Treatment of mild-to-moderate hypoglycemia in patients with type 1 diabetes treated with insulin pump therapy: are current recommendations effective?

Managing Impending Nonsevere Hypoglycemia With Oral Carbohydrates in Type 1 Diabetes: The REVERSIBLE Trial

OBJECTIVE

Current guidelines recommend initiating treatment for nonsevere (NS) hypoglycemia with 15 g carbohydrates (CHO) at 15-min intervals when blood glucose (BG) reaches <70 mg/dL (3.9 mmol/L). Despite this recommendation, NS hypoglycemia management remains challenging for individuals living with type 1 diabetes (T1D). We aimed to assess the efficacy of 15 g CHO at higher BG levels.

RESEARCH DESIGN AND METHODS

A total of 29 individuals with T1D participated in an open-label crossover study. After an inpatient subcutaneous insulin-induced decrease in BG in the fasting state, 16 g CHO was administered orally at a plasma glucose (PG) of <70 (3.9), ≤80 (4.5), or ≤90 mg/dL (5.0 mmol/L). The primary outcome was time spent in hypoglycemia (<70 mg/dL) after initial CHO intake.

RESULTS

When comparing the <70 (control) with the ≤80 and ≤90 mg/dL treatment groups, 100 vs. 86 (P = 0.1201) vs. 34% (P < 0.0001) of participants reached hypoglycemia, respectively. These hypoglycemic events lasted 26.0 ± 12.6 vs. 17.9 ± 14.7 (P = 0.026) vs. 7.1 ± 11.8 min (P = 0.002), with a PG nadir of 56.57 ± 9.91 vs. 63.60 ± 7.93 (P = 0.008) vs. 73.51 ± 9.37 mg/dL (P = 0.002), respectively. In the control group, 69% of participants required more than one treatment to reach or maintain normoglycemia (≥70 mg/dL), compared with 52% in the ≤80 mg/dL group and 31% in the ≤90 mg/dL group, with no significant rebound hyperglycemia (>180 mg/dL) within the first hour.

CONCLUSIONS

For some impending NS hypoglycemia episodes, individuals with TID could benefit from CHO intake at a higher BG level.

Non-severe hypoglycemia in type 1 diabetes: a randomized crossover trial comparing two quantities of oral carbohydrates at different insulin-induced hypoglycemia ranges

Aims

Non-severe hypoglycemia (NS-H) is challenging for people living with type 1 diabetes (PWT1D) and often results from relative iatrogenic hyper-insulinemia. Current guidelines recommend a one-size-fits-all approach of 15-20 g of simple carbohydrates (CHO) every 15 min regardless of the triggering conditions of the NS-H event. We aimed to test different amounts of CHO to treat insulin-induced NS-H at various glucose ranges.

Methods

This is a randomized, four-way, crossover study involving PWT1D, testing NS-H treatment outcomes with 16 g vs. 32 g CHO at two plasma glucose (PG) ranges: A: 3.0-3.5 mmol/L and B: <3.0 mmol/L. Across all study arms, participants consumed an additional 16 g of CHO if PG was still <3.0 mmol/L at 15 min and <4.0 mmol/L at 45 min post-initial treatment. Subcutaneous insulin was used in a fasting state to induce NS-H. Participants had frequent venous sampling of PG, insulin, and glucagon levels.

Results

Participants (n = 32; 56% female participants) had a mean (SD) age of 46.1 (17.1) years, had HbA1c at 54.0 (6.8 mmol/mol) [7.1% (0.9%)], and had a diabetes duration of 27.5 (17.0) years; 56% were insulin pump users. We compared NS-H correction parameters between 16 g and 32 g of CHO for range A, 3.0-3.5 mmol/L (n = 32), and range B, <3.0 mmol/L (n = 29). Change in PG at 15 min for A: 0.1 (0.8) mmol/L vs. 0.6 (0.9) mmol/L, p = 0.02; and for B: 0.8 (0.9) mmol/L vs. 0.8 (1.0) mmol/L, p = 1.0. Percentage of participants with corrected episodes at 15 min: (A) 19% vs. 47%, p = 0.09; (B) 21% vs. 24%, p = 1.0. A second treatment was necessary in (A) 50% vs. 15% of participants, p = 0.001; (B) 45% vs. 34% of participants, p = 0.37. No statistically significant differences in insulin and glucagon parameters were observed.

Conclusions

NS-H, in the context of hyper-insulinemia, is difficult to treat in PWT1D. Initial consumption of 32 g of CHO revealed some advantages at the 3.0-3.5 mmol/L range. This was not reproduced at lower PG ranges since participants needed additional CHO regardless of the amount of initial consumption.

Clinical trial registration

ClinicalTrials.gov, identifier NCT03489967.

Leeno: Type 1 diabetes management training environment using smart algorithms

A growing number of Type-1 Diabetes (T1D) patients globally use insulin pump technologies to monitor and manage their glucose levels. Although recent advances in closed-loop systems promise automated pump control in the near future, most patients worldwide still use open-loop continuous subcutaneous insulin infusion (CSII) devices which require close monitoring and continuous regulation. Apart from specialized diabetes units, hospital physicians and nurses generally lack necessary training to support the growing number of patients on insulin pumps. Most hospital staff and providers worldwide have never seen or operated an insulin pump device. T1D patients at nurseries, schools, in hospital emergency rooms, surgery theatres, and in-patient units all require close monitoring and active management. The lack of knowledge and necessary training to support T1D patients on pumps puts them at life-threatening risks. In this work, we develop a training simulation software for hospitals to educate and train their physicians and nurses on how to effectively operate a T1D pump and reduce hypoglycemia events. The software includes clinically validated T1D virtual patients that users can monitor and adjust their pump settings to improve glycemic outcomes. We develop a Fuzzy-Logic learning algorithm that helps guide users learn how to improve pump parameters for these patients. We recruited and trained 13 nurses on the software and report their improvement in pump administration, basal rates adjustments, and ICR modulation.

Understanding Hypoglycemia in the Real World

PURPOSE

The purpose of this study was to gain a better understanding of real-world hypoglycemia experiences from people living with diabetes.

METHODS

An exploratory cross-sectional study of a convenience sample of 374 English-speaking adults affected by diabetes using an online survey was conducted.

RESULTS

Participant mean age was 37 years with an average diabetes duration of 21 years. On average, participants reported feeling hypoglycemia at 64 mg/dL (3.6 mmol/L), worrying about hypoglycemia at 63 mg/dL (3.5 mmol/L), and treating hypoglycemia at 72 mg/dL (4 mmol/L). Terminology used by study participants did not match the current classifications of hypoglycemia used in clinical research. Participants who have been told they have hypoglycemia unawareness treat at a significantly lower level compared to those without hypoglycemia unawareness. Only 58% always carry hypoglycemia treatment; there was a relationship with increasing age and always carrying hypoglycemia treatment. Thirty-eight percent of participants treat hypoglycemia with the recommended 15 g of carbohydrate (CHO). Survey respondents who wore continuous glucose monitors reported using significantly less CHO to treat hypoglycemia.

CONCLUSIONS

In the real world, experiences related to feeling, worrying about, and treating hypoglycemia trend higher than what is noted in the standardized hypoglycemia classifications. Study findings have implications for teaching and supporting people with diabetes who experience hypoglycemia. Consuming less CHO to treat hypoglycemia could lead to fewer episodes of rebound hyperglycemia and less weight gain. Increased support for continuous glucose monitoring is warranted.

Optimal Carbohydrate Dose for Treatment of Nonsevere Hypoglycemia in Insulin-Treated Patients With Diabetes: A Narrative Review

Nonsevere hypoglycemia in people with diabetes is usually treated with rapid-acting carbohydrate, of which glucose is the most suitable form. A quantity of 15 g is recommended and repeated after 15 min if hypoglycemia persists. This recommendation has not changed for several years despite the introduction of continuous glucose monitoring, newer and more flexible insulin regimens and improved insulin delivery. The present review has examined published studies that have explored how effectively defined amounts of carbohydrate treat nonsevere hypoglycemia in adults with insulin-treated diabetes. For most nonsevere episodes of hypoglycemia, the optimal treatment is 15 to 20 g of oral glucose. However, this dose may not be appropriate with many current insulins and insulin pump therapy, where doses of glucose may have to be individualized, and based on body weight or the type of insulin delivery system. Current guidelines on hypoglycemia treatment for newer glucose-lowering therapies may require re-evaluation.