Devoting attention to glucose variability and hypoglycaemia in type 2 diabetes

Perceived Cognitive Function and Glycemic Variability: Baseline Results From a Cognitive Rehabilitation Intervention

PURPOSE

The purpose of this study was to examine the association between glucose variability, diabetes self-management, and cognitive function in participants enrolled in a cognitive rehabilitation intervention for people with type 2 diabetes.

METHODS

Baseline data from the Memory, Attention, and Problem-Solving Skills for Diabetes randomized controlled trial (n = 95; mean age 65.6 years, SD 5.99; 59.3% female; 59% non-Hispanic White) were analyzed and included scores from the PROMIS Cognitive Function version 2, a measure of perceived cognitive function; glucose variability measurements from continuous glucose monitors; and scores on the Summary of Diabetes Self-Care Activities Survey.

RESULTS

Participants had higher levels of perceived cognitive dysfunction than the US average. Lower PROMIS scores were associated with higher levels of glucose variability. Better perceived cognitive health was related to better diabetes self-management. Glucose variability, measured by the coefficient of variation, was a significant predictor of perceived cognitive function.

CONCLUSIONS

Perceived cognitive function was associated with diabetes self-management and glucose variability. Understanding this association can support the development of interventions to mitigate effects associated with glucose variability and changes in cognitive function. Including measurements of perceived cognitive function in assessments has the potential to alert health care providers about the need for additional support in diabetes management and the possibility of cognitive impairment that may need further objective assessment.

The role of cognitive rehabilitation in people with type 2 diabetes: A study protocol for a randomized controlled trial

Today, the prevalence of cognitive dysfunction and the prevalence of diabetes are increasing. Research shows that diabetes increases cognitive impairment risk, and cognitive impairment makes diabetes self-management more challenging. Diabetes self-management, essential to good glycemic control, requires patients to assimilate knowledge about their complex disease and to engage in activities such as glucose self-monitoring and the management of their medications. To test a comprehensive cognitive rehabilitation intervention-the Memory, Attention, and Problem-Solving Skills for Persons with Diabetes (MAPSS-DM) program. Our central hypothesis is that participants who take part in the MAPSS-DM intervention will have improved memory and executive function, increased use of compensatory cognitive skills, and improved self-management. We will also explore the role of glucose variability in those changes. This is a randomized controlled trial. Sixty-six participants with cognitive concerns and type 2 diabetes will be assigned to either the full MAPSS-DM intervention or an active control. Participants will use continuous glucose monitoring pre- and post-intervention to identify changes in glycemic variability. All participants will also be evaluated systematically via questionnaires and neuropsychological tests at three timepoints: baseline, immediately post-intervention, and 3 months post-intervention. This study will fill an important gap by addressing cognitive function in the management of diabetes. Diabetes is related to accelerated cognitive aging, cognitive deficits are related to poorer self-management, and improvements in cognitive performance as a result of cognitive rehabilitation can translate into improved performance in everyday life and, potentially, diabetes self-management. The results of the proposed study will therefore potentially inform strategies to support cognitive function and diabetes self-management, as well as offer new mechanistic insights into cognitive function through the use of continuous glucose monitoring. Trial registration: This study has been registered at ClinicalTrials.gov (NCT04831775).

The Association of Glucose Variability and Dementia Incidence in Latinx Adults with Type 2 Diabetes: A Retrospective Study

Latinx adults with both cognitive dysfunction and type 2 diabetes mellitus (T2DM) are significantly more likely than Latinx adults with diabetes alone to have complications such as cardiovascular disease. Glucose variability may be a risk for dementia, but the course of glucose variability in the time before a dementia diagnosis for Latinx adults with T2DM has not been examined. We used a 10-year retrospective cohort of medical records of Latinx patients with T2DM who had at least one use of a continuous glucose monitor. The objective was to examine how glucose variability was associated with future dementia diagnoses. A total of 116 charts were included. Mean of daily differences and mean amplitude of glycemic excursions were more strongly associated with dementia diagnoses than other variability indices (p < .01). Understanding the relationships between cognitive function, glucose variability, and barriers to health care can translate into improved interventions to enhance diabetes care.

Relationships Among Perception of Cognitive Function, Diabetes Self-Management, and Glucose Variability in Older Adults: A Mixed Methods Study

The aim of the current study was to explore relationships among perceived cognitive function, glucose variability, and self-management in older adults with type 2 diabetes mellitus (T2DM). A mixed methods design was used with data from: (a) questionnaires on perceived cognitive function and diabetes self-management; (b) continuous glucose monitoring (CGM) reports; and (c) semi-structured interviews. Thirty adults with T2DM (47% female; mean age = 68.5 [SD = 5.2] years) participated. Those who exercised more days per week had more stable glucose. Those who reported fewer days of diet adherence had more hypoglycemia. Participants who reported higher levels of memory dissatisfaction exhibited higher levels of glucose variability. Findings point to the potential of glucose variability as a target to reduce the effect of diabetes on cognitive function. Instruction in recognition of glucose patterns found via CGM can be integrated into self-management education to improve self-management and subsequent glucose control and cognitive function. [Research in Gerontological Nursing, xx(x), xx-xx.].

Diabetes drugs and stroke risk: Intensive versus conventional glucose-lowering strategies, and implications of recent cardiovascular outcome trials

People with diabetes mellitus are at higher risk of ischaemic stroke and worse outcomes thereafter. However, whether it is better to prescribe intensive glucose-lowering treatment compared with conventional treatment in people with diabetes to prevent recurrent stroke is debated. It is also crucial to consider whether specific antidiabetic agents are more efficacious and safer than others for prevention of stroke. In this review, we provide an overview of the efficacy of intensive and conventional glucose-lowering treatment in post-stroke management. Our conclusion is that the overall evidence for a beneficial effect of intensive glycaemic control on risk of stroke is limited. We also discuss evidence from recent large clinical trials of thiazolidinediones and new antidiabetic medications, including dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1RAs), and sodium-glucose co-transporter-2 inhibitors. On the basis of the findings of these trials, our conclusion is that pioglitazone and the GLP-1RA class (other than short-acting lixisenatide) are likely to lessen the occurrence of cerebrovascular disease (by mechanisms not dependent on glucose-lowering per se), whereas there is no consistent evidence for other drug classes.

Fast Assessment of Glycemic Control based on Continuous Glucose Monitoring Data

Diabetes has become a major public health problem in the world. In this context, early assessment of glycemic control is essential in order to avoid life-threatening health complications. A panel of diabetes experts have recently proposed a list of recommendations when using Continuous Glucose Monitoring (CGM) for glycemic control assessment including a minimum of two weeks of CGM data. A recent study has further introduced a metric called Glucose Profile Indicator (GPI) for CGM based diabetes management including a subset of the recommended CGM metrics. In this pilot study, it was investigated if less than two weeks of CGM data would impact the performance of GPI compared to the proposed two weeks of CGM data. Furthermore, logistic regression (LR) was used to examine if an improvement could be achieved taking as input the CGM metrics used to quantify GPI. The population mean accuracy for accumulated day 1 to 13 varied between 72.8 ± 2.0% - 98.3 ± 0.4% with no clear sign of improvement using LR. Hence, this indicates a trade-off between the amount of available CGM data and the precision in which the GPI outcome using all 14 days can be achieved when considering features of the GPI alone. Future work is needed to investigate if this trade-off can be improved by the use of additional features of the CGM.

Cause-specific risk of major adverse cardiovascular outcomes and hypoglycemic in patients with type 2 diabetes: a multicenter prospective cohort study

PURPOSE

Glycated hemoglobin A1_c (HbA1_c) and fasting plasma glucose (FPG) was identified to account for the risk of cardiovascular diseases in type 2 diabetic patients, but no study evaluated the risk based on both HbA1_c and FPG levels. We described the risk of major adverse cardiovascular events (MACE) and hypoglycemic in type 2 diabetic patients according to both HbA1_c and FPG levels.

METHODS

With the usage of databases of Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE), 1815 patients from 61 centers in China was identified and grouped according to the criterion value of HbA1_c and FPG: Good glycemic control (HbA1_c < 6.5%, FPG < 6.1 mmol/L); Insufficient glycemic control (HbA1_c < 6.5%, FPG ≥ 6.1 mmol/L or HbA1_c ≥ 6.5%, FPG < 6.1 mmol/L); Poor glycemic control (HbA1_c ≥ 6.5%, FPG ≥ 6.1 mmol/L). Time-varying multivariable Cox proportional hazards models were employed.

RESULTS

Average age was 64.8 ± 5.8 years, with a median of 4.8 years of follow-up. Overall, the incidence rates of MACE were 20.6 per 1000-person-years in Good glycemic control compared with 45.9 per 1000-person-years in Insufficient glycemic control (adjusted hazard ratio (aHR): 1.99; 95% CI 1.11-3.56; p = 0.02) and 54.7 per 1000-person-years in Poor glycemic control (aHR: 2.46; 95% CI 1.38-4.40; p = 0.002), respectively. The risk of hypoglycemic was highest in Insufficient glycemic control; 67.3 per 1000-person-years compared with 46.3 per 1000-person-years in Good glycemic control (aHR: 1.62; 95% CI 1.03-2.56; p = 0.04). Apart from this, we also observed that both MACE (aHR:1.41; 95% CI 1.13-1.77; p = 0.003) and hypoglycemic episodes (aHR: 1.82; 95% CI 1.48-2.24; p < 0.001) were sufficiently more frequent in the insulin-exposed group than the non-exposed group. In a post-hoc analysis, the risk of MACE (aHR:1.43; 95% CI 1.09-1.86; p = 0.01) and hypoglycemic (aHR: 1.99; 95% CI 1.46-2.69; p < 0.001) were more pronounced in Insufficient glycemic control with insulin exposure.

CONCLUSIONS

We observed a significant association of cause-specific risk of MACE and hypoglycemic with Insufficient glycemic control, particularly with insulin exposure.

Glucose-Lowering Therapies for Cardiovascular Risk Reduction in Type 2 Diabetes Mellitus: State-of-the-Art Review

Type 2 diabetes mellitus (T2DM) is a major cardiovascular (CV) risk factor. Although antihyperglycemic therapies have typically focused on glycemic control, a paradigm shift for the treatment of T2DM has occurred, with an increased focus on CV risk reduction. Clinicians should base their clinical decisions on the beneficial effects of specific glucose-lowering agents on CV outcomes, while avoiding those therapeutic strategies with potential detrimental effects. Importantly, the presence of comorbidities (eg, established cardiovascular diseases, hypertension, obesity) should also guide the clinical decision toward therapies proven to reduce CV outcomes in that specific population. In this state-of-the-art review resulting from a comprehensive literature search (Pubmed, Google Scholar), we summarize the evidence related to the CV outcomes trials reported in the past several decades. Finally, we propose a therapeutic plan for patients with T2DM, suggesting the use of specific glucose-lowering agents based on the characteristics and presence of comorbidities of the individual patient.

Glycemic Variation and Cardiovascular Risk in the Veterans Affairs Diabetes Trial

OBJECTIVE

There is uncertainty about the importance of glycemic variability in cardiovascular complications in patients with type 2 diabetes. Using the Veterans Affairs Diabetes Trial (VADT), we investigated the association between variation in fasting glucose and glycated hemoglobin (HbA_1c) over time and the incidence of cardiovascular disease (CVD) and assessed whether this is influenced by intensive or standard glycemic control.

RESEARCH DESIGN AND METHODS

During the VADT, fasting glucose and HbA_1c were measured every 3 months for up to 84 months in 1,791 individuals. Variability measures included coefficient of variation (CV) and average real variability (ARV) for fasting glucose and HbA_1c. Overall mean glucose and HbA_1c measures as well as their maximum and the most recent measurement were also examined.

RESULTS

Variability measures (CV and ARV) of fasting glucose were significantly associated with CVD even after adjusting for other risk factors, including mean fasting glucose. When considering separately groups receiving intensive and standard glycemic control, this relationship was evident in the intensive treatment group but not in the standard group. Additional adjustment for severe hypoglycemic episodes did not alter the relationship between fasting glucose variability and CVD. Interestingly, no HbA_1c measures were associated with CVD after adjusting for multiple baseline risk factors.

CONCLUSIONS

Our analysis indicates that in the VADT, variability of fasting glucose plays a role in the development of CVD complications beyond the influence of standard fasting glucose measures. The adverse consequences of fasting glucose variability on CVD appear greatest in those receiving intensive glucose control.

Hypoglycemia, Cardiovascular Outcomes, and Death: The LEADER Experience

OBJECTIVE

In the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) cardiovascular (CV) outcomes trial (NCT01179048), liraglutide significantly reduced the risk of CV events (by 13%) and hypoglycemia versus placebo. This post hoc analysis examines the associations between hypoglycemia and CV outcomes and death.

RESEARCH DESIGN AND METHODS

Patients with type 2 diabetes and high risk for CV disease (n = 9,340) were randomized 1:1 to liraglutide or placebo, both in addition to standard treatment, and followed for 3.5-5 years. The primary end point was time to first major adverse cardiovascular event (MACE) (1,302 first events recorded), and secondary end points included incidence of hypoglycemia. We used Cox regression to analyze time to first MACE, CV death, non-CV death, or all-cause death with hypoglycemia as a factor or time-dependent covariate.

RESULTS

A total of 267 patients experienced severe hypoglycemia (liraglutide n = 114, placebo n = 153; rate ratio 0.69; 95% CI 0.51, 0.93). These patients had longer diabetes duration, higher incidence of heart failure and kidney disease, and used insulin more frequently at baseline than those without severe hypoglycemia. In combined analysis (liraglutide and placebo), patients with severe hypoglycemia were more likely to experience MACE, CV death, and all-cause death, with higher risk shortly after hypoglycemia. The impact of liraglutide on risk of MACE was similar in patients with and without severe hypoglycemia (P-interaction = 0.90).

CONCLUSIONS

Patients experiencing severe hypoglycemia were at greater risk of CV events and death, particularly shortly after the hypoglycemic episode. While causality remains unclear, reducing hypoglycemia remains an important goal in diabetes management.

Beyond HbA1c: Comparing Glycemic Variability and Glycemic Indices in Predicting Hypoglycemia in Type 1 and Type 2 Diabetes

BACKGROUND

Hypoglycemia is the major impediment to therapy intensification in diabetes. Although higher individualized HbA1c targets are perceived to reduce the risk of hypoglycemia in those at risk of hypoglycemia, HbA1c itself is a poor predictor of hypoglycemia. We assessed the use of glycemic variability (GV) and glycemic indices as independent predictors of hypoglycemia.

METHODS

A retrospective observational study of 60 type 1 and 100 type 2 diabetes subjects. All underwent professional continuous glucose monitoring (CGM) for 3-6 days and recorded self-monitored blood glucose (SMBG). Indices were calculated from both CGM and SMBG. Statistical analyses included regression and area under receiver operator curve (AUC) analyses.

RESULTS

Hypoglycemia frequency (53.3% vs. 24%, P < 0.05) and %CV (40.1% ± 10% vs. 29.4% ± 7.8%, P < 0.001) were significantly higher in type 1 diabetes compared with type 2 diabetes. HbA1c was, at best, a weak predictor of hypoglycemia. %CV_CGM, Low Blood Glucose Index (LBGI)_CGM, Glycemic Risk Assessment Diabetes Equation (GRADE)Hypoglycemia_CGM, and Hypoglycemia Index_CGM predicted hypoglycemia well. %CV_CGM and %CV_SMBG consistently remained a robust discriminator of hypoglycemia in type 1 diabetes (AUC 0.88). In type 2 diabetes, a combination of HbA1c and %CV_SMBG or LBGI_SMBG could help discriminate hypoglycemia.

CONCLUSION

Assessment of glycemia should go beyond HbA1c and incorporate measures of GV and glycemic indices. %CV_SMBG in type 1 diabetes and LBGI_SMBG or a combination of HbA1c and %CV_SMBG in type 2 diabetes discriminated hypoglycemia well. In defining hypoglycemia risk using GV and glycemic indices, diabetes subtypes and data source (CGM vs. SMBG) must be considered.

Long-term visit-to-visit glycemic variability as predictor of micro- and macrovascular complications in patients with type 2 diabetes: The Rio de Janeiro Type 2 Diabetes Cohort Study

BACKGROUND

Long-term visit-to-visit glycemic variability is an additional measure of glycemic control. We aimed to evaluate the prognostic value of several measures of glycemic variability for the occurrence of micro- and macrovascular complications, and all-cause mortality in patients with type 2 diabetes.

METHODS

654 individuals were followed-up over a median of 9.3 years. Glycemic variability (SDs and coefficients of variation of HbA1c and fasting glycaemia) was measured during the first 12- and 24-months. Multivariate Cox analysis, adjusted for risk factors and mean HbA1c and fasting glycaemia levels, examined the associations between glycemic variability and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications [total cardiovascular events (CVE), major adverse CVEs (MACE) and cardiovascular mortality], and of all-cause mortality.

RESULTS

During follow-up, 128 patients had a CVE (96 MACE), and 158 patients died (67 from cardiovascular diseases); 152 newly-developed or worsened diabetic retinopathy, 183 achieved the renal composite outcome (89 newly developed microalbuminuria and 91 deteriorated renal function), and 96 newly-developed or worsened peripheral neuropathy. Glycemic variability, particularly the 24-month parameters either estimated by HbA1c or by fasting glycemia, predicted all endpoints, except for retinopathy and peripheral neuropathy development/progression, and was a better predictor than mean HbA1c. Glycemic variability predicted retinopathy development/progression in patients with good glycemic control (HbA1c ≤ 7.5%, 58 mmol/mol) and predicted new-incident peripheral neuropathy.

CONCLUSIONS

Long-term visit-to-visit glycemic variability is an additional and frequently a better glycemic parameter than mean HbA1c levels for assessing the risk of future development of micro- and macrovascular complications in patients with type 2 diabetes.