251
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Cigrovski Berković M, Herman Mahečić D, Gradišer M, Bilić-Ćurčić I. Impact of health policy and practice on finding the best fit for patients with type 2 diabetes after metformin failure: Croatian pilot study. Prim Care Diabetes 2017; 11:265-272. [PMID: 28314484 DOI: 10.1016/j.pcd.2017.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 02/17/2017] [Accepted: 02/21/2017] [Indexed: 10/20/2022]
Abstract
AIM We assessed the impact of clinical practice and health policy on the choice and efficacy of different second-line therapies for the treatment of type 2 diabetes (T2DM) after failure of metformin. METHODS This retrospective database analysis included 200 patients with a follow-up period of 6 months. The primary end-point was achievement of HbA1c <7% and fasting (FBG) and postprandial glucose levels (PPG) <7.2mmol/L and <10mmol/L, respectively after three and six months of different add-on treatments. Secondary end-points were weight change during treatment and incidence of hypoglycemia. RESULTS All second-line therapeutic options, except human basal insulin (BHI) and thiazolidendions (TZD) significantly increased the proportion of patients reaching target HbA1c after 6 months (p<0.01). Only sulfonylurea (SU) and dipeptidyl peptidase-4 (DPP-4) inhibitors significantly reduced all monitored parameters of glucoregulation without changing body weight and BMI after 3 and 6 months as opposed to insulin agents. However, there were no statistically significant differences between the groups when adjusting for starting HbA1c, FBG and PPG (F=1.16, p=NS), although a statistically significant difference in HbA1c levels (F=3.35, p<0.01) persisted in DPP-4 inhibitor users. The incidence of hypoglycemia was significantly higher in patients treated with NPH insulin and premixed insulin than in patients treated with other agents. CONCLUSION A more aggressive approach is needed with early treatment intensification using available agents.
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Affiliation(s)
- Maja Cigrovski Berković
- Department for Endocrinology, Diabetes and Metabolism, University Hospital Centre "Sestre milosrdnice", Zagreb, Croatia.
| | - Davorka Herman Mahečić
- Department for Endocrinology, Diabetes and Metabolism, University Hospital Centre "Sestre milosrdnice", Zagreb, Croatia
| | - Marina Gradišer
- Department for Internal Medicine, General Hospital Čakovec, Čakovec, Croatia
| | - Ines Bilić-Ćurčić
- Faculty of Medicine, J.J. Strossmayer University Osijek, Clinical Hospital Center Osijek, J. Huttlera 4, 31000 Osijek, Croatia
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252
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Abstract
Continuous glucose monitoring (CGM) is developing into an increasingly useful tool for glucose monitoring and therapeutic guidance in the treatment of diabetes. Multiple daily doses of insulin (MDI) is the most common method for intensive insulin treatment of type 1 diabetes and is also becoming more common in the treatment of type 2 diabetes as an increasing population with type 2 diabetes experiences progressive beta cell loss. The clinical evidence demonstrating the benefit of CGM in the outcomes of patients treated with MDI is becoming clearer, particularly with the recent completion of several randomized clinical trials addressing both type 1 and 2 diabetes. This evidence is reviewed.
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Affiliation(s)
| | - Andrew Ahmann
- Oregon Health & Science University, Portland, Oregon
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253
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Balijepalli C, Druyts E, Siliman G, Joffres M, Thorlund K, Mills EJ. Hypoglycemia: a review of definitions used in clinical trials evaluating antihyperglycemic drugs for diabetes. Clin Epidemiol 2017; 9:291-296. [PMID: 28579834 PMCID: PMC5448700 DOI: 10.2147/clep.s129268] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective To understand the severity and potential impact of heterogeneity in definitions of hypoglycemia used in diabetes research, we aimed to review the hypoglycemia definitions adopted in randomized controlled trials (RCTs). Methods We reviewed 109 RCTs included in the Canadian Agency for Drugs and Technologies in Health reports for the second- and third-line therapy for the patients with type 2 diabetes (T2D). Results Nearly 60% (n=66) of the studies reviewed presented the definitions for overall hypoglycemia, and another 20% (n=22) of the studies reported the results for hypoglycemia but did not report a definition. Among these 66 studies, only 9 (14%) followed the American Diabetes Association/European Medicines Agency specified guidelines to define hypoglycemia, with an exact threshold of plasma glucose ≤3.9 mmol/L. Fifty-two of the 66 studies (79%) used a threshold considerably lower than the recommended ≤3.9 mmol/L, and 16 studies used a threshold between 3.8 and 4.0 mmol/L. The proportion of the trials that used a cutoff value of <3.1 mmol/L appeared to be slightly similar among the more commonly used non-insulin treatments, GLP-1s (7 of 18 [39%]), thiazolidinediones (TZDs; 6 of 11 [55%]), DPP-4s (12 of 19 [64%]), and sulfonylureas (11 of 20 [55%]). Among trials with intermediate-long-acting insulins (neutral protamine Hagedorn insulin, detemir, glargine), 7 of 26 trials (27%) used a cutoff of <3.1 mmol/L. The definition of severe hypoglycemia was also subject to substantial heterogeneity, in both the utilized threshold and accompanying soft definitions. Conclusion This review demonstrates that substantial heterogeneity exists in the definition of overall, severe/major, and nocturnal hypoglycemia across RCTs investigating T2D interventions.
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Affiliation(s)
- Chakrapani Balijepalli
- Faculty of Health Sciences, Simon Fraser University, Burnaby.,Precision Health Economics, Vancouver, BC
| | | | | | - Michel Joffres
- Faculty of Health Sciences, Simon Fraser University, Burnaby
| | - Kristian Thorlund
- Precision Health Economics, Vancouver, BC.,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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254
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Lin Y, Shen J, Li D, Ming J, Liu X, Zhang N, Lai J, Shi M, Ji Q, Xing Y. MiR-34a contributes to diabetes-related cochlear hair cell apoptosis via SIRT1/HIF-1α signaling. Gen Comp Endocrinol 2017; 246:63-70. [PMID: 28263817 DOI: 10.1016/j.ygcen.2017.02.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/05/2017] [Accepted: 02/28/2017] [Indexed: 12/18/2022]
Abstract
Type 2 diabetes (T2DM) has been considered to be associated with a higher likelihood of hearing impairment (HI). However, the molecular mechanisms underlying the association between diabetes and HI are poorly understood. MicroRNAs have recently been demonstrated to be closely associated with hearing loss and considered as promising therapeutic targets. Herein, we investigated whether miR-34a contributes to diabetes-related cochlear hair cell apoptosis and sought to identify the underlying mechanism. The results showed that miR-34a was up-regulated in the cochleas of db/db mice, accompanied by significant hearing threshold elevation and hair cell loss. However, the expression of SIRT1 was significantly down-regulated, while hypoxia-inducible factor-1alpha (HIF-1α) levels were dramatically increased in the cochleas of db/db mice. In addition, in the high-glucose cultured House Ear Institute-Organ of Corti 1 (HEI-OC1) cell line, miR-34a overexpression inhibited sirtuin1 (SIRT1) expression, increased HIF-1α levels and promoted apoptosis. MiR-34a knockdown exerted effects that were diametrically opposed to those observed with overexpression. Interestingly, HIF-1α knockdown almost eliminated the cell apoptosis induced by high glucose levels. We also examined the modulation of HIF-1α expression by SIRT1. The results showed that SIRT1 knockdown further promoted high-glucose-induced HIF-1α expression, while SIRT1 overexpression significantly inhibited HIF-1α level induced by high glucose. These findings point to a new mechanism by which miR-34a exerts its detrimental effects by negatively regulating SIRT1/HIF-1α signaling and provide new therapeutic targets for treating hearing impairment during diabetes.
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MESH Headings
- Animals
- Apoptosis/genetics
- Blotting, Western
- Cells, Cultured
- Diabetes Mellitus, Experimental/genetics
- Diabetes Mellitus, Experimental/metabolism
- Diabetes Mellitus, Experimental/pathology
- Disease Models, Animal
- Gene Expression Regulation
- Hair Cells, Auditory/metabolism
- Hair Cells, Auditory/pathology
- Hearing Loss/etiology
- Hearing Loss/metabolism
- Hearing Loss/pathology
- Hypoxia-Inducible Factor 1, alpha Subunit/genetics
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Male
- Mice
- Mice, Inbred C57BL
- MicroRNAs/genetics
- RNA, Messenger/genetics
- Real-Time Polymerase Chain Reaction
- Reverse Transcriptase Polymerase Chain Reaction
- Signal Transduction
- Sirtuin 1/genetics
- Sirtuin 1/metabolism
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Affiliation(s)
- Ying Lin
- Department of Otolaryngology, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Jinjin Shen
- Department of Otolaryngology, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Danfeng Li
- Department of Otolaryngology, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Jie Ming
- Department of Endocrinology and Metabolism Disease, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Xiangyang Liu
- Department of Endocrinology and Metabolism Disease, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Nana Zhang
- Department of Endocrinology and Metabolism Disease, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Jingbo Lai
- Department of Endocrinology and Metabolism Disease, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Min Shi
- Department of Endocrinology and Metabolism Disease, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China
| | - Qiuhe Ji
- Department of Endocrinology and Metabolism Disease, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China.
| | - Ying Xing
- Department of Endocrinology and Metabolism Disease, Xijing Hospital, Forth Military Medical University, Xi'an, Shaanxi 710032, China.
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255
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Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, Kowalski A, Rabasa-Lhoret R, McCrimmon RJ, Hume C, Annan F, Fournier PA, Graham C, Bode B, Galassetti P, Jones TW, Millán IS, Heise T, Peters AL, Petz A, Laffel LM. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol 2017; 5:377-390. [PMID: 28126459 DOI: 10.1016/s2213-8587(17)30014-1] [Citation(s) in RCA: 501] [Impact Index Per Article: 71.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 11/20/2016] [Accepted: 11/21/2016] [Indexed: 12/28/2022]
Abstract
Type 1 diabetes is a challenging condition to manage for various physiological and behavioural reasons. Regular exercise is important, but management of different forms of physical activity is particularly difficult for both the individual with type 1 diabetes and the health-care provider. People with type 1 diabetes tend to be at least as inactive as the general population, with a large percentage of individuals not maintaining a healthy body mass nor achieving the minimum amount of moderate to vigorous aerobic activity per week. Regular exercise can improve health and wellbeing, and can help individuals to achieve their target lipid profile, body composition, and fitness and glycaemic goals. However, several additional barriers to exercise can exist for a person with diabetes, including fear of hypoglycaemia, loss of glycaemic control, and inadequate knowledge around exercise management. This Review provides an up-to-date consensus on exercise management for individuals with type 1 diabetes who exercise regularly, including glucose targets for safe and effective exercise, and nutritional and insulin dose adjustments to protect against exercise-related glucose excursions.
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Affiliation(s)
- Michael C Riddell
- Muscle Health Research Centre, York University, Toronto, ON, Canada.
| | - Ian W Gallen
- Royal Berkshire NHS Foundation Trust Centre for Diabetes and Endocrinology, Royal Berkshire Hospital, Reading, UK
| | - Carmel E Smart
- Hunter Medical Research Institute, School of Health Sciences, University of Newcastle, Rankin Park, NSW, Australia
| | - Craig E Taplin
- Division of Endocrinology and Diabetes, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Peter Adolfsson
- Department of Pediatrics, The Hospital of Halland, Kungsbacka, Sweden; Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alistair N Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Aaron Kowalski
- Juvenile Diabetes Research Foundation, New York, NY, USA
| | - Remi Rabasa-Lhoret
- Department of Nutrition and Institut de Recherches Cliniques de Montréal, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Rory J McCrimmon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | | | - Francesca Annan
- Children and Young People's Diabetes Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Paul A Fournier
- School of Sport Science, Exercise, and Health, Perth, WA, Australia
| | | | - Bruce Bode
- Atlanta Diabetes Associates, Atlanta, GA, USA
| | - Pietro Galassetti
- Department of Pediatrics, University of California Irvine, Irvine, CA, USA; AstraZeneca, Gaithersburg, MD, USA
| | - Timothy W Jones
- The University of Western Australia, Perth, WA, Australia; Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia; Telethon Kids Institute, Perth, WA, Australia
| | - Iñigo San Millán
- Department of Physical Medicine and Rehabilitation, University of Colorado, School of Medicine, Aurora, CO, USA
| | | | - Anne L Peters
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Lori M Laffel
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA; Pediatric, Adolescent and Young Adult Section, Joslin Diabetes Center, Boston, MA, USA
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256
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Middleton TL, Wong J, Molyneaux L, Brooks BA, Yue DK, Twigg SM, Wu T. Cardiac Effects of Sulfonylurea-Related Hypoglycemia. Diabetes Care 2017; 40:663-670. [PMID: 28223296 DOI: 10.2337/dc16-1972] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/05/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the effect of sulfonylurea-related hypoglycemia on cardiac repolarization and ectopy in the setting of well-controlled type 2 diabetes. RESEARCH DESIGN AND METHODS Thirty subjects with sulfonylurea-treated type 2 diabetes underwent 48 h of concurrent continuous glucose monitoring and ambulatory electrocardiography. Ventricular repolarization (QTc) and QT dynamicity were analyzed during periods of hypoglycemia (<3.5 mmol/L for >20 min) and compared with periods of euglycemia and hyperglycemia combined. Cardiac ectopy rates during hypoglycemia were compared with ectopy rates when blood glucose was 4-10 mmol/L. RESULTS Mean HbA1c was 6.9% (52 mmol/mol). Hypoglycemia was detected in 9 of 30 subjects (30%); episodes were typically nocturnal (67%) and asymptomatic (73%). Hypoglycemia-associated QTc prolongation was seen in five of nine subjects with a large variation in individual response. Higher QT dynamicity, a poor prognostic factor in cardiac disease, was seen in subjects who experienced hypoglycemia compared with subjects who did not (0.193 vs. 0.159 for the nocturnal period; P = 0.01). This finding persisted after the hypoglycemic event. The rates of ventricular and supraventricular ectopy demonstrated a nonsignificant trend toward an increase during hypoglycemia (median rate ratio 1.58 and 1.33, respectively). Similar, nonsignificant results were observed in a separate insulin-treated cohort. CONCLUSIONS Hypoglycemia, often unrecognized, is a frequent finding in well-controlled sulfonylurea-treated type 2 diabetes. It is associated with the novel finding of increased QT dynamicity and QTc prolongation in some individuals. Our findings suggest sulfonylurea-related hypoglycemia can have detrimental cardiovascular sequelae. Similar effects are also seen in the setting of insulin therapy.
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Affiliation(s)
- Timothy L Middleton
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia .,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Jencia Wong
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Lynda Molyneaux
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Belinda A Brooks
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,School of Nursing, University of Sydney, Sydney, New South Wales, Australia
| | - Dennis K Yue
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Stephen M Twigg
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Ted Wu
- Diabetes Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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257
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Bally L, Thabit H, Kojzar H, Mader JK, Qerimi-Hyseni J, Hartnell S, Tauschmann M, Allen JM, Wilinska ME, Pieber TR, Evans ML, Hovorka R. Day-and-night glycaemic control with closed-loop insulin delivery versus conventional insulin pump therapy in free-living adults with well controlled type 1 diabetes: an open-label, randomised, crossover study. Lancet Diabetes Endocrinol 2017; 5:261-270. [PMID: 28094136 PMCID: PMC5379244 DOI: 10.1016/s2213-8587(17)30001-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/08/2016] [Accepted: 12/09/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tight control of blood glucose concentration in people with type 1 diabetes predisposes to hypoglycaemia. We aimed to investigate whether day-and-night hybrid closed-loop insulin delivery can improve glucose control while alleviating the risk of hypoglycaemia in adults with HbA1c below 7·5% (58 mmol/mol). METHODS In this open-label, randomised, crossover study, we recruited adults (aged ≥18 years) with type 1 diabetes and HbA1c below 7·5% from Addenbrooke's Hospital (Cambridge, UK) and Medical University of Graz (Graz, Austria). After a 2-4 week run-in period, participants were randomly assigned (1:1), using web-based randomly permuted blocks of four, to receive insulin via the day-and-night hybrid closed-loop system or usual pump therapy for 4 weeks, followed by a 2-4 week washout period and then the other intervention for 4 weeks. Treatment interventions were unsupervised and done under free-living conditions. During the closed-loop period, a model-predictive control algorithm directed insulin delivery, and prandial insulin delivery was calculated with a standard bolus wizard. The primary outcome was the proportion of time when sensor glucose concentration was in target range (3·9-10·0 mmol/L) over the 4 week study period. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02727231, and is completed. FINDINGS Between March 21 and June 24, 2016, we recruited 31 participants, of whom 29 were randomised. One participant withdrew during the first closed-loop period because of dissatisfaction with study devices and glucose control. The proportion of time when sensor glucose concentration was in target range was 10·5 percentage points higher (95% CI 7·6-13·4; p<0·0001) during closed-loop delivery compared with usual pump therapy (65·6% [SD 8·1] when participants used usual pump therapy vs 76·2% [6·4] when they used closed-loop). Compared with usual pump therapy, closed-loop delivery also reduced the proportion of time spent in hypoglycaemia: the proportion of time with glucose concentration below 3·5 mmol/L was reduced by 65% (53-74, p<0·0001) and below 2·8 mmol/L by 76% (59-86, p<0·0001). No episodes of serious hypoglycaemia or other serious adverse events occurred. INTERPRETATION Use of day-and-night hybrid closed-loop insulin delivery under unsupervised, free-living conditions for 4 weeks in adults with type 1 diabetes and HbA1c below 7·5% is safe and well tolerated, improves glucose control, and reduces hypoglycaemia burden. Larger and longer studies are warranted. FUNDING Swiss National Science Foundation (P1BEP3_165297), JDRF, UK National Institute for Health Research Cambridge Biomedical Research Centre, and Wellcome Strategic Award (100574/Z/12/Z).
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Affiliation(s)
- Lia Bally
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes & Endocrinology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK; Department of Diabetes, Endocrinology, Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes & Endocrinology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Harald Kojzar
- Department of Internal Medicine, Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Julia K Mader
- Department of Internal Medicine, Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Jehona Qerimi-Hyseni
- Department of Internal Medicine, Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Sara Hartnell
- Department of Diabetes & Endocrinology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Janet M Allen
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Thomas R Pieber
- Department of Internal Medicine, Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Mark L Evans
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes & Endocrinology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK.
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258
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Abstract
PURPOSE OF REVIEW Episodic hypoglycemia is an almost inevitable consequence of exogenous insulin treatment of type 1 diabetes, and in up to 30% of patients, this can lead to impaired awareness of hypoglycemia. This predisposes to recurrent severe hypoglycemia and has a huge impact on quality of life. Although many patients can get resolution of severe hypoglycemia through novel education and technology, some patients continue to have ongoing life-threatening hypoglycemia. Islet transplantation offers an alternative therapeutic option for these patients, in whom these conventional approaches have been unsuccessful. This review discusses the selection process of identifying suitable candidates based on recent clinical data. RECENT FINDINGS Results from studies of islet transplantation suggest the optimal recipient characteristics for successful islet transplantation include age >35 years, insulin requirements <1.0/kg, and weight < 85 kg. Islet transplantation can completely resolve hypoglycemia and near-normalize glucose levels, achieving insulin independence for a limited period of time in up to 40% of patients. The selection of appropriate candidates, optimizing donor selection, the use of an optimized protocol for islet cell extraction, and immunosuppression therapy have been proved to be the key criteria for a favorable outcome in islet transplantation.
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Affiliation(s)
- Nantia Othonos
- Department of Diabetes, King's College London, Denmark Hill, London, SE5 9RJ, UK
| | - Pratik Choudhary
- Department of Diabetes, King's College London, Denmark Hill, London, SE5 9RJ, UK.
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259
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Pereira LX, Viana CTR, Orellano LAA, Almeida SA, Vasconcelos AC, Goes ADM, Birbrair A, Andrade SP, Campos PP. Synthetic matrix of polyether-polyurethane as a biological platform for pancreatic regeneration. Life Sci 2017; 176:67-74. [PMID: 28336399 DOI: 10.1016/j.lfs.2017.03.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/17/2017] [Accepted: 03/19/2017] [Indexed: 02/07/2023]
Abstract
AIMS Several alternative cellular approaches using biomaterials to host insulin-producing cells derived from stem cells have been developed to overcome the limitations of type 1 diabetes treatment (exogenous insulin injection). However, none seem to fulfill all requirements needed to induce pancreatic cells successful colonization of the scaffolds. Here, we report a polymeric platform adherent to the native mice pancreas filled with human adipose stem cells (hASCs) that was able to induce growth of pancreatic parenchyma. MAIN METHODS Synthetic polyether-polyurethane discs were placed adjacent to pancreas of normoglycemic and streptozotocin-induced diabetic mice. At day 4 post implantation, 1×106 hASCs were injected intra-implant in groups of normoglycemic and diabetic mice. Immunohistochemistry analysis of the implants was performed to identify insulin positive cells in the newly formed tissue. In addition, metabolic, inflammatory and angiogenic parameters were carried out in those mice. KEY FINDINGS This study provides evidence of the ability of a biohybrid device to induce the growth of differentiated pancreas parenchyma in both normoglycemic and streptozotocin-induced diabetic mice as detected by histological analysis. Glucose metabolism and body weight of hyperglycemic mice bearing hASCs implants improved. SIGNIFICANCE The synthetic porous scaffold bearing hASC cells placed adjacent to the native animal pancreas exhibits the potential to be exploited in future cell-based type 1 diabetes therapies.
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Affiliation(s)
- Luciana Xavier Pereira
- Department of General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Celso Tarso Rodrigues Viana
- Department of General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Laura Alejandra Ariza Orellano
- Department of General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Simone Aparecida Almeida
- Department of General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Anilton Cesar Vasconcelos
- Department of General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Alexander Birbrair
- Department of General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Silvia Passos Andrade
- Department of Physiology and Biophysics, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Paula Peixoto Campos
- Department of General Pathology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
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260
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Hendrieckx C, Hagger V, Jenkins A, Skinner TC, Pouwer F, Speight J. Severe hypoglycemia, impaired awareness of hypoglycemia, and self-monitoring in adults with type 1 diabetes: Results from Diabetes MILES-Australia. J Diabetes Complications 2017; 31:577-582. [PMID: 27993524 DOI: 10.1016/j.jdiacomp.2016.11.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/17/2016] [Accepted: 11/23/2016] [Indexed: 11/19/2022]
Abstract
AIMS To assess prevalence of severe hypoglycemia, awareness and symptoms of hypoglycemia, and their associations with self-monitoring of blood glucose. METHODS Diabetes MILES-Australia Study participants completed validated questionnaires and study-specific items. RESULTS Of 642 adults with type 1 diabetes, 21% reported ≥1 severe hypoglycemic event in the past six months, and 21% reported impaired awareness of hypoglycemia (IAH). Severe hypoglycemia was increased four-fold for those with IAH compared with intact awareness (1.4±3.9 versus 0.3±1.0). Of those with IAH, 92% perceived autonomic and 88% neuroglycopenic symptoms, albeit at lower glucose thresholds compared to people with intact awareness. Those with IAH were more likely to perceive both symptom types at the same glucose level or to perceive neuroglycopenic symptoms first (all p<0.001). Eighteen percent with IAH treated hypoglycemia only when they perceived symptoms and another 18% only when their capillary glucose was <3.0mmol/L. CONCLUSIONS One in five adults with type 1 diabetes had IAH or experienced severe hypoglycemia in the past sixmonths. Total loss of hypoglycemia symptoms was rare; most people with IAH retained autonomic symptoms, perceived at relatively low glucose levels. Frequent self-monitoring of blood glucose prompted early recognition and treatment of hypoglycemia, suggesting severe hypoglycemia risk can be minimized.
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Affiliation(s)
- Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Victoria, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia.
| | - Virginia Hagger
- School of Psychology, Deakin University, Geelong, Victoria, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - Alicia Jenkins
- University of Melbourne, Department of Medicine, St Vincent's Hospital, Melbourne, Australia; NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Timothy Chas Skinner
- School of Psychology and Clinical Sciences, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Frans Pouwer
- Centre of Research on Psychology in Somatic diseases (CoRPS) & Department of Medical and Clinical Psychology, Tilburg University, The Netherlands
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia; AHP Research, Hornchurch, Essex, UK
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261
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Yardley JE, Colberg SR. Update on Management of Type 1 Diabetes and Type 2 Diabetes in Athletes. Curr Sports Med Rep 2017; 16:38-44. [PMID: 28067740 DOI: 10.1249/jsr.0000000000000327] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Optimal blood glucose management still remains the biggest challenge in active individuals with diabetes, particularly in insulin users, but some newer strategies have been introduced to maintain blood glucose control. Recent studies emphasize the importance of exercise intensity on glycemic balance. In individuals with type 1 and type 2 diabetes, both resistance and high-intensity intermittent exercise have been shown to confer beneficial physiological adaptations in training studies, while also showing acute glycemic benefits from single sessions. At the same time, anyone training at higher intensities also should take into consideration potential impairments in thermoregulation in individuals with diabetes, which can increase the risk of heat stress during exercise in hot and/or humid conditions. Recent studies of medication effects on electrolyte balance and hydration give a more complete picture of potential exercise risks for athletes with diabetes. Use of the latest diabetes-related technologies also may benefit the athlete with diabetes.
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Affiliation(s)
- Jane E Yardley
- 1Department of Social Sciences, University of Alberta, Augustana Faculty, Camrose, AB, CANADA; and 2Human Movement Sciences Department, Old Dominion University, Norfolk, VA
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262
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Colberg SR. Key Points from the Updated Guidelines on Exercise and Diabetes. Front Endocrinol (Lausanne) 2017; 8:33. [PMID: 28265261 PMCID: PMC5317029 DOI: 10.3389/fendo.2017.00033] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 02/07/2017] [Indexed: 12/27/2022] Open
Affiliation(s)
- Sheri R. Colberg
- Human Movement Sciences Department, Old Dominion University, Norfolk, VA, USA
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263
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Engineering an endocrine Neo-Pancreas by repopulation of a decellularized rat pancreas with islets of Langerhans. Sci Rep 2017; 7:41777. [PMID: 28150744 PMCID: PMC5288794 DOI: 10.1038/srep41777] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 12/29/2016] [Indexed: 01/06/2023] Open
Abstract
Decellularization of pancreata and repopulation of these non-immunogenic matrices with islets and endothelial cells could provide transplantable, endocrine Neo- Pancreata. In this study, rat pancreata were perfusion decellularized and repopulated with intact islets, comparing three perfusion routes (Artery, Portal Vein, Pancreatic Duct). Decellularization effectively removed all cellular components but conserved the pancreas specific extracellular matrix. Digital subtraction angiography of the matrices showed a conserved integrity of the decellularized vascular system but a contrast emersion into the parenchyma via the decellularized pancreatic duct. Islets infused via the pancreatic duct leaked from the ductular system into the peri-ductular decellularized space despite their magnitude. TUNEL staining and Glucose stimulated insulin secretion revealed that islets were viable and functional after the process. We present the first available protocol for perfusion decellularization of rat pancreata via three different perfusion routes. Furthermore, we provide first proof-of-concept for the repopulation of the decellularized rat pancreata with functional islets of Langerhans. The presented technique can serve as a bioengineering platform to generate implantable and functional endocrine Neo-Pancreata.
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264
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Ishtiak-Ahmed K, Carstensen B, Pedersen-Bjergaard U, Jørgensen ME. Incidence Trends and Predictors of Hospitalization for Hypoglycemia in 17,230 Adult Patients With Type 1 Diabetes: A Danish Register Linkage Cohort Study. Diabetes Care 2017; 40:226-232. [PMID: 27899494 DOI: 10.2337/dc16-0862] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 11/02/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study aimed to examine nationwide incidence trends and predictors of hospitalization for hypoglycemia (HH) in the adult population with type 1 diabetes in Denmark. RESEARCH DESIGN AND METHODS All 17,230 patients with type 1 diabetes aged 16 years and above registered in the Danish Adult Diabetes Database (DADD) from 2006 were followed to 2012 by linkage of registers. Incidence rates of HH were modeled by Poisson regression by calendar time, taking sex, age, diabetes duration, clinical variables, and previous HH into account. RESULTS A total of 2,369 events of HH occurred among 1,735 patients with type 1 diabetes of HH during 70,002 patient-years (mean follow-up 3.7 years). A decrease in incidence rate was observed with calendar time with an 8.4% (4.9-11.7%) annual decrease. Predictors of HH included previous HH, age, diabetes duration, albuminuria, and HbA1c. CONCLUSIONS This study revealed a decreasing trend in incidence of HH in patients with type 1 diabetes. Previous HH, longer diabetes duration, macroalbuminuria, and HbA1c were associated with increased risk of HH in type 1 diabetes, and attention to those factors is warranted in both clinical and public health aspects.
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Affiliation(s)
- Kazi Ishtiak-Ahmed
- Steno Diabetes Centre, Gentofte, Denmark.,Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Ulrik Pedersen-Bjergaard
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital Hillerød, Hillerød, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marit E Jørgensen
- Steno Diabetes Centre, Gentofte, Denmark .,National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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265
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Hodge M, McArthur E, Garg AX, Tangri N, Clemens KK. Hypoglycemia Incidence in Older Adults by Estimated GFR. Am J Kidney Dis 2017; 70:59-68. [PMID: 28139395 DOI: 10.1053/j.ajkd.2016.11.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 11/07/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Bedside estimates of the risk for hypoglycemia by estimated glomerular filtration rate (eGFR), urine albumin-creatinine ratio (ACR), and use of antihyperglycemic medications would be helpful. STUDY DESIGN Population-based cohort study. SETTING & PARTICIPANTS Older adults (mean age, 75 years) in Ontario, Canada, from April 2002 through March 2013. FACTORS eGFR stage, ACR stage, and use of antihyperglycemic medications. OUTCOME 3-year incidence rate of a hospital encounter with hypoglycemia (emergency department or inpatient encounter). RESULTS In users and nonusers of antihyperglycemic medications, there was a graded increase in risk for hypoglycemia by eGFR stage. Incidence rates in antihyperglycemic medication users were 82 (95% CI, 71-94), 122 (95% CI, 115-130), 235 (95% CI, 218-254), 379 (95% CI, 349-413), 596 (95% CI, 524-678), and 785 (95% CI, 689-894) encounters per 10,000 person-years when eGFR was ≥90, 60 to <90, 45 to <60, 30 to <45, 15 to <30, and <15mL/min/1.73m2 or the patient was receiving dialysis, respectively (P<0.001). Corresponding values in nonusers were 2 (95% CI, 2-4), 3 (95% CI, 3-4), 3 (95% CI, 2-4), 7 (95% CI, 5-9), 14 (95% CI, 9-22), and 55 (95% CI, 43-71) encounters/10,000 person-years, respectively (P<0.001). A similar relationship was evident by eGFR and ACR risk category. LIMITATIONS Only hypoglycemia episodes that were associated with a hospital encounter were assessed. Results cannot be generalized to younger patients. CONCLUSIONS In older adults, the risk for hypoglycemia is higher in those with lower kidney function. Our results may aid the patient-provider dialogue and inform future studies to prevent hypoglycemia in an at-risk population.
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Affiliation(s)
- Meryl Hodge
- School of Health Studies, Western University, London, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Navdeep Tangri
- Division of Nephrology, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Kristin K Clemens
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, Ontario, Canada.
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266
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Kacheva S, Karges B, Göller K, Marx N, Mischke K, Karges W. QT prolongation caused by insulin-induced hypoglycaemia - An interventional study in 119 individuals. Diabetes Res Clin Pract 2017; 123:165-172. [PMID: 28024277 DOI: 10.1016/j.diabres.2016.11.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 11/03/2016] [Accepted: 11/27/2016] [Indexed: 02/03/2023]
Abstract
AIMS Hypoglycaemia is associated with increased risk of cardiovascular events and mortality in patients with diabetes, but the extent and mechanisms of this link are ill defined. We here prospectively studied cardiac repolarization abnormalities during insulin-induced hypoglycaemia in humans. METHODS 119 individuals (69 males, age 47.5±13.4years, range 18-82years) were assessed during hypoglycaemia after the injection of 0.1-0.25units/kg human insulin. Corrected QT intervals (QTc) and QT dispersion (QTd) were calculated from serially recorded twelve lead electrocardiograms, and plasma glucose and other endocrine markers were studied. RESULTS QTc increased from 415.1±21.9ms (mean±standard deviation) at baseline to 444.9±26.5ms during hypoglycaemia (plasma glucose nadir, 1.6±0.5mmol/L, p=0.001), accompanied by an increase of QTd from 45.0±22.7ms to 64.1±40.0ms (p<0.001). Hypoglycaemia-induced abnormal QTc prolongation (defined as ⩾460ms in females and ⩾450ms in males) occurred in 17% (9/54) of females and 26% (17/65) of males. 97 of 119 of individuals (82%) developed transient hypokalaemia (K+ ⩽3.6mmol/L), and plasma epinephrine increased from 220.4±169.5pmol/L at baseline to 2945.6±2421.4pmol/L during hypoglycaemia. Baseline QTc, but not age or gender, was a significant predictor of hypoglycaemia-induced QTc prolongation (p=0.001). CONCLUSIONS Insulin-induced hypoglycaemia frequently causes abnormal QT prolongation and is associated with hypokalaemia and sympathoadrenal activation, thereby increasing the potential risk for ventricular arrhythmias, particularly in individuals with pre-existing high normal QTc.
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Affiliation(s)
- Stella Kacheva
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Katrin Göller
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Karl Mischke
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Wolfram Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
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267
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Hayashide JM, Buschinelli JTP. Critérios de decisão para a definição de exames médicos ocupacionais em atividades críticas: proposição de modelo e exemplos de aplicação no trabalho em altura. REVISTA BRASILEIRA DE SAÚDE OCUPACIONAL 2017. [DOI: 10.1590/2317-6369000128615] [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] Open
Abstract
Resumo Introdução: no Brasil, tem-se observado uma grande disparidade entre os protocolos de exames médicos utilizados para avaliar trabalhadores que exercem atividades críticas. Objetivo: propor e verificar a aplicabilidade de um modelo baseado em critérios para a tomada de decisão na definição de exames médicos ocupacionais na avaliação de aptidão de trabalhadores que executam atividades críticas de trabalho. Métodos: ensaio baseado em pesquisa bibliográfica. O modelo proposto baseia-se no princípio As Low As Reasonably Practicable (ALARP), do Health and Safety Executive (HSE). O modelo foi aplicado a duas condições clínicas que podem resultar em eventos agudos de perda de consciência e levar à queda durante o trabalho em altura, caso falhem ou não tenham sido adotadas medidas de segurança: diabetes e epilepsia. Discussão: verificou-se que o modelo proposto se mostrou aplicável para os dois exemplos analisados, oferecendo subsídios para a tomada de decisão do médico do trabalho em relação à necessidade de se investigar condições clínicas que podem ocasionar acidentes fatais durante a realização de atividades críticas de trabalho.
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268
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Yun JS, Ko SH. Risk Factors and Adverse Outcomes of Severe Hypoglycemia in Type 2 Diabetes Mellitus. Diabetes Metab J 2016; 40:423-432. [PMID: 27766794 PMCID: PMC5167706 DOI: 10.4093/dmj.2016.40.6.423] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/24/2016] [Indexed: 12/15/2022] Open
Abstract
Hypoglycemia has been considered as a major barrier to achieving the proper glycemic target in type 2 diabetes mellitus patients. In particular, severe hypoglycemia (SH), which is defined as a hypoglycemic episode requiring the assistance of another person to raise the patient's glucose level, is a serious complication of diabetes because of its possible fatal outcomes. Recently, the recommendations for diabetes care have emphasized a patient-centered approach, considering the individualized patient factors including hypoglycemia. Many studies have been performed which analyzed the risk factors and clinical outcomes for SH. From the studies, researchers recommend that targeting a less stringent glycosylated hemoglobin level and selecting a safer class of drugs for hypoglycemia are appropriate for patients with a high risk of SH. Also, careful clinical attention to prevent hypoglycemia, including intensive education, is necessary to minimize the risk of SH and SH-related fatal outcomes.
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Affiliation(s)
- Jae Seung Yun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 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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269
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Abstract
The necessity of strict glycemic control is unquestionable. However, hypoglycemia remains a major limiting factor in achieving satisfactory glucose control, and evidence is mounting to show that hypoglycemia is not benign. Over the past decade, evidence has consistently shown that real-time continuous glucose monitoring improves glycemic control in terms of lowering glycated hemoglobin levels. However, real-time continuous glucose monitoring has not met the expectations of the diabetes community with regard to hypoglycemia prevention. The earlier trials did not demonstrate any effect on either mild or severe hypoglycemia and the effect of real-time continuous glucose monitoring on nocturnal hypoglycemia was often not reported. However, trials specifically designed to reduce hypoglycemia in patients with a high hypoglycemia risk have demonstrated a reduction in hypoglycemia, suggesting that real-time continuous glucose monitoring can prevent hypoglycemia when it is specifically used for that purpose. Moreover, the newest generation of diabetes technology currently available commercially, namely sensor-augmented pump therapy with a (predictive) low glucose suspend feature, has provided more convincing evidence for hypoglycemia prevention. This article provides an overview of the hypoglycemia outcomes of randomized controlled trials that investigate the effect of real-time continuous glucose monitoring alone or sensor-augmented pump therapy with a (predictive) low glucose suspend feature. Furthermore, several possible explanations are provided why trials have not shown a reduction in severe hypoglycemia. In addition, existing evidence is presented of real-time continuous glucose monitoring in patients with impaired awareness of hypoglycemia who have the highest risk of severe hypoglycemia.
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Affiliation(s)
- Cornelis A J van Beers
- Diabetes Center, Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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270
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van Beers CAJ, DeVries JH, Kleijer SJ, Smits MM, Geelhoed-Duijvestijn PH, Kramer MHH, Diamant M, Snoek FJ, Serné EH. Continuous glucose monitoring for patients with type 1 diabetes and impaired awareness of hypoglycaemia (IN CONTROL): a randomised, open-label, crossover trial. Lancet Diabetes Endocrinol 2016; 4:893-902. [PMID: 27641781 DOI: 10.1016/s2213-8587(16)30193-0] [Citation(s) in RCA: 248] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/22/2016] [Accepted: 07/22/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with type 1 diabetes who have impaired awareness of hypoglycaemia have a three to six times increased risk of severe hypoglycaemia. We aimed to assess whether continuous glucose monitoring (CGM) improves glycaemia and prevents severe hypoglycaemia compared with self-monitoring of blood glucose (SMBG) in this high-risk population. METHODS We did a randomised, open-label, crossover trial (IN CONTROL) at two medical centres in the Netherlands. Eligible participants were patients diagnosed with type 1 diabetes according to American Diabetes Association criteria, aged 18-75 years, with impaired awareness of hypoglycaemia as confirmed by a Gold score of at least 4, and treated with either continuous subcutaneous insulin infusion or multiple daily insulin injections and doing at least three SMBG measurements per day. After screening, re-education about diabetes management, and a 6-week run-in phase (to obtain baseline CGM data), we randomly assigned patients (1:1) with a computer-generated allocation sequence (block size of four) to either 16 weeks of CGM followed by 12 weeks of washout and 16 weeks of SMBG, or 16 weeks of SMBG followed by 12 weeks of washout and 16 weeks of CGM (where the SMBG phase was the control). During the CGM phase, patients used a real-time CGM system consisting of a Paradigm Veo system with a MiniLink transmitter and an Enlite glucose sensor (Medtronic, CA, USA). During the SMBG phase, patients were equipped with a masked CGM device, consisting of an iPro 2 continuous glucose monitor and an Enlite glucose sensor, which does not display real-time glucose values. The number of SMBG measurements per day and SMBG systems were not standardised between patients, to mimic real-life conditions. During both intervention periods, patients attended follow-up visits at the centres each month and had telephone consultations 2 weeks after each visit inquiring about adverse events, episodes of hypoglycaemia, etc. The primary endpoint was the mean difference in percentage of time spent in normoglycaemia (4-10 mmol/L) over the total intervention periods, analysed on an intention-to-treat basis. Severe hypoglycaemia (requiring third party assistance) was a secondary endpoint. This trial is registered with ClinicalTrials.gov, number NCT01787903. FINDINGS Between March 4, 2013, and Feb 9, 2015, we recruited and randomly assigned 52 patients to either the CGM-SMBG sequence (n=26) or the SMBG-CGM sequence (n=26). The last patient visit was on March 21, 2016. Time spent in normoglycaemia was higher during CGM than during SMBG: 65·0% (95% CI 62·8-67·3) versus 55·4% (53·1-57·7; mean difference 9·6%, 95% CI 8·0-11·2; p<0·0001), with reductions in both time spent in hypoglycaemia (ie, blood glucose ≤3·9 mmol/L [6·8% vs 11·4%, mean difference 4·7%, 3·4-5·9; p<0·0001]) and time spent in hyperglycaemia (ie, blood glucose >10 mmol/L [28·2% vs 33·2%, mean difference 5·0%, 3·1-6·9; p<0·0001]). During CGM, the number of severe hypoglycaemic events was lower (14 events vs 34 events, p=0·033). Five serious adverse events other than severe hypoglycaemia occurred during the trial, but all were deemed unrelated to the trial intervention. Additionally, no mild to moderate adverse events were related to the trial intervention. INTERPRETATION CGM increased time spent in normoglycaemia and reduced severe hypoglycaemia in patients with type 1 diabetes and impaired awareness of hypoglycaemia, compared with SMBG. Our results support the concept of using CGM in this high-risk population. FUNDING Eli Lilly and Sanofi.
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Affiliation(s)
| | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Susanne J Kleijer
- Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Mark M Smits
- Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
| | | | - Mark H H Kramer
- Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Michaela Diamant
- Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
| | - Frank J Snoek
- Department of Medical Psychology, VU University Medical Center, Amsterdam, Netherlands; Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Erik H Serné
- Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
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271
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Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, Tate DF. Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016; 39:2065-2079. [PMID: 27926890 PMCID: PMC6908414 DOI: 10.2337/dc16-1728] [Citation(s) in RCA: 1385] [Impact Index Per Article: 173.1] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Sheri R Colberg
- Department of Human Movement Sciences, Old Dominion University, Norfolk, VA
| | - Ronald J Sigal
- Departments of Medicine, Cardiac Sciences, and Community Health Sciences, Faculties of Medicine and Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Jane E Yardley
- Department of Social Sciences, Augustana Campus, University of Alberta, Camrose, Alberta, Canada
| | - Michael C Riddell
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
| | - David W Dunstan
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Paddy C Dempsey
- Baker IDI Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Edward S Horton
- Harvard Medical School and Joslin Diabetes Center, Boston, MA
| | | | - Deborah F Tate
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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272
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Dacks PA, Armstrong JJ, Brannan SK, Carman AJ, Green AM, Kirkman MS, Krakoff LR, Kuller LH, Launer LJ, Lovestone S, Merikle E, Neumann PJ, Rockwood K, Shineman DW, Stefanacci RG, Velentgas P, Viswanathan A, Whitmer RA, Williamson JD, Fillit HM. A call for comparative effectiveness research to learn whether routine clinical care decisions can protect from dementia and cognitive decline. ALZHEIMERS RESEARCH & THERAPY 2016; 8:33. [PMID: 27543171 PMCID: PMC4992192 DOI: 10.1186/s13195-016-0200-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Common diseases like diabetes, hypertension, and atrial fibrillation are probable risk factors for dementia, suggesting that their treatments may influence the risk and rate of cognitive and functional decline. Moreover, specific therapies and medications may affect long-term brain health through mechanisms that are independent of their primary indication. While surgery, benzodiazepines, and anti-cholinergic drugs may accelerate decline or even raise the risk of dementia, other medications act directly on the brain to potentially slow the pathology that underlies Alzheimer’s and other dementia. In other words, the functional and cognitive decline in vulnerable patients may be influenced by the choice of treatments for other medical conditions. Despite the importance of these questions, very little research is available. The Alzheimer’s Drug Discovery Foundation convened an advisory panel to discuss the existing evidence and to recommend strategies to accelerate the development of comparative effectiveness research on how choices in the clinical care of common chronic diseases may protect from cognitive decline and dementia.
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Affiliation(s)
- Penny A Dacks
- Alzheimer's Drug Discovery Foundation, 57 West 57th St. Suite 901, New York, NY, 10019, USA.
| | - Joshua J Armstrong
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Aaron J Carman
- Alzheimer's Drug Discovery Foundation, 57 West 57th St. Suite 901, New York, NY, 10019, USA
| | | | - M Sue Kirkman
- Department of Medicine, Division of Endocrinology and Metabolism, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Lewis H Kuller
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lenore J Launer
- Intramural Research Program, National Institute on Aging, NIH, Bethesda, MD, USA
| | | | | | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Kenneth Rockwood
- Geriatric Medicine Research Unit, Department of Medicine, Dalhousie University, Halifax, NS, Canada.,DGI Clinical, Halifax, NS, Canada.,Nova Scotia Health Authority, Halifax, NS, Canada
| | - Diana W Shineman
- Alzheimer's Drug Discovery Foundation, 57 West 57th St. Suite 901, New York, NY, 10019, USA
| | - Richard G Stefanacci
- Thomas Jefferson College of Population Health, The Access Group, Philadelphia, PA, USA
| | - Priscilla Velentgas
- Scientific Affairs, Quintiles Real World Late Phase Research, Cambridge, MA, USA
| | - Anand Viswanathan
- Representative for the American Heart Association; Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, MA, USA
| | - Rachel A Whitmer
- Kaiser Permanente Division of Research, Population Science and Brain Aging, Oakland, CA, USA
| | | | - Howard M Fillit
- Alzheimer's Drug Discovery Foundation, 57 West 57th St. Suite 901, New York, NY, 10019, USA
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273
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Andersen SE, Christensen M. Hypoglycaemia when adding sulphonylurea to metformin: a systematic review and network meta-analysis. Br J Clin Pharmacol 2016; 82:1291-1302. [PMID: 27426428 DOI: 10.1111/bcp.13059] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/21/2016] [Accepted: 06/24/2016] [Indexed: 01/01/2023] Open
Abstract
AIMS The risk of hypoglycaemia may differ among sulphonylureas (SUs), but evidence from head-to-head comparisons is sparse. Performing a network meta-analysis to use indirect evidence from randomized controlled trials (RCTs), we compared the relative risk of hypoglycaemia with newer generation SUs when added to metformin. METHODS A systematic review identified RCTs lasting 12-52 weeks and evaluating SUs added to inadequate metformin monotherapy (≥1000 mg/day) in type 2 diabetes. Adding RCTs investigating the active comparators from the identified SU trials, we established a coherent network. Hypoglycaemia of any severity was the primary end point. RESULTS Thirteen trials of SUs and 14 of oral non-SU antihyperglycaemic agents (16 260 patients) were included. All reported hypoglycaemia only as adverse events. Producing comparable reductions in HbA1C of -0.66 to -0.84% (-7 to -9 mmol/mol), the risk of hypoglycaemia was lowest with gliclazide compared to glipizide (OR 0.22, CrI: 0.05 to 0.96), glimepiride (OR 0.40, CrI: 0.13 to 1.27), and glibenclamide (OR 0.21, CrI: 0.03 to 1.48). A major limitation is varying definitions of hypoglycaemia across studies. CONCLUSIONS When added to metformin, gliclazide was associated with the lowest risk of hypoglycaemia between the newer generation SUs. Clinicians should consider the risk of hypoglycaemia agent-specific when selecting an SU agent.
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Affiliation(s)
- Stig Ejdrup Andersen
- Clinical Pharamcology Unit, Zealand University Hospital, DK-4000, Roskilde, Denmark.
| | - Mikkel Christensen
- Department of Clinical Pharmacology, Bispebjerg University Hospital, DK-2400, Copenhagen NV, Denmark
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274
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Hanefeld M, Frier BM, Pistrosch F. Hypoglycemia and Cardiovascular Risk: Is There a Major Link? Diabetes Care 2016; 39 Suppl 2:S205-9. [PMID: 27440834 DOI: 10.2337/dcs15-3014] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Severe hypoglycemia is recognized to be one of the strongest predictors of macrovascular events, adverse clinical outcomes, and mortality in patients with type 2 diabetes. However, it is uncertain whether a direct pathophysiological link exists or whether hypoglycemia is primarily a marker of vulnerability to these events. Large clinical trials have reported an increased hazard ratio for all-cause mortality and cardiovascular events in patients with type 2 diabetes and severe hypoglycemia, but such an association has not been demonstrated in prospective trials of people with type 1 diabetes. Several cardiovascular effects occur during hypoglycemia either as a result of low blood glucose levels per se or through activation of the sympathoadrenal response: hemodynamic changes with an increase in cardiac work load and potential attenuation of myocardial perfusion, electrophysiological changes that may be arrhythmogenic, induction of a prothrombotic state, and release of inflammatory markers. Although the potential for a causal relationship has been demonstrated in mechanistic studies, the evidence from large prospective studies that hypoglycemia is a major causal contributor to cardiovascular events is limited to date. Other preexisting cardiovascular risk factors in addition to hypoglycemia may be the major link to the final cardiovascular event, but a low blood glucose level can trigger these events in patients with a high cardiovascular risk.
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Affiliation(s)
- Markolf Hanefeld
- Study Centre Professor Hanefeld, GWT-TU Dresden GmbH, Dresden, Germany Medical Clinic III, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
| | - Brian M Frier
- British Heart Foundation Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, Scotland, U.K
| | - Frank Pistrosch
- Study Centre Professor Hanefeld, GWT-TU Dresden GmbH, Dresden, Germany Medical Clinic III, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
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275
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Leclair E, Liggins RT, Peckett AJ, Teich T, Coy DH, Vranic M, Riddell MC. Glucagon responses to exercise-induced hypoglycaemia are improved by somatostatin receptor type 2 antagonism in a rat model of diabetes. Diabetologia 2016; 59:1724-31. [PMID: 27075449 DOI: 10.1007/s00125-016-3953-0] [Citation(s) in RCA: 14] [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: 01/06/2016] [Accepted: 03/18/2016] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Regular exercise is at the cornerstone of care in type 1 diabetes. However, relative hyperinsulinaemia and a blunted glucagon response to exercise promote hypoglycaemia. Recently, a selective antagonist of somatostatin receptor 2, PRL-2903, was shown to improve glucagon counterregulation to hypoglycaemia in resting streptozotocin-induced diabetic rats. The aim of this study was to test the efficacy of PRL-2903 in enhancing glucagon counterregulation during repeated hyperinsulinaemic exercise. METHODS Diabetic rats performed daily exercise for 1 week and were then exposed to saline (154 mmol/l NaCl) or PRL-2903, 10 mg/kg, before hyperinsulinaemic exercise on two separate occasions spaced 1 day apart. In the following week, animals crossed over to the alternate treatment for a third hyperinsulinaemic exercise protocol. RESULTS Liver glycogen content was lower in diabetic rats compared with control rats, despite daily insulin therapy (p < 0.05). Glucagon levels failed to increase during exercise with saline but increased three-to-six fold with PRL-2903 (all p < 0.05). Glucose concentrations tended to be higher during exercise and early recovery with PRL-2903 on both days of treatment; this difference did not achieve statistical significance (p > 0.05). CONCLUSIONS/INTERPRETATION PRL-2903 improves glucagon counterregulation during exercise. However, liver glycogen stores or other factors limit the prevention of exercise-induced hypoglycaemia in rats with streptozotocin-induced diabetes.
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Affiliation(s)
- Erwan Leclair
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | | | - Ashley J Peckett
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - Trevor Teich
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - David H Coy
- Department of Medicine, Peptide Research Labs, Tulane University Medical Center, New Orleans, LA, USA
| | - Mladen Vranic
- Departments of Physiology and Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Riddell
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada.
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276
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Affiliation(s)
- Rhodri King
- a Division of Cardiovascular and Diabetes Research, Leeds Institute for Cardiovascular and Metabolic Medicine , University of Leeds Ringgold Standard Institution , Leeds , UK
| | - Ramzi Ajjan
- a Division of Cardiovascular and Diabetes Research, Leeds Institute for Cardiovascular and Metabolic Medicine , University of Leeds Ringgold Standard Institution , Leeds , UK
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277
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Mancini GBJ, Cheng AY, Connelly K, Fitchett D, Goldenberg R, Goodman SG, Leiter LA, Lonn E, Paty B, Poirier P, Stone J, Thompson D, Yale JF. Diabetes for Cardiologists: Practical Issues in Diagnosis and Management. Can J Cardiol 2016; 33:366-377. [PMID: 28340996 DOI: 10.1016/j.cjca.2016.07.512] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus (DM), a chronic metabolic disease characterized by hyperglycemia, is a profound cardiovascular (CV) risk factor. It compounds the effects of all other risk factors, leads to premature micro- and macrovascular disease, facilitates development of heart failure, worsens the clinical course of all CV diseases, and shortens life expectancy. Established DM, unrecognized DM, and dysglycemia that may progress to DM are all commonly present at the time of presentation of overt CV disease. Thus, CV specialists and trainees frequently treat patients with dysglycemia. The traditional and proven role of cardiologists in reducing the risk of macrovascular events in this population is through aggressive lipid and blood pressure treatment. However, a more proactive role in the detection and management of DM is likely to become increasingly important as the prevalence continues to increase and therapies continue to improve. The latter include antihyperglycemic therapies with proven cardiovascular safety profiles and CV event reduction properties not yet fully elucidated and not necessarily related to glycemic control. Accordingly, the purpose of this article is to (1) expand the interest of cardiologists in earlier stages of the natural history of DM, when prevention or early detection might help achieve greatest benefit; (2) highlight principles of optimal glycemic management, with an emphasis on add-on choices showing promising reduction of CV events and lacking CV adverse effects; and (3) encourage cardiologists to become proactive partners in the multidisciplinary care needed to ensure optimal lifelong vascular health in patients with, or who are at risk of, DM.
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Affiliation(s)
- G B John Mancini
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Alice Y Cheng
- Division of Endocrinology and Metabolism, University of Toronto, Toronto, Ontario, Canada
| | - Kim Connelly
- Division of Cardiology, Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, University of Toronto, Ontario, Canada
| | - David Fitchett
- Division of Cardiology, Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, University of Toronto, Ontario, Canada
| | - Ronald Goldenberg
- Endocrinology and Metabolism, North York General Hospital and LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Division of Cardiology, Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, University of Toronto, Ontario, Canada
| | - Lawrence A Leiter
- Division of Endocrinology and Metabolism, Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, University of Toronto, Ontario, Canada
| | - Eva Lonn
- Population Health Research Institute and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Breay Paty
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Poirier
- Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - James Stone
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David Thompson
- Division of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean-François Yale
- Division of Endocrinology, McGill University Health Centre, McGill University, Montreal, Québec, Canada
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278
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Okajima F, Emoto N, Kato K, Sugihara H. Effect of Glycemic Control on Chylomicron Metabolism and Correlation between Postprandial Metabolism of Plasma Glucose and Chylomicron in Patients with Type 2 Diabetes Treated with Basal-bolus Insulin Therapy with or without Vildagliptin. J Atheroscler Thromb 2016; 24:157-168. [PMID: 27397060 PMCID: PMC5305676 DOI: 10.5551/jat.32409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aim: Glucagon-like peptide-1 can reduce both postprandial plasma glucose (PG) and chylomicron (CM) levels in patients with type 2 diabetes. However, there have been no reports regarding the relationship between the postprandial metabolism of PG and CM. Methods: Patients with type 2 diabetes who were admitted for glycemic control were randomized to insulin alone (Ins; n = 16) or insulin plus vildagliptin 100 mg (InsV; n = 16) groups. The insulin dose was adjusted to maintain normal blood glucose levels. The daily profiles of serum TG, remnant lipoprotein cholesterol (RemL-C), and apolipoprotein B48 (ApoB48) were estimated by frequent blood collection on admission and before discharge, and the daily glucose fluctuation profile was also estimated using continuous glucose monitoring (CGM) before discharge. Results: The daily profiles of serum TG and RemL-C indicated a significant decrease before discharge compared with on admission; however, no significant changes in serum ApoB48 levels were observed in either group. At discharge, daily glucose fluctuation profile and the change in the serum ApoB48 level from fasting to the peak of the daily profile was significantly smaller in the InsV group than in the Ins group. The increment of serum ApoB48 level was significantly correlated with the mean amplitude of glycemic excursions calculated using CGM data only in the Ins group (R2 = 0.5242, P <0.001). Conclusions: Short-term glycemic control decreased serum TG and RemL-C levels, but not ApoB48 levels, and the postprandial metabolism of PG and CM might be regulated by the same mechanism except GLP-1 effect.
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Affiliation(s)
- Fumitaka Okajima
- Division of Endocrinology, Department of Medicine, Chiba-Hokusoh Hospital, Nippon Medical School
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279
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Hering BJ, Clarke WR, Bridges ND, Eggerman TL, Alejandro R, Bellin MD, Chaloner K, Czarniecki CW, Goldstein JS, Hunsicker LG, Kaufman DB, Korsgren O, Larsen CP, Luo X, Markmann JF, Naji A, Oberholzer J, Posselt AM, Rickels MR, Ricordi C, Robien MA, Senior PA, Shapiro AMJ, Stock PG, Turgeon NA. Phase 3 Trial of Transplantation of Human Islets in Type 1 Diabetes Complicated by Severe Hypoglycemia. Diabetes Care 2016; 39:1230-40. [PMID: 27208344 PMCID: PMC5317236 DOI: 10.2337/dc15-1988] [Citation(s) in RCA: 414] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 02/21/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Impaired awareness of hypoglycemia (IAH) and severe hypoglycemic events (SHEs) cause substantial morbidity and mortality in patients with type 1 diabetes (T1D). Current therapies are effective in preventing SHEs in 50-80% of patients with IAH and SHEs, leaving a substantial number of patients at risk. We evaluated the effectiveness and safety of a standardized human pancreatic islet product in subjects in whom IAH and SHEs persisted despite medical treatment. RESEARCH DESIGN AND METHODS This multicenter, single-arm, phase 3 study of the investigational product purified human pancreatic islets (PHPI) was conducted at eight centers in North America. Forty-eight adults with T1D for >5 years, absent stimulated C-peptide, and documented IAH and SHEs despite expert care were enrolled. Each received immunosuppression and one or more transplants of PHPI, manufactured on-site under good manufacturing practice conditions using a common batch record and standardized lot release criteria and test methods. The primary end point was the achievement of HbA1c <7.0% (53 mmol/mol) at day 365 and freedom from SHEs from day 28 to day 365 after the first transplant. RESULTS The primary end point was successfully met by 87.5% of subjects at 1 year and by 71% at 2 years. The median HbA1c level was 5.6% (38 mmol/mol) at both 1 and 2 years. Hypoglycemia awareness was restored, with highly significant improvements in Clarke and HYPO scores (P > 0.0001). No study-related deaths or disabilities occurred. Five of the enrollees (10.4%) experienced bleeds requiring transfusions (corresponding to 5 of 75 procedures), and two enrollees (4.1%) had infections attributed to immunosuppression. Glomerular filtration rate decreased significantly on immunosuppression, and donor-specific antibodies developed in two patients. CONCLUSIONS Transplanted PHPI provided glycemic control, restoration of hypoglycemia awareness, and protection from SHEs in subjects with intractable IAH and SHEs. Safety events occurred related to the infusion procedure and immunosuppression, including bleeding and decreased renal function. Islet transplantation should be considered for patients with T1D and IAH in whom other, less invasive current treatments have been ineffective in preventing SHEs.
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Affiliation(s)
- Bernhard J Hering
- Schulze Diabetes Institute and Department of Surgery, University of Minnesota, Minneapolis, MN
| | - William R Clarke
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, IA
| | - Nancy D Bridges
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Thomas L Eggerman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Rodolfo Alejandro
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
| | - Melena D Bellin
- Schulze Diabetes Institute and Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Kathryn Chaloner
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, IA
| | - Christine W Czarniecki
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Julia S Goldstein
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Lawrence G Hunsicker
- Clinical Trials Statistical and Data Management Center, University of Iowa, Iowa City, IA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin, Madison, WI
| | - Olle Korsgren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Xunrong Luo
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ali Naji
- Institute for Diabetes, Obesity and Metabolism and Departments of Surgery and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jose Oberholzer
- Division of Transplantation, University of Illinois Hospital and Health Sciences System, Chicago, IL
| | - Andrew M Posselt
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael R Rickels
- Institute for Diabetes, Obesity and Metabolism and Departments of Surgery and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Camillo Ricordi
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
| | - Mark A Robien
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - 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, San Francisco, CA
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280
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Russell SJ, Beck RW. Design Considerations for Artificial Pancreas Pivotal Studies. Diabetes Care 2016; 39:1161-7. [PMID: 27330125 DOI: 10.2337/dc15-2449] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 12/19/2015] [Indexed: 02/03/2023]
Abstract
The development of artificial pancreas systems has evolved to the point that pivotal studies designed to assess efficacy and safety are in progress or soon to be initiated. These pivotal studies are intended to provide the necessary data to gain clearance from the U.S. Food and Drug Administration, coverage by payers, and adoption by patients and clinicians. Although there will not be one design that is appropriate for every system, there are certain aspects of protocol design that will be considerations in all pivotal studies designed to assess efficacy and safety. One key aspect of study design is the intervention to be used by the control group. A case can be made that the control group should use the currently available best technology, which is sensor-augmented pump therapy. However, an equally, if not more, compelling case can be made that the control intervention should be usual care. In this Perspective, we elaborate on this issue and provide a pragmatic approach to the design of clinical trials of artificial pancreas systems.
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Affiliation(s)
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
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281
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Blauw H, Keith-Hynes P, Koops R, DeVries JH. A Review of Safety and Design Requirements of the Artificial Pancreas. Ann Biomed Eng 2016; 44:3158-3172. [PMID: 27352278 PMCID: PMC5093196 DOI: 10.1007/s10439-016-1679-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/13/2016] [Indexed: 01/03/2023]
Abstract
As clinical studies with artificial pancreas systems for automated blood glucose control in patients with type 1 diabetes move to unsupervised real-life settings, product development will be a focus of companies over the coming years. Directions or requirements regarding safety in the design of an artificial pancreas are, however, lacking. This review aims to provide an overview and discussion of safety and design requirements of the artificial pancreas. We performed a structured literature search based on three search components—type 1 diabetes, artificial pancreas, and safety or design—and extended the discussion with our own experiences in developing artificial pancreas systems. The main hazards of the artificial pancreas are over- and under-dosing of insulin and, in case of a bi-hormonal system, of glucagon or other hormones. For each component of an artificial pancreas and for the complete system we identified safety issues related to these hazards and proposed control measures. Prerequisites that enable the control algorithms to provide safe closed-loop control are accurate and reliable input of glucose values, assured hormone delivery and an efficient user interface. In addition, the system configuration has important implications for safety, as close cooperation and data exchange between the different components is essential.
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Affiliation(s)
- Helga Blauw
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100 DD, Amsterdam, The Netherlands. .,Inreda Diabetic BV, Goor, The Netherlands.
| | - Patrick Keith-Hynes
- TypeZero Technologies, LLC, Charlottesville, VA, USA.,Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | | | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100 DD, Amsterdam, The Netherlands
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282
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Duan P, Tu P, Si L, Hu W, Liu M, Liu J, Xue Y. Gene Polymorphisms in the RANKL/RANK/OPG Pathway Are Associated with Type 2 Diabetes Mellitus in Southern Han Chinese Women. Genet Test Mol Biomarkers 2016; 20:285-90. [PMID: 27171030 DOI: 10.1089/gtmb.2015.0306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Peng Duan
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Endocrinology and Metabolism, The Third Hospital of Nanchang, Nanchang, China
| | - Ping Tu
- Department of Endocrinology and Metabolism, The Third Hospital of Nanchang, Nanchang, China
| | - Lian Si
- Department of Endocrinology and Metabolism, The Third Hospital of Nanchang, Nanchang, China
| | - Wan Hu
- Department of Endocrinology and Metabolism, The Third Hospital of Nanchang, Nanchang, China
| | - Meng Liu
- Department of Endocrinology and Metabolism, The Third Hospital of Nanchang, Nanchang, China
| | - Jia Liu
- Department of Endocrinology and Metabolism, The Third Hospital of Nanchang, Nanchang, China
| | - Yaoming Xue
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
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283
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Poddar S, Kesharwani D, Datta M. Histone deacetylase inhibition regulates miR-449a levels in skeletal muscle cells. Epigenetics 2016; 11:579-87. [PMID: 27184529 DOI: 10.1080/15592294.2016.1188247] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
microRNAs (miRNAs) are small non-coding RNAs that regulate cellular processes by fine-tuning the levels of their target mRNAs. However, the regulatory elements determining cellular miRNA levels are not well studied. Previously, we had described an altered miRNA signature in the skeletal muscle of db/db mice. Here, we sought to explore the role of epigenetic mechanisms in altering these miRNAs. We show that histone deacetylase (HDAC) protein levels and activity are upregulated in the skeletal muscle of diabetic mice. In C2C12 cells, HDAC inhibition using suberoylanilide hydroxamic acid (SAHA) altered the levels of 24 miRNAs: 15 were downregulated and 9 were upregulated. miR-449a, an intronic miRNA localized within the Cdc20b gene, while being downregulated in the skeletal muscle of diabetic mice, was the most highly upregulated during HDAC inhibition. The host gene, Cdc20b, was also significantly upregulated during HDAC inhibition. Bioinformatics analyses identified a common promoter for both Cdc20b and miR-449a that harbors significant histone acetylation marks, suggesting the possibility of regulation by histone acetylation-deacetylation. These observations suggest an inverse correlation between miR-449a levels and HDAC activity, in both SAHA-treated skeletal muscle cells and db/db mice skeletal muscle. Further, in SAHA-treated C2C12 cells, we observed augmented occupancy of acetylated histones on the Cdc20b/miR-449a promoter, which possibly promotes their upregulation. In vivo injection of SAHA to db/db mice significantly restored skeletal muscle miR-449a levels. Our results provide insights into the potential regulatory role of epigenetic histone acetylation of the miR-449a promoter that may regulate its expression in the diabetic skeletal muscle.
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Affiliation(s)
- Shagun Poddar
- a CSIR-Institute of Genomics and Integrative Biology , Delhi , India.,b AcSIR , Training and Development Complex, CSIR Campus , Taramani, Chennai , India
| | - Devesh Kesharwani
- a CSIR-Institute of Genomics and Integrative Biology , Delhi , India.,b AcSIR , Training and Development Complex, CSIR Campus , Taramani, Chennai , India
| | - Malabika Datta
- a CSIR-Institute of Genomics and Integrative Biology , Delhi , India.,b AcSIR , Training and Development Complex, CSIR Campus , Taramani, Chennai , India
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284
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Salvo F, Moore N, Arnaud M, Robinson P, Raschi E, De Ponti F, Bégaud B, Pariente A. Addition of dipeptidyl peptidase-4 inhibitors to sulphonylureas and risk of hypoglycaemia: systematic review and meta-analysis. BMJ 2016; 353:i2231. [PMID: 27142267 PMCID: PMC4854021 DOI: 10.1136/bmj.i2231] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To quantify the risk of hypoglycaemia associated with the concomitant use of dipeptidyl peptidase-4 (DPP-4) inhibitors and sulphonylureas compared with placebo and sulphonylureas. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, ISI Web of Science, SCOPUS, Cochrane Central Register of Controlled Trials, and clinicaltrial.gov were searched without any language restriction. STUDY SELECTION Placebo controlled randomised trials comprising at least 50 participants with type 2 diabetes treated with DPP-4 inhibitors and sulphonylureas. REVIEW METHODS Risk of bias in each trial was assessed using the Cochrane Collaboration tool. The risk ratio of hypoglycaemia with 95% confidence intervals was computed for each study and then pooled using fixed effect models (Mantel Haenszel method) or random effect models, when appropriate. Subgroup analyses were also performed (eg, dose of DPP-4 inhibitors). The number needed to harm (NNH) was estimated according to treatment duration. RESULTS 10 studies were included, representing a total of 6546 participants (4020 received DPP-4 inhibitors plus sulphonylureas, 2526 placebo plus sulphonylureas). The risk ratio of hypoglycaemia was 1.52 (95% confidence interval 1.29 to 1.80). The NNH was 17 (95% confidence interval 11 to 30) for a treatment duration of six months or less, 15 (9 to 26) for 6.1 to 12 months, and 8 (5 to 15) for more than one year. In subgroup analysis, no difference was found between full and low doses of DPP-4 inhibitors: the risk ratio related to full dose DPP-4 inhibitors was 1.66 (1.34 to 2.06), whereas the increased risk ratio related to low dose DPP-4 inhibitors did not reach statistical significance (1.33, 0.92 to 1.94). CONCLUSIONS Addition of DPP-4 inhibitors to sulphonylurea to treat people with type 2 diabetes is associated with a 50% increased risk of hypoglycaemia and to one excess case of hypoglycaemia for every 17 patients in the first six months of treatment. This highlights the need to respect recommendations for a decrease in sulphonylureas dose when initiating DPP-4 inhibitors and to assess the effectiveness of this risk minimisation strategy.
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Affiliation(s)
- Francesco Salvo
- University of Bordeaux, UMR1219, F-33000 Bordeaux, France INSERM, UMR1219, Bordeaux Population Health Research Center, Pharmacoepidemiology team, Bordeaux, France CHU Bordeaux, Bordeaux, France
| | - Nicholas Moore
- University of Bordeaux, UMR1219, F-33000 Bordeaux, France INSERM, UMR1219, Bordeaux Population Health Research Center, Pharmacoepidemiology team, Bordeaux, France CHU Bordeaux, Bordeaux, France CIC Bordeaux CIC1401, Bordeaux, France
| | - Mickael Arnaud
- University of Bordeaux, UMR1219, F-33000 Bordeaux, France INSERM, UMR1219, Bordeaux Population Health Research Center, Pharmacoepidemiology team, Bordeaux, France
| | - Philip Robinson
- CIC Bordeaux CIC1401, Bordeaux, France ADERA, Pessac, France
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Bernard Bégaud
- University of Bordeaux, UMR1219, F-33000 Bordeaux, France INSERM, UMR1219, Bordeaux Population Health Research Center, Pharmacoepidemiology team, Bordeaux, France CHU Bordeaux, Bordeaux, France
| | - Antoine Pariente
- University of Bordeaux, UMR1219, F-33000 Bordeaux, France INSERM, UMR1219, Bordeaux Population Health Research Center, Pharmacoepidemiology team, Bordeaux, France CHU Bordeaux, Bordeaux, France
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285
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Ajjan RA, Abougila K, Bellary S, Collier A, Franke B, Jude EB, Rayman G, Robinson A, Singh BM. Sensor and software use for the glycaemic management of insulin-treated type 1 and type 2 diabetes patients. Diab Vasc Dis Res 2016; 13:211-9. [PMID: 27000105 DOI: 10.1177/1479164115624680] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Lowering glucose levels, while avoiding hypoglycaemia, can be challenging in insulin-treated patients with diabetes. We evaluated the role of ambulatory glucose profile in optimising glycaemic control in this population. Insulin-treated patients with type 1 and type 2 diabetes were recruited into a prospective, multicentre, 100-day study and randomised to control (n = 28) or intervention (n = 59) groups. The intervention group used ambulatory glucose profile, generated by continuous glucose monitoring, to assess daily glucose levels, whereas the controls relied on capillary glucose testing. Patients were reviewed at days 30 and 45 by the health care professional to adjust insulin therapy. Comparing first and last 2 weeks of the study, ambulatory glucose profile-monitored type 2 diabetes patients (n = 28) showed increased time in euglycaemia (mean ± standard deviation) by 1.4 ± 3.5 h/day (p = 0.0427) associated with reduction in HbA1c from 77 ± 15 to 67 ± 13 mmol/mol (p = 0.0002) without increased hypoglycaemia. Type 1 diabetes patients (n = 25) showed reduction in hypoglycaemia from 1.4 ± 1.7 to 0.8 ± 0.8 h/day (p = 0.0472) associated with a marginal HbA1c decrease from 75 ± 10 to 72 ± 8 mmol/mol (p = 0.0508). Largely similar findings were observed comparing intervention and control groups at end of study. In conclusion, ambulatory glucose profile helps glycaemic management in insulin-treated diabetes patients by increasing time spent in euglycaemia and decreasing HbA1c in type 2 diabetes patients, while reducing hypoglycaemia in type 1 diabetes patients.
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Affiliation(s)
- Ramzi A Ajjan
- St. James's University Hospital, Leeds Teaching Hospitals Trust and LIGHT Laboratories, University of Leeds, Leeds, UK
| | - Kamal Abougila
- County Durham and Darlington NHS Foundation Trust, County Durham, UK
| | - Srikanth Bellary
- Aston Research Centre for Healthy Ageing (ARCHA), Aston University, Birmingham, UK
| | | | - Bernd Franke
- Rotherham Hospital NHS Foundation Trust, Rotherham, UK
| | - Edward B Jude
- Tameside Hospital NHS Foundation Trust, Ashton-under-Lyne, UK
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286
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Ding S, Schumacher M. Sensor Monitoring of Physical Activity to Improve Glucose Management in Diabetic Patients: A Review. SENSORS 2016; 16:s16040589. [PMID: 27120602 PMCID: PMC4851102 DOI: 10.3390/s16040589] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/14/2016] [Accepted: 04/21/2016] [Indexed: 12/11/2022]
Abstract
Diabetic individuals need to tightly control their blood glucose concentration. Several methods have been developed for this purpose, such as the finger-prick or continuous glucose monitoring systems (CGMs). However, these methods present the disadvantage of being invasive. Moreover, CGMs have limited accuracy, notably to detect hypoglycemia. It is also known that physical exercise, and even daily activity, disrupt glucose dynamics and can generate problems with blood glucose regulation during and after exercise. In order to deal with these challenges, devices for monitoring patients’ physical activity are currently under development. This review focuses on non-invasive sensors using physiological parameters related to physical exercise that were used to improve glucose monitoring in type 1 diabetes (T1DM) patients. These devices are promising for diabetes management. Indeed they permit to estimate glucose concentration either based solely on physical activity parameters or in conjunction with CGM or non-invasive CGM (NI-CGM) systems. In these last cases, the vital signals are used to modulate glucose estimations provided by the CGM and NI-CGM devices. Finally, this review indicates possible limitations of these new biosensors and outlines directions for future technologic developments.
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Affiliation(s)
- Sandrine Ding
- HESAV, University of Applied Sciences and Arts Western Switzerland (HES-SO), Av. Beaumont 21, Lausanne 1011, Switzerland.
| | - Michael Schumacher
- Institute of Information Systems, University of Applied Sciences and Arts Western Switzerland (HES-SO), Techno-Pôle 3, Sierre 3960, Switzerland.
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287
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Shimatsu A. [Endocrine and Metabolic Emergencies; Points of Initial Management. Topics: VII. Hypoglycemic coma]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2016; 105:683-689. [PMID: 27491262 DOI: 10.2169/naika.105.683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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288
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Functional identification of a neurocircuit regulating blood glucose. Proc Natl Acad Sci U S A 2016; 113:E2073-82. [PMID: 27001850 DOI: 10.1073/pnas.1521160113] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Previous studies implicate the hypothalamic ventromedial nucleus (VMN) in glycemic control. Here, we report that selective inhibition of the subset of VMN neurons that express the transcription factor steroidogenic-factor 1 (VMN(SF1) neurons) blocks recovery from insulin-induced hypoglycemia whereas, conversely, activation of VMN(SF1) neurons causes diabetes-range hyperglycemia. Moreover, this hyperglycemic response is reproduced by selective activation of VMN(SF1) fibers projecting to the anterior bed nucleus of the stria terminalis (aBNST), but not to other brain areas innervated by VMN(SF1) neurons. We also report that neurons in the lateral parabrachial nucleus (LPBN), a brain area that is also implicated in the response to hypoglycemia, make synaptic connections with the specific subset of glucoregulatory VMN(SF1) neurons that project to the aBNST. These results collectively establish a physiological role in glucose homeostasis for VMN(SF1) neurons and suggest that these neurons are part of an ascending glucoregulatory LPBN→VMN(SF1)→aBNST neurocircuit.
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289
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Rodriguez-Gutierrez R, Lipska KJ, McCoy RG, Ospina NS, Ting HH, Montori VM. Hypoglycemia as an indicator of good diabetes care. BMJ 2016; 352:i1084. [PMID: 26951142 PMCID: PMC6886856 DOI: 10.1136/bmj.i1084] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Rene Rodriguez-Gutierrez and colleagues argue that more attention should be paid to hypoglycemia when assessing management of diabetes
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Affiliation(s)
- Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA Division of Endocrinology, University Hospital Dr Jose E Gonzalez, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | - Kasia J Lipska
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA
| | - Rozalina G McCoy
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Naykky Singh Ospina
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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290
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Kyi M, Wentworth JM, Nankervis AJ, Fourlanos S, Colman PG. Recent advances in type 1 diabetes. Med J Aust 2016; 203:290-3. [PMID: 26424063 DOI: 10.5694/mja14.01691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 07/22/2015] [Indexed: 12/31/2022]
Abstract
Type 1 diabetes (T1D) is caused by an autoimmune attack on pancreatic beta cells that leads to insulin deficiency. The incidence of T1D in Australia has doubled over the past 20 years. T1D treatment focuses on physiological insulin replacement, aiming for near-normal blood glucose levels. Hypoglycaemia is a significant cause of morbidity and mortality in T1D. Optimal T1D management is complex, and is enhanced by empowering individuals in all aspects of managing diabetes. New technologies, including insulin pumps, continuous glucose monitors and sensor-augmented pumps, can assist people achieve better glycaemic control and reduce the risk of severe hypoglycaemia. Women with T1D can achieve significantly better outcomes during pregnancy and for their infants by planning for their pregnancy and by intensive glycaemic control. Several trials are underway that seek to identify the determinants of autoimmunity and to develop therapies that prevent T1D in at-risk individuals. Pancreatic and islet cell transplants are proven therapies, but are only offered to individuals with diabetes and renal failure (pancreas) or severe hypoglycaemia unawareness (islet cell transplants). Although T1D is still associated with considerable premature mortality, recent findings show that a significant improvement in life expectancy has occurred.
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Affiliation(s)
- Mervyn Kyi
- Royal Melbourne Hospital, Melbourne, VIC
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291
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Duncan EAS, Fitzpatrick D. Improving self-referral for diabetes care following hypoglycaemic emergencies: a feasibility study with linked patient data analysis. BMC Emerg Med 2016; 16:13. [PMID: 26893294 PMCID: PMC4757997 DOI: 10.1186/s12873-016-0078-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/14/2016] [Indexed: 11/20/2022] Open
Abstract
Background Hypoglycaemia is a common and potentially life threatening consequence of insulin and sulphonylurea treated Diabetes. Some severe hypoglycaemic events result in emergency ambulance attendance. Many of these patients are treated at home and do not require immediate transportation to an Emergency Department. However only 27-37 % of patients then follow up their care with a diabetes specialist. Consequently repeat severe hypoglycaemic events occur. Methods The intervention was implemented for 8 months, using a prospective cohort design with a historic control, in one Scottish Health Board in 2012. Data was collected using postal survey questionnaires to patients and ambulance clinicians, telephone survey follow-up questions to patients. Scottish Ambulance Service electronic records were linked with the SCI-Diabetes database of patient records to enable objective measurement of follow-up behaviour. Results Ambulance clinicians’ (n = 92) awareness of the intervention was high and both the prompt card and telephone call components of the intervention were delivered to most eligible patients. The intervention was perceived as highly acceptable to patients (n = 37), and very useful by both patients and ambulance clinicians. However, comparison of patient follow-up behaviours using linked-data (n = 205), suggest that the intervention was unsuccessful in improving rates of patients’ following up their care. Conclusions This study shows that the intervention is implementable, highly acceptable to patients, and considered very useful by both patients and ambulance clinicians. However, preliminary evidence of effectiveness is not encouraging. The study’s novel use of linking existing clinical data for outcome measurement exposed challenges in the feasibility of using this data for intervention development and evaluation. Future research should examine challenges to the successful testing and effectiveness of the intervention. Revisions are likely to be required, both to study design and the optimisation of the intervention’s content and components. Electronic supplementary material The online version of this article (doi:10.1186/s12873-016-0078-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edward A S Duncan
- Nursing, Midwifery & Allied Health Professions Research Unit, Scion House, University of Stirling FK9 4NF, Scotland, UK.
| | - David Fitzpatrick
- Clinical Research Paramedic (Scottish Ambulance Service), Nursing, Midwifery & Allied Health Professions Research Unit, Scion House, University of Stirling FK9 4NF, Scotland, UK
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292
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Kim MK. Letter: Cardiovascular Disease Predicts Severe Hypoglycemia in Patients with Type 2 Diabetes (Diabetes Metab J 2015;39:498-506). Diabetes Metab J 2016; 40:83-4. [PMID: 26912158 PMCID: PMC4768055 DOI: 10.4093/dmj.2016.40.1.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Mi Kyung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea.
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293
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Sircar M, Bhatia A, Munshi M. Review of Hypoglycemia in the Older Adult: Clinical Implications and Management. Can J Diabetes 2015; 40:66-72. [PMID: 26752195 DOI: 10.1016/j.jcjd.2015.10.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/15/2015] [Accepted: 10/16/2015] [Indexed: 12/16/2022]
Abstract
The aging of the population is a worldwide phenomenon. The prevalence of diabetes rises with increasing age, so the personal and financial costs of diabetes in the aging population have become significant burdens. In 2012, 104 billion (59%) of the estimated $176 billion in United States healthcare expenditures attributable to diabetes were utilized by patients older than 65 years of age [American Diabetes Association (1)]. With improvement in diabetes management and better glycemic control in the general population, there is an increase in the prevalence of hypoglycemia, which is the complication of the treatment of diabetes. Older adults with diabetes have a higher risk for hypoglycemia due to altered adaptive physiologic responses to low glucose levels. These patients also have comorbidities, such as cognitive and functional loss, that interfere with prompt identification and/or appropriate treatment of hypoglycemia. Older adults who suffer from hypoglycemia also have increased risk for falls, fall-related fractures, seizures and comas and exacerbation of chronic conditions, such as cognitive dysfunction and cardiac events. Thus, hypoglycemia in the older adult must be proactively avoided to decrease significant morbidity and mortality. Education of the patients and caregivers is important in prevention and treatment of hypoglycemia. In this article, we discuss the important aspects and unique challenges pertaining to hypoglycemia in older population. We also highlight the risks, consequences and prevention and management strategies for hypoglycemia that can be used by healthcare providers caring for older populations.
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Affiliation(s)
- Mousumi Sircar
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Ashmeet Bhatia
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Medha Munshi
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Joslin Diabetes Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
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294
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Affiliation(s)
- Hyeong Kyu Park
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea.
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295
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Morales C, de Luis D, de Arellano AR, Ferrario MG, Lizán L. Cost-Effectiveness Analysis of Insulin Detemir Compared to Neutral Protamine Hagedorn (NPH) in Patients with Type 1 and Type 2 Diabetes Mellitus in Spain. Diabetes Ther 2015; 6:593-610. [PMID: 26589521 PMCID: PMC4674462 DOI: 10.1007/s13300-015-0143-x] [Citation(s) in RCA: 6] [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: 09/24/2015] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION An Excel® (Microsoft Corporation) model was adapted to estimate the short-term (1-year) cost effectiveness of insulin detemir (IDet) versus neutral protamine Hagedorn (NPH) insulin in patients initiating insulin treatment with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in Spain. METHODS Clinical benefits included the non-severe hypoglycemia rate for T1DM and T2DM, and weight change for T2DM. Three scenarios were included with different hypoglycemia rates estimated on the basis of clinical trials and observational studies. Costs, estimated from perspective of the Spanish Public Healthcare System (Euros 2014), included insulin treatment and non-severe hypoglycemia management costs. Non-severe hypoglycemia, defined as a self-managed event, implied the use of extra glucose testing strips and a general practitioner visit during the week following the event for 25% of patients. An average disutility value was associated to non-severe hypoglycemia events and, for T2DM, to one body mass index unit gain to calculate quality-adjusted life years (QALYs). RESULTS For the three scenarios a range of 0.025-0.076 QALYs for T1DM and 0.014-0.051 QALYs for T2DM were gained for IDet versus NPH due to non-severe hypoglycemia and weight gain avoidance, in return of an incremental cost of €145-192 for T1DM and €128-206 for T2DM. This resulted in the IDet versus NPH incremental cost-effectiveness ratio (ICER) ranging between €1910/QALY and €7682/QALY for T1DM and €2522/QALY and €15,009/QALY for T2DM. CONCLUSION IDet was a cost-effective alternative to NPH insulin in the first year of treatment of patients with T1DM and patients with T2DM in Spain, with ICERs under the threshold value commonly accepted in Spain (€30,000/QALY). FUNDING Novo Nordisk.
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Affiliation(s)
| | - Daniel de Luis
- Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | | | - Luis Lizán
- Outcomes'10, Universidad Jaume I, Castellón, Spain
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296
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Abstract
Severe hypoglycemia is recognized to be one of the strongest predictors of macrovascular events, adverse clinical outcomes, and mortality in patients with type 2 diabetes. Large clinical trials have reported an increased hazard ratio for all-cause mortality and cardiovascular events in patients with type 2 diabetes and severe hypoglycemia. However, these trials also reported an increased hypoglycemia-associated mortality rate in patients allocated to standard treatment by a factor of 1.5-2 despite a significant 50 % to 70 % lower incidence of hypoglycemia compared to the intensive treatment group. Although the potential for a causal relationship has been demonstrated in mechanistic studies, the evidence from large prospective studies suggest that other pre-existing cardiovascular risk factors in addition to hypoglycemia may be the major link to the final cardiovascular event, and that a low blood glucose level can trigger these events in patients with a high cardiovascular risk.
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Affiliation(s)
- Frank Pistrosch
- Study Center Professor Hanefeld, GWT TU-Dresden GmbH, Fiedlerstrasse 34, 01307, Dresden, Germany.
- Medical Clinic III, Universitätsklinikum "Carl Gustav Carus", Dresden, Germany.
| | - Markolf Hanefeld
- Study Center Professor Hanefeld, GWT TU-Dresden GmbH, Fiedlerstrasse 34, 01307, Dresden, Germany
- Medical Clinic III, Universitätsklinikum "Carl Gustav Carus", Dresden, Germany
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297
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Risk of Hospitalization for Hypoglycemia in Older Patients with Diabetes Using Antipsychotic Drugs. Am J Geriatr Psychiatry 2015; 23:1144-53. [PMID: 26419734 DOI: 10.1016/j.jagp.2015.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 04/16/2015] [Accepted: 04/29/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Antipsychotics may disrupt metabolic regulation in patients with diabetes mellitus. The risk of hypoglycemia in older users of antipsychotics with diabetes is largely unknown. Therefore, we investigated the association between the use of antipsychotic drugs and hypoglycemia requiring hospital admission in older patients with diabetes. METHODS In a nested case-control study using community pharmacy records linked to hospital admission data in the Netherlands (1998-2008), a cohort of 68,314 patients at least 65 years with diabetes was studied. Cases were patients from the study cohort with a first hospital admission for hypoglycemia; up to five comparison subjects were selected for each case. Exposure to antipsychotic drugs was the primary determinant of interest. Logistic regression analysis was performed to estimate the strength of the association between antipsychotic drug use and hypoglycemia, taking into account potential confounders. RESULTS Eight hundred fifteen patients were admitted to hospital for hypoglycemia. Current use of antipsychotic drugs was associated with an increased risk of hypoglycemia compared with non-use (adjusted OR: 2.26; 95% CI: 1.45-3.52; Wald χ(2) = 13.08, df = 1, p ≤0.001), especially in the first 30 days of treatment (adjusted OR: 7.65; 95% CI: 2.50-23.41; Wald χ(2) = 12.72, df = 1, p ≤0.001) and with higher doses (adjusted OR: 8.20; 95% CI: 3.09-21.75; Wald χ(2) = 17.90, df = 1, p ≤0.001). CONCLUSION Use of antipsychotic drugs by older patients with diabetes mellitus was associated with an increased risk of hospitalization for hypoglycemia. Our findings suggest that glucose levels should be monitored closely after initiation of antipsychotic drugs.
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298
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Abstract
Hypoglycemia is one of the major barriers in optimizing glycemic control. In type 2 diabetes, hypoglycemia is associated with multiple morbidities (eg, myocardial ischemia, cardiac arrhythmia, stroke, dementia, psychosocial dysfunction, obesity, microvascular complications, cancer, and diseases of respiratory, digestive, and dermatological systems). Risk factors associated with hypoglycemia in patients with type 2 diabetes include old age, long disease duration, low body mass index, high baseline glycated hemoglobin (HbA1c), treatment with insulin and sulphonylurea, renal dysfunction, albuminuria, reduced level of low density lipoprotein cholesterol, low triglyceride and depression. There are considerable overlaps between phenotypes associated with severe hypoglycemia and all-site cancer suggesting that hypoglycemia may be a marker of vulnerability. In patients with severe hypoglycemia, comprehensive assessment is recommended to detect silent conditions, such as renal dysfunction, cancer, depression as well as review of treatment strategies including drug use to prevent morbidities and mortality.
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Affiliation(s)
- Alice P S Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, SAR, China,
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299
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Abstract
BACKGROUND Hypoglycemia in children and adolescents with type 1 diabetes has diverse etiologies. CASE CHARACTERISTICS We report recurrent hypoglycemia in three children with type 1 diabetes because of insulin overdose. INTERVENTION Hospitalization and counselling by treating team and psychologist helped in resolving the recurrent hypoglycemia. OUTCOME Improvement in glycemic control was achieved. MESSAGE Adolescents with type 1 diabetes may take extra insulin to consume more carbohydrates, or to seek attention. Parents should share the responsibility of care of adolescents during transition phase for better glycemic control.
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300
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Lavernia F, Kushner P, Trence D, Rice D, Dailey G, Kuritzky L. Recognizing and minimizing hypoglycemia: The need for individualized care. Postgrad Med 2015; 127:801-7. [PMID: 26359949 DOI: 10.1080/00325481.2015.1086628] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Hypoglycemia is a condition known to disrupt many everyday activities and is associated with increased risks of hospitalization, falls, motor vehicle accidents and mortality. Many patients with diabetes have an increased risk of hypoglycemia due to interventions targeting glycemic control. In these patients, hypoglycemia and fear of hypoglycemia may further reduce adherence to glucose-lowering regimens, contributing to the further aggravation of diabetes-related complications. Avoiding hypoglycemia should be one of the principal goals of any treatment strategies employing agents that can induce hypoglycemia in order to prevent the occurrence of associated symptoms and consequences. The education of patients and their families is an important feature of individualized management strategies in order to prevent, mitigate and treat hypoglycemic episodes. Patients with diabetes need to be made aware of how to recognize the signs of hypoglycemia and of the simple, highly effective steps that they can take to self-manage hypoglycemic episodes. Clinicians should be familiar with the risk factors for hypoglycemia, especially the profiles of the different classes of glucose-lowering medications such as the sulfonylureas and insulin. This article aims to review the risk factors for hypoglycemia and its implications for patients and healthcare systems, and provide practical advice for minimizing the risk of hypoglycemia and its consequences.
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Affiliation(s)
- Frank Lavernia
- a 1 North Broward Diabetes Center , Coconut Creek, FL, USA
| | | | - Dace Trence
- c 3 University of Washington , Seattle, WA, USA
| | - Donna Rice
- d 4 Sanofi U.S., Inc. , Bridgewater, NJ, USA
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