mediated 12% of the association between T2DM and epilepsy. CONCLUSION Our findings supported that SH may increase the risk of epilepsy, and that T2DM may increase risk of epilepsy independent of SH.
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Affiliation(s)
- Chin-Li Lu
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung Hsing University, Taichung, Taiwan
| | - Ya-Hui Chang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu Sun
- Department of Neurology, En Chu Kong Hospital, Sanxia District, New Taipei City, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan.
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214
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Marina N, Turovsky E, Christie IN, Hosford PS, Hadjihambi A, Korsak A, Ang R, Mastitskaya S, Sheikhbahaei S, Theparambil SM, Gourine AV. Brain metabolic sensing and metabolic signaling at the level of an astrocyte. Glia 2018; 66:1185-1199. [PMID: 29274121 PMCID: PMC5947829 DOI: 10.1002/glia.23283] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/04/2017] [Accepted: 11/29/2017] [Indexed: 12/18/2022]
Abstract
Astrocytes support neuronal function by providing essential structural and nutritional support, neurotransmitter trafficking and recycling and may also contribute to brain information processing. In this article we review published results and report new data suggesting that astrocytes function as versatile metabolic sensors of central nervous system (CNS) milieu and play an important role in the maintenance of brain metabolic homeostasis. We discuss anatomical and functional features of astrocytes that allow them to detect and respond to changes in the brain parenchymal levels of metabolic substrates (oxygen and glucose), and metabolic waste products (carbon dioxide). We report data suggesting that astrocytes are also sensitive to circulating endocrine signals-hormones like ghrelin, glucagon-like peptide-1 and leptin, that have a major impact on the CNS mechanisms controlling food intake and energy balance. We discuss signaling mechanisms that mediate communication between astrocytes and neurons and consider how these mechanisms are recruited by astrocytes activated in response to various metabolic challenges. We review experimental data suggesting that astrocytes modulate the activities of the respiratory and autonomic neuronal networks that ensure adaptive changes in breathing and sympathetic drive in order to support the physiological and behavioral demands of the organism in ever-changing environmental conditions. Finally, we discuss evidence suggesting that altered astroglial function may contribute to the pathogenesis of disparate neurological, respiratory and cardiovascular disorders such as Rett syndrome and systemic arterial hypertension.
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Affiliation(s)
- Nephtali Marina
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
- Research Department of Metabolism and Experimental Therapeutics, Division of MedicineUniversity College LondonLondonWC1E 6JJUnited Kingdom
| | - Egor Turovsky
- Laboratory of Intracellular SignallingInstitute of Cell Biophysics, Russian Academy of SciencesPushchinoRussia
| | - Isabel N Christie
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Patrick S Hosford
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Anna Hadjihambi
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Alla Korsak
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Richard Ang
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Svetlana Mastitskaya
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Shahriar Sheikhbahaei
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Shefeeq M Theparambil
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
| | - Alexander V Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology & PharmacologyUniversity College LondonLondonWC1E 6BTUnited Kingdom
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Zhao F, Deng J, Xu X, Cao F, Lu K, Li D, Cheng X, Wang X, Zhao Y. Aquaporin-4 deletion ameliorates hypoglycemia-induced BBB permeability by inhibiting inflammatory responses. J Neuroinflammation 2018; 15:157. [PMID: 29793504 PMCID: PMC5968550 DOI: 10.1186/s12974-018-1203-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/15/2018] [Indexed: 11/18/2022] Open
Abstract
Background Severe hypoglycemia induces brain edema by upregulating aquaporin-4 (AQP4) expression and by degrading tight junctions. Acute severe hypoglycemia induces a proinflammatory environment that may contribute to a disruption in the epithelial barrier by decreasing tight junction protein expression. Interestingly, the altered AQP4 expression has been considered to play a critical role in neuroinflammation during acute brain injury. It has been shown that AQP4 deletion reduces brain inflammation in AQP4-null mice after intracerebral LPS injection. However, the effect of AQP4 deletion regarding protection against hypoglycemia-induced blood-brain barrier (BBB) breakdown is unknown. Methods An acute severe hypoglycemic stress model was established via injection of 4 unit/kg body weight of insulin. Evans blue (EB) staining and water measurement were used to assess BBB permeability. Western blot, reverse transcription polymerase chain reaction, and immunofluorescence were used to detect the expression of related proteins. The production of cytokines was assessed via enzyme-linked immunosorbent assay. Results Hypoglycemia-induced brain edema and BBB leakage were reduced in AQP4−/− mice. AQP4 deletion upregulated PPAR-γ and inhibited proinflammatory responses. Moreover, knockdown of aquaporin-4 by small interfering RNA in astrocytes co-cultured with endothelial cells effectively reduced transendothelial permeability and degradation of tight junctions. Treatment with PPAR-γ inhibitors showed that upregulation of PPAR-γ was responsible for the protective effect of AQP4 deletion under hypoglycemic conditions. Conclusions Our data suggest that AQP4 deletion protects BBB integrity by reducing inflammatory responses due to the upregulation of PPAR-γ expression and attenuation of proinflammatory cytokine release. Reduction in AQP4 may be protective in acute severe hypoglycemia. Electronic supplementary material The online version of this article (10.1186/s12974-018-1203-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fei Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Xuhui District, Shanghai, China
| | - Jiangshan Deng
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Xuhui District, Shanghai, China
| | - Xiaofeng Xu
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Xuhui District, Shanghai, China
| | - Fengya Cao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Xuhui District, Shanghai, China
| | - Kaili Lu
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Xuhui District, Shanghai, China
| | - Dawei Li
- School of Pharmacy, Shanghai Jiao Tong University, No. 800, Dongchuan Road, Minhang District, Shanghai, China
| | - Xiaojuan Cheng
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Xuhui District, Shanghai, China
| | - Xiuzhe Wang
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Xuhui District, Shanghai, China
| | - Yuwu Zhao
- Department of Neurology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Xuhui District, Shanghai, China.
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216
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Leow ZZX, Guelfi KJ, Davis EA, Jones TW, Fournier PA. The glycaemic benefits of a very-low-carbohydrate ketogenic diet in adults with Type 1 diabetes mellitus may be opposed by increased hypoglycaemia risk and dyslipidaemia. Diabet Med 2018; 35:1258-1263. [PMID: 29737587 DOI: 10.1111/dme.13663] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 01/22/2023]
Abstract
AIMS To investigate whether very-low-carbohydrate high-fat diets, typical of ketogenic diets, can improve glycaemic control without causing any ill health effects in adults with Type 1 diabetes. METHODS In this observational study, 11 adults with Type 1 diabetes (seven men, four women, mean ± sd age 36.1± 6.8 years, mean ± sd duration of diabetes 12.8 ± 10.3 years), who followed a ketogenic diet (< 55 g carbohydrate per day) for a mean ± sd of 2.6 ± 3.3 years (β-hydroxybutyrate 1.6 ± 1.3 mmol/l), underwent sampling and analysis of fasting blood, and were fitted with a blinded continuous glucose monitor for 7 days to measure glycaemic variability. RESULTS The mean ± sd HbA1c levels were 35±4 mmol/mol (5.3±0.4%), and participants spent 74±20 and 3±8% of their time in the euglycaemic (4-8 mmol/l) and hyperglycaemic (>10 mmol/l) ranges, respectively, with little daily glycaemic variability (sd 1.5±0.7 mmol/l; coefficient of variation 26±8%). Blood glucose levels were <3.0 mmol/l for 3.6% of the time, and participants experienced a median (range) of 0.9 (0.0-2.0) daily episodes of hypoglycaemia. Total cholesterol, LDL cholesterol, total cholesterol/HDL cholesterol ratio, and triglycerides were above the recommended range in 82%, 82%, 64% and 27% of participants, respectively; however, HDL cholesterol levels were within the recommended range for all participants. Participants displayed no or little evidence of hepatic or renal dysfunction. CONCLUSION This study provides the first evidence that, ketogenic diets in adults with Type 1 diabetes are associated with excellent HbA1c levels and little glycaemic variability, but may also be associated with dyslipidaemia and a high number of hypoglycaemic episodes.
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Affiliation(s)
- Z Z X Leow
- School of Human Sciences, University of Western Australia, Perth, Australia
| | - K J Guelfi
- School of Human Sciences, University of Western Australia, Perth, Australia
| | - E A Davis
- Department of Endocrinology and Diabetes, Princess Margaret Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - T W Jones
- Department of Endocrinology and Diabetes, Princess Margaret Hospital, Perth, Australia
- Telethon Kids Institute, University of Western Australia, Perth, Australia
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
| | - P A Fournier
- School of Human Sciences, University of Western Australia, Perth, Australia
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217
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Rama Chandran S, Tay WL, Lye WK, Lim LL, Ratnasingam J, Tan ATB, Gardner DSL. Beyond HbA1c: Comparing Glycemic Variability and Glycemic Indices in Predicting Hypoglycemia in Type 1 and Type 2 Diabetes. Diabetes Technol Ther 2018; 20:353-362. [PMID: 29688755 DOI: 10.1089/dia.2017.0388] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hypoglycemia is the major impediment to therapy intensification in diabetes. Although higher individualized HbA1c targets are perceived to reduce the risk of hypoglycemia in those at risk of hypoglycemia, HbA1c itself is a poor predictor of hypoglycemia. We assessed the use of glycemic variability (GV) and glycemic indices as independent predictors of hypoglycemia. METHODS A retrospective observational study of 60 type 1 and 100 type 2 diabetes subjects. All underwent professional continuous glucose monitoring (CGM) for 3-6 days and recorded self-monitored blood glucose (SMBG). Indices were calculated from both CGM and SMBG. Statistical analyses included regression and area under receiver operator curve (AUC) analyses. RESULTS Hypoglycemia frequency (53.3% vs. 24%, P < 0.05) and %CV (40.1% ± 10% vs. 29.4% ± 7.8%, P < 0.001) were significantly higher in type 1 diabetes compared with type 2 diabetes. HbA1c was, at best, a weak predictor of hypoglycemia. %CVCGM, Low Blood Glucose Index (LBGI)CGM, Glycemic Risk Assessment Diabetes Equation (GRADE)HypoglycemiaCGM, and Hypoglycemia IndexCGM predicted hypoglycemia well. %CVCGM and %CVSMBG consistently remained a robust discriminator of hypoglycemia in type 1 diabetes (AUC 0.88). In type 2 diabetes, a combination of HbA1c and %CVSMBG or LBGISMBG could help discriminate hypoglycemia. CONCLUSION Assessment of glycemia should go beyond HbA1c and incorporate measures of GV and glycemic indices. %CVSMBG in type 1 diabetes and LBGISMBG or a combination of HbA1c and %CVSMBG in type 2 diabetes discriminated hypoglycemia well. In defining hypoglycemia risk using GV and glycemic indices, diabetes subtypes and data source (CGM vs. SMBG) must be considered.
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Affiliation(s)
| | - Wei Lin Tay
- 1 Department of Endocrinology, Singapore General Hospital , Singapore
| | - Weng Kit Lye
- 2 Centre for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Medical School , Singapore
| | - Lee Ling Lim
- 3 Division of Endocrinology, Department of Internal Medicine, University of Malaya , Kuala Lumpur, Malaysia
| | - Jeyakantha Ratnasingam
- 3 Division of Endocrinology, Department of Internal Medicine, University of Malaya , Kuala Lumpur, Malaysia
| | - Alexander Tong Boon Tan
- 3 Division of Endocrinology, Department of Internal Medicine, University of Malaya , Kuala Lumpur, Malaysia
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218
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Pacaud D, Hermann JM, Karges B, Rosenbauer J, Danne T, Dürr R, Herbst A, Lindauer S, Müther S, Pötzsch S, Raile K, Witsch M, Holl RW. Risk of recurrent severe hypoglycemia remains associated with a past history of severe hypoglycemia up to 4 years: Results from a large prospective contemporary pediatric cohort of the DPV initiative. Pediatr Diabetes 2018; 19:493-500. [PMID: 29218766 DOI: 10.1111/pedi.12610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/17/2017] [Accepted: 10/18/2017] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES In a contemporary cohort of youth with type 1 diabetes, we examined the interval between episodes of severe hypoglycemia (SH) as a risk factor for recurrent SH or hypoglycemic coma (HC). METHODS This was a large longitudinal observational study. Using the DPV Diabetes Prospective follow-up data, we analyzed frequency and timing of recurrent SH (defined as requiring assistance from another person) and HC (loss of consciousness or seizures) in 14 177 youths with type 1 diabetes aged <20 years and at least 5 years of follow-up. RESULTS Among 14 177 patients with type 1 diabetes, 72% (90%) had no, 14% (6.8%) had 1 and 14% (3.2%) >1 SH (HC). SH or HC in the last year of observation was highest with SH in the previous year (odds ratio [OR] 4.7 [CI 4.0-5.5]/4.6 [CI 3.6-6.0]), but remained elevated even 4 years after an episode (OR 2.0 [CI 1.6-2.7]/2.2 [CI 1.5-3.1]). The proportion of patients who experienced SH or HC during the last year of observation was highest with SH/HC recorded during the previous year (23% for SH and 13% for HC) and lowest in those with no event (4.6% for SH and 2% for HC) in the initial 4 years of observation. CONCLUSIONS Even 4 years after an episode of SH/HC, risk for SH/HC remains higher compared to children who never experienced SH/HC. Clinicians should continue to regularly track hypoglycemia history at every visit, adjust diabetes education and therapy in order to avoid recurrences.
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Affiliation(s)
- D Pacaud
- Department of Pediatrics, University of Calgary, Calgary, Canada.,Department of Pediatric Diabetes and Endocrinology, Alberta Children's Hospital, Calgary, Canada.,Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | - J M Hermann
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich, Germany
| | - B Karges
- Division of Endocrinology and Diabetes, Medical Faculty, German Center for Diabetes Research (DZD), RWTH Aachen University, Aachen, Germany
| | - J Rosenbauer
- German Center for Diabetes Research (DZD), Munich, Germany.,German Diabetes Center, Institute for Biometrics and Epidemiology, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | - T Danne
- Diabetes Centre for Children and Adolescents, Children's and Youth Hospital "AUF DER BULT", Hannover, Germany
| | - R Dürr
- Department of Children and Adolescent Medicine, Rems-Murr-Clinics, Winnenden, Germany
| | - A Herbst
- Center for Paediatrics, Medical Clinic Leverkusen, Leverkusen, Germany
| | - S Lindauer
- Department for Children and Adolescent Medicine, Hospital Barmherzige Schwestern Linz, Linz, Austria
| | - S Müther
- Diabetes Center for Children and Adolescent, DRK Clinics Berlin Westend, Berlin, Germany
| | - S Pötzsch
- Department for Children and Adolescent Medicine, Helios Vogtland Clinic Plauen, Plauen, Germany
| | - K Raile
- Department of Pediatric Endocrinology and Diabetes, Charité Berlin, Berlin, Germany
| | - M Witsch
- Centre Hospitalier de Luxembourg, Clinique Pediatrie, Luxembourg, Luxembourg
| | - R W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich, Germany
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219
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Nedergaard S, Andreasen M. Opposing effects of 2-deoxy-d-glucose on interictal- and ictal-like activity when K+ currents and GABAA receptors are blocked in rat hippocampus in vitro. J Neurophysiol 2018; 119:1912-1923. [DOI: 10.1152/jn.00732.2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The ketogenic diet (KD), a high-fat, carbohydrate-restricted diet, is used as an alternative treatment for drug-resistant epileptic patients. Evidence suggests that compromised glucose metabolism has a significant role in the anticonvulsant action of the KD; however, it is unclear what part of the glucose metabolism that is important. The present study investigates how selective alterations in glycolysis and oxidative phosphorylation influence epileptiform activity induced by blocking K+ currents and GABAA and NMDA receptors in the hippocampal slice preparation. Blocking glycolysis with the glucose derivative 2-deoxy-d-glucose (2-DG; 10 mM) gave a fast reduction of the frequency of interictal discharge (IED) consistent with findings in other in vitro models. However, this was followed by the induction of seizure-like discharges in area CA1 and CA3. Substituting glucose with sucrose (glucopenia) had effects similar to those of 2-DG, whereas substitution with l-lactate or pyruvate reduced the IED but had a less proconvulsant effect. Blockade of ATP-sensitive K+ channels, glycine or adenosine 1 receptors, or depletion of the endogenous anticonvulsant compound glutathione did not prevent the actions of 2-DG. Baclofen (2 μM) reproduced the effect of 2-DG on IED activity. The proconvulsant effect of 2-DG could be reproduced by blocking the oxidative phosphorylation with the complex I toxin rotenone (4 μM). The data suggest that inhibition of IED, induced by 2-DG and glucopenia, is a direct consequence of impairment of glycolysis, likely exerted via a decreased recurrent excitatory synaptic transmission in area CA3. The accompanying proconvulsant effect is caused by an excitatory mechanism, depending on impairment of oxidative phosphorylation. NEW & NOTEWORTHY This study reveals two opposing effects of 2-deoxy-d-glucose (2-DG) and glucopenia on in vitro epileptiform discharge observed during combined blockade of K+ currents and GABAA receptors. Interictal-like activity is inhibited by a mechanism that selectively depends on impairment of glycolysis and that results from a decrease in the strength of excitatory recurrent synaptic transmission in area CA3. In contrast, 2-DG and glucopenia facilitate ictal-like activity by an excitatory mechanism, depending on impairment of mitochondrial oxidative phosphorylation.
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220
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Duncan EAS, Fitzpatrick D, Ikegwuonu T, Evans J, Maxwell M. Role and prevalence of impaired awareness of hypoglycaemia in ambulance service attendances to people who have had a severe hypoglycaemic emergency: a mixed-methods study. BMJ Open 2018; 8:e019522. [PMID: 29691243 PMCID: PMC5922484 DOI: 10.1136/bmjopen-2017-019522] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES (1) To compare the experiences of people who are affected by diabetes-related hypoglycaemia and either do or do not require an emergency attendance and (2) to measure the prevalence of impaired awareness of hypoglycaemia in patients who are attended by an ambulance service due to a severe hypoglycaemic event. DESIGN A sequential mixed-methods study. SETTING A qualitative interview study was undertaken with 31 people with diabetes (types 1 and 2) resident in the central belt of Scotland. A national prevalence survey of 590 Scottish Ambulance Service patients who had recently experienced a severe hypoglycaemic emergency requiring ambulance clinicians attendance. Impaired awareness of hypoglycaemia was measured using two standardised measures. RESULTS Considerable differences in impaired awareness of hypoglycaemia were found in the experiences of participants who did or did not require the ambulance service to treat their severe hypoglycaemic events. Those who required an ambulance reported fewer warning signs and symptoms. The prevalence of impaired awareness of hypoglycaemia in ambulance service call-outs as assessed by two standardised measures was 53% and 60%, respectively. CONCLUSIONS The prevalence of impaired awareness of hypoglycaemia among those who require an ambulance following a hypoglycaemic event is more than twice that found in the general population of people with diabetes. This may be because the experiences of impaired awareness in people who require an ambulance following a severe hypoglycaemic event differ to those who do not. This study provides important information to guide future prehospital clinical practice, and to develop and evaluate theoretically informed interventions. Improvements in prehospital care for this patient population could lead to global improvements in health outcomes and decreased service costs.
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Affiliation(s)
- Edward A S Duncan
- Nursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU), Faculty of Health Sciences and Sport, The University of Stirling, Stirling, UK
| | - David Fitzpatrick
- Faculty of Health Science and Sport, University of Stirling, Stirling, UK
| | - Theresa Ikegwuonu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Josie Evans
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Margaret Maxwell
- Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, UK
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221
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Chen Y, Chen L, Zhang H, Huang S, Xiong Y, Xia C. Interaction of Sulfonylureas with Liver Uptake Transporters OATP1B1 and OATP1B3. Basic Clin Pharmacol Toxicol 2018; 123:147-154. [PMID: 29498478 DOI: 10.1111/bcpt.12992] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 02/13/2018] [Indexed: 12/20/2022]
Abstract
Sulfonylureas (SUs) such as glibenclamide, gliclazide, glimepiride, glipizide and gliquidone are one of the first oral medicines available for the treatment of type 2 diabetes and are widely used for the treatment of hyperglycaemia. The hepatic transporters, organic anion transporting polypeptide 1B1 (OATP1B1) and organic anion transporting polypeptide 1B3 (OATP1B3), play an important role in the disposition of a variety of drugs by mediating their uptake from blood into hepatocytes. Drug-drug interactions mediated by OATP1B1/1B3 may result in the hepatic transporting change for drug substrates. The inhibitory effects of glibenclamide and glimepiride on sulfobromophthalein (BSP) uptake have been previously studied, and glibenclamide has been reported as the substrate of OATP1B3, but it remains unclear whether other SUs such as gliclazide, glipizide and gliquidone are substrates of OATP1B1 and OATP1B3. Here, we investigated the relationship between the five most commonly applied SUs (glibenclamide, gliclazide, glimepiride, glipizide, gliquidone) and OATP1B1 and OATP1B3. We performed uptake and inhibition assays in HEK293T cells stably expressing OATP1B1 or OATP1B3, respectively, and established a liquid chromatography-mass spectrometry (LC-MS) method for the simultaneous measurement of five SUs. We demonstrated that gliclazide and glimepiride are substrates of OATP1B1 and glibenclamide and glipizide are substrates of OATP1B3. We also confirmed the interaction between these SUs and rosuvastatin. No transporting was observed for gliquidone, suggesting that it is not a substrate of either transporter.
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Affiliation(s)
- Yu Chen
- Clinical Pharmacology Institute, Nanchang University, Nanchang, China.,Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Lin Chen
- Clinical Pharmacology Institute, Nanchang University, Nanchang, China
| | - Hong Zhang
- Clinical Pharmacology Institute, Nanchang University, Nanchang, China
| | - Shibo Huang
- Clinical Pharmacology Institute, Nanchang University, Nanchang, China
| | - Yuqing Xiong
- Clinical Pharmacology Institute, Nanchang University, Nanchang, China
| | - Chunhua Xia
- Clinical Pharmacology Institute, Nanchang University, Nanchang, China
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Heinemann L, Freckmann G, Ehrmann D, Faber-Heinemann G, Guerra S, Waldenmaier D, Hermanns N. Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycaemia awareness or severe hypoglycaemia treated with multiple daily insulin injections (HypoDE): a multicentre, randomised controlled trial. Lancet 2018; 391:1367-1377. [PMID: 29459019 DOI: 10.1016/s0140-6736(18)30297-6] [Citation(s) in RCA: 325] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effectiveness of real-time continuous glucose monitoring (rtCGM) in avoidance of hypoglycaemia among high-risk individuals with type 1 diabetes treated with multiple daily insulin injections (MDI) is unknown. We aimed to ascertain whether the incidence and severity of hypoglycaemia can be reduced through use of rtCGM in these individuals. METHODS The HypoDE study was a 6-month, multicentre, open-label, parallel, randomised controlled trial done at 12 diabetes practices in Germany. Eligible participants had type 1 diabetes and a history of impaired hypoglycaemia awareness or severe hypoglycaemia during the previous year. All participants wore a masked rtCGM system for 28 days and were then randomly assigned to 26 weeks of unmasked rtCGM (Dexcom G5 Mobile system) or to the control group (continuing with self-monitoring of blood glucose). Block randomisation with 1:1 allocation was done centrally, with the study site as the stratifying variable. Masking of participants and study sites was not possible. Control participants wore a masked rtCGM system during the follow-up phase (weeks 22-26). The primary outcome was the baseline-adjusted number of hypoglycaemic events (defined as glucose ≤3·0 mmol/L for ≥20 min) during the follow-up phase. The full dataset analysis comprised participants who wore the rtCGM system during the baseline and follow-up phases. The intention-to-treat analysis comprised all randomised participants. This trial is registered with ClinicalTrials.gov, number NCT02671968. FINDINGS Between March 4, 2016, and Jan 12, 2017, 149 participants were randomly assigned (n=74 to the control group; n=75 to the rtCGM group) and 141 completed the follow-up phase (n=66 in the control group, n=75 in the rtCGM group). The mean number of hypoglycaemic events per 28 days among participants in the rtCGM group was reduced from 10·8 (SD 10·0) to 3·5 (4·7); reductions among control participants were negligible (from 14·4 [12·4] to 13·7 [11·6]). Incidence of hypoglycaemic events decreased by 72% for participants in the rtCGM group (incidence rate ratio 0·28 [95% CI 0·20-0·39], p<0·0001). 18 serious adverse events were reported: seven in the control group, ten in the rtCGM group, and one before randomisation. No event was considered to be related to the investigational device. INTERPRETATION Usage of rtCGM reduced the number of hypoglycaemic events in individuals with type 1 diabetes treated by MDI and with impaired hypoglycaemia awareness or severe hypoglycaemia. FUNDING Dexcom Inc.
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Affiliation(s)
- 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
| | - Dominic Ehrmann
- Research Institute Diabetes of the Diabetes Academy Mergentheim (FIDAM) (FIDAM), Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
| | | | | | - Delia Waldenmaier
- IDT-Institut für Diabetes-Technologie, Forschungs-und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Norbert Hermanns
- Research Institute Diabetes of the Diabetes Academy Mergentheim (FIDAM) (FIDAM), Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany.
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223
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Bergenstal RM. Continuous glucose monitoring: transforming diabetes management step by step. Lancet 2018; 391:1334-1336. [PMID: 29459022 DOI: 10.1016/s0140-6736(18)30290-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 02/08/2018] [Indexed: 10/18/2022]
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Reddy M, Jugnee N, El Laboudi A, Spanudakis E, Anantharaja S, Oliver N. A randomized controlled pilot study of continuous glucose monitoring and flash glucose monitoring in people with Type 1 diabetes and impaired awareness of hypoglycaemia. Diabet Med 2018; 35:483-490. [PMID: 29230878 PMCID: PMC5888121 DOI: 10.1111/dme.13561] [Citation(s) in RCA: 176] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2017] [Indexed: 12/20/2022]
Abstract
AIM Hypoglycaemia in Type 1 diabetes is associated with mortality and morbidity, especially where awareness of hypoglycaemia is impaired. Clinical pathways for access to continuous glucose monitoring (CGM) and flash glucose monitoring technologies are unclear. We assessed the impact of CGM and flash glucose monitoring in a high-risk group of people with Type 1 diabetes. METHODS A randomized, non-masked parallel group study was undertaken. Adults with Type 1 diabetes using a multiple-dose insulin-injection regimen with a Gold score of ≥ 4 or recent severe hypoglycaemia were recruited. Following 2 weeks of blinded CGM, they were randomly assigned to CGM (Dexcom G5) or flash glucose monitoring (Abbott Freestyle Libre) for 8 weeks. The primary outcome was the difference in time spent in hypoglycaemia (below 3.3 mmol/l) from baseline to endpoint with CGM versus flash glucose monitoring. RESULTS Some 40 participants were randomized to CGM (n = 20) or flash glucose monitoring (n = 20). The participants (24 men, 16 women) had a median (IQR) age of 49.6 (37.5-63.5) years, duration of diabetes of 30.0 (21.0-36.5) years and HbA1c of 56 (48-63) mmol/mol [7.3 (6.5-7.8)%]. The baseline median percentage time < 3.3 mmol/l was 4.5% in the CGM group and 6.7% in the flash glucose monitoring. At the end-point the percentage time < 3.3 mmol/l was 2.4%, and 6.8% respectively (median between group difference -4.3%, P = 0.006). Time spent in hypoglycaemia at all thresholds, and hypoglycaemia fear, were different between groups, favouring CGM. CONCLUSION CGM more effectively reduces time spent in hypoglycaemia in people with Type 1 diabetes and impaired awareness of hypoglycaemia compared with flash glucose monitoring. (Clinical Trial Registry No: NCT03028220).
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Affiliation(s)
- M. Reddy
- Division of Diabetes, Endocrinology and MetabolismFaculty of MedicineImperial CollegeLondonUK
| | - N. Jugnee
- Division of Diabetes, Endocrinology and MetabolismFaculty of MedicineImperial CollegeLondonUK
| | - A. El Laboudi
- Division of Diabetes, Endocrinology and MetabolismFaculty of MedicineImperial CollegeLondonUK
| | - E. Spanudakis
- Division of Diabetes, Endocrinology and MetabolismFaculty of MedicineImperial CollegeLondonUK
| | - S. Anantharaja
- Division of Diabetes, Endocrinology and MetabolismFaculty of MedicineImperial CollegeLondonUK
| | - N. Oliver
- Division of Diabetes, Endocrinology and MetabolismFaculty of MedicineImperial CollegeLondonUK
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225
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Wysham CH, Campos C, Kruger D. Safety and Efficacy of Insulin Degludec/Liraglutide (IDegLira) and Insulin Glargine U100/Lixisenatide (iGlarLixi), Two Novel Co-Formulations of a Basal Insulin and a Glucagon-Like Peptide-1 Receptor Agonist, in Patients With Diabetes Not Adequately Controlled on Oral Antidiabetic Medications. Clin Diabetes 2018; 36:149-159. [PMID: 29686454 PMCID: PMC5898162 DOI: 10.2337/cd17-0064] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IN BRIEF Novel co-formulations of basal insulin analogs and glucagon-like peptide-1 (GLP-1) receptor agonists have provided new options for patients with type 2 diabetes who are not reaching recommended glycemic targets. The components of currently available co-formulations (insulin degludec/ liraglutide [IDegLira,] and insulin glargine U100/lixisenatide [iGlarLixi]) act synergistically to address multiple pathophysiologic defects while minimizing the side effects associated with either component when used alone. In Europe, these products are approved for use in patients on regimens of one or more oral antidiabetic drugs; in the United States, they are indicated for use as an adjunct to diet and exercise in patients with type 2 diabetes inadequately controlled with either basal insulin or their respective GLP-1 receptor agonist component. This article reviews key clinical trials in which these products were initiated in insulin-naive patients and describes how they can be safely and effectively titrated in clinical practice.
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Affiliation(s)
| | - Carlos Campos
- Department of Family Medicine, UT Health San Antonio, San Antonio, TX
| | - Davida Kruger
- Henry Ford Health System, Division of Endocrinology, Diabetes, Bone and Mineral Disease, Detroit, MI
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226
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Diallyl trisulfide ameliorates myocardial ischemia-reperfusion injury by reducing oxidative stress and endoplasmic reticulum stress-mediated apoptosis in type 1 diabetic rats: role of SIRT1 activation. Apoptosis 2018; 22:942-954. [PMID: 28455824 DOI: 10.1007/s10495-017-1378-y] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Diallyl trisulfide (DATS) protects against apoptosis during myocardial ischemia-reperfusion (MI/R) injury in diabetic state, although the underlying mechanisms remain poorly defined. Previously, we and others demonstrated that silent information regulator 1 (SIRT1) activation inhibited oxidative stress and endoplasmic reticulum (ER) stress during MI/R injury. We hypothesize that DATS reduces diabetic MI/R injury by activating SIRT1 signaling. Streptozotocin (STZ)-induced type 1 diabetic rats were subjected to MI/R surgery with or without perioperative administration of DATS (40 mg/kg). We found that DATS treatment markedly improved left ventricular systolic pressure and the first derivative of left ventricular pressure, reduced myocardial infarct size as well as serum creatine kinase and lactate dehydrogenase activities. Furthermore, the myocardial apoptosis was also suppressed by DATS as evidenced by reduced apoptotic index and cleaved caspase-3 expression. However, these effects were abolished by EX527 (the inhibitor of SIRT1 signaling, 5 mg/kg). We further found that DATS effectively upregulated SIRT1 expression and its nuclear distribution. Additionally, PERK/eIF2α/ATF4/CHOP-mediated ER stress-induced apoptosis was suppressed by DATS treatment. Moreover, DATS significantly activated Nrf-2/HO-1 antioxidant signaling pathway, thus reducing Nox-2/4 expressions. However, the ameliorative effects of DATS on oxidative stress and ER stress-mediated myocardial apoptosis were inhibited by EX527 administration. Taken together, these data suggest that perioperative DATS treatment effectively ameliorates MI/R injury in type 1 diabetic setting by enhancing cardiac SIRT1 signaling. SIRT1 activation not only upregulated Nrf-2/HO-1-mediated antioxidant signaling pathway but also suppressed PERK/eIF2α/ATF4/CHOP-mediated ER stress level, thus reducing myocardial apoptosis and eventually preserving cardiac function.
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227
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Sulfonylureas as Initial Treatment for Type 2 Diabetes and the Risk of Severe Hypoglycemia. Am J Med 2018; 131:317.e11-317.e22. [PMID: 29032229 DOI: 10.1016/j.amjmed.2017.09.044] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/28/2017] [Accepted: 09/12/2017] [Indexed: 01/07/2023]
Abstract
PURPOSE The magnitude of the risk of severe hypoglycemia associated with sulfonylureas as the initial treatment for type 2 diabetes in the real-world setting is unknown. We assessed the risk of severe hypoglycemia associated with initiating monotherapy with sulfonylurea compared with metformin for the treatment of type 2 diabetes. METHODS By using the UK Clinical Practice Research Datalink and Hospital Episode Statistics linked to the Office for National Statistics, we identified a cohort of patients with type 2 diabetes who initiated sulfonylureas or metformin monotherapy between April 1, 1998, and December 31, 2012, with follow-up until December 31, 2013. Sulfonylurea users were matched one-to-one to metformin users by high-dimensional propensity scores. Hazard ratios (HRs) and 95% confidence intervals (CIs) of severe hypoglycemia, defined as requiring hospitalization, were estimated using Cox proportional hazards models comparing sulfonylureas with metformin monotherapy. RESULTS The study cohort consisted of 14,012 initiators of sulfonylureas matched to 14,012 initiators of metformin. The mean treated follow-up time was 1.41 (standard deviation, 1.84) years. Use of sulfonylurea was associated with an elevated incidence of severe hypoglycemia compared with metformin as the initiating monotherapy for type 2 diabetes (incidence rate, 2.4/1000 person-years; 95% CI, 1.90-2.90; HR, 4.53; 95% CI, 2.76-7.45). CONCLUSIONS Sulfonylureas, when prescribed as the initiating monotherapy for the treatment of type 2 diabetes, is associated with a 4.5-fold increase in the risk of severe hypoglycemia. Given the negative consequences of this outcome, clinicians should consider alternative hypoglycemic agents when metformin is not tolerated or contraindicated.
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228
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Oskarsson P, Antuna R, Geelhoed-Duijvestijn P, Krӧger J, Weitgasser R, Bolinder J. Impact of flash glucose monitoring on hypoglycaemia in adults with type 1 diabetes managed with multiple daily injection therapy: a pre-specified subgroup analysis of the IMPACT randomised controlled trial. Diabetologia 2018; 61:539-550. [PMID: 29273897 PMCID: PMC6448969 DOI: 10.1007/s00125-017-4527-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/09/2017] [Indexed: 01/01/2023]
Abstract
AIMS/HYPOTHESIS Evidence for the effectiveness of interstitial glucose monitoring in individuals with type 1 diabetes using multiple daily injection (MDI) therapy is limited. In this pre-specified subgroup analysis of the Novel Glucose-Sensing Technology and Hypoglycemia in Type 1 Diabetes: a Multicentre, Non-masked, Randomised Controlled Trial' (IMPACT), we assessed the impact of flash glucose technology on hypoglycaemia compared with capillary glucose monitoring. METHODS This multicentre, prospective, non-masked, RCT enrolled adults from 23 European diabetes centres. Individuals were eligible to participate if they had well-controlled type 1 diabetes (diagnosed for ≥5 years), HbA1c ≤ 58 mmol/mol [7.5%], were using MDI therapy and on their current insulin regimen for ≥3 months, reported self-monitoring of blood glucose on a regular basis (equivalent to ≥3 times/day) for ≥2 months and were deemed technically capable of using flash glucose technology. Individuals were excluded if they were diagnosed with hypoglycaemia unawareness, had diabetic ketoacidosis or myocardial infarction in the preceding 6 months, had a known allergy to medical-grade adhesives, used continuous glucose monitoring (CGM) within the previous 4 months or were currently using CGM or sensor-augmented pump therapy, were pregnant or planning pregnancy or were receiving steroid therapy for any disorders. Following 2 weeks of blinded (to participants and investigator) sensor wear by all participants, participants with sensor data for more than 50% of the blinded wear period (or ≥650 individual sensor results) were randomly assigned, in a 1:1 ratio by a central interactive web response system (IWRS) using the biased-coin minimisation method, to flash sensor-based glucose monitoring (intervention group) or self-monitoring of capillary blood glucose (control group). The control group had two further 14 day blinded sensor-wear periods at the 3 and 6 month time points. Participants, investigators and staff were not masked to group allocation. The primary outcome was the change in time in hypoglycaemia (<3.9 mmol/l) between baseline and 6 months in the full analysis set. RESULTS Between 4 September 2014 and 12 February 2015, 167 participants using MDI were enrolled. After screening and the baseline phase, participants were randomised to intervention (n = 82) and control groups (n = 81). One woman from each group was excluded owing to pregnancy; the full analysis set included 161 randomised participants. At 6 months, mean time in hypoglycaemia was reduced by 46.0%, from 3.44 h/day to 1.86 h/day in the intervention group (baseline adjusted mean change, -1.65 h/day), and from 3.73 h/day to 3.66 h/day in the control group (baseline adjusted mean change, 0.00 h/day), with a between-group difference of -1.65 (95% CI -2.21, -1.09; p < 0.0001). For participants in the intervention group, the mean ± SD daily sensor scanning frequency was 14.7 ± 10.7 (median 12.3) and the mean number of self-monitored blood glucose tests performed per day reduced from 5.5 ± 2.0 (median 5.4) at baseline to 0.5 ± 1.0 (median 0.1). The baseline frequency of self-monitored blood glucose tests by control participants was maintained (from 5.6 ± 1.9 [median 5.2] to 5.5 ± 2.6 [median 5.1] per day). Treatment satisfaction and perception of hypo/hyperglycaemia were improved compared with control. No device-related hypoglycaemia or safety-related issues were reported. Nine serious adverse events were reported for eight participants (four in each group), none related to the device. Eight adverse events for six of the participants in the intervention group were also reported, which were related to sensor insertion/wear; four of these participants withdrew because of the adverse event. CONCLUSIONS/INTERPRETATION Use of flash glucose technology in type 1 diabetes controlled with MDI therapy significantly reduced time in hypoglycaemia without deterioration of HbA1c, and improved treatment satisfaction. TRIAL REGISTRATION ClinicalTrials.gov NCT02232698 FUNDING: Abbott Diabetes Care, Witney, UK.
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Affiliation(s)
- Per Oskarsson
- Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institute, 141 86, Stockholm, Sweden
| | - Ramiro Antuna
- Department of Medicine, Clinica Diabetologica, Gijon, Spain
| | | | - Jens Krӧger
- Department of Diabetes, Zentrum für Diabetologie Hamburg Bergedorf, Hamburg, Germany
| | - Raimund Weitgasser
- Department of Medicine, Wehrle-Diakonissen Hospital, Salzburg, Austria
- 1st Department of Medicine, University Hospital of Paracelsus Medical Private University, Salzburg, Austria
| | - Jan Bolinder
- Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institute, 141 86, Stockholm, Sweden.
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229
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Gilsanz P, Karter AJ, Beeri MS, Quesenberry CP, Whitmer RA. The Bidirectional Association Between Depression and Severe Hypoglycemic and Hyperglycemic Events in Type 1 Diabetes. Diabetes Care 2018; 41:446-452. [PMID: 29255060 PMCID: PMC5829958 DOI: 10.2337/dc17-1566] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/20/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Severe hyperglycemia and hypoglycemia ("severe dysglycemia") are serious complications of type 1 diabetes (T1D). Depression has been associated with severe dysglycemia in type 2 diabetes but has not been thoroughly examined specifically in T1D. We evaluated bidirectional associations between depression and severe dysglycemia among older people with T1D. RESEARCH DESIGN AND METHODS We abstracted depression and severe dysglycemia requiring emergency room visit or hospitalization from medical health records in 3,742 patients with T1D during the study period (1996-2015). Cox proportional hazards models estimated the associations between depression and severe dysglycemia in both directions, adjusting for demographics, micro- and macrovascular complications, and HbA1c. RESULTS During the study period, 41% had depression and 376 (11%) and 641 (20%) had hyperglycemia and hypoglycemia, respectively. Depression was strongly associated with a 2.5-fold increased risk of severe hyperglycemic events (hazard ratio [HR] 2.47 [95% CI 2.00, 3.05]) and 89% increased risk of severe hypoglycemic events (HR 1.89 [95% CI 1.61, 2.22]). The association was strongest within the first 6 months (HRhyperglycemia 7.14 [95% CI 5.29, 9.63]; HRhypoglycemia 5.58 [95% CI 4.46, 6.99]) to 1 year (HRhyperglycemia 5.16 [95% CI 3.88, 6.88]; HRhypoglycemia 4.05 [95% CI 3.26, 5.04]) after depression diagnosis. In models specifying severe dysglycemia as the exposure, hyperglycemic and hypoglycemic events were associated with 143% (HR 2.43 [95% CI 2.03, 2.91]) and 74% (HR 1.75 [95% CI 1.49, 2.05]) increased risk of depression, respectively. CONCLUSIONS Depression and severe dysglycemia are associated bidirectionally among patients with T1D. Depression greatly increases the risk of severe hypoglycemic and hyperglycemic events, particularly in the first 6 months to 1 year after diagnosis, and depression risk increases after severe dysglycemia episodes.
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Affiliation(s)
- Paola Gilsanz
- Division of Research, Kaiser Permanente, Oakland, CA .,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | | | - Michal Schnaider Beeri
- Icahn School of Medicine at Mount Sinai, New York, NY.,The Joseph Sagol Neuroscience Center, Sheba Medical Center, Ramat Gan, Israel
| | | | - Rachel A Whitmer
- Division of Research, Kaiser Permanente, Oakland, CA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
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230
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Yi SW, Won YJ, Yi JJ. Low normal fasting glucose and risk of accidental death in Korean adults: A prospective cohort study. DIABETES & METABOLISM 2018; 45:60-66. [PMID: 29395814 DOI: 10.1016/j.diabet.2018.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 12/17/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
Abstract
AIM This study aimed to prospectively examine whether low normal glucose levels and hypoglycaemia are associated with increased mortality due to external causes, especially unintentional accidents. METHODS A total of 345,318 normoglycaemic Korean adults who had undergone health examinations during 2002-2003 were followed-up to 2013. To avoid potential biases related to glucose-lowering medication use, those with known diabetes or hyperglycaemia were excluded. RESULTS During 3.6 million person-years of follow-up, 1293 participants died because of unintentional accidents. Hazard ratios (HRs) for these accidental deaths were 1.26 (95% CI: 1.11-1.42), 1.60 (1.21-2.11) and 3.07 (1.37-6.85) for fasting serum glucose (FSG) levels of 70-79, 55-69 and <55mg/dL (3.9-4.4, 3.05-3.83 and <3.05mmol/L), respectively, compared with 80-99mg/dL (4.44-5.5mmol/L). FSG levels<80mg/dL were associated with an approximately 30% higher mortality due to accidents: specifically, 40% were non-fall-related injury; 50% were automobile-related; and 80% were motorcycle-related. The associations were weak (approximately 10% higher mortality, with P>0.05 for each cause) for deaths due to traffic accidents (pedestrians, pedal cyclists), falls, intentional self-harm and physical assault. The population attributable risks for FSG levels <80mg/dL were 10% (95% CI: 2-18%) for non-fall-related injury, 11% (6-17%) for car accidents and 17% (6-27%) for motorcycle accidents. CONCLUSION FSG levels of 70-79mg/dL (3.9-4.4mmol/L) as well as <70mg/dL are risk factors for accidental death. Appropriate management of the impact of FSG levels <80mg/dL might reduce unintended deaths due to non-fall-related injury, and automobile and motorcycle accidents, by ≥10%.
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Affiliation(s)
- S-W Yi
- Department of Preventive Medicine and Public Health, Catholic Kwandong University College of Medicine, Bumil-ro 579, 25601 Gangneung, Republic of Korea; Institute for Clinical and Translational Research, Catholic Kwandong University College of Medicine, 25601 Gangneung, Republic of Korea.
| | - Y J Won
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Catholic Kwandong University International St. Mary's Hospital, 22711 Incheon, Republic of Korea
| | - J-J Yi
- Institute for Occupational and Environmental Health, Catholic Kwandong University, 25601 Gangneung, Republic of Korea
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231
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Glutazumab, a novel long-lasting GLP-1/anti-GLP-1R antibody fusion protein, exerts anti-diabetic effects through targeting dual receptor binding sites. Biochem Pharmacol 2018; 150:46-53. [PMID: 29355505 DOI: 10.1016/j.bcp.2018.01.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/12/2018] [Indexed: 12/13/2022]
Abstract
AIMS Glucagon like-peptide-1 (GLP-1)-based drugs have been proposed as mono- or combined therapy for type 2 diabetes mellitus. Thus we characterized a novel antibody fusion protein engineered by linking the human GLP-1 derivative to a humanized GLP-1 receptor (GLP-1R) antibody via a peptide linker. MATERIALS AND METHODS Glutazumab was characterized by receptor binding and reporter activation assays, and its specificity was investigated with the aid of the cognate receptor antagonist exendin (9-39) and antibody Ab1. Pharmacokinetics was evaluated in Sprague-Dawley (SD) rats and cynomolgus monkeys, and pharmacodynamics was assessed in normal ICR and spontaneous type 2 diabetic KKAy mice. Hypoglycemic effects were evaluated after acute administration and glucose metabolism and β-cell function were assessed with repeated administrations. Dulaglutide was a positive control in all experiments. RESULTS Glutazumab significantly bound and activated GLP-1R, but the receptor antagonist exendin (9-39) did not inhibit the activation except when combined with Ab1. Single injection of glutazumab reduced the blood glucose in ICR mice and KKAy mice, and the half-lives in SD rats and cynomolgus monkeys were 18 h and 33.6 h. Repeated injections of glutazumab controlled glycemic fluctuations and improved β-cell function in KKAy mice. CONCLUSIONS As a novel GLP-1R agonist, glutazumab may be a potential treatment for T2DM.
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232
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Kaarsholm NC, Lin S, Yan L, Kelly T, van Heek M, Mu J, Wu M, Dai G, Cui Y, Zhu Y, Carballo-Jane E, Reddy V, Zafian P, Huo P, Shi S, Antochshuk V, Ogawa A, Liu F, Souza SC, Seghezzi W, Duffy JL, Erion M, Nargund RP, Kelley DE. Engineering Glucose Responsiveness Into Insulin. Diabetes 2018; 67:299-308. [PMID: 29097375 DOI: 10.2337/db17-0577] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 10/30/2017] [Indexed: 11/13/2022]
Abstract
Insulin has a narrow therapeutic index, reflected in a small margin between a dose that achieves good glycemic control and one that causes hypoglycemia. Once injected, the clearance of exogenous insulin is invariant regardless of blood glucose, aggravating the potential to cause hypoglycemia. We sought to create a "smart" insulin, one that can alter insulin clearance and hence insulin action in response to blood glucose, mitigating risk for hypoglycemia. The approach added saccharide units to insulin to create insulin analogs with affinity for both the insulin receptor (IR) and mannose receptor C-type 1 (MR), which functions to clear endogenous mannosylated proteins, a principle used to endow insulin analogs with glucose responsivity. Iteration of these efforts culminated in the discovery of MK-2640, and its in vitro and in vivo preclinical properties are detailed in this report. In glucose clamp experiments conducted in healthy dogs, as plasma glucose was lowered stepwise from 280 mg/dL to 80 mg/dL, progressively more MK-2640 was cleared via MR, reducing by ∼30% its availability for binding to the IR. In dose escalations studies in diabetic minipigs, a higher therapeutic index for MK-2640 (threefold) was observed versus regular insulin (1.3-fold).
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MESH Headings
- Animals
- Animals, Inbred Strains
- Binding, Competitive
- CHO Cells
- Cricetulus
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/metabolism
- Dogs
- Dose-Response Relationship, Drug
- Drug Design
- Drug Evaluation, Preclinical
- Half-Life
- Humans
- Hyperglycemia/prevention & control
- Hypoglycemia/chemically induced
- Hypoglycemia/prevention & control
- Hypoglycemic Agents/administration & dosage
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/pharmacokinetics
- Hypoglycemic Agents/therapeutic use
- Insulin, Regular, Human/adverse effects
- Insulin, Regular, Human/analogs & derivatives
- Insulin, Regular, Human/pharmacokinetics
- Insulin, Regular, Human/therapeutic use
- Lectins, C-Type/agonists
- Lectins, C-Type/genetics
- Lectins, C-Type/metabolism
- Ligands
- Male
- Mannose Receptor
- Mannose-Binding Lectins/agonists
- Mannose-Binding Lectins/genetics
- Mannose-Binding Lectins/metabolism
- Metabolic Clearance Rate
- Receptor, Insulin/agonists
- Receptor, Insulin/genetics
- Receptor, Insulin/metabolism
- Receptors, Cell Surface/agonists
- Receptors, Cell Surface/genetics
- Receptors, Cell Surface/metabolism
- Recombinant Proteins/adverse effects
- Recombinant Proteins/metabolism
- Recombinant Proteins/pharmacokinetics
- Recombinant Proteins/therapeutic use
- Swine
- Swine, Miniature
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Affiliation(s)
| | - Songnian Lin
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Lin Yan
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Theresa Kelly
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | - James Mu
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Margaret Wu
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Ge Dai
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Yan Cui
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Yonghua Zhu
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | - Vijay Reddy
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Peter Zafian
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Pei Huo
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Shuai Shi
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | - Aimie Ogawa
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Franklin Liu
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Sandra C Souza
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | | | - Joseph L Duffy
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Mark Erion
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Ravi P Nargund
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - David E Kelley
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
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233
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Abstract
BACKGROUND Treatment with antipsychotic drugs has been associated with glucose dysregulation in older outpatients, especially in the early stage of therapy. The underlying mechanism is, however, unclear. The aim of this study was to investigate changes in glucose levels during haloperidol use compared with the use of placebo among older hospitalized patients. METHODS This substudy was part of a larger multicenter, randomized, double blind, placebo-controlled clinical trial among hospitalized patients aged 70 years and older who had an increased risk of in-hospital delirium. Patients who were admitted to the Jeroen Bosch Hospital in 's-Hertogenbosch between June 2014 and February 2015 were invited to participate in the study. Participating patients were randomized for treatment and given 1 mg of haloperidol or a placebo twice daily for a maximum of 7 consecutive days (14 doses). Exclusion criteria for this substudy were the use of corticosteroids and changes in diabetes medication. Random blood samples to determine glucose levels were collected before day 1 and on day 6 of the study. Student independent sample t test was used to determine differences in glucose changes between both groups. RESULTS Twenty-nine patients were included (haloperidol, n = 14; placebo, n = 15). The mean glucose level for placebo users was 139.3 mg/dL (SD, 50.1) on day 1 and 140.8 mg/dL (SD, 45.7) on day 6, and the mean glucose level for haloperidol users was 139.9 mg/dL (SD, 71.0) on day 1 and 150.2 mg/dL (SD, 39.1) on day 6. The difference was not statistically significant (P = 0.685). CONCLUSIONS Short-term prophylactic use of haloperidol was not associated with changes in glucose levels in older hospitalized patients compared with those given a placebo in this small study.
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234
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Brandt SJ, Mayer JP, Ford J, Gelfanov VM, DiMarchi RD. Controlled intramolecular antagonism as a regulator of insulin receptor maximal activity. Peptides 2018; 100:18-23. [PMID: 29412818 DOI: 10.1016/j.peptides.2017.11.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 01/27/2023]
Abstract
In the treatment of insulin-dependent diabetes the risk of a fatal insulin overdose is a persistent fear to most patients. In order to potentially reduce the risk of overdose, we report the design, synthesis, and biochemical characterization of a set of insulin analogs designed to be fractionally reduced in maximal agonism at the insulin receptor isoforms. These analogs consist of native insulin that is site-specifically conjugated to a peptide-based insulin receptor antagonist. The structural refinement of the antagonist once conjugated to insulin provided a set of partial agonists exhibiting between 25 and 70% of the maximal agonism of native insulin at the two insulin receptor isoforms, with only slight differences in inherent potency. These rationally-designed partial agonists provide an approach to interrogate whether control of maximal activity can provide glycemic control with reduced hypoglycemic risk.
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Affiliation(s)
- Sara J Brandt
- Institute for Diabetes and Obesity, Helmholtz Center D-85748 Munich, Germany; Department of Chemistry, Indiana University, Bloomington, IN, 47405, United States
| | - John P Mayer
- Department of Chemistry, Indiana University, Bloomington, IN, 47405, United States
| | - James Ford
- Center for Genomics and Bioinformatics, Indiana University, Bloomington, IN, 47405, United States
| | - Vasily M Gelfanov
- Department of Chemistry, Indiana University, Bloomington, IN, 47405, United States; Novo Nordisk Research Center Indianapolis, Indianapolis, Indiana, 46241, United States
| | - Richard D DiMarchi
- Department of Chemistry, Indiana University, Bloomington, IN, 47405, United States; Novo Nordisk Research Center Indianapolis, Indianapolis, Indiana, 46241, United States.
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235
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Tentolouris A, Eleftheriadou I, Tentolouris N. Insulin degludec U100 is associated with lower risk for severe and symptomatic hypoglycemia as compared with insulin glargine U100 in subjects with type 1 diabetes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:63. [PMID: 29610753 DOI: 10.21037/atm.2017.12.28] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Anastasios Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Ioanna Eleftheriadou
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Nikolaos Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
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236
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Bally L, Thabit H, Hovorka R. Glucose-responsive insulin delivery for type 1 diabetes: The artificial pancreas story. Int J Pharm 2017; 544:309-318. [PMID: 29258910 DOI: 10.1016/j.ijpharm.2017.12.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/04/2017] [Accepted: 12/10/2017] [Indexed: 12/20/2022]
Abstract
Insulin replacement therapy is integral to the management of type 1 diabetes, which is characterised by absolute insulin deficiency. Optimal glycaemic control, as assessed by glycated haemoglobin, and avoidance of hyper- and hypoglycaemic excursions have been shown to prevent diabetes-related complications. Insulin pump use has increased considerably over the past decade with beneficial effects on glycaemic control, quality of life and treatment satisfaction. The advent and progress of ambulatory glucose sensor technology has enabled continuous glucose monitoring based on real-time glucose levels to be integrated with insulin therapy. Low glucose and predictive low glucose suspend systems are currently used in clinical practice to mitigate against hypoglycaemia, and provide the first step towards feedback glucose control. The more advanced technology approach, an artificial pancreas or a closed-loop system, gradually increases and decreases insulin delivery in a glucose-responsive fashion to mitigate against hyper- and hypoglycaemia. Randomised outpatient clinical trials over the past 5 years have demonstrated the feasibility, safety and efficacy of the approach, and the recent FDA approval of the first single hormone closed-loop system establishes a new standard of care for people with type 1 diabetes.
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Affiliation(s)
- Lia Bally
- Department of Diabetes, Endocrinology Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Hood Thabit
- Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom; Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
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237
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de Decker L, Hanon O, Boureau AS, Chapelet G, Dibon C, Pichelin M, Berrut G, Cariou B. Association Between Hypoglycemia and the Burden of Comorbidities in Hospitalized Vulnerable Older Diabetic Patients: A Cross-Sectional, Population-Based Study. Diabetes Ther 2017; 8:1405-1413. [PMID: 29086351 PMCID: PMC5688985 DOI: 10.1007/s13300-017-0319-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION From a patient-centered perspective, the assessment of risk factors of hypoglycemia is of critical importance for the management of type 2 diabetes (T2D). However, the association between the occurrence of hypoglycemia and high burden of comorbidities has been poorly studied in vulnerable older patients. Here, we aimed to determine whether a high burden of comorbidities is associated with hypoglycemia in very old patients with T2D. METHODS A total of 1552 elderly (age ≥ 80 years old) patients with T2D were recruited in a nationwide cross-sectional study performed in French geriatric care units. Hypoglycemia was defined as a confirmed blood glucose value level ≤ 70 mg/dL. Comorbidities were assessed using the Charlson Comorbidity Index (CCI). RESULTS Amongst the 1552 recruited patients (mean age 86.4 years), 415 (26.7%) had documented hypoglycemia. Compared to patients in whom hypoglycemia was not reported, they have a lower body weight (p = 0.004), a reduced eGFR (p < 0.001), a greater level of dependency (p < 0.001) as well as history of dementia (p = 0.006) and cardiovascular disease (p < 0.001), and a higher CCI (4.7 vs 3.8, p < 0.001). Patients with hypoglycemia had a higher frequency of daily self-monitoring blood glucose (SMBG) (p < 0.001) and insulin use (p < 0.001), with reduced sulfonylurea use (p < 0.001). In multivariate logistic regression analysis, insulin therapy (OR 3.32, p < 0.001), daily SMBG (OR 1.79, p = 0.02), CCI (OR 1.24, p = 0.01), and age (OR 0.96, p = 0.03) were independently associated with the risk of hypoglycemia. CONCLUSION In addition to insulin therapy, a high burden of comorbidities was independently associated with hypoglycemia in older vulnerable patients with T2D.
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Affiliation(s)
- Laure de Decker
- Laboratory of clinical and experimental therapeutics of infections, EA 3628, Nantes University, 44000, Nantes, France
- Department of Geriatrics, Nantes University Hospital, 44000, Nantes, France
| | - Olivier Hanon
- Department of Geriatrics, Broca Hospital, Public Hospital of Paris, 75013 Paris, France
- Laboratory of Alzheimer disease : genetic and vascular markers, neuropsychology, psychosocial interventions and technologies, EA 4468, Paris Descartes University, Sorbonne Paris Cité, 75006 Paris, France
| | | | - Guillaume Chapelet
- Laboratory of clinical and experimental therapeutics of infections, EA 3628, Nantes University, 44000, Nantes, France
- Department of Geriatrics, Nantes University Hospital, 44000, Nantes, France
| | - Christelle Dibon
- Department of Geriatrics, Nantes University Hospital, 44000, Nantes, France
| | - Matthieu Pichelin
- Department of Endocrinology, l'institut du thorax, Nantes University Hospital, 44000, Nantes, France
| | - Gilles Berrut
- Department of Geriatrics, Nantes University Hospital, 44000, Nantes, France
| | - Bertrand Cariou
- Department of Endocrinology, l'institut du thorax, Nantes University Hospital, 44000, Nantes, France.
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Sampson M, Bailey M, Clark J, Evans ML, Fong R, Hall H, Hambling C, Hadley-Brown M, Morrish N, Murphy H, Rayman GA, Vithian K, Winocour P, Harries A. A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health Science Network (EAHSN) model. Diabetes Res Clin Pract 2017; 133:50-59. [PMID: 28892731 DOI: 10.1016/j.diabres.2017.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/14/2017] [Accepted: 08/22/2017] [Indexed: 12/16/2022]
Abstract
AIMS We developed a new clinical integrated pathway linking a regional Ambulance Trust with a severe hypoglycaemia (SH) prevention team. We present clinical data from the first 2000 emergency calls taken through this new clinical pathway in the East of England. METHODS SH patients attended by Ambulance crew receive written information on SH avoidance, and are contacted for further education through a new regional SH prevention team. All patients are contacted unless they actively decline. RESULTS Median age (IQR) was 67 (50-80) years, 23.6% of calls were for patients over 80years old, and patients more than 90years old were more common than 20-25year olds in this population. Most calls were for patients (84.9%) who were insulin treated, even those over 80years (75%). One - third of patients attended after a call were unconscious on attendance. 5.6% of patients in this call population had 3 or more ambulance call outs, and they generated 17.6% of all calls. In total, 728 episodes (36.4%) were repeat calls. Insulin related events were clinically more severe than oral hypoglycaemic related events. Patients conveyed to hospitals (13.8%) were significantly older, with poorer recovery in biochemical hypoglycaemia after ambulance crew attendance. Only 19 (1%) opted out of further contact. Patients were contacted by the SH prevention team after a median 3 (0-6) days. The most common patient self - reported cause for their SH episode was related to perceived errors in insulin management (31.4%). CONCLUSIONS This new clinical service is simple, acceptable to patients, and a translatable model for prevention of recurrent SH in this largely elderly insulin treated SH population.
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Affiliation(s)
- Michael Sampson
- Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK.
| | | | - John Clark
- Department of Diabetes and Endocrinology, West Suffolk Hospital NHS Trust, Bury St. Edmunds, UK.
| | - Mark L Evans
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
| | - Rebekah Fong
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Helen Hall
- East of England Ambulance Trust, Melbourn, UK
| | | | | | - Nick Morrish
- Department of Diabetes and Endocrinology, Bedford Hospital NHS Trust, Bedford, UK.
| | - Helen Murphy
- Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK.
| | - Gerry A Rayman
- The Ipswich Diabetes Centre, Ipswich General Hospital NHS Trust, Ipswich, UK.
| | | | - Peter Winocour
- ENHIDE, East and North Hertfordshire NHS Trust, Herts, UK.
| | - Amanda Harries
- Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
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239
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Graveling AJ, Frier BM. The risks of nocturnal hypoglycaemia in insulin-treated diabetes. Diabetes Res Clin Pract 2017; 133:30-39. [PMID: 28888993 DOI: 10.1016/j.diabres.2017.08.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 12/29/2022]
Abstract
Over half of all episodes of severe hypoglycaemia (requiring external help) occur during sleep, but nocturnal hypoglycaemia is often asymptomatic and unrecognised. The precise incidence of nocturnal hypoglycaemia is difficult to determine with no agreed definition, but continuous glucose monitoring has shown that it occurs frequently in people taking insulin. Attenuation of the counter-regulatory responses to hypoglycaemia during sleep may explain why some episodes are undetected and more prolonged, and modifies cardiovascular responses. The morbidity and mortality associated with nocturnal hypoglycaemia is probably much greater than realised, causing seizures, coma and cardiovascular events and affecting quality of life, mood and work performance the following day. It may induce impaired awareness of hypoglycaemia. Cardiac arrhythmias that occur during nocturnal hypoglycaemia include bradycardia and ectopics that may provoke dangerous arrhythmias. Treatment strategies are discussed that may help to minimise the frequency of nocturnal hypoglycaemia.
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Affiliation(s)
- Alex J Graveling
- JJR Macleod Centre for Diabetes & Endocrinology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZP, UK.
| | - Brian M Frier
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK.
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240
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Haynes A, Hermann JM, Miller KM, Hofer SE, Jones TW, Beck RW, Maahs DM, Davis EA, Holl RW. Severe hypoglycemia rates are not associated with HbA1c: a cross-sectional analysis of 3 contemporary pediatric diabetes registry databases. Pediatr Diabetes 2017; 18:643-650. [PMID: 27878914 PMCID: PMC7162500 DOI: 10.1111/pedi.12477] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 09/07/2016] [Accepted: 10/15/2016] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the association between glycated hemoglobin (HbA1c) and severe hypoglycemia rates in patients with type 1 diabetes receiving usual care, by analysing data from the US Type 1 Diabetes Exchange (T1DX), German/Austrian Diabetes Patienten Verlaufsdokumenation (DPV), and Western Australian Children Diabetes Database (WACDD) diabetes registries. METHODS Data for patients with type 1 diabetes, aged <18 years with a minimum duration of diabetes of 2 years, were extracted from each registry for a 12-month observation period between 2011 and 2012 (7,102 T1DX, 18,887 DPV, and 865 WACDD). Rates of severe hypoglycemia (self-reported loss of consciousness/convulsion) were estimated per 100 patient-years and analyzed by HbA1c, source registry, treatment regimen, and age group. RESULTS Overall, the severe hypoglycemia rate per 100 patient years was 7.1, 3.3, and 6.7 in T1DX, DPV, and WACDD patients, respectively. Lower HbA1c was not associated with an increased rate of severe hypoglycemia when examined by source registry, treatment regimen, or age group. CONCLUSION An inverse relationship between mean HbA1c and risk of severe hypoglycemia was not observed in this study of 3, independent cohorts of children and adolescents with type 1 diabetes. Investigation in other large, longitudinal cohorts is recommended to further characterize the contemporary relationship between glycemic control and risk of severe hypoglycemia rates in pediatric patients with type 1 diabetes.
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Affiliation(s)
- Aveni Haynes
- Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Julia M. Hermann
- University of Ulm, ZIBMT, Institute of Epidemiology and Medical Biometry, Ulm, Germany,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | | | - Sabine E. Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Timothy W. Jones
- Telethon Kids Institute, The University of Western Australia, Perth, Australia,Department of Diabetes & Endocrinology, Princess Margaret Hospital, Perth, Australia
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida
| | - David M. Maahs
- Department of Pediatrics, Stanford University, Stanford, California
| | - Elizabeth A. Davis
- Telethon Kids Institute, The University of Western Australia, Perth, Australia,Department of Diabetes & Endocrinology, Princess Margaret Hospital, Perth, Australia
| | - Reinhard W. Holl
- University of Ulm, ZIBMT, Institute of Epidemiology and Medical Biometry, Ulm, Germany,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
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241
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Abstract
PURPOSE OF REVIEW In this article, we examine the nature of the complex relationship between insulin and cardiovascular disease. With metabolic abnormalities comes increased risk for cardiovascular complications. We discuss the key factors implicated in development and progression of cardiovascular disease, its relationship to insulin therapy, and what can be learned from large, recent cardiovascular outcome studies. RECENT FINDINGS Preclinical studies suggest that insulin has positive effects of facilitating glucose entry into cells and maintaining euglycemia and negative effects of favoring obesity and atherogenesis under certain conditions. Confounding this relationship is that cardiovascular morbidity is linked closely to duration and control of diabetes, and insulin is often used in patients with diabetes of longer duration. However, more recent clinical studies examining the cardiovascular safety of insulin therapy have been reassuring. Diabetes and cardiovascular outcomes are closely linked. Many studies have implicated insulin resistance and hyperinsulinemia as a major factor for poor cardiovascular outcomes. Additional studies link the anabolic effects of therapeutic insulin to weight gain, along with hypoglycemia, which may further aggravate cardiovascular risk in this population. Though good glycemic control has been shown to improve microvascular risks in type 1 and type 2 diabetes, what are the known cardiovascular effects of insulin therapy? The ORIGIN trial suggests at least a neutral effect of the basal insulin glargine on cardiovascular outcomes. Recent studies have demonstrated that ultra-long-acting insulin analogs like insulin degludec are non-inferior to insulin glargine with regard to cardiovascular outcomes.
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Affiliation(s)
- Sahana Pai Dongerkery
- MedStar Union Memorial Hospital, 201 East University Parkway, 33rd Street Professional Building, Baltimore, MD, 21218, USA
| | - Pamela R Schroeder
- MedStar Union Memorial Hospital, 201 East University Parkway, 33rd Street Professional Building, Baltimore, MD, 21218, USA
| | - Mansur E Shomali
- MedStar Union Memorial Hospital, 201 East University Parkway, 33rd Street Professional Building, Baltimore, MD, 21218, USA.
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242
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Abstract
Hypoglycemia is a common problem in patients with diabetes, and often limits those trying to achieve tight glucose control. Achieving optimal glucose control is necessary to prevent microvascular complications. Hypoglycemia can cause mild disturbances to daily life, but in severe cases can be fatal. Patient education of hypoglycemic medications, risk factors, contributing factors, and prevention strategies should be included in the care plan of patients at risk of developing hypoglycemia.
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Affiliation(s)
- Marjorie R Ortiz
- Department of Endocrine Neoplasia and Hormonal Disorders, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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243
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Zaccardi F, Dhalwani NN, Davies MJ, Khunti K. Comment on: "Strengths and Limitations of Healthcare Databases in the Evaluation of Hypoglycaemia". Diabetes Obes Metab 2017; 19:1495-1496. [PMID: 28523737 DOI: 10.1111/dom.13014] [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: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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244
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Bally L, Thabit H. Real-World Challenges of Controller Adaptation with the Artificial Pancreas. Diabetes Technol Ther 2017; 19:552-554. [PMID: 29045172 DOI: 10.1089/dia.2017.0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lia Bally
- 1 Department of Diabetes, Endocrinology, Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern , Switzerland
- 2 Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern , Switzerland
| | - Hood Thabit
- 3 Central Manchester University Hospitals NHS foundation Trust , Manchester Academic Health Science Centre, Manchester, UK
- 4 Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, UK
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245
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Maran A, Crepaldi C, Del Piccolo F, Macdonald I, Zarantonello L, Avogaro A, Amodio P. Cognitive, neurophysiologic and metabolic sequelae of previous hypoglycemic coma revealed by hyperinsulinemic-hypoglycemic clamp in type 1 diabetic patients. Metab Brain Dis 2017; 32:1543-1551. [PMID: 28589447 DOI: 10.1007/s11011-017-0041-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/24/2017] [Indexed: 12/16/2022]
Abstract
To examine the relationship between electroencephalographic (EEG) activity and hypoglycemia unawareness, we investigated early parameters of vigilance and awareness of various symptom categories in response to hypoglycemia in intensively treated type 1 diabetic (T1DM) patients with different degrees of hypoglycemia unawareness. Hypoglycemia was induced with a hyperinsulinemic-hypoglycemic clamp in six T1DM patients with a history of hypoglycemia unawareness previous severe hypoglycemic coma (SH) and in six T1DM patients without (C) history of hypoglycemia unawareness previous severe hypoglycemic coma. Cognitive function tests (four choice reaction time), counterregulatory responses (adrenaline), and symptomatic responses were evaluated at euglycemia (90 mg/dl) and during step-wise plasma glucose reduction (68, 58 and 49 mg/dl). EEG activity was recorded continuously throughout the study and analyzed by spectral analysis. Cognitive function deteriorated significantly at a glucose threshold of 55 ± 1 mg/dl in both groups (p = ns) during hypoglycemia, while the glucose threshold for autonomic symptoms was significantly lower in SH patients than in C patients (49 ± 1 vs. 54 ± 1 mg/dl, p < 0.05, respectively). In SH patients, eye-closed resting EEG showed a correlation between the mean dominance frequency and plasma glucose (r = 0.62, p < 0.001). Theta relative power increased during controlled hypoglycemia compared to euglycemia (21.6 ± 6 vs. 15.5 ± 3% Hz p < 0.05) and was higher than in the C group (21.6 ± 6 vs. 13.8 ± 3%, p < 0.03). The cognitive task beta activity was lower in the SH group than in the C group (14.8 ± 3 Hz, vs. 22.6 ± 4 vs. p < 0.03). Controlled hypoglycemia elicits cognitive dysfunction in both C and SH patients; however, significant EEG alterations during hypoglycemia were detected mainly in patients with a history of hypoglycemia unawareness and previous severe hypoglycemic coma. These data suggest that prior episodes of hypoglycemic coma modulate brain electric activity.
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Affiliation(s)
- Alberto Maran
- Department of Medicine, University of Padova, Padova, Italy.
- Cattedra di Malattie del Metabolismo, Dipartimento di Medicina, Università di Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Cristina Crepaldi
- Department of Medicine, University of Padova, Padova, Italy
- Cattedra di Malattie del Metabolismo, Dipartimento di Medicina, Università di Padova, Via Giustiniani 2, 35128, Padova, Italy
| | | | | | | | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
- Cattedra di Malattie del Metabolismo, Dipartimento di Medicina, Università di Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Piero Amodio
- Department of Medicine, University of Padova, Padova, Italy
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246
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Wang H, Donnan PT, Leese CJ, Duncan E, Fitzpatrick D, Frier BM, Leese GP. Temporal changes in frequency of severe hypoglycemia treated by emergency medical services in types 1 and 2 diabetes: a population-based data-linkage cohort study. Clin Diabetes Endocrinol 2017; 3:7. [PMID: 28824815 PMCID: PMC5558664 DOI: 10.1186/s40842-017-0045-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/04/2017] [Indexed: 02/03/2023] Open
Abstract
Background Almost 20 years ago, the frequencies of severe hypoglycemia requiring emergency medical treatment were reported in people with types 1 and 2 diabetes in the Tayside region of Scotland. With subsequent improvements in the treatment of diabetes, concurrent with changes in the provision of emergency medical care, a decline in the frequency of severe hypoglycemia could be anticipated. The present population-based data-linkage cohort study aimed to ascertain whether a temporal change has occurred in the incidence rates of hypoglycemia requiring emergency medical services in people with types 1 and 2 diabetes. Methods The study population comprised all people with diabetes in Tayside, Scotland over the period 1 January 2011 to 31 December 2012. Patients’ data from different healthcare sources were linked anonymously to measure the incidence rates of hypoglycemia requiring emergency medical services that include treatment by ambulance staff and in hospital emergency departments, and necessitated hospital admission. These were compared with data recorded in 1997–1998 in the same region. Results In January 2011 to December 2012, 2029 people in Tayside had type 1 diabetes and 21,734 had type 2 diabetes, compared to 977 and 7678, respectively, in June 1997 to May 1998. In people with type 2 diabetes, the proportion treated with sulfonylureas had declined from 36.8 to 22.4% (p < 0.001), while insulin-treatment had increased from 11.7 to 18.7% (p < 0.001). The incidence rate of hypoglycemia requiring emergency medical treatment had significantly fallen from 0.115 (95% CI: 0.094–0.136) to 0.082 (0.073–0.092) events per person per year in type 1 diabetes (p < 0.001), and from 0.118 (0.095–0.141) to 0.037 (0.003–0.041) in insulin-treated type 2 diabetes (p = 0.008). However, the absolute annual number of hypoglycemia events requiring emergency treatment was 1.4-fold higher. Conclusions Although from 1998 to 2012 the incidences of hypoglycemia requiring emergency medical services appeared to have declined by a third in type 1 diabetes and by two thirds in insulin-treated type 2 diabetes, because the prevalence of diabetes was higher (2.7 fold), the number of severe hypoglycemia events requiring emergency medical treatment was greater.
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Affiliation(s)
- Huan Wang
- Dundee Epidemiology and Biostatistics Unit, Population Health Sciences, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF UK
| | - Peter T Donnan
- Dundee Epidemiology and Biostatistics Unit, Population Health Sciences, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF UK
| | - Callum J Leese
- University of Edinburgh, Faculty of Medicine, Edinburgh, UK
| | - Edward Duncan
- NMAHP Research Unit, University of Stirling, Stirling, UK
| | - David Fitzpatrick
- NMAHP Research Unit, University of Stirling, Stirling, UK.,Scottish Ambulance Service, National Headquarters, Edinburgh, UK
| | - Brian M Frier
- BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Graham P Leese
- School of Medicine, Ninewells Hospital and Medical School, Dundee, UK
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247
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Zhong VW, Crandell JL, Shay CM, Gordon-Larsen P, Cole SR, Juhaeri J, Kahkoska AR, Maahs DM, Seid M, Forlenza GP, Mayer-Davis EJ. Dietary intake and risk of non-severe hypoglycemia in adolescents with type 1 diabetes. J Diabetes Complications 2017; 31:1340-1347. [PMID: 28476567 PMCID: PMC5526710 DOI: 10.1016/j.jdiacomp.2017.04.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/29/2017] [Accepted: 04/16/2017] [Indexed: 12/12/2022]
Abstract
AIMS To determine the association between dietary intake and risk of non-severe hypoglycemia in adolescents with type 1 diabetes. METHODS Type 1 adolescents from a randomized trial wore a blinded continuous glucose monitoring (CGM) system at baseline for one week in free-living conditions. Dietary intake was calculated as the average from two 24-h dietary recalls. Non-severe hypoglycemia was defined as having blood glucose <70mg/dL for ≥10min but not requiring external assistance, categorized as daytime and nocturnal (11PM-7AM). Data were analyzed using logistic regression models. RESULTS Among 98 participants with 14,277h of CGM data, 70 had daytime hypoglycemia, 66 had nocturnal hypoglycemia, 55 had both, and 17 had neither. Soluble fiber and protein intake were positively associated with both daytime and nocturnal hypoglycemia. Glycemic index, monounsaturated fat, and polyunsaturated fat were negatively associated with daytime hypoglycemia only. Adjusting for total daily insulin dose per kilogram eliminated all associations. CONCLUSIONS Dietary intake was differentially associated with daytime and nocturnal hypoglycemia. Over 80% of type 1 adolescents had hypoglycemia in a week, which may be attributed to the mismatch between optimal insulin dose needed for each meal and actually delivered insulin dose without considering quality of carbohydrate and nutrients beyond carbohydrate. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01286350.
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Affiliation(s)
- Victor W Zhong
- Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA
| | - Jamie L Crandell
- School of Nursing and Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - Christina M Shay
- Center for Health Metrics and Evaluation, the American Heart Association, Dallas, TX, USA
| | - Penny Gordon-Larsen
- Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Stephen R Cole
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Juhaeri Juhaeri
- Global Pharmacovigilance and Epidemiology, Sanofi, Bridgewater, NJ, USA
| | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA
| | - David M Maahs
- Lucile Packard Children's Hospital and Stanford University Medical Center, Stanford University, Palo Alto, CA, USA
| | - Michael Seid
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Gregory P Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
| | - Elizabeth J Mayer-Davis
- Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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248
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Lane W, Bailey TS, Gerety G, Gumprecht J, Philis-Tsimikas A, Hansen CT, Nielsen TSS, Warren M. Effect of Insulin Degludec vs Insulin Glargine U100 on Hypoglycemia in Patients With Type 1 Diabetes: The SWITCH 1 Randomized Clinical Trial. JAMA 2017; 318:33-44. [PMID: 28672316 PMCID: PMC5817477 DOI: 10.1001/jama.2017.7115] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 06/12/2017] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Hypoglycemia, common in patients with type 1 diabetes, is a major barrier to achieving good glycemic control. Severe hypoglycemia can lead to coma or death. OBJECTIVE To determine whether insulin degludec is noninferior or superior to insulin glargine U100 in reducing the rate of symptomatic hypoglycemic episodes. DESIGN, SETTING, AND PARTICIPANTS Double-blind, randomized, crossover noninferiority trial involving 501 adults with at least 1 hypoglycemia risk factor treated at 84 US and 6 Polish centers (January 2014-January 12, 2016) for two 32-week treatment periods, each with a 16-week titration and a 16-week maintenance period. INTERVENTIONS Patients were randomized 1:1 to receive once-daily insulin degludec followed by insulin glargine U100 (n = 249) or to receive insulin glargine U100 followed by insulin degludec (n = 252) and randomized 1:1 to morning or evening dosing within each treatment sequence. MAIN OUTCOMES AND MEASURES The primary end point was the rate of overall severe or blood glucose-confirmed (<56 mg/dL) symptomatic hypoglycemic episodes during the maintenance period. Secondary end points included the rate of nocturnal symptomatic hypoglycemic episodes and proportion of patients with severe hypoglycemia during the maintenance period. The noninferiority criterion for the primary end point and for the secondary end point of nocturnal hypoglycemia was defined as an upper limit of the 2-sided 95% CI for a rate ratio of 1.10 or lower; if noninferiority was established, 2-sided statistical testing for superiority was conducted. RESULTS Of the 501 patients randomized (mean age, 45.9 years; 53.7% men), 395 (78.8%) completed the trial. During the maintenance period, the rates of overall symptomatic hypoglycemia were 2200.9 episodes per 100 person-years' exposure (PYE) in the insulin degludec group vs 2462.7 episodes per 100 PYE in the insulin glargine U100 group for a rate ratio (RR) of 0.89 (95% CI, 0.85-0.94; P < .001 for noninferiority; P < .001 for superiority; rate difference, -130.31 episodes per 100 PYE; 95% CI, -193.5 to -67.16). The rates of nocturnal symptomatic hypoglycemia were 277.1 per 100 PYE in the insulin degludec group vs 428.6 episodes per 100 PYE in the insulin glargine U100 group, for an RR of 0.64 (95% CI, 0.56-0.73; P < .001 for noninferiority; P < .001 for superiority; rate difference, -61.94 episodes per 100 PYE; 95% CI, -83.85 to -40.03). A lower proportion of patients in the insulin degludec than in the insulin glargine U100 group experienced severe hypoglycemia during the maintenance period (10.3%, 95% CI, 7.3%-13.3% vs 17.1%, 95% CI, 13.4%-20.8%, respectively; McNemar P = .002; risk difference, -6.8%; 95% CI, -10.8% to -2.7%). CONCLUSIONS AND RELEVANCE Among patients with type 1 diabetes and at least 1 risk factor for hypoglycemia, 32 weeks' treatment with insulin degludec vs insulin glargine U100 resulted in a reduced rate of overall symptomatic hypoglycemic episodes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02034513.
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Affiliation(s)
- Wendy Lane
- Mountain Diabetes and Endocrine Center, Asheville, North Carolina
| | | | | | | | | | | | - Thor S. S. Nielsen
- Biostatistics Insulin & Diabetes Outcomes, Novo Nordisk A/S, Søborg, Denmark
| | - Mark Warren
- Physicians East PA, Greenville, North Carolina
- School of Osteopathic Medicine, Campbell University, Lillington, North Carolina
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249
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Klonoff DC, Alexander Fleming G, Muchmore DB, Frier BM. Hypoglycemia evaluation and reporting in diabetes: Importance for the development of new therapies. Diabetes Metab Res Rev 2017; 33. [PMID: 28054743 DOI: 10.1002/dmrr.2883] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/26/2016] [Indexed: 12/23/2022]
Abstract
Hypoglycemia complicating diabetes therapy is well recognized to be an ever-present threat to patients, their families, providers, payers, and regulators. Despite this being widely acknowledged, the regulatory stance on hypoglycemia as an endpoint in clinical trials to support new product registration has not evolved in any meaningful way since the publication of a position paper by an American Diabetes Association (ADA) Workgroup in 2005. As the impact of hypoglycemia on persons affected by diabetes is of major importance when assessing new treatments, the historical position of regulatory agencies on hypoglycemia is reviewed with respect to product approvals. The purpose of this article is to present proposals for facilitating development of therapies that reduce hypoglycemia risk through (1) development of composite measures of benefit for regulatory endpoints and (2) facilitation of the fulfillment of an unmet clinical need for reducing hypoglycemia. In view of greater comprehension of the effects of hypoglycemia, coupled with improved methodology to assess its frequency, the authors recommend: (1) a numerical cut point of <54 mg/dl (<3.0 mmol/L) as a clinically relevant level with which to define meaningful hypoglycemia for trials of diabetes therapies; (2) utilization in clinical trials of mature glucose monitoring technologies for purposes of regulatory evaluation and clinical decision-making; and (3) development of primary efficacy endpoint composites that include hypoglycemia rates and glycemic control.
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Affiliation(s)
- David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Health Services, San Mateo, California, USA
| | | | | | - Brian M Frier
- The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
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250
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Yoon S, Cho H, Kim J, Lee DW, Kim GH, Hong YS, Moon S, Park S, Lee S, Lee S, Bae S, Simonson DC, Lyoo IK. Brain changes in overweight/obese and normal-weight adults with type 2 diabetes mellitus. Diabetologia 2017; 60:1207-1217. [PMID: 28447116 DOI: 10.1007/s00125-017-4266-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 03/01/2017] [Indexed: 01/21/2023]
Abstract
AIMS/HYPOTHESIS Overweight and obesity may significantly worsen glycaemic and metabolic control in type 2 diabetes. However, little is known about the effects of overweight and obesity on the brains of people with type 2 diabetes. Here, we investigate whether the presence of overweight or obesity influences the brain and cognitive functions during early stage type 2 diabetes. METHODS This study attempted to uncouple the effects of overweight/obesity from those of type 2 diabetes on brain structures and cognition. Overweight/obese participants with type 2 diabetes had more severe and progressive abnormalities in their brain structures and cognition during early stage type 2 diabetes compared with participants with normal weight. Relationships between each of these measures and disease duration were also examined. RESULTS Global mean cortical thickness was lower in the overweight/obese type 2 diabetes group than in the normal-weight type 2 diabetes group (z = -2.96, p for group effect = 0.003). A negative correlation was observed between disease duration and global mean white matter integrity (z = 2.42, p for interaction = 0.02) in the overweight/obese type 2 diabetes group, but not in the normal-weight type 2 diabetes group. Overweight/obese individuals with type 2 diabetes showed a decrease in psychomotor speed performance related to disease duration (z = -2.12, p for interaction = 0.03), while normal-weight participants did not. CONCLUSIONS/INTERPRETATION The current study attempted to uncouple the effects of overweight/obesity from those of type 2 diabetes on brain structures and cognition. Overweight/obese participants with type 2 diabetes had more severe and progressive abnormalities in brain structures and cognition during early stage type 2 diabetes compared with normal-weight participants.
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Affiliation(s)
- Sujung Yoon
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea
- Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea
| | - Hanbyul Cho
- The Brain Institute, University of Utah, Salt Lake City, UT, USA
| | - Jungyoon Kim
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea
- Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea
| | - Do-Wan Lee
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea
| | - Geon Ha Kim
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea
| | - Young Sun Hong
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, South Korea
| | - Sohyeon Moon
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea
- Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, South Korea
| | - Shinwon Park
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea
- Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea
| | - Sunho Lee
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea
- Interdisciplinary Program in Neurosciences, Seoul National University, Seoul, South Korea
| | - Suji Lee
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea
- Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea
| | - Sujin Bae
- Department of Psychiatry, Chung Ang University Hospital, Seoul, South Korea
| | - Donald C Simonson
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - In Kyoon Lyoo
- Ewha Brain Institute, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemun-gu, Seoul, 03760, South Korea.
- Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea.
- Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, South Korea.
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