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Nørgaard SK, Mathiesen ER, Nørgaard K, Clausen TD, Damm P, Ringholm L. CopenFast trial: Faster-acting insulin Fiasp versus insulin NovoRapid in the treatment of women with type 1 or type 2 diabetes during pregnancy and lactation - a randomised controlled trial. BMJ Open 2021; 11:e045650. [PMID: 33837106 PMCID: PMC8043014 DOI: 10.1136/bmjopen-2020-045650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Faster-acting insulin aspart (Fiasp) is approved for use in pregnancy and lactation, but no clinical study has evaluated its effects during this life stage in women with pre-existing diabetes. The aim of the CopenFast trial is to evaluate the effect of Fiasp compared with insulin aspart (NovoRapid) on maternal glycaemic control during pregnancy, delivery and lactation and on fetal growth and infant health. METHODS AND ANALYSIS An open-label randomised controlled trial of pregnant women with type 1 or type 2 diabetes including women on multiple daily injection (MDI) therapy or insulin pump therapy. During a 2-year inclusion period, approximately 220 women will be randomised 1:1 to Fiasp or NovoRapid in early pregnancy and followed until 3 months after delivery. At 9, 21 and 33 gestational weeks and during planned induction of labour or caesarean section, women are offered blinded continuous glucose monitoring (CGM) for 7 days. Randomisation will stratify for type of diabetes and insulin treatment modality (MDI or insulin pump therapy, respectively). Health status of the infants will be followed until 3 months of age. The primary outcome is birth weight SD score adjusted for gestational age and gender. Secondary outcomes include maternal glycaemic control including glycated haemoglobin, preprandial and postprandial self-monitored plasma glucose levels, episodes of mild and severe hypoglycaemia, maternal gestational weight gain and weight retention, CGM time spent in, above and below target ranges as well as pregnancy outcomes including pre-eclampsia, preterm delivery, perinatal mortality and neonatal morbidity. Data analysis will be performed according to the intention-to-treat principle. ETHICS AND DISSEMINATION The trial has been approved by the Regional Ethics Committee (H-19029966) on 7 August 2019. Results will be sought disseminated in peer-reviewed journals and at scientific meetings. TRIAL REGISTRATION NUMBER NCT03770767.
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Affiliation(s)
- Sidse Kjærhus Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth Reinhardt Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | | | - Tine Dalsgaard Clausen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Gynaecology and Obstetrics, Nordsjaellands Hospital, Hillerod, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
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202
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Kuniss N, Kramer G, Müller UA, Wolf G, Kloos C. Diabetes related distress is high in inpatients with diabetes. Diabetol Metab Syndr 2021; 13:40. [PMID: 33836823 PMCID: PMC8034190 DOI: 10.1186/s13098-021-00659-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/29/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The aim of the present study was to assess diabetes-related distress in inpatients and its association with metabolic control in people with diabetes type 1 (DM1) and type 2 (DM2). RESEARCH DESIGN AND METHODS In a cross-sectional study, 107 inpatients with DM1 (age 45.9 years, diabetes duration 18.7 years, HbA1c 8.4%/67.8 mmol/mol) and 109 with DM2 (age 62.0 years, diabetes duration 16.2 years, HbA1c 8.9%/74.3 mmol/mol) from a University department for endocrinology and metabolic diseases (Germany) were included over 2 years. Diabetes-related distress was assessed with the PAID questionnaire (range 0-100, higher scores imply higher diabetes-related distress, cut-off ≥ 40). The PAID questionnaire was completed by 214 of 216 participants. RESULTS Fifty-one of 214 individuals (23.8%) showed high distress (PAID score ≥ 40). The mean PAID score was 28.1 ± 17.5 in all participants with no difference between DM1 and DM2 (28.1 ± 17.4 vs. 26.2 ± 16.9, p = 0.532). Individuals with DM2 on insulin scored higher than patients without insulin (27.8 ± 17.6 vs. 18.7 ± 8.5, p = 0.004). Additionally, people with DM1 treated with a system for continuous glucose monitoring (n = 50, 33.1 ± 18.8) scored higher than participants without such system (n = 32, 20.6 ± 13.3, p = 0.001). HbA1c was not correlated with the PAID score in both, DM1 (r = 0.040, p = 0.684) and DM2 (r = - 0.024, p = 0.804). Participants with DM2 and severe hypoglycaemia/last 12 months scored higher than people without (PAID score 43.0 ± 20.4 vs. 25.1 ± 16.5, p = 0.026). Frequency of non-severe hypoglycaemia was not associated with the PAID score in DM1 and DM2. CONCLUSIONS Patients with diabetes treated in hospital for problems with diabetes suffer frequently from diabetes-related distress (~ 24%) regardless of diabetes type.
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Affiliation(s)
- Nadine Kuniss
- Department of Internal Medicine III, Endocrinology and Metabolic Disorders, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
- Outpatient Healthcare Centre Dr. med. Kielstein, Erfurt, Germany.
| | - Guido Kramer
- Department of Internal Medicine III, Endocrinology and Metabolic Disorders, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Ulrich A Müller
- Outpatient Healthcare Centre Dr. med. Kielstein, Erfurt, Germany
| | - Gunter Wolf
- Department of Internal Medicine III, Endocrinology and Metabolic Disorders, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Christof Kloos
- Department of Internal Medicine III, Endocrinology and Metabolic Disorders, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
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203
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Malone C, Mathiason MA, Stenstrup E, Tracy MF. Hypoglycemia: Comparison of Health Status Outcomes Between Patients After Allogeneic Hematopoietic Cell Transplantation. Clin J Oncol Nurs 2021; 25:161-168. [PMID: 33739342 DOI: 10.1188/21.cjon.161-168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients who have undergone hematopoietic cell transplantation (HCT) often face lengthy hospital stays. Hospitalized patients' compromised health status puts them at risk for complications to recovery when glucose is not controlled. OBJECTIVES This study aimed to investigate differences in outcomes in patients who experienced hypoglycemia compared to patients who did not experience hypoglycemia post-allogeneic HCT. METHODS A retrospective chart review and secondary data analysis were conducted. The sample consisted of 198 adult patients hospitalized for their first allogeneic HCT at the University of Minnesota Medical Center between August 2015 and December 2017. Hypoglycemic patients were compared with nonhypoglycemic patients until discharge or 100 hospitalization days post-transplantation. FINDINGS A total of 20 patients (10%) experienced hypoglycemic events during the study time frame. There were significant differences between the two groups. Hypoglycemia may be a marker for higher acuity illness in this population. Nurses should increase vigilance in managing the blood glucose levels of patients undergoing HCT with known comorbidities and complications.
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204
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von Herrath M, Bain SC, Bode B, Clausen JO, Coppieters K, Gaysina L, Gumprecht J, Hansen TK, Mathieu C, Morales C, Mosenzon O, Segel S, Tsoukas G, Pieber TR. Anti-interleukin-21 antibody and liraglutide for the preservation of β-cell function in adults with recent-onset type 1 diabetes: a randomised, double-blind, placebo-controlled, phase 2 trial. Lancet Diabetes Endocrinol 2021; 9:212-224. [PMID: 33662334 DOI: 10.1016/s2213-8587(21)00019-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Type 1 diabetes is characterised by progressive loss of functional β-cell mass, necessitating insulin treatment. We aimed to investigate the hypothesis that combining anti-interleukin (IL)-21 antibody (for low-grade and transient immunomodulation) with liraglutide (to improve β-cell function) could enable β-cell survival with a reduced risk of complications compared with traditional immunomodulation. METHODS This randomised, parallel-group, placebo-controlled, double-dummy, double-blind, phase 2 trial was done at 94 sites (university hospitals and medical centres) in 17 countries. Eligible participants were adults aged 18-45 years with recently diagnosed type 1 diabetes and residual β-cell function. Individuals with unstable type 1 diabetes (defined by an episode of severe diabetic ketoacidosis within 2 weeks of enrolment) or active or latent chronic infections were excluded. Participants were randomly assigned (1:1:1:1), with stratification by baseline stimulated peak C-peptide concentration (mixed-meal tolerance test [MMTT]), to the combination of anti-IL-21 and liraglutide, anti-IL-21 alone, liraglutide alone, or placebo, all as an adjunct to insulin. Investigators, participants, and funder personnel were masked throughout the treatment period. The primary outcome was the change in MMTT-stimulated C-peptide concentration at week 54 (end of treatment) relative to baseline, measured via the area under the concentration-time curve (AUC) over a 4 h period for the full analysis set (intention-to-treat population consisting of all participants who were randomly assigned). After treatment cessation, participants were followed up for an additional 26-week off-treatment observation period. This trial is registered with ClinicalTrials.gov, NCT02443155. FINDINGS Between Nov 10, 2015, and Feb 27, 2019, 553 adults were assessed for eligibility, of whom 308 were randomly assigned to receive either anti-IL-21 plus liraglutide, anti-IL-21, liraglutide, or placebo (77 assigned to each group). Compared with placebo (ratio to baseline 0·61, 39% decrease), the decrease in MMTT-stimulated C-peptide concentration from baseline to week 54 was significantly smaller with combination treatment (0·90, 10% decrease; estimated treatment ratio 1·48, 95% CI 1·16-1·89; p=0·0017), but not with anti-IL-21 alone (1·23, 0·97-1·57; p=0·093) or liraglutide alone (1·12, 0·87-1·42; p=0·38). Despite greater insulin use in the placebo group, the decrease in HbA1c (a key secondary outcome) at week 54 was greater with all active treatments (-0·50 percentage points) than with placebo (-0·10 percentage points), although the differences versus placebo were not significant. The effects diminished upon treatment cessation. Changes in immune cell subsets across groups were transient and mild (<10% change over time). The most frequently reported adverse events included gastrointestinal disorders, in keeping with the known side-effect profile of liraglutide. The rate of hypoglycaemic events did not differ significantly between active treatment groups and placebo, with an exception of a lower rate in the liraglutide group than in the placebo group during the treatment period. No events of diabetic ketoacidosis were observed. One participant died while on liraglutide (considered unlikely to be related to trial treatment) in connection with three reported adverse events (hypoglycaemic coma, pneumonia, and brain oedema). INTERPRETATION The combination of anti-IL-21 and liraglutide could preserve β-cell function in recently diagnosed type 1 diabetes. The efficacy of this combination appears to be similar to that seen in trials of other disease-modifying interventions in type 1 diabetes, but with a seemingly better safety profile. Efficacy and safety should be further evaluated in a phase 3 trial programme. FUNDING Novo Nordisk.
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Affiliation(s)
| | | | - Bruce Bode
- Atlanta Diabetes Associates, Atlanta, GA, USA; Emory University School of Medicine, Atlanta, GA, USA
| | | | | | | | | | | | - Chantal Mathieu
- Clinical and Experimental Endocrinology, UZ Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Cristobal Morales
- Endocrinology and Nutrition Department, Virgen Macarena Hospital, Seville, Spain
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Centre, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - George Tsoukas
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
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205
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Markmann JF, Rickels MR, Eggerman TL, Bridges ND, Lafontant DE, Qidwai J, Foster E, Clarke WR, Kamoun M, Alejandro R, Bellin MD, Chaloner K, Czarniecki CW, Goldstein JS, Hering BJ, Hunsicker LG, Kaufman DB, Korsgren O, Larsen CP, Luo X, Naji A, Oberholzer J, Posselt AM, Ricordi C, Senior PA, Shapiro AMJ, Stock PG, Turgeon NA. Phase 3 trial of human islet-after-kidney transplantation in type 1 diabetes. Am J Transplant 2021; 21:1477-1492. [PMID: 32627352 PMCID: PMC9074710 DOI: 10.1111/ajt.16174] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 01/25/2023]
Abstract
Allogeneic islet transplant offers a minimally invasive option for β cell replacement in the treatment of type 1 diabetes (T1D). The CIT consortium trial of purified human pancreatic islets (PHPI) in patients with T1D after kidney transplant (CIT06), a National Institutes of Health-sponsored phase 3, prospective, open-label, single-arm pivotal trial of PHPI, was conducted in 24 patients with impaired awareness of hypoglycemia while receiving intensive insulin therapy. PHPI were manufactured using standardized processes. PHPI transplantation was effective with 62.5% of patients achieving the primary endpoint of freedom from severe hypoglycemic events and HbA1c ≤ 6.5% or reduced by ≥ 1 percentage point at 1 year posttransplant. Median HbA1c declined from 8.1% before to 6.0% at 1 year and 6.3% at 2 and 3 years following transplant (P < .001 for all vs baseline), with related improvements in hypoglycemia awareness and glucose variability. The improved metabolic control was associated with better health-related and diabetes-related quality of life. The procedure was safe and kidney allograft function remained stable after 3 years. These results add to evidence establishing allogeneic islet transplant as a safe and effective treatment for patients with T1D and unstable glucose control despite intensive insulin treatment, supporting the indication for PHPI in the post-renal transplant setting.
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Affiliation(s)
- James F. Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael R. Rickels
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Thomas L. Eggerman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Nancy D. Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - David E. Lafontant
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, Iowa
| | - Julie Qidwai
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, Iowa
| | - Eric Foster
- Ferring Pharmaceuticals, Parsippany, New Jersey
| | - William R. Clarke
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, Iowa
| | - Malek Kamoun
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rodolfo Alejandro
- Diabetes Research Institute and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, Florida
| | - Melena D. Bellin
- Department of Endocrinology, University of Minnesota, Minneapolis, Minnesota
| | - Kathryn Chaloner
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, Iowa
| | - Christine W. Czarniecki
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Julia S. Goldstein
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Bernhard J. Hering
- Schulze Diabetes Institute and Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Lawrence G. Hunsicker
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, Iowa
| | - Dixon B. Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Olle Korsgren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Xunrong Luo
- Department of Medicine, Duke University, Durham, North Carolina
| | - Ali Naji
- Division of Transplantation, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - José Oberholzer
- Department of Surgery, University of Illinois, Chicago, Illinois
| | - Andrew M. Posselt
- Department of Surgery, University of California, San Francisco, California
| | - Camillo Ricordi
- Diabetes Research Institute and Clinical Cell Transplant Program, University of Miami Miller School of Medicine, Miami, Florida
| | - Peter A. Senior
- Clinical Islet Transplant Program and Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - A. M. James Shapiro
- Clinical Islet Transplant Program and Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Peter G. Stock
- Department of Surgery, University of California, San Francisco, California
| | - Nicole A. Turgeon
- Department of Surgery, University of Texas Dell Medical School, Austin, Texas
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206
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Chrzanowski J, Michalak A, Łosiewicz A, Kuśmierczyk H, Mianowska B, Szadkowska A, Fendler W. Improved Estimation of Glycated Hemoglobin from Continuous Glucose Monitoring and Past Glycated Hemoglobin Data. Diabetes Technol Ther 2021; 23:293-305. [PMID: 33112161 DOI: 10.1089/dia.2020.0433] [Citation(s) in RCA: 3] [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] [Indexed: 12/18/2022]
Abstract
Background: Accurate estimation of glycated hemoglobin (HbA1c) from continuous glucose monitoring (CGM) remains challenging in clinic. We propose two statistical models and validate them in real-life conditions against the current standard, glucose management indicator (GMI). Materials and Methods: Modeling utilized routinely collected data from patients with type 1 diabetes from central Poland (eligibility criteria: age >1 year, diabetes duration >3 months, and CGM use between 01/01/2015 and 12/31/2019). CGM records were extracted from dedicated Medtronic/Abbott databases and cross-referenced with HbA1c values; 28-day periods preceding HbA1c measurement with >75% of the sensor-active time were analyzed. We developed a mixed linear regression, including glycemic variability indices and patient's ID (glucose variability-based patient specific model, GV-PS) intended for closed-group use and linear regression using patient-specific error of GMI (proportional error-based patient agnostic model, PE-PA) for general use. Models were validated with either new HbA1cs from closed-group patients or separate patient-HbA1c pool. External validation was performed with data from clinical trials. Performance metrics included bias, its 95% confidence interval (95% CI), coefficient of determination (R2), and root mean square error (RMSE). Results: We included 723 HbA1c-CGM pairs from 174 patients (mean age 9.9 ± 4.4 years and diabetes duration 3.7 ± 3.6 years). GMI yielded R2 = 0.58, with different bias between Medtronic and Abbott devices [0.120% vs. -0.152%, P < 0.0001], and overall 95% CI = -0.9% to +1%, RMSE = 0.47%. GV-PS successfully captured patient-specific variance (closed-group validation: R2 = 0.83, bias = 0.026%, 95% CI = -0.562% to 0.591%, RMSE = 0.31%). PE-PA performed similarly on new patients (R2 = 0.76, bias = -0.069%, 95% CI = -0.790% to 0.653%, RMSE = 0.37%). In external validation GMI, GV-PS, and PE-PA produced 73.8%, 87.5%, and 91.0% predictions within 0.5% (5.5 mmol/mol) from the true value. Conclusion: Constructed models performed better than GMI. PE-PA provided an accurate estimate of HbA1c with fast and straightforward implementation.
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Affiliation(s)
- Jędrzej Chrzanowski
- Department of Biostatistics and Translational Medicine, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Arkadiusz Michalak
- Department of Biostatistics and Translational Medicine, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Aleksandra Łosiewicz
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Hanna Kuśmierczyk
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Beata Mianowska
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Szadkowska
- Department of Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Wojciech Fendler
- Department of Biostatistics and Translational Medicine, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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207
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Henriksen MM, Andersen HU, Thorsteinsson B, Pedersen-Bjergaard U. Effects of continuous glucose monitor-recorded nocturnal hypoglycaemia on quality of life and mood during daily life in type 1 diabetes. Diabetologia 2021; 64:903-913. [PMID: 33443591 DOI: 10.1007/s00125-020-05360-9] [Citation(s) in RCA: 8] [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: 05/06/2020] [Accepted: 10/26/2020] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS The aim of this work was to assess the effect of spontaneous nocturnal hypoglycaemia on quality of life and mood during subsequent days in type 1 diabetes. METHODS A total of 153 people with type 1 diabetes participated in 6 days of blinded continuous glucose monitoring while documenting hypoglycaemic symptoms, quality of life and mood, daily. Hypoglycaemia was defined by interstitial glucose ≤3.9 mmol/l (IG3.9) and ≤ 3.0 mmol/l (IG3.0) for ≥15 min and was classified as asymptomatic if no hypoglycaemic symptoms were reported. RESULTS Self-estimated quality of life assessed by the EQ-5D VAS (but not by the WHO Well-Being Index) was higher the day after asymptomatic (but not after symptomatic) hypoglycaemic nights, as compared with non-hypoglycaemic nights (IG3.9, p = 0.021; IG3.0, p = 0.048). The effect increased with lower glucose nadir and longer duration of nocturnal hypoglycaemia (IG3.9, p = 0.03). The finding was confined to participants with impaired hypoglycaemia awareness. There was no effect of nocturnal hypoglycaemia on mood or self-estimated effectiveness at work the following day. CONCLUSIONS/INTERPRETATION Individuals with type 1 diabetes and impaired hypoglycaemia awareness reported higher quality of life on days preceded by nights with asymptomatic (but not symptomatic) hypoglycaemia. The effect was amplified by lower glucose nadir and longer duration of the episodes and may help explain resistance to implementation of interventions to reduce hypoglycaemia in many people with impaired hypoglycaemia awareness.
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Affiliation(s)
- Marie M Henriksen
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark.
| | | | - Birger Thorsteinsson
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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208
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Edelman SV, Cavaiola TS, Boeder S, Pettus J. Utilizing continuous glucose monitoring in primary care practice: What the numbers mean. Prim Care Diabetes 2021; 15:199-207. [PMID: 33257275 DOI: 10.1016/j.pcd.2020.10.013] [Citation(s) in RCA: 4] [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: 06/17/2020] [Revised: 10/26/2020] [Accepted: 10/31/2020] [Indexed: 12/17/2022]
Abstract
Use of continuous glucose monitoring (CGM) has been shown to improve glycemia control, reduce hypoglycemia, lower glycemic variability and enhance quality of life for individuals with type 1 diabetes and type 2 diabetes. However, many primary care physicians may be unfamiliar with the how CGM data can interpreted and acted upon. As adoption of this technology continues to grow, primary care physicians will be challenged to integrate CGM into their clinical practices. This article is intended to provide clinicians with practical guidance in interpreting and utilizing CGM data with their patients.
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Affiliation(s)
- Steven V Edelman
- University of California San Diego and Taking Control of Your Diabetes 501c3, San Diego, CA 92161, USA.
| | - Tricia Santos Cavaiola
- Department of Medicine, Clinical and Translational Research Institute (CTRI), San Diego, CA 92161, USA.
| | - Schafer Boeder
- Department of Medicine, Clinical and Translational Research Institute (CTRI), University of California SanDiego, San Diego, CA 92161, USA.
| | - Jeremy Pettus
- Department of Medicine, Clinical and Translational Research Institute (CTRI), University of California SanDiego, San Diego, CA 92161, USA.
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209
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Urva S, Quinlan T, Landry J, Martin J, Loghin C. Effects of Renal Impairment on the Pharmacokinetics of the Dual GIP and GLP-1 Receptor Agonist Tirzepatide. Clin Pharmacokinet 2021; 60:1049-1059. [PMID: 33778934 PMCID: PMC8332596 DOI: 10.1007/s40262-021-01012-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 12/27/2022]
Abstract
Background and Aims The pharmacokinetics (PK) and single-dose tolerability of tirzepatide, a dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist being developed for once-weekly treatment of type 2 diabetes (T2D), weight management, and nonalcoholic steatohepatitis, was evaluated in subjects with renal impairment versus healthy subjects with normal renal function. Methods Forty-five subjects, categorized by baseline renal status, i.e. mild (n = 8, estimated glomerular filtration rate [eGFR] 60–89 mL/min/1.73m2), moderate (n = 8, eGFR 30–59 mL/min/1.73m2), severe renal impairment (n = 7, eGFR < 30 mL/min/1.73m2), end-stage renal disease requiring dialysis (n = 8), and normal renal function (n = 14, eGFR ≥ 90 mL/min/1.73m2), received a single subcutaneous dose of tirzepatide 5 mg. Tirzepatide plasma concentrations up to 648 h postdose were measured to compute PK parameters. The primary analysis evaluated the ratios of area under the plasma concentration–time curves (AUCs) and maximum plasma drug concentration (Cmax) of renal impairment versus the normal renal function group (90% confidence interval [CI]). In addition, the relationship between PK parameters and continuous variables of renal function was assessed by linear regression. Results Tirzepatide exposure was similar across renal impairment groups and healthy subjects. The 90% CI of ratios of AUCs and Cmax comparing each renal impairment group versus normal renal function spanned unity, except for a 25–29% increase in AUCs in the moderate renal impairment group. There was no significant relationship between tirzepatide exposure and eGFR. Few adverse events were reported across the renal impairment and normal renal function groups. The majority were mild in severity and of a gastrointestinal nature in the renal impairment groups. Conclusion There were no clinically relevant effects of renal impairment on tirzepatide PK. Dose adjustment may not be required for patients with renal impairment. Clinical Trial Registration ClinicalTrials.gov NCT03482024. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01012-2.
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Affiliation(s)
- Shweta Urva
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
| | - Tonya Quinlan
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - John Landry
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Jennifer Martin
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Corina Loghin
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
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210
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Cruz-Flores S. Neurological Complications of Endocrine Emergencies. Curr Neurol Neurosci Rep 2021; 21:21. [PMID: 33709163 DOI: 10.1007/s11910-021-01105-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Endocrine disorders are the result of insufficient or excessive hormonal production. The clinical course is long, and the manifestations are nonspecific due to the systemic effect of hormones across many organs and systems including the nervous system. This is a narrative review of the recent evidence of the diagnosis and treatment approach of these medical and neurological emergencies. RECENT FINDINGS With the possible exception of diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia, endocrinological emergencies are complex, uncommon yet life-threatening conditions with protean and often nonspecific early clinical signs. They frequently are the first manifestation of the endocrine derangement. The systemic effects of hormones extend to the nervous system and as such, these conditions can present with neurological complications manifested, in most cases, by a diffuse dysfunction of the brain in the form of encephalopathy, delirium, seizures, and coma; or specific and peculiar syndromes such as hemichorea, hemiballism, and epilepsia partialis continua. The severity of these conditions often necessitates management in the intensive care unit requiring substantial supportive care in addition to specific targeted therapy to correct the hormonal metabolic abnormalities while at the same time blocking hormonal activity, in cases of excessive function, or supplementing hormonal deficiencies. Endocrine emergencies and their neurological complications are infrequent. The major challenge for most is early recognition. Their morbidity and mortality are high and their diagnosis requires high index of suspicion. The neurological complication most often improves with the correction of the metabolic derangement and their acuity and severity require admission to the intensive care unit.
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Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA.
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Frias JP, Bonora E, Nevarez Ruiz L, Li YG, Yu Z, Milicevic Z, Malik R, Bethel MA, Cox DA. Efficacy and Safety of Dulaglutide 3.0 mg and 4.5 mg Versus Dulaglutide 1.5 mg in Metformin-Treated Patients With Type 2 Diabetes in a Randomized Controlled Trial (AWARD-11). Diabetes Care 2021; 44:765-773. [PMID: 33397768 PMCID: PMC7896253 DOI: 10.2337/dc20-1473] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/01/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare efficacy and safety of dulaglutide at doses of 3.0 and 4.5 mg versus 1.5 mg in patients with type 2 diabetes inadequately controlled with metformin. RESEARCH DESIGN AND METHODS Patients were randomly assigned to once-weekly dulaglutide 1.5 mg, 3.0 mg, or 4.5 mg for 52 weeks. The primary objective was determining superiority of dulaglutide 3.0 mg and/or 4.5 mg over 1.5 mg in HbA1c reduction at 36 weeks. Secondary superiority objectives included change in body weight. Two estimands addressed efficacy objectives: treatment regimen (regardless of treatment discontinuation or rescue medication) and efficacy (on treatment without rescue medication) in all randomly assigned patients. RESULTS Mean baseline HbA1c and BMI in randomly assigned patients (N = 1,842) was 8.6% (70 mmol/mol) and 34.2 kg/m2, respectively. At 36 weeks, dulaglutide 4.5 mg provided superior HbA1c reductions compared with 1.5 mg (treatment-regimen estimand: -1.77 vs. -1.54% [-19.4 vs. -16.8 mmol/mol], estimated treatment difference [ETD] -0.24% (-2.6 mmol/mol), P < 0.001; efficacy estimand: -1.87 vs. -1.53% [-20.4 vs. -16.7 mmol/mol], ETD -0.34% (-3.7 mmol/mol), P < 0.001). Dulaglutide 3.0 mg was superior to 1.5 mg for reducing HbA1c, using the efficacy estimand (ETD -0.17% [-1.9 mmol/mol]; P = 0.003) but not the treatment-regimen estimand (ETD -0.10% [-1.1 mmol/mol]; P = 0.096). Dulaglutide 4.5 mg was superior to 1.5 mg for weight loss at 36 weeks for both estimands (treatment regimen: -4.6 vs. -3.0 kg, ETD -1.6 kg, P < 0.001; efficacy: -4.7 vs. -3.1 kg, ETD -1.6 kg, P < 0.001). Common adverse events through 36 weeks included nausea (1.5 mg, 13.4%; 3 mg, 15.6%; 4.5 mg, 16.4%) and vomiting (1.5 mg, 5.6%; 3 mg, 8.3%; 4.5 mg, 9.3%). CONCLUSIONS In patients with type 2 diabetes inadequately controlled by metformin, escalation from dulaglutide 1.5 mg to 3.0 mg or 4.5 mg provided clinically relevant, dose-related reductions in HbA1c and body weight with a similar safety profile.
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Affiliation(s)
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy
| | | | - Ying G Li
- Eli Lilly and Company, Indianapolis, IN
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212
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Choi SY, Ko SH. Severe hypoglycemia as a preventable risk factor for cardiovascular disease in patients with type 2 diabetes mellitus. Korean J Intern Med 2021; 36:263-270. [PMID: 32872725 PMCID: PMC7969056 DOI: 10.3904/kjim.2020.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/05/2020] [Indexed: 12/11/2022] Open
Abstract
Glucose-lowering medication and lifestyle modification are essential for optimal glycemic control in patients with type 2 diabetes mellitus (T2DM). However, glucose-lowering agents, particularly insulin and insulin secretagogues, may cause hypoglycemia, which has multiple negative effects on the cardiovascular (CV) system and may cause death. Previous studies using institutional data from the Korean Nationwide Health Insurance database have consistently found a causal relationship between severe hypoglycemia and CV outcomes and mortality. Screening for high-risk patients, appropriate management, and intensive individualized education are the most effective measures and essential for the prevention of harmful hypoglycemic events. Based on identified risk factors that predict severe hypoglycemia, we developed an 1-year risk prediction model for severe hypoglycemia that can be used in clinical settings. In this review, we describe the current understanding of severe hypoglycemia and the clinical implications in patients with T2DM. Furthermore, we highlight the importance of intensive individualized education for high-risk patients and the risk prediction model to reduce severe hypoglycemia.
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Affiliation(s)
- Soo-Yeon Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Seung-Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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213
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Mertens M, Dauben L, Roden M, Müssig K. [Acute metabolic complications in diabetes]. Dtsch Med Wochenschr 2021; 146:266-278. [PMID: 33592663 DOI: 10.1055/a-1270-8878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Over time, diabetes patients are at increased risk for microvascular and macrovascular complications leading to increased morbidity and mortality compared to metabolically healthy people. In addition, acute life-threatening metabolic derangements at first manifestation as well as during the course of the disease may occur, comprising diabetic ketoacidosis, hyperosmolar hyperglycaemic state and hypoglycaemia. Diabetes-related emergencies require fast diagnosis and early treatment initiation as well as close monitoring of vital signs and laboratory parameters. The present article gives an overview on the acute metabolic complications in diabetes, focussing on diagnostic work-up and treatment goals.
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214
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Nocturnal Hypoglycaemia in Patients with Diabetes Mellitus: Database Analysis of a Cohort Using Telemedicine Support for Self-Monitoring of Blood Glucose over a 10-Year-Long Period. MEDICINA-LITHUANIA 2021; 57:medicina57020167. [PMID: 33672913 PMCID: PMC7918473 DOI: 10.3390/medicina57020167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/27/2021] [Accepted: 02/08/2021] [Indexed: 01/09/2023]
Abstract
Background and Objectives: In patients with diabetes mellitus, hypoglycaemic episodes, especially during night hours, carry a significant risk. Data about the occurrence of nocturnal hypoglycaemia in real-world settings are of clinical importance. The aim of our study was to evaluate the occurrence of nocturnal hypoglycaemia among patients with diabetes using self-monitoring of blood glucose (SMBG) with telemedicine support. Materials and Methods: We retrospectively analysed the central database of an internet-based supportive system between 2010 and 2020 when 8190 SMBG users uploaded nearly 10 million capillary blood glucose values. Nocturnal hypoglycaemia was defined as capillary blood glucose < 3.0 mmol/L measured between 00:00 and 05:59 h. Results: The database contained 914,146 nocturnal blood glucose values from 7298 users; 24,623 (2.7%) glucose values were below the hypoglycaemic threshold and 2363 patients (32.4%) had at least one hypoglycaemic glucose value. Nocturnal hypoglycaemia was more often found in patients with type 1 vs. type 2 diabetes (n = 1890 (80.0%) vs. n = 387 (16.4%), respectively). Hypoglycaemic blood glucose values were most frequently observed in the age group of 10.0–19.9 years (n = 481 (20.4%)). Patients with nocturnal hypoglycaemia were mostly on insulin treatment (1854 (78.5%) patients with 20,727 (84.1%) hypoglycaemic glucose values). Only 356 patients (15.1%) with nocturnal hypoglycaemia performed a retest within 120 min. Within a one-day-long (1440 min) timeframe, the elapsed median time until a retest, yielding a safe blood glucose value (>3.9 mml/L), was 273 min (interquartile range: 157–300 min). Conclusions: Nocturnal hypoglycaemia should be considered as a persisting challenge to antihyperglycaemic treatment in patients living with diabetes. Continuous efforts are needed to improve both antihyperglycaemic treatment and patient education for preventing nocturnal hypoglycaemia, and to act adequately if hypoglycaemic values are detected.
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215
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Myat A, Redwood SR, Arri S, Gersh BJ, Bhatt DL, Marber MS. Liraglutide to Improve corONary haemodynamics during Exercise streSS (LIONESS): a double-blind randomised placebo-controlled crossover trial. Diabetol Metab Syndr 2021; 13:17. [PMID: 33579317 PMCID: PMC7881597 DOI: 10.1186/s13098-021-00635-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/03/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Glucagon-like peptide-1 receptor (GLP-1R) activation may improve myocardial performance in the context of ischaemia, independent of glycaemic control, in individuals with and without type 2 diabetes mellitus. METHODS The LIONESS trial was a single-centre randomised double-blind placebo-controlled crossover study to determine whether prolonged GLP-1R activation could improve exercise haemodynamics in chronic stable angina patients. Eligibility criteria comprised angiographic evidence of obstructive coronary artery disease (CAD) and an abnormal baseline exercise tolerance test (ETT) demonstrating > 0.1 mV of planar or downsloping ST-segment depression (STD). Those randomised to active agent started with a 1-week run-in phase of 0.6 mg liraglutide daily, an established injectable GLP-1R agonist, followed by 1 week of 1.2 mg liraglutide, after which patients performed a week 2 ETT. Patients then self-administered 1.8 mg liraglutide for a week before completing a week 3 ETT. The placebo arm received visually and temporally matched daily saline injections. Participants then crossed over to a 3-week course of saline injections interspersed with a week 5 ETT and week 6 ETT and vice versa. Co-primary endpoints were rate pressure product (RPP) at 0.1 mV STD and magnitude of STD at peak exercise. RESULTS Twenty-two patients (21 without diabetes) were randomised. There was no significant difference between saline versus liraglutide in the co-primary endpoints of RPP achieved at 0.1 mV STD (saline vs. liraglutide 1.2 mg p = 0.097; saline vs. liraglutide 1.8 mg p = 0.48) or the degree of STD at peak exercise (saline vs. liraglutide 1.2 mg p = 0.68; saline vs. liraglutide 1.8 mg p = 0.57). Liraglutide did not cause symptomatic hypoglycaemia, renal dysfunction, acute pancreatitis or provoke early withdrawal from the trial. Liraglutide significantly reduced weight (baseline 88.75 ± 16.5 kg vs. after liraglutide 87.78 ± 16.9 kg; p = 0.0008) and improved the lipid profile (mean total cholesterol: at baseline 3.97 ± 0.88 vs. after liraglutide 3.56 ± 0.71 mmol/L; p < 0.0001). CONCLUSION Liraglutide did not enhance exercise tolerance or haemodynamics compared with saline placebo during serial treadmill testing in patients with established obstructive CAD. It did, however, significantly reduce weight and improve the lipid profile. Trial Registration ClinicalTrials.gov Identifier NCT02315001. Retrospectively registered on 11th December 2014.
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Affiliation(s)
- Aung Myat
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
- Frimley Park Hospital, Frimley Health NHS Foundation Trust, Portsmouth Road, Frimley, GU16 7UJ, Camberley, UK.
| | - Simon R Redwood
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Satpal Arri
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN, 55905, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Centre and Harvard Medical School, Boston, MA, 02115, USA
| | - Michael S Marber
- King's College London British Heart Foundation Centre of Research Excellence, The Rayne Institute, Cardiovascular Division, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
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Akhan O, Ardahanli I. Hypoglycemia in the emergency, is there any effect on endothelial and diastolic functions? Echocardiography 2021; 38:450-459. [PMID: 33539572 DOI: 10.1111/echo.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Several homeostatic changes like an increase in sympathoadrenal response and oxidative stress occur in hypoglycemia. As a result of these findings, an increase in inflammation and preatherogenic factors is observed, and these changes may lead to endothelial dysfunction. AIM Our study aims to reveal possible cardiac risks (systolic-diastolic functions and endothelial dysfunctions) in patients who have applied to the emergency department with hypoglycemia. METHODS This cross-sectional, case-control study included 46 hypoglycemia patients who admitted to the emergency with symptoms compatible with hypoglycemia and diagnosed with hypoglycemia and 30 healthy volunteers. All patients were evaluated with baseline echocardiography, tissue-Doppler imaging (carotid and brachial artery). Also, the fasting blood tests of the patients referred to the internal medicine department were examined. RESULTS There were no differences between the groups regarding age, weight, body mass index, and systolic blood pressure. Total cholesterol, LDL, HDL, Vitamin B12, TSH, and fasting blood glucose levels were similar in the groups' blood tests (all P values > .05). We observed a statistically significant decrease in diastolic dysfunction parameters: E/A and E/e' ratios (respectively, P = .020 and 0.026). It was shown that insulin resistance was influential in forming these considerable differences. The patient group observed that the carotid intima-media thickness was more remarkable (P = .001), and the brachial flow-mediated dilatation value was smaller (P = .003), giving an idea about endothelial functions. CONCLUSION As a message, we can say that hypoglycemia may affect diastolic functions in addition to endothelial dysfunction. Therefore, even young individuals without any chronic diseases may need follow-up in terms of possible risks.
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Affiliation(s)
- Onur Akhan
- Cardiology, Bilecik Training and Research Hospital, Bilecik, Turkey
| | - Isa Ardahanli
- Cardiology, Bilecik Training and Research Hospital, Bilecik, Turkey
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217
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Effectiveness and Safety of SGLT2 Inhibitors in Clinical Routine Treatment of Patients with Diabetes Mellitus Type 2. J Clin Med 2021; 10:jcm10040571. [PMID: 33546360 PMCID: PMC7913515 DOI: 10.3390/jcm10040571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 12/26/2022] Open
Abstract
The aim of this study was to investigate the effectiveness of SGLT2 inhibitors with regard to metabolic parameters and patient safety under routine ambulatory conditions. Retrospective longitudinal study of 95 patients with type 2 diabetes (diabetes duration 13.3 y; HbA1c 8.9%; eGFR 80.1 mL/min) receiving SGLT-2-inhibitors. Metabolic control and adverse event profile were evaluated. The mean follow-up time was 1.2 ± 0.8 years. The following changes were observed: HbA1c -1.0% ± 1.9 (p < 0.001), eGFR -7.0 mL/min ± 13.3 (p < 0.001), albuminuria -23.9 mg/g creatinine ± 144.5 (p = 0.118), bodyweight -3.0 kg ± 5.8 (p < 0.001), systolic blood pressure -6 mmHg ± 22 (p = 0.01), diastolic blood pressure -2 mmHg ± 14 (p = 0.243). 53 participants continuously applied the therapy. Twenty-eight participants discontinued SGLT-2-inhibitors due to various reasons: 20 participants because of genital- or urinary tract infections. One for dysuria, seven due to reduced eGFR below 45 mL/min. This study showed a considerable reduction of HbA1c and a modest reduction of eGFR, bodyweight and systolic blood pressure under clinical routine conditions. Genital infections occurred markedly more often than in randomized controlled trials. To apply SGLT-2-inhibitors more safely in clinical routine individual risks for genital and urinary tract infections should be considered and re-evaluated during therapy.
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218
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Espeland MA, Pratley RE, Rosenstock J, Kadowaki T, Seino Y, Zinman B, Marx N, McGuire DK, Andersen KR, Mattheus M, Keller A, Weber M, Johansen OE. Cardiovascular outcomes and safety with linagliptin, a dipeptidyl peptidase-4 inhibitor, compared with the sulphonylurea glimepiride in older people with type 2 diabetes: A subgroup analysis of the randomized CAROLINA trial. Diabetes Obes Metab 2021; 23:569-580. [PMID: 33185002 PMCID: PMC7839453 DOI: 10.1111/dom.14254] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/29/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
AIM To compare the cardiovascular (CV) safety of linagliptin with glimepiride in older and younger participants in the CAROLINA trial in both prespecified and post hoc analyses. MATERIALS AND METHODS People aged 40 to 85 years with relatively early type 2 diabetes, inadequate glycaemic control and elevated CV risk were randomly assigned to linagliptin 5 mg or glimepiride 1 to 4 mg. The primary endpoint was time to first occurrence of three-point major adverse CV events (MACE: CV death, non-fatal myocardial infarction, or non-fatal stroke). We evaluated clinical and safety outcomes across age groups. RESULTS Of 6033 participants, 50.7% were aged <65 years, 35.3% were aged 65 to 74 years, and 14.0% were aged ≥75 years. During the 6.3-year median follow-up, CV/mortality outcomes did not differ between linagliptin and glimepiride overall (hazard ratio [HR] for three-point MACE 0.98, 95.47% confidence interval [CI] 0.84, 1.14) or across age groups (interaction P >0.05). Between treatment groups, reductions in glycated haemoglobin were comparable across age groups but moderate-to-severe hypoglycaemia was markedly reduced with linagliptin (HR 0.18, 95% CI 0.15, 0.21) with no differences among age groups (P = 0.23). Mean weight was -1.54 kg (95% CI -1.80, -1.28) lower for linagliptin versus glimepiride. Adverse events increased with age, but were generally balanced between treatment groups. Significantly fewer falls or fractures occurred with linagliptin. CONCLUSIONS Linagliptin and glimepiride were comparable for CV/mortality outcomes across age groups. Linagliptin had significantly lower risk of hypoglycaemia and falls or fractures than glimepiride, including in "older-old" individuals for whom these are particularly important treatment considerations.
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Affiliation(s)
- Mark A. Espeland
- Division of Gerontology and Geriatric MedicineWake Forest School of MedicineWinston‐SalemNorth Carolina
| | | | | | | | - Yutaka Seino
- Kansai Electric Power Medical Research InstituteKobeJapan
- Kansai Electric Power HospitalOsakaJapan
| | - Bernard Zinman
- Lunenfeld‐Tanenbaum Research Institute, Mount Sinai HospitalUniversity of TorontoTorontoOntarioCanada
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital AachenRWTH Aachen UniversityAachenGermany
| | - Darren K. McGuire
- Division of CardiologyDepartment of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Health and Hospital SystemDallasTexas
| | | | | | - Annett Keller
- Boehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | - Maria Weber
- Boehringer Ingelheim International GmbHIngelheimGermany
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Strollo F, Furia A, Verde P, Bellia A, Grussu M, Mambro A, Petrelli MD, Gentile S. Technological innovation of Continuous Glucose Monitoring (CGM) as a tool for commercial aviation pilots with insulin-treated diabetes and stakeholders/regulators: A new chance to improve the directives? Diabetes Res Clin Pract 2021; 172:108638. [PMID: 33358969 DOI: 10.1016/j.diabres.2020.108638] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/12/2020] [Accepted: 12/16/2020] [Indexed: 11/30/2022]
Abstract
Civil aviation pilots who develop insulin-treated diabetes and want to renew a Commercial Pilot License (CPL) represent a medical, social and regulatory problem. This depends on justified concerns about hypoglycemia, the most threatening event for people who carry out jobs requiring a high level of concentration and reliability. This negatively affects social and working aspects of pilots' lives, who have a high profile and a high-cost professional qualification. It could be possible now to revise this attitude thanks to the availability of Continuous Glucose Monitoring (CGM) devices. CGM clearly showed to prevent hypoglycemic events in insulin-treated diabetic patients by allowing strict monitoring and trend prediction of glucose levels. By systematizing available data on such devices and present regulations in CPL issuance worldwide, our review can be used as handy tool for a fruitful discussion among the scientific community, national and international civil aviation regulators, stakeholders and pilots, aimed at evaluating the evidence-based opportunity to revise CPL issuance criteria for insulin-treated diabetic pilots. For the above-mentioned reasons, there are, among the regulatory administrations of Civil Aviation around the globe, several different approaches and limitations set for the subjects with insulin-treated diabetes who want to obtain, or renew, a CPL.
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Affiliation(s)
- F Strollo
- AMD (Associazione Medici Diabetologi), ESAM (European Society of Aerospace Medicine) and IRCCS San Raffaele Pisana, Rome, Italy.
| | - A Furia
- ENAC (Italian National Civil Aviation Authority), Aeromedical Section, Rome, Italy
| | - P Verde
- AIMAS (Italian Association of AeroSpace Medicine) and IAF (Italian Air Force), Experimental Flight Center, Aerospace Medicine Department, Pratica di Mare, Rome, Italy
| | - A Bellia
- SID (Società Italiana di Diabetologia), Department of Systems Medicine, Rome University, "Tor Vergata", Italy
| | - M Grussu
- ANIAD (Italian National Association of Athletes with Diabetes), Oristano, Italy
| | - A Mambro
- AIMAS (Italian Association of AeroSpace Medicine), Anesthesiology and Resuscitation Unit, Alesini CTO Hospital, Rome, Italy
| | - M D Petrelli
- SID (Società Italiana di Diabetologia), Clinic of Endocrinology and Metabolic Diseases, Polytechnic University of Marche, Ancona, Italy
| | - S Gentile
- Associazione Medici Diabetologi), Campania University "Luigi Vanvitelli", Naples, Italy, and Nefrocenter Research & Nyx Start-UP, Naples, Italy
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Phillip M, Mathieu C, Lind M, Araki E, di Bartolo P, Bergenstal R, Heller S, Hansen L, Scheerer MF, Thoren F, Arya N, Xu J, Iqbal N, Dandona P. Long-term efficacy and safety of dapagliflozin in patients with inadequately controlled type 1 diabetes: pooled 52-week outcomes from the DEPICT-1 and -2 studies. Diabetes Obes Metab 2021; 23:549-560. [PMID: 33145944 PMCID: PMC7839492 DOI: 10.1111/dom.14248] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/27/2020] [Accepted: 11/01/2020] [Indexed: 02/06/2023]
Abstract
AIM To evaluate the efficacy and safety of adjunct dapagliflozin therapy in patients with type 1 diabetes (T1D). MATERIALS AND METHODS DEPICT-1 and -2 were randomized, double-blind, parallel-group, 24-week studies, with 28-week extension periods. Adults with T1D and HbA1c 7.5%-10.5% were randomized (1:1:1) to receive dapagliflozin 5 mg, 10 mg or placebo. The short- and long-term efficacy and safety of dapagliflozin were examined in an exploratory pooled analysis of both studies. RESULTS Efficacy analyses included 530, 529 and 532 and safety analysis included 548, 566 and 532 patients in the dapagliflozin 5 mg, 10 mg and placebo groups, respectively. Baseline characteristics were similar between treatment groups. At week 24, reductions were seen with dapagliflozin 5 and 10 mg compared with placebo in HbA1c (-0.40%, -0.43% vs. 0.00%) and body weight (-2.45, -2.91 vs. 0.11 kg). HbA1c and body weight reductions versus placebo were also seen after 52 weeks of treatment. There was no imbalance in occurrence of severe hypoglycaemic events between groups. The proportion of patients experiencing definite diabetic ketoacidosis (DKA) was higher with dapagliflozin 5 mg (4.0%) and 10 mg (3.5%) compared with placebo (1.1%) over 52 weeks; most events were of mild or moderate severity, and all resolved with treatment. CONCLUSIONS Over 52 weeks, dapagliflozin provided glycaemic and weight benefits, with no increased frequency of severe hypoglycaemia compared with placebo. More DKA events were reported with dapagliflozin than placebo, highlighting the importance of appropriate patient selection, education and risk-mitigation strategies.
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Affiliation(s)
- Moshe Phillip
- Institute for Endocrinology and Diabetes, Schneider Children's Medical Center of IsraelPetah TikvaIsrael
- Sackler Faculty of Medicine, Tel Aviv UniversityTel AvivIsrael
| | - Chantal Mathieu
- Clinical and Experimental EndocrinologyUniversity of LeuvenLeuvenBelgium
| | - Marcus Lind
- Department of Molecular and Clinical MedicineUniversity of GothenburgGothenburgSweden
- Department of MedicineNU‐Hospital GroupUddevallaSweden
| | - Eiichi Araki
- Department of Metabolic MedicineKumamoto UniversityKumamotoJapan
| | - Paolo di Bartolo
- Ravenna Internal Medicine DepartmentRavenna Diabetes Clinic, Romagna Local Health AuthorityRavennaItaly
| | - Richard Bergenstal
- International Diabetes CenterHealth Partners InstituteMinneapolisMinnesotaUSA
| | - Simon Heller
- Department of Oncology and MetabolismUniversity of Sheffield School of MedicineSheffieldUK
| | - Lars Hansen
- BioPharmaceuticals R&D, AstraZenecaGaithersburgMarylandUSA
| | | | | | - Niki Arya
- BioPharmaceuticals R&D, AstraZenecaGaithersburgMarylandUSA
| | - John Xu
- BioPharmaceuticals R&D, AstraZenecaGaithersburgMarylandUSA
| | - Nayyar Iqbal
- BioPharmaceuticals R&D, AstraZenecaGaithersburgMarylandUSA
| | - Paresh Dandona
- Department of EndocrinologyKaleida HealthBuffaloNew YorkUSA
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221
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Ji L, Dong X, Li Y, Li Y, Lim S, Liu M, Ning Z, Rasmussen S, Skjøth TV, Yuan G, Eliaschewitz FG. Efficacy and safety of once-weekly semaglutide versus once-daily sitagliptin as add-on to metformin in patients with type 2 diabetes in SUSTAIN China: A 30-week, double-blind, phase 3a, randomized trial. Diabetes Obes Metab 2021; 23:404-414. [PMID: 33074557 PMCID: PMC7839591 DOI: 10.1111/dom.14232] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 12/22/2022]
Abstract
AIM To evaluate the efficacy and safety of once-weekly subcutaneous semaglutide, a glucagon-like peptide-1 (GLP-1) analogue, versus once-daily sitagliptin as add-on to metformin in patients with type 2 diabetes (T2D) in a multiregional clinical trial. MATERIALS AND METHODS In the 30-week, randomized, double-blind, double-dummy, active comparator SUSTAIN China trial, 868 adults with T2D inadequately controlled on metformin (HbA1c 7.0%-10.5%) were randomized to receive once-weekly semaglutide 0.5 mg (n = 288), semaglutide 1.0 mg (n = 290) or once-daily sitagliptin 100 mg (n = 290). The primary and confirmatory secondary endpoints were change from baseline to week 30 in HbA1c and body weight, respectively. RESULTS The trial enrolled ~70% (605/868) of the patients in China, and the remaining patients from four other countries, including the Republic of Korea. Both doses of semaglutide were superior to sitagliptin in reducing HbA1c and body weight after 30 weeks of treatment. The odds of achieving target HbA1c of less than 7.0% (53 mmol/mol), weight loss of 5% or higher, or 10% or higher, and the composite endpoint of HbA1c less than 7.0% (53 mmol/mol) without severe or blood glucose-confirmed symptomatic hypoglycaemia no weight gain, were all significantly higher with both semaglutide doses compared with sitagliptin. The safety profile for semaglutide was consistent with the known class effects of GLP-1 receptor agonists (RAs). Consistent efficacy and safety findings were seen in the Chinese subpopulation. CONCLUSIONS Once-weekly semaglutide was superior to sitagliptin in improving glycaemic control and reducing body weight in patients with T2D inadequately controlled on metformin. The safety and tolerability profiles were consistent with those of semaglutide and other GLP-1 RAs. Semaglutide is an effective once-weekly treatment option for the Chinese population.
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Affiliation(s)
- Linong Ji
- Peking University People's Hospital No. 11BeijingChina
| | - Xiaolin Dong
- Jinan Central HospitalAffiliated to Shandong University No. 105JinanChina
| | - Yiming Li
- Shanghai Huashan HospitalAffiliated to Fudan University No. 12ShanghaiChina
| | - Yufeng Li
- Beijing Pinggu Hospital No. 59BeijingChina
| | - Soo Lim
- Department of Internal MedicineSeoul National University College of Medicine, Seoul National University Bundang HospitalSeongnamKorea
| | - Ming Liu
- General Hospital of Tianjin Medical University No. 154TianjinChina
| | - Zu Ning
- Novo Nordisk (China) Pharmaceuticals Co., LtdBeijingChina
| | | | | | - Guoyue Yuan
- The Affiliated Hospital of Jiangsu University No. 438ZhenjiangChina
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Iwase M, Komorita Y, Ohkuma T, Fujii H, Ide H, Yoshinari M, Oku Y, Higashi T, Nakamura U, Kitazono T. Incidence of stroke and its association with glycemic control and lifestyle in Japanese patients with type 2 diabetes mellitus: The Fukuoka diabetes registry. Diabetes Res Clin Pract 2021; 172:108518. [PMID: 33096191 DOI: 10.1016/j.diabres.2020.108518] [Citation(s) in RCA: 3] [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: 08/19/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 11/22/2022]
Abstract
AIMS We prospectively investigated the incidence of stroke and its subtypes, risk factors and prognosis in Japanese patients with type 2 diabetes. METHODS A total of 4,875 participants with type 2 diabetes (mean age 65.4 years, male 57%, previous stroke 10%) were investigated for the development of stroke for 5 years. Risk factors were evaluated using multivariable adjusted Cox proportional models. RESULTS The incidence rates per 1,000 person-years were 6.7 for new-onset stroke (ischemic 5.5, hemorrhagic 1.2) and 22.7 for recurrent stroke (ischemic 18.8, hemorrhagic 3.8), respectively. Ischemic stroke was significantly associated with age, male, reduced regular physical activity, HbA1c, diabetic kidney disease and previous stroke. Lacunar infarction was significantly associated with obesity, reduced regular physical activity, HbA1c and diabetic kidney disease, whereas atherothrombotic stroke was significantly associated with age, reduced intake of dietary fiber, reduced regular physical activity, HbA1c and previous stroke. Recurrent stroke was significantly associated with depressive symptom. Thirty-day and one-year survival was 76% and 64% for hemorrhagic stroke, and 96% and 91% for ischemic stroke, respectively. CONCLUSIONS The current study reemphasized the importance of glycemic control and lifestyle modification such as regular physical exercise for stroke prevention in patients with type 2 diabetes.
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Affiliation(s)
- Masanori Iwase
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Diabetes Center and Clinical Research Center, Hakujyuji Hospital, Fukuoka, Japan.
| | - Yuji Komorita
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiaki Ohkuma
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroki Fujii
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hitoshi Ide
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Diabetes Center and Clinical Research Center, Hakujyuji Hospital, Fukuoka, Japan
| | - Masahito Yoshinari
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaro Oku
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Taiki Higashi
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Udai Nakamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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223
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Lawrence L, Ali KF, Buehler L, Bailey R, Bena J, Gambino RR, Hamaty M. Prediction of Hypoglycemia By Quality of Life Measures: A Retrospective Analysis of Electronically Patient-Reported Data. Endocr Pract 2021; 26:1153-1165. [PMID: 33471717 DOI: 10.4158/ep-2020-0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/13/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We aimed to examine the utility of electronically patient-reported data (e-PRD) in exploring the risk of diabetes-related hypoglycemia and to evaluate hypoglycemia prediction by the quality of life (QoL) measures. METHODS A retrospective analysis of e-PRD for patients with diabetes mellitus who completed the American Diabetes Association's Low Blood Sugar Questionnaire (Hypo-Q) and the Patient-Reported Outcomes Measurement Information System (PROMIS) for QoL assessment. Associations between Hypo-Q answers and PROMIS scores were described using Spearman correlations and 95% confidence intervals, or medians and quartiles. RESULTS Records of 538 subjects were reviewed; 55% were female, 95% were non-Hispanic, with a mean age (± SD) of 53 ± 15 years. Patients with type 1 diabetes had a longer disease duration and more hypoglycemic episodes (P<.001) with higher PROMIS Physical and Mental T-scores (P<.001, both), when compared to patients with type 2 diabetes. The latter had a higher number of co-existing conditions. Having >5 episodes of either moderate or severe hypoglycemia in a year were reported by 18% and 5% of all patients, respectively. Mean PROMIS Physical and Mental health T-scores were 46 ± 10 and 47 ± 10, respectively. Patients with fewer moderate and severe hypoglycemic episodes had better Physical (P = .047 and P<.001) and Mental (P = .015 and P<.001) PROMIS T-scores with incremental decreases in the odds of hypoglycemia with each point increase in PROMIS T-scores. CONCLUSION e-PRD of QoL measures and Hypo-Q were effective in exposing the risks for hypoglycemia and reproducing published findings with significant associations between QoL measures and hypoglycemia risks while providing new insights.
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Affiliation(s)
- Lima Lawrence
- From the Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Khawla F Ali
- From the Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lauren Buehler
- From the Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard Bailey
- the School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - James Bena
- the Section of Biostatistics, Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Ronald R Gambino
- From the Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marwan Hamaty
- From the Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio.
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McCarthy O, Pitt J, Eckstein ML, Moser O, Bain SC, Bracken RM. Pancreatic β-Cell Function Is Associated with Augmented Counterregulation to In-Exercise Hypoglycemia in Type 1 Diabetes. Med Sci Sports Exerc 2021; 53:1326-1333. [PMID: 34127632 DOI: 10.1249/mss.0000000000002613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE This study aimed to investigate the influence of residual β-cell function on counterregulatory hormonal responses to hypoglycemia during acute physical exercise in people with type 1 diabetes (T1D). A secondary aim was to explore relationships between biomarkers of pancreatic β-cell function and indices of glycemia following acute exercise including the nocturnal period. METHODS This study involved an exploratory, secondary analysis of data from individuals with T1D who partook in a four-peroid, randomized, cross-over trial involving a bout of evening exercise followed by an overnight stay in a clinical laboratory facility. Participants were split into two groups: (i) a stimulated C-peptide level of ≥30 pmol⋅L-1 (low-level secretors [LLS], n = 6) or (ii) <30 pmol⋅L-1 (microsecretors [MS], n = 10). Pancreatic hormones (C-peptide, proinsulin, and glucagon), catecholamines (epinephrine [EPI] and norepinephrine [NE]), and metabolic biomarkers (blood glucose, blood lactate, and β-hydroxybutyrate) were measured at rest, during exercise with and without a hypoglycemic (blood glucose ≤3.9 mmol⋅L-1) episode, and throughout a 13-h postexercise period. Interstitial glucose monitoring was used to assess indices of glycemic variability. RESULTS During in-exercise hypoglycemia, LLS presented with greater sympathoadrenal (EPI and NE P ≤ 0.05) and ketone (P < 0.01) concentrations. Glucagon remained similar (P = 0.09). Over exercise, LLS experienced larger drops in C-peptide and proinsulin (both P < 0.01) as well as greater increases in EPI (P < 0.01) and β-hydroxybutyrate (P = 0.03). LLS spent less time in the interstitial-derived hypoglycemic range acutely postexercise and had lower glucose variability throughout the nocturnal period. CONCLUSION Higher residual β-cell function was associated with greater sympathoadrenal and ketonic responses to exercise-induced hypoglycemia as well as improved glycemia leading into and throughout the nocturnal hours. Even a minimal amount of residual β-cell function confers a beneficial effect on glycemic outcomes during and after exercise in people with T1D.
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Affiliation(s)
- Olivia McCarthy
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), College of Engineering, Swansea University, Swansea, UNITED KINGDOM
| | - Jason Pitt
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), College of Engineering, Swansea University, Swansea, UNITED KINGDOM
| | | | | | - Stephen C Bain
- Diabetes Research Group, Medical School, Swansea University, Swansea, UNITED KINGDOM
| | - Richard M Bracken
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), College of Engineering, Swansea University, Swansea, UNITED KINGDOM
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225
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Bengtsen MB, Knudsen JS, Bengtsen MB, Møller N, Thomsen RW. Hospitalization for hypoglycaemia in people with diabetes in Denmark, 1997-2017: Time trends in incidence and HbA 1c and glucose-lowering drug use before and after hypoglycaemia. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00227. [PMID: 34277957 PMCID: PMC8279622 DOI: 10.1002/edm2.227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/09/2020] [Accepted: 01/09/2021] [Indexed: 11/24/2022]
Abstract
Objective To assess incidence trends of first hospitalization for hypoglycaemia in Denmark and to examine HbA1c levels and glucose‐lowering drug use before and after hospitalization among individuals with type 1 or type 2 diabetes. Research Design and Methods We performed a population‐based study linking diagnosis, prescription and laboratory data. Standardized incidence of first hospitalization for hypoglycaemia in Denmark was assessed for each calendar year 1997–2017. HbA1c and glucose‐lowering drug use was compared with age‐ and sex‐matched diabetes comparisons without hospitalization for hypoglycaemia. Results The annual age‐ and sex‐standardized incidence rate of first hospitalization for hypoglycaemia per 100,000 person‐years increased during 1997–2003 (from 17.7 to 30.3 per 100,000 person‐years), remained stable until 2010 (30.4) and gradually declined until 2017 (22.0). During this period, we identified 3,479 people with type 1 diabetes and 15,329 people with type 2 diabetes experiencing first hospitalization for hypoglycaemia. Both diabetes groups experienced a mean HbA1c decrease of ~12%–15% in the months preceding first hospitalization, followed by a gradually increasing HbA1c afterwards. People with type 1 diabetes and hospitalization used similar insulin therapies as those without hospitalization. People with type 2 diabetes and hospitalization more often received insulin (55%) than comparisons (45%), and 45% discontinued insulin or stopped all glucose‐lowering therapy after first hospitalization. Conclusions Incidence of hospitalizations for hypoglycaemia has declined by one fourth the last decade in the Danish population. A HbA1c decrease precedes first hospitalization for hypoglycaemia in individuals with diabetes, and profound changes in glucose‐lowering drug therapy for type 2 diabetes occur after hospitalization.
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Affiliation(s)
- Mads Bisgaard Bengtsen
- Department of Endocrinology and Internal Medicine Aarhus University Hospital Aarhus Denmark.,Department of Internal Medicine Regional Hospital of Horsens Horsens Denmark
| | - Jakob Schöllhammer Knudsen
- Department of Clinical Epidemiology Institute of Clinical Medicine Aarhus University Hospital Aarhus Denmark.,Department of Clinical Pharmacology Aarhus University Hospital Aarhus Denmark
| | - Maria Bisgaard Bengtsen
- Department of Clinical Epidemiology Institute of Clinical Medicine Aarhus University Hospital Aarhus Denmark
| | - Niels Møller
- Department of Endocrinology and Internal Medicine Aarhus University Hospital Aarhus Denmark
| | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology Institute of Clinical Medicine Aarhus University Hospital Aarhus Denmark
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226
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Alão S, Conceição J, Dores J, Santos L, Araújo F, Pape E, Reis M, Chipepo Á, Nascimento E, Baptista A, Pires V, Marques C, Lages ADS, Pelicano-Romano J, de Jesus PM. Hypoglycemic episodes in hospitalized people with diabetes in Portugal: the HIPOS-WARD study. Clin Diabetes Endocrinol 2021; 7:2. [PMID: 33402217 PMCID: PMC7786902 DOI: 10.1186/s40842-020-00114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We intended to estimate the proportion hypoglycemic/hyperglycemic emergency episodes in treated diabetes mellitus (DM) patients admitted to a hospital ward, and calculate the prevalence of risk factors for hypoglycemia and diabetic complications. METHODS In this cross-sectional, multicentered study, the observational data was collected by physicians from patient's hospitalization to discharge/death. Statistical tests were 2-tailed considering 5% significance level. RESULTS There were 646 ward admissions due to hyperglycemic emergencies and 176 hypoglycemic episodes with a ratio hypoglycemia/hyperglycemia 0.27 for all DM patients. In T2DM patients the ratio was 0.38. These were mainly female (55.1%), functionally dependent (61.4%) and retired/disabled (73.1%). Median age was 75 years and median duration of disease 11 years. Half the patients were on insulin-based therapy and 30.1% on secretagogue-based therapy. Approximately 57% of patients needed occasional/full assistance to manage the disease. The most frequent risk factor for hypoglycemia was polypharmacy (85.0%). Hypoglycemia in the 12 months before admission was higher in insulin-based therapy patients (66.1%; p = 0.001). CONCLUSIONS Hyperglycemic emergencies are the most frequent cause of hospitalization in Portugal, although severe hypoglycemic events represent a health and social problem in elderly/frail patients. There is still the need to optimize therapy in terms of the potential for hypoglycemia in this patient group and a review of anti-hyperglycemic agents to add on to insulin.
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Affiliation(s)
- Sílvia Alão
- MSD Portugal, R. Qta da Fonte 19, 2770-192, Paço de Arcos, Portugal.
| | - João Conceição
- MSD International GmbH (Singapore Branch), Medical Affairs, Singapore, Singapore
| | - Jorge Dores
- Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Lèlita Santos
- Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | | | | | - Mónica Reis
- Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal
| | | | | | - Ana Baptista
- Centro Hospitalar Universitário do Algarve - Faro, Faro, Portugal
| | - Vanessa Pires
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Carlos Marques
- Unidade Local de Saúde do Baixo Alentejo, Beja, Portugal
| | | | | | - Paula M de Jesus
- MSD Portugal, R. Qta da Fonte 19, 2770-192, Paço de Arcos, Portugal
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227
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Ogawa W, Hirota Y, Osonoi T, Tosaki T, Kato Y, Utsunomiya K, Nishimura R, Nakamura J. Effect of the FreeStyle Libre™ flash glucose monitoring system on glycemic control in individuals with type 2 diabetes treated with basal-bolus insulin therapy: An open label, prospective, multicenter trial in Japan. J Diabetes Investig 2021; 12:82-90. [PMID: 32562376 PMCID: PMC7779269 DOI: 10.1111/jdi.13327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS/INTRODUCTION We investigated the effect of FreeStyle LibreTM on glycemic control in Japanese type 2 diabetes patients treated with basal-bolus insulin therapy. MATERIALS AND METHODS This prospective, 90-day single-arm study enrolled 94 adults with type 2 diabetes treated with insulin. A 14-day masked baseline phase was followed by an 11-week treatment phase during which participants used the device to monitor glucose levels. The primary end-point was time spent in hypoglycemia (<70 mg/dL) for baseline versus study end (days 76-90). Secondary end-points included other measures of glycemic control, along with patient satisfaction using the Japanese Diabetes Treatment and Satisfaction Questionnaire. RESULTS Time spent in hypoglycemia was low at baseline (0.51 ± 0.93 h/day) and did not significantly decrease at study end (0.47 ± 0.63 h/day, P = 0.6354). Time in range, time in hyperglycemia and estimated A1c all improved versus baseline (by +1.7 ± 3.0 h/day, -1.6 ± .4 h/day and -0.4 ± 0.8%, respectively, P < 0.0001 in each). Finger stick tests fell from 2.9 ± 1.3 to 1.9 ± 1.4/day, and mean scanning frequency during the intervention phase was 11.3/day. The mean treatment satisfaction score increased by 11.8 ± 5.3 (P < 0.0001). Two severe hypoglycemia-related adverse events were reported; one of which was possibly related to the device. Three participants reported mild device-related skin trauma, site discomfort or subcutaneous bleeding. CONCLUSIONS Use of FreeStyle Libre by Japanese type 2 patients diabetes treated with basal-bolus insulin therapy showed a low baseline of hypoglycemia, and enabled improved glycemic control and treatment satisfaction.
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Affiliation(s)
- Wataru Ogawa
- Division of Diabetes and EndocrinologyDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yushi Hirota
- Division of Diabetes and EndocrinologyDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | | | - Takahiro Tosaki
- TDE Healthcare CorporationTOSAKI Clinic for Diabetes and EndocrinologyAichiJapan
| | - Yoshiro Kato
- Division of DiabetesDepartment of Internal MedicineAichi Medical University School of MedicineAichiJapan
| | - Kazunori Utsunomiya
- Division of Diabetes, Metabolism and EndocrinologyDepartment of Internal MedicineThe Jikei University HospitalTokyoJapan
| | - Rimei Nishimura
- Division of Diabetes, Metabolism and EndocrinologyDepartment of Internal MedicineThe Jikei University HospitalTokyoJapan
| | - Jiro Nakamura
- Division of DiabetesDepartment of Internal MedicineAichi Medical University School of MedicineAichiJapan
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228
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Isaacs DM, Kruger DF, Spollett GR. Optimizing Therapeutic Outcomes With Oral Semaglutide: A Patient-Centered Approach. Diabetes Spectr 2021; 34:7-19. [PMID: 33627989 PMCID: PMC7887531 DOI: 10.2337/ds20-0016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
In September 2019, the U.S. Food and Drug Administration approved oral semaglutide as the first orally administered glucagon-like peptide 1 (GLP-1) receptor agonist for treating people with type 2 diabetes. Although injectable GLP-1 receptor agonists are well-established treatment options for people with type 2 diabetes, clinical experience with an oral formulation in this class is limited. This article provides practical guidance for diabetes care and education specialists on how to effectively counsel patients initiating therapy with oral semaglutide on appropriate administration of the treatment and its possible effects on glycemic control, body weight, and quality of life. Strategies for mitigating potential side effects typical of the GLP-1 receptor agonist class, namely nausea, vomiting, and diarrhea, are also provided. Involving patients in treatment decisions and educating them about available and prescribed medications are key strategies for encouraging treatment adherence and ensuring optimal therapeutic outcomes.
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Stegaru D, Nicodim S, Vladu D, Guțu O, Onaca A, Pîrvu F, Moise M, Guja C. Effectiveness and safety of insulin glargine Gla-300 in insulin-naïve type 2 diabetes subjects in a real-life setting-the GOAL_RO trial. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:105. [PMID: 33569407 PMCID: PMC7867914 DOI: 10.21037/atm-20-4533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Basal insulin is the first choice for insulin initiation in type 2 diabetes (T2DM), with the second generation of basal insulin analogues having a lower risk of hypoglycemia compared to the first generation of basal insulins. The aim of our study was to assess on a large cohort of insulin-naïve T2DM subjects the effectiveness and safety of insulin glargine 300 U/mL (Gla-300) in a real-life setting. Methods This was a multicenter, prospective, non-interventional, 24 weeks, 3 visits (baseline, 3 and 6 months) trial performed in adult T2DM subjects not achieving glycemic target (HbA1c >7%) with prior oral or GLP-1 RA therapy. The study included 1,095 subjects (55.2% M/44.8% F) in 124 study sites. Mean (±SD) age was 61.1±8.5 years while mean duration of diabetes was 8.8±5.2 years. Mean BMI was 31.7±5.4 kg/m2 with 91.2% being overweight or obese. Baseline diabetes treatment included metformin (88.4% of subjects), sulphonylureas (75.4%), DPP-4i (16.7%) and GLP-1 RAs (8%). Comparison between quantitative variables was made with the paired sample t test. Results Mean HbA1c at baseline was 9.8%±1.7% with a mean fasting plasma glucose (FBG) of 231.5±67.4 mg/dL. Mean HbA1c decreased to 7.7%±1.2% at 6 months with a mean change from baseline of -2.1% (P<0.001). Overall, 30.7% of subjects reached the HbA1c target of 7%. Final mean dose of Gla-300 was 0.4 IU/kg/day. Mean weight gain was 0.4 kg over 6 months. Adverse events (AEs) were reported by 11.1% of subjects with 2.3% reporting serious adverse events (SAEs). Overall, 4.4% of subjects reporting at least one event of symptomatic or confirmed hypoglycemia. Only 7 episodes of nocturnal and one of severe hypoglycemia were reported. Conclusions In conclusion, a significant 2.1% decrease of HbA1c was recorded after 6 months of treatment with Gla-300 with no unexpected safety signals, low risk of hypoglycemia and modest weight gain.
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Affiliation(s)
- Daniela Stegaru
- Department of Diabetes, Nutrition and Metabolic Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Simona Nicodim
- Emergency Clinical County Hospital Constanța, Constanța, Romania
| | - Delia Vladu
- Emergency Clinical County Hospital Craiova, Craiova, Romania
| | | | | | - Florina Pîrvu
- Municipal Hospital "Dr. Gheorghe Marinescu" Târnăveni, Mureș, Romania
| | | | - Cristian Guja
- Department of Diabetes, Nutrition and Metabolic Diseases, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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Ri M, Nunobe S, Ida S, Ishizuka N, Atsumi S, Hayami M, Makuuchi R, Kumagai K, Ohashi M, Sano T. Postprandial Asymptomatic Glycemic Fluctuations after Gastrectomy for Gastric Cancer Using Continuous Glucose Monitoring Device. J Gastric Cancer 2021; 21:325-334. [PMID: 35079436 PMCID: PMC8753281 DOI: 10.5230/jgc.2021.21.e31] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/26/2021] [Accepted: 09/26/2021] [Indexed: 12/09/2022] Open
Abstract
Purpose Although dumping symptoms are thought to involve postprandial glycemic changes, postprandial glycemic variability without dumping symptoms remains poorly understood due to the lack of a method that allows the easy and continuous measurement of blood glucose levels. Materials and Methods Patients having undergone distal gastrectomy with Billroth-I (DG-BI) or Roux-en-Y reconstruction (DG-RY), total gastrectomy with RY (TG-RY) and pylorus preserving gastrectomy (PPG) for gastric cancer 3 months to 3 years prior, diagnosed as pathological stage I or II, were prospectively enrolled from March 2018 to January 2020. The interstitial tissue glycemic levels were measured every 15 min, up to 14 days by continuous glucose monitoring. Moreover, using a diary recording the diet and symptoms, asymptomatic glucose profiles without sugar supplementation within 3 h postprandially were compared among the four procedures. Results A total of 40 patients were enrolled, 10 patients for each of the four procedures. There were 47 glucose profiles with DG-BI, 46 profiles with DG-RY, 38 profiles with TG-RY, and 46 profiles with PPG. PPG showed the slowest increase with a subsequent gradual decrease in glucose fluctuations, without hyperglycemia or hypoglycemia, among the four procedures. In contrast, TG-RY and DG-RY showed spike-like glycemic variability, sharp rises during meals, and rapid drops. The glucose profiles of DG-BI were milder than those of RY. Conclusions The asymptomatic glycemic changes after meals differ among the types of surgical procedures for gastric cancer. Given the mild glycemic fluctuations in PPG and the glucose spikes in TG-RY and DG-RY, pylorus preservation and physiological reconstruction without changes in food pathways may optimize postprandial glucose profiles after gastrectomy.
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Affiliation(s)
- Motonari Ri
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Ishizuka
- Department of Clinical Trial Planning and Management, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinichiro Atsumi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masaru Hayami
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Rie Makuuchi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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231
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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232
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Yosef T. Hypoglycemia Among Type 1 Diabetes Patients After Insulin Use in Southwest Ethiopia. Front Endocrinol (Lausanne) 2021; 12:684570. [PMID: 34690922 PMCID: PMC8531583 DOI: 10.3389/fendo.2021.684570] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 09/03/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Glycemic control is a valuable goal for people with diabetes; however, the greatest challenge to achieving tight glycemic control is hypoglycemia. Hypoglycemic events are probably common in type 1 diabetes; however, little is known about hypoglycemia in Ethiopia. Therefore, this study aimed to assess the prevalence and the associated factors of hypoglycemia among type 1 diabetes (T1D) patients after insulin use at Metu Karl Referral Hospital in southwest Ethiopia. MATERIALS AND METHODS A hospital-based cross-sectional study was conducted among 242 T1D patients at Metu Karl Referral Hospital in southwest Ethiopia. The prevalence of hypoglycemia was assessed by a structured questionnaire through a face-to-face interview in which all the possible symptoms of hypoglycemia were included. If the patients reported that they had experienced the symptoms at least two times in a month and the symptoms were relieved upon consuming sugar/candy/honey, such cases were considered to have had a hypoglycemic episode. Binary logistic regression analysis was done to identify the factors associated with the occurrence of hypoglycemia. RESULTS Out of 242 T1D patients interviewed, 114 (47.1%) had self-reported hypoglycemia. The most reported symptom of hypoglycemia was sweating (91.7%), followed by dizziness and hunger and nausea with a prevalence of 24.8 and 14.5%, respectively. The study also found that educational level with reading and writing skills up to primary level [adjusted odds ratio, AOR = 0.41; 95% confidence interval, CI (0.19-0.88)] and secondary level and above [AOR = 0.32, 95% CI (0.14-0.70)], poor knowledge of diabetes [AOR = 2.26, 95% CI (1.06-4.84)], good knowledge of insulin self-administration [AOR = 0.54, 95% CI (0.30-0.99)], and duration of insulin use ≥5 years [AOR = 3.93, 95% CI (1.44-10.7)] were factors associated with hypoglycemia. CONCLUSIONS The prevalence of hypoglycemia was found remarkable. We can conclude that hypoglycemia is of public health importance among T1D patients. Since the study assesses hypoglycemia after insulin injection, this prevalence may be due to the poor practice of insulin injection. Therefore, imparting education on the proper technique of insulin administration should be considered at each follow-up visit.
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Affiliation(s)
- Tewodros Yosef
- *Correspondence: Tewodros Yosef, ; orcid.org/0000-0002-3173-6753
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233
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Gomez-Peralta F, Abreu C, Benito M, Barranco RJ. Geographical clustering and socioeconomic factors associated with hypoglycemic events requiring emergency assistance in Andalusia (Spain). BMJ Open Diabetes Res Care 2021; 9:9/1/e001731. [PMID: 33397670 PMCID: PMC7783525 DOI: 10.1136/bmjdrc-2020-001731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/26/2020] [Accepted: 12/05/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The geographical distribution of hypoglycemic events requiring emergency assistance was explored in Andalusia (Spain), and potentially associated societal factors were determined. RESEARCH DESIGN AND METHODS This was a database analysis of hypoglycemia requiring prehospital emergency assistance from the Public Company for Health Emergencies (Empresa Pública de Emergencias Sanitarias (EPES)) in Andalusia during 2012, which served 8 393 159 people. Databases of the National Statistics Institute, Basic Spatial Data of Andalusia and System of Multiterritorial Information of Andalusia were used to retrieve spatial data and population characteristics. Geographic Information System software (QGIS and GeoDA) was used for analysis and linkage across databases. Spatial analyses of geographical location influence in hypoglycemic events were assessed using Moran's I statistics, and linear regressions were used to determine their association with population characteristics. RESULTS The EPES attended 1 137 738 calls requesting medical assistance, with a mean hypoglycemia incidence of 95.0±61.6 cases per 100 000 inhabitants. There were significant differences in hypoglycemia incidence between basic healthcare zones attributable to their geographical location in the overall population (Moran's I index 0.122, z-score 7.870, p=0.001), women (Moran's I index 0.088, z-score 6.285, p=0.001), men (Moran's I index 0.076, z-score 4.914, p=0.001) and aged >64 years (Moran's I index 0.147, z-score 9.753, p=0.001). Hypoglycemia incidence was higher within unemployed individuals (β=0.003, p=0.001) and unemployed women (β=0.005, p=0.001), while lower within individuals aged <16 years (β=-0.004, p=0.040), higher academic level (secondary studies) (β=-0.003, p=0.004) and women with secondary studies (β=-0.005, p<0.001). In subjects aged >64 years, lower rate of hypoglycemia was associated with more single-person homes (β=-0.008, p=0.022) and sports facilities (β=-0.342, p=0.012). CONCLUSIONS This analysis supports the geographical distribution of hypoglycemia in the overall population, both genders and subjects aged >64 years, which was affected by societal factors such as unemployment, literacy/education, housing and sports facilities. These data can be useful to design specific prevention programs.
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Affiliation(s)
| | - Cristina Abreu
- Endocrinology and Nutrition Unit, Hospital General de Segovia, Segovia, Spain
| | - Manuel Benito
- Department of Urbanism, School of Architecture, Polytechnic University of Madrid, Madrid, Spain
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234
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Moheet A, Chan CL, Granados A, Ode KL, Moran A, Battezzati A. Hypoglycemia in cystic fibrosis: Prevalence, impact and treatment. J Cyst Fibros 2020; 18 Suppl 2:S19-S24. [PMID: 31679723 DOI: 10.1016/j.jcf.2019.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 12/19/2022]
Abstract
Hypoglycemia is a common and feared complication of insulin therapy. As in type 1 and type 2 diabetes, people with cystic fibrosis related diabetes are also at risk for hypoglycemia related to insulin therapy. Spontaneous hypoglycemia is also common in patients with CF without diabetes, who are not on glucose lowering medications. Spontaneous hypoglycemia in CF may also occur during or after an oral glucose tolerance test. In this review, we will discuss the definition, epidemiology, pathophysiology and impact of hypoglycemia, with a focus on people with cystic fibrosis. We will also review strategies to manage and prevent hypoglycemia.
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Affiliation(s)
- Amir Moheet
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Christine L Chan
- Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Andrea Granados
- Department of Pediatrics, Washington University School of Medicine in St. Louis, MO, USA
| | - Katie Larson Ode
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Alberto Battezzati
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food, Environmental and Nutritional Sciences (DeFENS), Università degli Studi di Milano, Milan, Italy
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235
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Fadini GP, Giordano C, Salvi L, Nicolucci A. Reduced Rates of Hypoglycemia in Type 1 or Type 2 Diabetes After Switching to Insulin Degludec: Results from the Italian Cohort of the ReFLeCT Study. Diabetes Ther 2020; 11:2909-2920. [PMID: 33011923 PMCID: PMC7644665 DOI: 10.1007/s13300-020-00936-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/19/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION To evaluate in an Italian real-world setting the safety and effectiveness of insulin degludec 100 units/mL, given once daily in patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) after switching from other basal insulins. METHODS ReFLeCT was a multicenter, prospective, observational study conducted across seven European countries which involved adult patients whose physician planned to switch their medication from basal insulin to insulin degludec. The primary outcome was the change in the number of hypoglycemic episodes before and after the switch to insulin degludec. Results are expressed as 12-month follow-up/baseline incidence rate ratios (IRRs) with 95% confidence intervals (95% CIs). RESULTS The Italian cohort of the ReFLect study comprised 148 patients with T1DM and 311 patients with T2DM. In patients with T1DM, the switch to insulin degludec was associated with significantly lower rates of overall (IRR 0.69, 95% CI 0.57-0.82), non-severe (IRR 0.72, 95% CI 0.60-0.85), and nocturnal hypoglycemia (IRR 0.46, 95% CI 0.31-0.69). Following the switch, hemoglobin A1c (HbA1c) levels decreased significantly by 0.35% (95% CI - 0.50 to - 0.20), with no significant changes in fasting plasma glucose (FPG) and basal insulin dose. Body weight increased by 0.83 kg (95% CI 0.16-1.50). In patients with T2DM, significant reductions in the rates of overall (IRR 0.40, 95% CI 0.29-0.55), non-severe (IRR 0.47, 95% CI 0.34-0.63), and nocturnal hypoglycemia (IRR 0.27, 95% CI 0.09-0.86) were documented. HbA1c and FPG decreased significantly by 0.45% (95% CI - 0.58 to - 0.31) and 0.90 mmol/L (95% CI - 1.21 to - 0.59], respectively, with no significant changes in basal insulin dose or body weight. Treatment satisfaction significantly improved in both diabetes types. CONCLUSION In Italian routine clinical practice, switching from other basal insulins to insulin degludec reduced the total episodes of hypoglycemia and improved glycemic control and treatment satisfaction in patients with T1DM and T2DM. TRIAL REGISTRATION ClinicalTrials.gov NCT02392117.
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Affiliation(s)
| | - Carla Giordano
- Section of Endocrinology, Diabetology and Metabolism, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | | | - Antonio Nicolucci
- The Center for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
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Heller S, Lingvay I, Marso SP, Philis‐Tsimikas A, Pieber TR, Poulter NR, Pratley RE, Hachmann‐Nielsen E, Kvist K, Lange M, Moses AC, Andresen MT, Buse JB. Risk of severe hypoglycaemia and its impact in type 2 diabetes in DEVOTE. Diabetes Obes Metab 2020; 22:2241-2247. [PMID: 32250536 PMCID: PMC7754351 DOI: 10.1111/dom.14049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/30/2020] [Indexed: 01/10/2023]
Abstract
AIMS To undertake a post-hoc analysis, utilizing a hypoglycaemia risk score based on DEVOTE trial data, to investigate if a high risk of severe hypoglycaemia was associated with an increased risk of cardiovascular events, and whether reduced rates of severe hypoglycaemia in patients identified as having the highest risk affected the risk of cardiovascular outcomes. MATERIALS AND METHODS The DEVOTE population was divided into quartiles according to patients' individual hypoglycaemia risk scores. For each quartile, the observed incidence and rate of severe hypoglycaemia, major adverse cardiovascular event (MACE) and all-cause mortality were determined to investigate whether those with the highest risk of hypoglycaemia were also at the greatest risk of MACE and all-cause mortality. In addition, treatment differences within each risk quartile [insulin degludec (degludec) vs. insulin glargine 100 units/mL (glargine U100)] in terms of severe hypoglycaemia, MACE and all-cause mortality were investigated. RESULTS Patients with the highest risk scores had the highest rates of severe hypoglycaemia, MACE and all-cause mortality. Treatment ratios between degludec and glargine U100 in the highest risk quartile were 95% confidence interval (CI) 0.56 (0.39; 0.80) (severe hypoglycaemia), 95% CI 0.76 (0.58; 0.99) (MACE) and 95% CI 0.77 (0.55; 1.07) (all-cause mortality). CONCLUSIONS The risk score demonstrated that a high risk of severe hypoglycaemia was associated with a high incidence of MACE and all-cause mortality and that, in this high-risk group, those treated with degludec had a lower incidence of MACE. These observations support the hypothesis that hypoglycaemia is a risk factor for cardiovascular events.
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Affiliation(s)
- Simon Heller
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
| | - Ildiko Lingvay
- Department of Internal Medicine and Department of Population and Data SciencesUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Steven P. Marso
- HCA Midwest Health Heart and Vascular InstituteOverland ParkKansasUSA
| | | | - Thomas R. Pieber
- Department of Internal MedicineMedical University of GrazGrazAustria
| | - Neil R. Poulter
- Imperial Clinical Trials Unit, National Heart and Lung InstituteImperial College LondonLondonUK
| | | | | | | | | | - Alan C. Moses
- Novo Nordisk A/SSøborgDenmark
- Independent consultant, Novo Nordisk A/SPortsmouthNew HampshireUSA
| | | | - John B. Buse
- University of North Carolina School of MedicineChapel HillNorth CarolinaUSA
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237
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Lingvay I, Capehorn MS, Catarig AM, Johansen P, Lawson J, Sandberg A, Shaw R, Paine A. Efficacy of Once-Weekly Semaglutide vs Empagliflozin Added to Metformin in Type 2 Diabetes: Patient-Level Meta-analysis. J Clin Endocrinol Metab 2020; 105:5896001. [PMID: 32827435 PMCID: PMC7549924 DOI: 10.1210/clinem/dgaa577] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/19/2020] [Indexed: 12/27/2022]
Abstract
CONTEXT No head-to-head trials have directly compared once-weekly (OW) semaglutide, a human glucagon-like peptide-1 analog, with empagliflozin, a sodium-glucose co-transporter-2 inhibitor, in type 2 diabetes (T2D). OBJECTIVE We indirectly compared the efficacy of OW semaglutide 1 mg vs once-daily (OD) empagliflozin 25 mg in patients with T2D inadequately controlled on metformin monotherapy, using individual patient data (IPD) and meta-regression methodology. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS IPD for patients with T2D receiving metformin monotherapy and randomized to OW semaglutide 1 mg (SUSTAIN 2, 3, 8 trials), or to OD empagliflozin 25 mg (PIONEER 2 trial) were included. Meta-regression analyses were adjusted for potential prognostic factors and effect modifiers. MAIN OUTCOME MEASURES The primary efficacy outcomes were change from baseline to end-of-treatment (~1 year) in HbA1c (%-point) and body weight (kg). Responder outcomes and other clinically relevant efficacy measures were analyzed. RESULTS Baseline characteristics were similar between OW semaglutide (n = 995) and empagliflozin (n = 410). Our analyses showed that OW semaglutide significantly reduced mean HbA1c and body weight vs empagliflozin (estimated treatment difference: -0.61%-point [95% confidence interval (CI): -0.72; -0.49] and -1.65 kg [95% CI: -2.22; -1.08], respectively; both P < 0.0001). Complementary analyses supported the robustness of these results. A significantly greater proportion of patients on OW semaglutide vs empagliflozin also achieved HbA1c targets and weight-loss responses. CONCLUSIONS This indirect comparison suggests that OW semaglutide 1 mg provides superior reductions in HbA1c and body weight vs OD empagliflozin 25 mg in patients with T2D when added to metformin monotherapy.
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Affiliation(s)
- Ildiko Lingvay
- University of Texas Southwestern Medical Center at Dallas, Harry Hines Boulevard, Dallas, Texas
| | - Matthew S Capehorn
- Rotherham Institute for Obesity, Clifton Medical Centre, Doncaster Gate, Rotherham, UK
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238
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Heller S, Lingvay I, Marso SP, Philis‐Tsimikas A, Pieber TR, Poulter NR, Pratley RE, Hachmann‐Nielsen E, Kvist K, Lange M, Moses AC, Trock Andresen M, Buse JB. Development of a hypoglycaemia risk score to identify high-risk individuals with advanced type 2 diabetes in DEVOTE. Diabetes Obes Metab 2020; 22:2248-2256. [PMID: 32996693 PMCID: PMC7756403 DOI: 10.1111/dom.14208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 09/21/2020] [Accepted: 09/25/2020] [Indexed: 12/21/2022]
Abstract
AIMS The ability to differentiate patient populations with type 2 diabetes at high risk of severe hypoglycaemia could impact clinical decision making. The aim of this study was to develop a risk score, using patient characteristics, that could differentiate between populations with higher and lower 2-year risk of severe hypoglycaemia among individuals at increased risk of cardiovascular disease. MATERIALS AND METHODS Two models were developed for the risk score based on data from the DEVOTE cardiovascular outcomes trials. The first, a data-driven machine-learning model, used stepwise regression with bidirectional elimination to identify risk factors for severe hypoglycaemia. The second, a risk score based on known clinical risk factors accessible in clinical practice identified from the data-driven model, included: insulin treatment regimen; diabetes duration; sex; age; and glycated haemoglobin, all at baseline. Both the data-driven model and simple risk score were evaluated for discrimination, calibration and generalizability using data from DEVOTE, and were validated against the external LEADER cardiovascular outcomes trial dataset. RESULTS Both the data-driven model and the simple risk score discriminated between patients at higher and lower hypoglycaemia risk, and performed similarly well based on the time-dependent area under the curve index (0.63 and 0.66, respectively) over a 2-year time horizon. CONCLUSIONS Both the data-driven model and the simple hypoglycaemia risk score were able to discriminate between patients at higher and lower risk of severe hypoglycaemia, the latter doing so using easily accessible clinical data. The implementation of such a tool (http://www.hyporiskscore.com/) may facilitate improved recognition of, and education about, severe hypoglycaemia risk, potentially improving patient care.
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Affiliation(s)
- Simon Heller
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
| | - Ildiko Lingvay
- Department of Internal Medicine and Department of Population and Data SciencesUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Steven P. Marso
- HCA Midwest Health Heart and Vascular InstituteOverland ParkKansasUSA
| | | | - Thomas R. Pieber
- Department of Internal MedicineMedical University of GrazGrazAustria
| | - Neil R. Poulter
- Imperial Clinical Trials Unit, Imperial College LondonLondonUK
| | | | | | | | | | - Alan C. Moses
- Novo Nordisk A/SSøborgDenmark
- Independent ConsultantPortsmouthNew HampshireUSA
| | | | - John B. Buse
- University of North Carolina School of MedicineChapel HillNorth CarolinaUSA
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239
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Patel DM, Patel MV, Gurumukhani JK, Patel MM, Mahadevia HJ, Gajjar RA. Hypoglycemic Hemiparesis Masquerading As Ischemic Stroke: When Guideline Fails. CURRENT DRUG THERAPY 2020. [DOI: 10.2174/1574885515666191227155624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Hypoglycemia may rarely present as hemiparesis and sometimes it is difficult to differentiate from ischemic stroke. When random blood sugar (RBS) value is between 50 and 80 mg % in patients presenting with focal neurological deficit, no guideline exists to consider the possibility of hypoglycemia before initiating thrombolytic therapy.
Clinical Case:
A 58-year-old male, who was a known case of diabetes and hypertension, was brought to the emergency room with acute onset of right hemiparesis and dysarthria of 90 minutes duration. His NIHSS Score was 9, blood pressure was 150/90 mm of Hg and RBS was 79 mg% on admission. His CT scan brain was normal and was considered for thrombolysis. Resident doctor not aware of previous sugar repeated RBS before thrombolysis which was surprisingly 60 mg% 60 minutes after the first RBS. Even though he was a candidate for thrombolysis, intravenous 25 % dextrose was administered considering the possibility of hypoglycemia. He made a complete recovery within 20 minutes and thrombolytic therapy was withheld.
In Diabetic patients with focal neurological deficit and RBS less than 80 mg% on admission, RBS should be rechecked and in appropriate cases should be challenged with IV dextrose considering the possibility of hypoglycemia before commencing thrombolytic therapy.
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240
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Mathieu C, Dandona P, Birkenfeld AL, Hansen TK, Iqbal N, Xu J, Repetto E, Scheerer MF, Thoren F, Phillip M. Benefit/risk profile of dapagliflozin 5 mg in the DEPICT-1 and -2 trials in individuals with type 1 diabetes and body mass index ≥27 kg/m 2. Diabetes Obes Metab 2020; 22:2151-2160. [PMID: 32691513 PMCID: PMC7693058 DOI: 10.1111/dom.14144] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/03/2020] [Accepted: 07/16/2020] [Indexed: 12/11/2022]
Abstract
AIM The DEPICT-1 and -2 studies (NCT02268214, NCT02460978) evaluated the efficacy and safety of dapagliflozin in individuals with type 1 diabetes who were receiving intensive insulin therapy. The DEPICT-1 and -2 studies (NCT02268214, NCT02460978) evaluated the efficacy and safety of dapagliflozin in individuals with type 1 diabetes. This post-hoc study investigated the safety and efficacy of dapagliflozin in individuals with BMI ≥27 kg/m2 to assess if the benefit/risk ratio associated with dapagliflozin treatment can be further improved than that observed in the overall DEPICT population. METHODS Changes in glycated haemoglobin (HbA1c) and body weight, percentage change in daily insulin dose and proportion of participants achieving HbA1c reduction ≥0.5% without severe hypoglycaemia were evaluated at weeks 24 and 52. Changes in mean interstitial glucose, mean amplitude of glycaemic excursions and time in target glycaemic range were evaluated at week 24. Safety was assessed until week 56. RESULTS Week-52 adjusted mean (SE) change from baseline for HbA1c was -0.26% (0.05) with dapagliflozin versus +0.08% (0.05) with placebo and for body weight was -2.74 kg (0.25) with dapagliflozin versus +0.81 kg (0.26) with placebo. Mean (SE) percentage change in daily insulin dose was -10.5% (1.23) with dapagliflozin versus -1.4% (1.36) with placebo. Time spent in target glycaemic range increased by 2.2 h/day versus placebo. Dapagliflozin was well tolerated, with fewer participants experiencing diabetic ketoacidosis (dapagliflozin, 1.7%; placebo, 1.0%) than dapagliflozin 5 mg receiving participants in the pooled DEPICT populations. CONCLUSIONS Compared with the pooled DEPICT population, the benefit/risk profile of adjunct dapagliflozin therapy was more favourable in individuals with type 1 diabetes with body mass index ≥27 kg/m2 because of the reduced risk of diabetic ketoacidosis in this population.
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Affiliation(s)
- Chantal Mathieu
- Clinical and Experimental Endocrinology, UZ GasthuisbergUniversity of LeuvenLeuvenBelgium
| | - Paresh Dandona
- State University of New York at BuffaloWilliamsvilleNew YorkUSA
| | - Andreas L Birkenfeld
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre MunichUniversity of TübingenTübingenGermany
- German Center for Diabetes Research (DZD)TübingenGermany
- Department of Internal Medicine, Division of Endocrinology, Diabetology and NephrologyEberhard Karls University TübingenTübingenGermany
| | | | - Nayyar Iqbal
- Late‐stage Development Cardiovascular, Renal and MetabolismAstraZenecaGaithersburgMarylandUSA
| | - John Xu
- Late‐stage Development Cardiovascular, Renal and MetabolismAstraZenecaGaithersburgMarylandUSA
| | - Enrico Repetto
- Global Medical AffairsAstraZenecaGaithersburgMarylandUSA
| | | | - Fredrik Thoren
- Late‐stage Development Cardiovascular, Renal and MetabolismAstraZenecaGothenburgSweden
| | - Moshe Phillip
- Schneider Children's Medical Center of IsraelPetah TikvaIsrael
- Sacller Faculty of MedicineTel Aviv UniversityTel AvivIsrael
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241
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Vijayakumar P, Liu S, McCoy RG, Karter AJ, Lipska KJ. Changes in Management of Type 2 Diabetes Before and After Severe Hypoglycemia. Diabetes Care 2020; 43:e188-e189. [PMID: 32943439 PMCID: PMC7576416 DOI: 10.2337/dc20-0458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/20/2020] [Indexed: 02/03/2023]
Affiliation(s)
| | - Shuling Liu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.,OptumLabs, Cambridge, MA
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Kasia J Lipska
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT .,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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Ibrahim M, Baker J, Cahn A, Eckel RH, El Sayed NA, Fischl AH, Gaede P, Leslie RD, Pieralice S, Tuccinardi D, Pozzilli P, Richelsen B, Roitman E, Standl E, Toledano Y, Tuomilehto J, Weber SL, Umpierrez GE. Hypoglycaemia and its management in primary care setting. Diabetes Metab Res Rev 2020; 36:e3332. [PMID: 32343474 DOI: 10.1002/dmrr.3332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/30/2020] [Accepted: 04/20/2020] [Indexed: 12/14/2022]
Abstract
Hypoglycaemia is common in patients with type 1 diabetes and type 2 diabetes and constitutes a major limiting factor in achieving glycaemic control among people with diabetes. While hypoglycaemia is defined as a blood glucose level under 70 mg/dL (3.9 mmol/L), symptoms may occur at higher blood glucose levels in individuals with poor glycaemic control. Severe hypoglycaemia is defined as an episode requiring the assistance of another person to actively administer carbohydrate, glucagon, or take other corrective actions to assure neurologic recovery. Hypoglycaemia is the most important safety outcome in clinical studies of glucose lowering agents. The American Diabetes Association Standards of Medical Care recommends that a management protocol for hypoglycaemia should be designed and implemented by every hospital, along with a clear prevention and treatment plan. A tailored approach, using clinical and pathophysiologic disease stratification, can help individualize glycaemic goals and promote new therapies to improve quality of life of patients. Data from recent large clinical trials reported low risk of hypoglycaemic events with the use of newer anti-diabetic drugs. Increased hypoglycaemia risk is observed with the use of insulin and/or sulphonylureas. Vulnerable patients with T2D at dual risk of severe hypoglycaemia and cardiovascular outcomes show features of "frailty." Many of such patients may be better treated by the use of GLP-1 receptor agonists or SGLT2 inhibitors rather than insulin. Continuous glucose monitoring (CGM) should be considered for all individuals with increased risk for hypoglycaemia, impaired hypoglycaemia awareness, frequent nocturnal hypoglycaemia and with history of severe hypoglycaemia. Patients with impaired awareness of hypoglycaemia benefit from real-time CGM. The diabetes educator is an invaluable resource and can devote the time needed to thoroughly educate the individual to reduce the risk of hypoglycaemia and integrate the information within the entire construct of diabetes self-management. Conversations about hypoglycaemia facilitated by a healthcare professional may reduce the burden and fear of hypoglycaemia among patients with diabetes and their family members. Optimizing insulin doses and carbohydrate intake, in addition to a short warm up before or after the physical activity sessions may help avoiding hypoglycaemia. Several therapeutic considerations are important to reduce hypoglycaemia risk during pregnancy including administration of rapid-acting insulin analogues rather than human insulin, pre-conception initiation of insulin analogues, and immediate postpartum insulin dose reduction.
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Affiliation(s)
| | - Jason Baker
- Weill Cornell Medicine, New York, New York, USA
| | - Avivit Cahn
- The Diabetes Unit & Endocrinology and Metabolism Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Robert H Eckel
- University of Colorado Denver Anschutz Medical Campus and University of Colorado Hospital, Denver, Colorado, USA
| | - Nuha Ali El Sayed
- Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Hess Fischl
- University of Chicago Kovler Diabetes Center, Chicago, Illinois, USA
| | - Peter Gaede
- Department of Cardiology and Endocrinology, Slagelse Hospital, Slagelse, Denmark
| | - R David Leslie
- Blizard Institute, Queen Mary, University of London, London, UK
- Centre of Immunobiology, Barts and the London School of Medicine, Queen Mary, University of London, London, UK
| | - Silvia Pieralice
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Dario Tuccinardi
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Paolo Pozzilli
- Centre of Immunobiology, Barts and the London School of Medicine, Queen Mary, University of London, London, UK
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - Bjørn Richelsen
- Steno Diabetes Center Aarhus and Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Eytan Roitman
- Institute of Diabetes, Technology and Research, Clalit Health Services, Herzelia, Israel
| | - Eberhard Standl
- Forschergruppe Diabetes eV at Munich Helmholtz Centre, Munich, Germany
| | - Yoel Toledano
- Division of Maternal Fetal Medicine, Helen Schneider Women's Hospital, Rabin Medical Center, Petah Tikva, Israel
| | | | - Sandra L Weber
- Greenville Health System, University of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA
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Lin YK, Fisher SJ, Pop‐Busui R. Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies. J Diabetes Investig 2020; 11:1388-1402. [PMID: 32403204 PMCID: PMC7610104 DOI: 10.1111/jdi.13290] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022] Open
Abstract
Impaired awareness of hypoglycemia (IAH) is a reduction in the ability to recognize low blood glucose levels that would otherwise prompt an appropriate corrective therapy. Identified in approximately 25% of patients with type 1 diabetes, IAH has complex pathophysiology, and might lead to serious and potentially lethal consequences in patients with diabetes, particularly in those with more advanced disease and comorbidities. Continuous glucose monitoring systems can provide real-time glucose information and generate timely alerts on rapidly falling or low blood glucose levels. Given their improvements in accuracy, affordability and integration with insulin pump technology, continuous glucose monitoring systems are emerging as critical tools to help prevent serious hypoglycemia and mitigate its consequences in patients with diabetes. This review discusses the current knowledge on IAH and effective diagnostic methods, the relationship between hypoglycemia and cardiovascular autonomic neuropathy, a practical approach to evaluating cardiovascular autonomic neuropathy for clinicians, and recent evidence from clinical trials assessing the effects of the use of CGM technologies in patients with type 1 diabetes with IAH.
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Affiliation(s)
- Yu Kuei Lin
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Simon J Fisher
- Division of Endocrinology, Metabolism and DiabetesDepartment of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Rodica Pop‐Busui
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Amod A, Buse JB, McGuire DK, Pieber TR, Pop-Busui R, Pratley RE, Zinman B, Hansen MB, Jia T, Mark T, Poulter NR. Risk factors for kidney disorders in patients with type 2 diabetes at high cardiovascular risk: An exploratory analysis (DEVOTE 12). Diab Vasc Dis Res 2020; 17:1479164120970933. [PMID: 33280425 PMCID: PMC7919227 DOI: 10.1177/1479164120970933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIM To investigate risk factors associated with kidney disorders in patients with type 2 diabetes (T2D) at high cardiovascular (CV) risk. METHODS In DEVOTE, a cardiovascular outcomes trial, 7637 patients were randomised to insulin degludec (degludec) or insulin glargine 100 units/mL (glargine U100), with standard of care. In these exploratory post hoc analyses, serious adverse event reports were searched using Standardised MedDRA® Queries related to chronic kidney disease (CKD) or acute kidney injury (AKI). Baseline predictors of CKD, AKI and change in estimated glomerular filtration rate (eGFR) were identified using stepwise selection and Cox or linear regression. RESULTS Over 2 years, eGFR (mL/min/1.73 m2) decline was small and similar between treatments (degludec: 2.70; glargine U100: 2.92). Overall, 97 and 208 patients experienced CKD and AKI events, respectively. A history of heart failure was a risk factor for CKD (hazard ratio [HR] 1.97 [95% confidence interval [CI] 1.41; 2.75]) and AKI (HR 2.28 [95% CI 1.64; 3.17]). A history of hepatic impairment was a significant predictor of CKD (HR 3.28 [95% CI 2.12; 5.07]) and change in eGFR (estimate: -8.59 [95% CI -10.20; -7.00]). CONCLUSION Our findings indicate that traditional, non-modifiable risk factors for kidney disorders apply to insulin-treated patients with T2D at high CV risk. TRIAL REGISTRATION NCT01959529 (ClinicalTrials.gov).
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Affiliation(s)
- Aslam Amod
- Department of Diabetes and Endocrinology, Life Chatsmed Garden Hospital and Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Aslam Amod, Department of Diabetes and Endocrinology, Life Chatsmed Garden Hospital and Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, PO Box 201685, Durban North 4016, South Africa.
| | - John B Buse
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Darren K McGuire
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX, USA
| | - Thomas R Pieber
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rodica Pop-Busui
- Department of Internal Medicine, Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | | | - Bernard Zinman
- Department of Medicine, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Ting Jia
- Novo Nordisk A/S, Søborg, Hovedstaden, Denmark
| | - Thomas Mark
- Novo Nordisk A/S, Søborg, Hovedstaden, Denmark
| | - Neil R Poulter
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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Urakami T, Yoshida K, Kuwabara R, Mine Y, Aoki M, Suzuki J, Morioka I. Individualization of recommendations from the international consensus on continuous glucose monitoring-derived metrics in Japanese children and adolescents with type 1 diabetes. Endocr J 2020; 67:1055-1062. [PMID: 32565500 DOI: 10.1507/endocrj.ej20-0193] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We assessed the significance of recommendations from the international consensus on continuous glucose monitoring (CGM)-derived metrics in Japanese children and adolescents with type 1 diabetes. Eighty-five patients (age, 13.5 ± 4.7 years) who wore the FreeStyle® Libre for a 28-day period were enrolled in this study. Seventy-three patients were treated with multiple daily injections of insulin and 12 with insulin pump therapy without using a sensor-augmented pump or a predictive low-glucose suspend-function pump. We evaluated the relationship between CGM-derived metrics: time in range (TIR: 70-180 mg/dL), time below range (TBR: <70 mg/dL), and time above range (TAR: >180 mg/dL), and laboratory-measured HbA1c and estimated HbA1c (eA1c) levels calculated from the mean glucose values. The TIR was 50.7 ± 12.2% (23-75%), TBR was 11.8 ± 5.8% (2-27%), and TAR was 37.5 ± 13.5% (9-69%). The TIR was highly correlated with HbA1c level, eA1c level, and TAR, but not with TBR. An HbA1c level of 7.0% corresponded to a TIR of 55.1% (95% CI: 53.7-56.5%), whereas a TIR of 70% corresponded to an HbA1c level of 6.1% (95% CI: 5.9-6.3%). The results of eA1c levels were similar to those observed for HbA1c levels. From these findings, we conclude that low rates of a recommended TIR of 70% may be due to less use of advanced technology and insufficient comprehensive diabetes care. Ethnic characteristics including lifestyle and eating customs may have contributed to the result. CGM-derived targets must be individualized based on ethnic characteristics, insulin treatment and diabetes care, and needs of individuals with diabetes.
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Affiliation(s)
- Tatsuhiko Urakami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Kei Yoshida
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Remi Kuwabara
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Yusuke Mine
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Masako Aoki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Junichi Suzuki
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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Zhang Y, Li S, Zou Y, Wu X, Bi Y, Zhang L, Yuan Y, Gong W, Hayter M. Fear of hypoglycemia in patients with type 1 and 2 diabetes: a systematic review. J Clin Nurs 2020; 30:72-82. [PMID: 33091198 DOI: 10.1111/jocn.15538] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 10/14/2020] [Indexed: 01/17/2023]
Abstract
AIMS AND OBJECTIVES To summarize and thematize fear of hypoglycemia (FOH) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) to provide a theoretical basis for the development of effective interventions. BACKGROUND FOH is common in this population and can reduce quality of life(QOL) and adversely impact upon diabetes self-care management. DESIGN a systematic review METHODS: Articles published between 2000 and 2019 were searched in PubMed, MEDLINE, EMBASE, Web of Science and three Chinese databases (CNKI, Wan-fang data and VIP). Eligible articles were selected using the Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA) guidelines. The quality of all articles finally included was evaluated by the Joanna Briggs Institute (JBI) Critical Appraisal tools. RESULTS Eighteen studies from 8654 papers were included. The sample size of each study ranged from 48 to 3812 subjects. FOH negatively impacted QOL, particularly psychosocial functioning, daily life and sleep quality. CONCLUSIONS FOH is a common and serious problem for patients, leading to poor QOL. It has been suggested that psychological concerns, QOL and effective countermeasures in individuals with T1D and T2D should be taken seriously. Advanced technology should be evaluated for its benefits before being used by patients. RELEVANCE TO CLINICAL PRACTICE The review highlights that FOH negatively impacts QOL, including psychosocial factors, daily life and sleep quality. Healthcare providers should develop targeted and professional assessment tools for FOH and QOL for patients with T2D, especially for patients who are about 60 years old. Advanced technology should be evaluated for its benefits before being used by patients.
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Affiliation(s)
- Yu Zhang
- School of Nursing, Yangzhou University, Yangzhou, China
- Jiangsu Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Senile Diseases, Yangzhou, China
| | - Shuang Li
- School of Nursing, Yangzhou University, Yangzhou, China
| | - Yan Zou
- School of Nursing, Yangzhou University, Yangzhou, China
| | - Xiaxin Wu
- School of Nursing, Yangzhou University, Yangzhou, China
| | - Yaxin Bi
- School of Nursing, Yangzhou University, Yangzhou, China
| | - Lu Zhang
- School of Nursing, Yangzhou University, Yangzhou, China
| | - Yuan Yuan
- School of Nursing, Yangzhou University, Yangzhou, China
- Department of Nursing, Yangzhou University Affiliated Hospital, Yangzhou, China
| | - Weijuan Gong
- School of Nursing, Yangzhou University, Yangzhou, China
- Jiangsu Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Senile Diseases, Yangzhou, China
| | - Mark Hayter
- Faculty of Health Science, University of Hull, Hull, UK
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McCarthy O, Pitt J, Churm R, Dunseath GJ, Jones C, Bally L, Nakas CT, Deere R, Eckstein ML, Bain SC, Moser O, Bracken RM. Metabolomic, hormonal and physiological responses to hypoglycemia versus euglycemia during exercise in adults with type 1 diabetes. BMJ Open Diabetes Res Care 2020; 8:8/1/e001577. [PMID: 33020134 PMCID: PMC7536836 DOI: 10.1136/bmjdrc-2020-001577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/22/2020] [Accepted: 08/19/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION This study sought to compare the metabolomic, hormonal and physiological responses to hypoglycemia versus euglycemia during exercise in adults with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS Thirteen individuals with T1D (hemoglobin; 7.0%±1.3% (52.6±13.9 mmol/mol), age; 36±15 years, duration diabetes; 15±12 years) performed a maximum of 45 min submaximal exercise (60%±6% V̇O2max). Retrospectively identified exercise sessions that ended in hypoglycemia ((HypoEx) blood glucose (BG)≤3.9 mmol/L) were compared against a participant-matched euglycemic condition ((EuEx) BG≥4.0, BG≤10.0 mmol/L). Samples were compared for detailed physiological and hormonal parameters as well as metabolically profiled via large scale targeted ultra-high-performance liquid chromatography coupled to tandem mass spectrometry. Data were assessed using univariate and multivariate analysis techniques with false discovery rate adjustment. Significant results were considered at p≤0.05. RESULTS Cardiorespiratory and counterregulatory hormone responses, whole-body fuel use and perception of fatigue during exercise were similar under conditions of hypoglycemia and euglycemia (BG 3.5±0.3 vs 5.8±1.1 mmol/L, respectively p<0.001). HypoEx was associated with greater adenosine salvage pathway activity (5'-methylthioadenosine, p=0.023 and higher cysteine and methionine metabolism), increased utilization of glucogenic amino acids (glutamine, p=0.021, alanine, aspartate and glutamate metabolism and homoserine/threonine, p=0.045) and evidence of enhanced β-oxidation (lower carnitine p<0.001, higher long-chain acylcarnitines). CONCLUSIONS Exposure to acute hypoglycemia during exercise potentiates alterations in subclinical indices of metabolic stress at the level of the metabolome. However, the physiological responses induced by dynamic physical exercise may mask the symptomatic recognition of mild hypoglycemia during exercise in people with T1D, a potential clinical safety concern that reinforces the need for diligent glucose management. TRIAL REGISTRATION NUMBER DRKS00013509.
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Affiliation(s)
- Olivia McCarthy
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), Swansea University College of Engineering, Swansea, UK
| | - Jason Pitt
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), Swansea University College of Engineering, Swansea, UK
| | - Rachel Churm
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), Swansea University College of Engineering, Swansea, UK
| | - Gareth J Dunseath
- Diabetes Research Group, Swansea University Medical School, Swansea, UK
| | - Charlotte Jones
- Diabetes Research Group, Swansea University Medical School, Swansea, UK
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital University Hospital Bern, Bern, Switzerland
| | - Christos T Nakas
- Laboratory of Biometry, University of Thessaly, Volos, Thessaly, Greece
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Rachel Deere
- Department of Health, University of Bath, Bath, Somerset, UK
| | - Max L Eckstein
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stephen C Bain
- Diabetes Research Group, Swansea University Medical School, Swansea, UK
| | - Othmar Moser
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Richard M Bracken
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), Swansea University College of Engineering, Swansea, UK
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Groop PH, Dandona P, Phillip M, Gillard P, Edelman S, Jendle J, Xu J, Scheerer MF, Thoren F, Iqbal N, Repetto E, Mathieu C. Effect of dapagliflozin as an adjunct to insulin over 52 weeks in individuals with type 1 diabetes: post-hoc renal analysis of the DEPICT randomised controlled trials. Lancet Diabetes Endocrinol 2020; 8:845-854. [PMID: 32946821 DOI: 10.1016/s2213-8587(20)30280-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/09/2020] [Accepted: 07/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The DEPICT-1 and DEPICT-2 studies showed that dapagliflozin as an adjunct to insulin in individuals with inadequately controlled type 1 diabetes improved glycaemic control and bodyweight, without increase in risk of hypoglycaemia. We aimed to determine the effect of dapagliflozin on urinary albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) using pooled data from the DEPICT studies. METHODS In this post-hoc analysis, we used data pooled from both DEPICT studies (DEPICT-1 ran from Nov 11, 2014, to Aug 25, 2017; DEPICT-2 ran from July 8, 2015, to April 18, 2018), in which participants were aged 18-75 years, with inadequately controlled type 1 diabetes and with a baseline UACR of at least 30 mg/g. In the DEPICT studies, participants were randomly assigned (1:1:1) to receive dapagliflozin (5 mg or 10 mg) or placebo all plus insulin, for 24 weeks, with a 28-week long-term extension (ie, 52 weeks in total). In this post-hoc analysis, we assessed the percentage change from baseline in UACR and in eGFR, up to 52 weeks. UACR, eGFR, and safety were assessed in all eligible participants who had received at least one dose of study drug. HbA1c, bodyweight, and systolic blood pressure were assessed in all participants who received at least one dose of study drug during the first 24-week period, and who had a baseline and any post-baseline assessment for that parameter. The DEPICT trials were registered with ClinicalTrials.gov, NCT02268214 (DEPICT-1), NCT02460978 (DEPICT-2), and are now complete. RESULTS 251 participants with albuminuria at baseline were included in this post-hoc analysis; of whom 80 (32%) had been randomly assigned to dapagliflozin 5 mg, 84 (33%) to dapagliflozin 10 mg, and 87 (35%) to placebo. Compared with placebo, treatment with both dapagliflozin doses improved UACR over 52 weeks. At week 52, mean difference in change from baseline versus placebo in UACR was -13·3% (95% CI -37·2 to 19·8) for dapagliflozin 5 mg and -31·1% (-49·9 to -5·2) for dapagliflozin 10 mg. No notable change from baseline was seen in eGFR, with a mean difference in change from baseline versus placebo of 3·27 mL/min per 1·73 m2 (95% CI -0·92 to 7·45) for dapagliflozin 5 mg and 2·12 mL/min per 1·73 m2 (-2·03 to 6·27) for dapagliflozin 10 mg. Similar proportions of participants in each treatment group had adverse events and serious adverse events, including hypoglycaemia and diabetic ketoacidosis; no new safety signals were identified in this population. INTERPRETATION Treatment with dapagliflozin resulted in UACR reduction, which might provide renoprotective benefits in individuals with type 1 diabetes and albuminuria. Dedicated prospective studies are needed to confirm these findings as prespecified endpoints. FUNDING AstraZeneca.
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Affiliation(s)
- Per-Henrik Groop
- Abdominal Center, Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland; Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Paresh Dandona
- Jacob School of Medicine, State University of New York, Buffalo, NY, USA
| | - Moshe Phillip
- Institute for Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pieter Gillard
- Clinical and Experimental Endocrinology, UZ Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Steven Edelman
- Department of Medicine, University of California, San Diego, CA, USA
| | - Johan Jendle
- Institute of Medical Sciences, Örebro University, Örebro, Sweden
| | - John Xu
- Late-stage Development, Cardiovascular, Renal and Metabolism, AstraZeneca, Gaithersburg, MD, USA
| | | | - Fredrik Thoren
- Late-stage Development Cardiovascular, Renal and Metabolism, AstraZeneca, Gothenburg, Sweden
| | - Nayyar Iqbal
- Late-stage Development, Cardiovascular, Renal and Metabolism, AstraZeneca, Gaithersburg, MD, USA
| | - Enrico Repetto
- Global Medical Affairs, AstraZeneca, Gaithersburg, MD, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, UZ Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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The Effect of Food Intake on the Pharmacokinetics of Oral Basal Insulin: A Randomised Crossover Trial in Healthy Male Subjects. Clin Pharmacokinet 2020; 58:1497-1504. [PMID: 31093929 PMCID: PMC6856260 DOI: 10.1007/s40262-019-00772-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Oral insulin 338 is a novel tablet formulation of a long-acting basal insulin. This randomised, open-label, four-period crossover trial investigated the effect of timing of food intake on the single-dose pharmacokinetic properties of oral insulin 338. Methods After an overnight fast, 44 healthy males received single fixed doses of oral insulin 338 administered 0, 30, 60 or 360 min before consuming a standardised meal (500 kcal, 57 energy percent [E%] carbohydrate, 13 E% fat, 30 E% protein). Blood samples for pharmacokinetic assessment were taken up to 288 h post-dose. Results Total exposure (area under the concentration-time curve from time zero to infinity [AUCIns338,0–∞]) and maximum concentration (Cmax,Ins338) of insulin 338 were both significantly lower for 0 versus 360 min post-dose fasting (ratio [95% confidence interval (CI)]: 0.36 [0.26–0.49], p < 0.001, and 0.35 [0.25–0.49], p < 0.001, respectively). There were no significant differences in AUCIns338,0–∞ and Cmax,Ins338 for 30 or 60 versus 360 min post-dose fasting (ratio [95% CI] 30 versus 360 min: 0.85 [0.61–1.21], p = 0.36, and 0.86 [0.59–1.26], p = 0.42; ratio [95% CI] 60 versus 360 min: 0.96 [0.72–1.28], p = 0.77, and 0.99 [0.75–1.31], p = 0.95). The mean half-life was ~ 55 h independent of the post-dose fasting period. Oral insulin 338 was well-tolerated with no safety issues identified during the trial. Conclusions Oral insulin 338 pharmacokinetics are not affected by food intake from 30 min after dosing, implying that patients with diabetes mellitus do not need to wait more than 30 min after a morning dose of oral insulin 338 before having their breakfast. This is considered important for convenience and treatment compliance. ClinicalTrials.gov identifier NCT02304627. Electronic supplementary material The online version of this article (10.1007/s40262-019-00772-2) contains supplementary material, which is available to authorized users.
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Mosenzon O, Miller EM, Warren ML. Oral semaglutide in patients with type 2 diabetes and cardiovascular disease, renal impairment, or other comorbidities, and in older patients. Postgrad Med 2020; 132:37-47. [DOI: 10.1080/00325481.2020.1800286] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Ofri Mosenzon
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Centre, Jerusalem, Israel
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