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Escudero C, Husain A, Arnaout A. Hypoglycemia Unawareness and Recurrent Severe Hypoglycemia in an Individual With Type 1 Diabetes Mellitus on Insulin. AACE Clin Case Rep 2024; 10:101-104. [PMID: 38799042 PMCID: PMC11127593 DOI: 10.1016/j.aace.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/22/2024] [Accepted: 03/01/2024] [Indexed: 05/29/2024] Open
Abstract
Background/Objective Hypoglycemia unawareness is a complication of recurrent hypoglycemia that can complicate diabetes management and impact quality of life. We present the case of an individual with type 1 diabetes with hypoglycemia unawareness and recurrent severe hypoglycemia requiring emergency intervention. Case Report A 55-year-old man with type 1 diabetes was referred for hypoglycemia unawareness and recurrent hypoglycemia with seizures. Over the prior 4 years he had >400 paramedic responses with 56 hospitalizations. Blood glucose levels ranged between 0.7 and 2.4 mmol/L during these episodes and presenting Hemoglobin A1c (HbA1c) was 4.6% (28 mmol/mol). He was taking insulin glargine daily and aspart with meals via insulin pens with no alternative etiology for his hypoglycemia was identified. The patient expressed difficulty with self-management, social instability, and limited appointment attendance. He was provided a continuous glucose monitor, educational support, and glycemic targets were broadened. After 6 months, HbA1c was 4.6% (28 mmol/mol) and he had 65 paramedic responses. A multidisciplinary team was organized for biweekly follow-up, community outreach, remote technological support, and psychological counseling. After 2 years, the patient had 2 emergency responses and HbA1c was 7.2% (55.2 mmol/mol). Discussion Permissive hyperglycemia, educational interventions, and continuous glucose monitoring are validated strategies for prevention of hypoglycemia. Limiting hypoglycemia is crucial to restore hypoglycemia awareness, and in severe cases may require high intensity follow-up, community outreach, and psychosocial support. Conclusion Hypoglycemia unawareness can complicate hypoglycemia prevention. Severe refractory cases are often multifaceted and may warrant a multidisciplinary approach to identify and target patient-specific needs.
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Affiliation(s)
- Carlos Escudero
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alaa Husain
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Amel Arnaout
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
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Hölzen L, Schultes B, Meyhöfer SM, Meyhöfer S. Hypoglycemia Unawareness-A Review on Pathophysiology and Clinical Implications. Biomedicines 2024; 12:391. [PMID: 38397994 PMCID: PMC10887081 DOI: 10.3390/biomedicines12020391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/31/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Hypoglycemia is a particular problem in people with diabetes while it can also occur in other clinical circumstances. Hypoglycemia unawareness describes a condition in which autonomic and neuroglycopenic symptoms of hypoglycemia decrease and hence are hardly perceivable. A failure to recognize hypoglycemia in time can lead to unconsciousness, seizure, and even death. The risk factors include intensive glycemic control, prior episodes of severe hypoglycemia, long duration of diabetes, alcohol consumption, exercise, renal failure, and sepsis. The pathophysiological mechanisms are manifold, but mainly concern altered brain glucose sensing, cerebral adaptations, and an impaired hormonal counterregulation with an attenuated release of glucagon, epinephrine, growth hormone, and other hormones, as well as impaired autonomous and neuroglycopenic symptoms. Physiologically, this counterregulatory response causes blood glucose levels to rise. The impaired hormonal counterregulatory response to recurrent hypoglycemia can lead to a vicious cycle of frequent and poorly recognized hypoglycemic episodes. There is a shift in glycemic threshold to trigger hormonal counterregulation, resulting in hypoglycemia-associated autonomic failure and leading to the clinical syndrome of hypoglycemia unawareness. This clinical syndrome represents a particularly great challenge in diabetes treatment and, thus, prevention of hypoglycemia is crucial in diabetes management. This mini-review provides an overview of hypoglycemia and the associated severe complication of impaired hypoglycemia awareness and its symptoms, pathophysiology, risk factors, consequences, as well as therapeutic strategies.
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Affiliation(s)
- Laura Hölzen
- Institute for Endocrinology & Diabetes, University of Lübeck, 23562 Lübeck, Germany; (L.H.); (B.S.)
- Department of Internal Medicine 1, Endocrinology & Diabetes, University of Lübeck, 23562 Lübeck, Germany
| | - Bernd Schultes
- Institute for Endocrinology & Diabetes, University of Lübeck, 23562 Lübeck, Germany; (L.H.); (B.S.)
- Metabolic Center St. Gallen, friendlyDocs Ltd., 9016 St. Gallen, Switzerland
| | - Sebastian M. Meyhöfer
- Institute for Endocrinology & Diabetes, University of Lübeck, 23562 Lübeck, Germany; (L.H.); (B.S.)
- German Center for Diabetes Research (DZD), 85764 Neuherberg, Germany
| | - Svenja Meyhöfer
- Institute for Endocrinology & Diabetes, University of Lübeck, 23562 Lübeck, Germany; (L.H.); (B.S.)
- Department of Internal Medicine 1, Endocrinology & Diabetes, University of Lübeck, 23562 Lübeck, Germany
- German Center for Diabetes Research (DZD), 85764 Neuherberg, Germany
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3
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Hering BJ, Ballou CM, Bellin MD, Payne EH, Kandeel F, Witkowski P, Alejandro R, Rickels MR, Barton FB. Factors associated with favourable 5 year outcomes in islet transplant alone recipients with type 1 diabetes complicated by severe hypoglycaemia in the Collaborative Islet Transplant Registry. Diabetologia 2023; 66:163-173. [PMID: 36201044 DOI: 10.1007/s00125-022-05804-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/27/2022] [Indexed: 12/13/2022]
Abstract
AIMS/HYPOTHESIS Islet transplantation has been studied in small cohorts of recipients with type 1 diabetes complicated by severe hypoglycaemic events (SHEs). We determined factors associated with favourable outcomes in a large cohort of recipients reported to the Collaborative Islet Transplant Registry (CITR). METHODS In 398 non-uraemic islet transplant alone (ITA) recipients with type 1 diabetes and SHEs, transplanted between 1999 and 2015 and with at least 1 year follow-up, we analysed specified favourable outcomes against each of all available characteristics of pancreas donors, islet grafts, recipients and immunosuppressive regimens, as well as immunosuppression and procedure-related serious adverse events (SAEs). RESULTS Four factors were associated with the highest rates of favourable outcomes: recipient age ≥35 years; total infused islets ≥325,000 islet equivalents; induction immunosuppression with T cell depletion and/or TNF-α inhibition; and maintenance with both mechanistic target of rapamycin (mTOR) and calcineurin inhibitors. At 5 years after the last islet infusion, of the recipients meeting these four common favourable factors (4CFF; N=126), 95% were free of SHEs, 76% had HbA1c <53 mmol/mol (7.0%), 73% had HbA1c <53 mmol/mol (7.0%) and absence of SHEs, and 53% were insulin independent, significantly higher rates than in the remaining recipients (<4CFF; N=272). The incidence of procedural and immunosuppression-related SAEs per recipient that resulted in sequelae, disability or death was low in both the 4CFF (0.056 per person) and <4CFF (0.074 per person) groups. CONCLUSIONS/INTERPRETATION In recipients with type 1 diabetes complicated by SHEs, islet transplantation meeting 4CFF protected 95% from SHEs at 5 years after the last islet infusion and exerted a large and significant benefit on glycaemic control, with an acceptable safety profile for this subgroup of type 1 diabetes.
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Affiliation(s)
- Bernhard J Hering
- Schulze Diabetes Institute and Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | | | - Melena D Bellin
- Schulze Diabetes Institute and Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | | | - Fouad Kandeel
- Department of Clinical Diabetes, Endocrinology & Metabolism, City of Hope, Duarte, CA, USA
| | - Piotr Witkowski
- Pancreatic and Islet Transplant Program, Transplantation Institute, University of Chicago, Chicago, IL, USA
| | - Rodolfo Alejandro
- Diabetes Research Institute and Department of Medicine, University of Miami, Miami, FL, USA
| | - Michael R Rickels
- Institute for Diabetes, Obesity & Metabolism and Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Moreno-Fernandez J, Chico A, Martínez-Brocca MA, Beato-Víbora PI, Vidal M, Piedra M, Quirós C, Muñoz-Rodríguez JR. Continuous Subcutaneous Insulin Infusion in Type 1 Diabetes Mellitus Patients: Results from the Spanish National Registry. Diabetes Technol Ther 2022; 24:898-906. [PMID: 35947087 DOI: 10.1089/dia.2022.0207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Aim: To analyze the clinical effect of continuous subcutaneous insulin infusion (CSII) in type 1 diabetes mellitus (T1D) patients in the Spanish real-world scenario. Methods: All T1D patients on CSII registered in the SPAnish Insulin Pump (SPAIP) registry were included. The primary efficacy outcome was change in HbA1c during follow-up. Secondary efficacy outcomes included: insulin pump indications, diabetes complication rates, insulin and pump use, and continuous glucose monitoring (CGM) glycometrics. Patient data were typed through the web-based SPAIP registry. Results: Data from 2979 T1D patients treated with CSII were analyzed. The median age was 44 years (interquartile range [IQR] 34-52 years), and T1D duration was 27 years (IQR 18-35 years). The median duration of CSII therapy was 6 years (IQR 3-10 years). The main indications for treatment were suboptimal glycemic control (33.8%), hypoglycemia (22.1%), and increased glycemic variability (18.8%). Glycated hemoglobin decreased by 6 mmol/mol (95% CI, -5 to -6 mmol/mol, P < 0.001) [-0.5%, 95% CI, -0.4 to -0.5, P < 0.001] during the follow-up. The percentage of patients with severe hypoglycemia decreased from 14.9% to 0.9% (P < 0.001). We observed an inverse correlation between final HbA1c levels and CGM adherence (R = -0.24, P < 0.001) or percentage of time with active hybrid closed-loop functions (R = -0.25, P < 0.001). Conclusions: CSII treatment was associated with a sustained improvement in glycemic control in the Spanish population. This benefit was greater among patients with higher CGM or active hybrid closed-loop functions adherence. The protocol was publicly registered at ClinicalTrials.gov (NCT04761094).
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Affiliation(s)
- Jesus Moreno-Fernandez
- Department of Endocrinology and Nutrition, Ciudad Real General University Hospital, Ciudad Real, Spain
| | - Ana Chico
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Mercé Vidal
- Department of Endocrinology and Nutrition, Barcelona Clinic Hospital, Barcelona, Spain
| | - María Piedra
- Department of Endocrinology and Nutrition, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Carmen Quirós
- Department of Endocrinology and Nutrition, Terrassa Hospital, Terrassa, Barcelona, Spain
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He C, Li Q, Cui Y, Gao P, Shu W, Zhou Q, Wang L, Li L, Lu Z, Zhao Y, Ma H, Chen X, Jia H, Zheng H, Yang G, Liu D, Tepel M, Zhu Z. Recurrent moderate hypoglycemia accelerates the progression of cognitive deficits through impairment of TRPC6/GLUT3 pathway in diabetic APP/PS1 mice. JCI Insight 2022; 7:154595. [PMID: 35077394 PMCID: PMC8983129 DOI: 10.1172/jci.insight.154595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/20/2022] [Indexed: 11/17/2022] Open
Abstract
Currently, the most effective strategy for dealing with Alzheimer’s disease (AD) is delaying the onset of dementia. Severe hypoglycemia is strongly associated with dementia; however, the effects of recurrent moderate hypoglycemia (RH) on the progression of cognitive deficits in patients with diabetes with genetic susceptibility to AD remain unclear. Here, we report that insulin-controlled hyperglycemia slightly aggravated AD-type pathologies and cognitive impairment; however, RH significantly increased neuronal hyperactivity and accelerated the progression of cognitive deficits in streptozotocin-induced (STZ-induced) diabetic APP/PS1 mice. Glucose transporter 3–mediated (GLUT3-mediated) neuronal glucose uptake was not significantly altered under hyperglycemia but was markedly reduced by RH, which induced excessive mitochondrial fission in the hippocampus. Overexpression of GLUT3, specifically in the dentate gyrus (DG) area of the hippocampus, enhanced mitochondrial function and improved cognitive deficits. Activation of the transient receptor potential channel 6 (TRPC6) increased GLUT3-mediated glucose uptake in the brain and alleviated RH-induced cognitive deficits, and inactivation of the Ca2+/AMPK pathway was responsible for TRPC6-induced GLUT3 inhibition. Taken together, RH impairs brain GLUT3-mediated glucose uptake and further provokes neuronal mitochondrial dysfunction by inhibiting TRPC6 expression, which then accelerates progression of cognitive deficits in diabetic APP/PS1 mice. Avoiding RH is essential for glycemic control in patients with diabetes, and TRPC6/GLUT3 represents potent targets for delaying the onset of dementia in patients with diabetes.
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Affiliation(s)
- Chengkang He
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Qiang Li
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Yuanting Cui
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Peng Gao
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Wentao Shu
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Qing Zhou
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Lijuan Wang
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Li Li
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Zongshi Lu
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Yu Zhao
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Huan Ma
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Xiaowei Chen
- Brain Research Center, Army Medical University, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Hongbo Jia
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China
| | - Hongting Zheng
- Department of Endocrinology, Translational Research Key Laboratory for Diabetes, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Gangyi Yang
- Endocrine Department, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Daoyan Liu
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Martin Tepel
- Odense University Hospital, Department of Nephrology, University of Southern Denmark, Institute for Molecular Medicine, Cardiovascular and Renal Research, Institute of Clinical Research, Odense, Denmark
| | - Zhiming Zhu
- Department of Hypertension and Endocrinology, Center for Hypertension and Metabolic Diseases, Daping Hospital, Army Medical University, Chongqing Institute of Hypertension, Chongqing Institute for Brain and Intelligence, Chongqing, China
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Lai L, Yang Y, Cao P, Zhao S, Qin H, Yao C, Zhang H. Study on the changes of blood glucose in hemodialysis patients with diabetes. Rev Assoc Med Bras (1992) 2021; 67:822-827. [PMID: 34709324 DOI: 10.1590/1806-9282.20201143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/02/2021] [Indexed: 08/30/2023] Open
Abstract
OBJECTIVE The aims of this study were to observe the regularity of blood glucose changes in hemodialysis patients with diabetes, time of onset of hypoglycemia and blood glucose level during dialysis, and to explore the sensitive early warning indicators of hypoglycemia in dialysis patients. BACKGROUND Diabetes patients have a high incidence of hypoglycemia during hemodialysis. METHODS A total of 124 maintenance hemodialysis patients with diabetes were selected for this study. Before dialysis, one, two, and three h after dialysis, and when hypoglycemia symptoms occurred, the blood glucose changes were monitored, the blood glucose drop range was observed when hypoglycemia symptoms occurred, and the correlation between the two was analyzed. RESULTS After the start of the dialysis, the patient's blood glucose showed a downward trend. The symptoms of hypoglycemia were most obvious within one-two hours, with an incidence rate of 57.9%. When the blood glucose drop percentage reached 37.7%, the specificity and sensitivity of early warning hypoglycemia symptoms were 84.6 and 73%, respectively. CONCLUSIONS For hemodialysis patients with diabetes, attention should be paid to the symptoms of hypoglycemia during dialysis, and blood glucose should be monitored before dialysis and after 1-2 h of dialysis. If the blood glucose drop percentage is greater than 37.7%, the timely measures should be taken.
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Affiliation(s)
- Lanshuhui Lai
- Shanghai Jiao Tong University, Renji Hospital, School of Medicine, Department of Nursing - Shanghai, China
| | - Yan Yang
- Shanghai Jiao Tong University, Renji Hospital, School of Medicine, Department of Nursing - Shanghai, China
| | - Pan Cao
- Shanghai Jiao Tong University, Renji Hospital, School of Medicine, Department of Nursing - Shanghai, China
| | - Shiyu Zhao
- Shanghai Jiao Tong University, Renji Hospital, School of Medicine, Department of Nursing - Shanghai, China
| | - Haifeng Qin
- Shanghai Sixth People's Hospital - Shanghai, China
| | - Chunying Yao
- Shanghai Punan Hospital of Pudong New District - Shanghai, China
| | - Haifen Zhang
- Shanghai Jiao Tong University, Renji Hospital, School of Medicine, Department of Nursing - Shanghai, China
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La Sala L, Pontiroli AE. New Fast Acting Glucagon for Recovery from Hypoglycemia, a Life-Threatening Situation: Nasal Powder and Injected Stable Solutions. Int J Mol Sci 2021; 22:ijms221910643. [PMID: 34638984 PMCID: PMC8508740 DOI: 10.3390/ijms221910643] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/12/2022] Open
Abstract
The goal of diabetes care is to achieve and maintain good glycemic control over time, so as to prevent or delay the development of micro- and macrovascular complications in type 1 (T1D) and type 2 diabetes (T2D). However, numerous barriers hinder the achievement of this goal, first of all the frequent episodes of hypoglycemia typical in patients treated with insulin as T1D patients, or sulphonylureas as T2D patients. The prevention strategy and treatment of hypoglycemia are important for the well-being of patients with diabetes. Hypoglycemia is strongly associated with an increased risk of cardiovascular disease in diabetic patients, due probably to the release of inflammatory markers and prothrombotic effects triggered by hypoglycemia. Treatment of hypoglycemia is traditionally based on administration of carbohydrates or of glucagon via intramuscular (IM) or subcutaneous injection (SC). The injection of traditional glucagon is cumbersome, such that glucagon is an under-utilized drug. In 1983, it was shown for the first time that intranasal (IN) glucagon increases blood glucose levels in healthy volunteers, and in 1989-1992 that IN glucagon is similar to IM glucagon in resolving hypoglycemia in normal volunteers and in patients with diabetes, both adults and children. IN glucagon was developed in 2010 and continued in 2015; in 2019 IN glucagon obtained approval in the US, Canada, and Europe for severe hypoglycemia in children and adults. In the 2010s, two ready-to-use injectable formulations, a stable non-aqueous glucagon solution and the glucagon analog dasiglucagon, were developed, showing an efficacy similar to traditional glucagon, and approved in the US in 2020 and in 2021, respectively, for severe hypoglycemia in adults and in children. Fast-acting glucagon (nasal administration and injected solutions) appears to represent a major breakthrough in the treatment of severe hypoglycemia in insulin-treated patients with diabetes, both adults and children. It is anticipated that the availability of fast-acting glucagon will expand the use of glucagon, improve overall metabolic control, and prevent hypoglycemia-related complications, in particular cardiovascular complications and cognitive impairment.
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Affiliation(s)
- Lucia La Sala
- IRCCS MultiMedica, Lab of Diabetology and Dysmetabolic Disease, PST Via Fantoli 16/15, 20138 Milan, Italy
- Correspondence: ; Tel.: +39-02-5540-6534 (ext. 6587)
| | - Antonio E. Pontiroli
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20100 Milan, Italy;
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Reyes-García R, Mezquita-Raya P, Moreno-Pérez Ó, Muñoz-Torres M, Merino-Torres JF, Márquez Pardo R, Jódar-Gimeno E, Escalada San Martín J, Gargallo-Fernández M, Soto-Gonzalez A, González Pérez de Villar N, Bellido Guerrero D, Gómez-Peralta F, de Luis Román D, López de la Torre Casares M. Executive summary: Position document: Evaluation and management of hypoglycemia in the patient with diabetes mellitus 2020. Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition. ENDOCRINOL DIAB NUTR 2021; 68:270-276. [PMID: 34266639 DOI: 10.1016/j.endien.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/19/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To provide practical recommendations for the evaluation and management of hypoglycemia in patients with diabetes mellitus. PARTICIPANTS Members of the Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition (SEEN). METHODS The recommendations were made based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to establish both the strength of the recommendations and the level of evidence. A systematic search was made in MEDLINE (PubMed) for the available evidence on each subject, and articles written in English and Spanish with an inclusion date up to 30 November 2019 were reviewed. This executive summary takes account of the evidence incorporated since 2013. CONCLUSIONS The document establishes practical evidence-based recommendations regarding the evaluation and management of hypoglycemia in patients with diabetes mellitus.
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Affiliation(s)
- Rebeca Reyes-García
- Unidad de Endocrinología, Hospital Universitario Torrecárdenas, Almería, Spain.
| | - Pedro Mezquita-Raya
- Unidad de Endocrinología, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Óscar Moreno-Pérez
- Servicio de Endocrinología, Hospital General de Alicante, Alicante, Spain
| | - Manuel Muñoz-Torres
- UGC Endocrinología y Nutrición, Hospital Universitario San Cecilio, Granada, Spain
| | | | | | - Esteban Jódar-Gimeno
- Departamento Endocrinología y Nutrición, Hospital Universitario Quiron Salud Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Javier Escalada San Martín
- Departamento de Endocrinología y Nutrición, Clínica Universidad de Navarra, Pamplona, Spain; CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), ISCIII, Madrid, Spain; Grupo de Diabetes & Enfermedades Metabólicas, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Manuel Gargallo-Fernández
- Endocrinología y Nutrición, Hospital Universitario Infanta Leonor, Fundación Jiménez Díaz, Madrid, Spain
| | - Alfonso Soto-Gonzalez
- Servicio de Endocrinología y Nutrición de A Coruña, Hospital Universitario de A Coruña, A Coruña, Spain
| | | | - Diego Bellido Guerrero
- Servicio Endocrinología y Nutrición, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, Spain
| | | | - Daniel de Luis Román
- Servicio de Endocrinologia y Nutrición, HCUva, Centro Investigación Endocrinologia y Nutrición Uva, Valladolid, Spain
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Pilla SJ, Park J, Schwartz JL, Albert MC, Ephraim PL, Boulware LE, Mathioudakis NN, Maruthur NM, Beach MC, Greer RC. Hypoglycemia Communication in Primary Care Visits for Patients with Diabetes. J Gen Intern Med 2021; 36:1533-1542. [PMID: 33479925 PMCID: PMC8175615 DOI: 10.1007/s11606-020-06385-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 12/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hypoglycemia is a common and serious adverse effect of diabetes treatment, especially for patients using insulin or insulin secretagogues. Guidelines recommend that these patients be assessed for interval hypoglycemic events at each clinical encounter and be provided anticipatory guidance for hypoglycemia prevention. OBJECTIVE To determine the frequency and content of hypoglycemia communication in primary care visits. DESIGN Qualitative study PARTICIPANTS: We examined 83 primary care visits from one urban health practice representing 8 clinicians and 33 patients using insulin or insulin secretagogues. APPROACH Using a directed content analysis approach, we analyzed audio-recorded primary care visits collected as part of the Achieving Blood Pressure Control Together study, a randomized trial of behavioral interventions for hypertension. The coding framework included communication about interval hypoglycemia, defined as discussion of hypoglycemic events or symptoms; the components of hypoglycemia anticipatory guidance in diabetes guidelines; and hypoglycemia unawareness. Hypoglycemia documentation in visit notes was compared to visit transcripts. KEY RESULTS Communication about interval hypoglycemia occurred in 24% of visits, and hypoglycemic events were reported in 16%. Despite patients voicing fear of hypoglycemia, clinicians rarely assessed hypoglycemia frequency, severity, or its impact on quality of life. Hypoglycemia anticipatory guidance was provided in 21% of visits which focused on diet and behavior change; clinicians rarely counseled on hypoglycemia treatment or avoidance of driving. Limited discussions of hypoglycemia unawareness occurred in 8% of visits. Documentation in visit notes had low sensitivity but high specificity for ascertaining interval hypoglycemia communication or hypoglycemic events, compared to visit transcripts. CONCLUSIONS In this high hypoglycemia risk population, communication about interval hypoglycemia and counseling for hypoglycemia prevention occurred in a minority of visits. There is a need to support clinicians to more regularly assess their patients' hypoglycemia burden and enhance counseling practices in order to optimize hypoglycemia prevention in primary care.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA.
| | - Jenny Park
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica L Schwartz
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael C Albert
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Johns Hopkins University, Baltimore, MD, USA
| | - Patti L Ephraim
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - L Ebony Boulware
- Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Nestoras N Mathioudakis
- Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mary Catherine Beach
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Health, Behavior & Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Raquel C Greer
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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10
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Embracing new technology to overcome severe hypoglycaemia in a patient with visual impairment. PRACTICAL DIABETES 2021. [DOI: 10.1002/pdi.2331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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11
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Mujahid O, Contreras I, Vehi J. Machine Learning Techniques for Hypoglycemia Prediction: Trends and Challenges. SENSORS (BASEL, SWITZERLAND) 2021; 21:E546. [PMID: 33466659 PMCID: PMC7828835 DOI: 10.3390/s21020546] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
(1) Background: the use of machine learning techniques for the purpose of anticipating hypoglycemia has increased considerably in the past few years. Hypoglycemia is the drop in blood glucose below critical levels in diabetic patients. This may cause loss of cognitive ability, seizures, and in extreme cases, death. In almost half of all the severe cases, hypoglycemia arrives unannounced and is essentially asymptomatic. The inability of a diabetic patient to anticipate and intervene the occurrence of a hypoglycemic event often results in crisis. Hence, the prediction of hypoglycemia is a vital step in improving the life quality of a diabetic patient. The objective of this paper is to review work performed in the domain of hypoglycemia prediction by using machine learning and also to explore the latest trends and challenges that the researchers face in this area; (2) Methods: literature obtained from PubMed and Google Scholar was reviewed. Manuscripts from the last five years were searched for this purpose. A total of 903 papers were initially selected of which 57 papers were eventually shortlisted for detailed review; (3) Results: a thorough dissection of the shortlisted manuscripts provided an interesting split between the works based on two categories: hypoglycemia prediction and hypoglycemia detection. The entire review was carried out keeping this categorical distinction in perspective while providing a thorough overview of the machine learning approaches used to anticipate hypoglycemia, the type of training data, and the prediction horizon.
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Affiliation(s)
- Omer Mujahid
- Model Identification and Control Laboratory, Institut d’Informatica i Applicacions, Universitat de Girona, 17003 Girona, Spain; (O.M.); (I.C.)
| | - Ivan Contreras
- Model Identification and Control Laboratory, Institut d’Informatica i Applicacions, Universitat de Girona, 17003 Girona, Spain; (O.M.); (I.C.)
| | - Josep Vehi
- Model Identification and Control Laboratory, Institut d’Informatica i Applicacions, Universitat de Girona, 17003 Girona, Spain; (O.M.); (I.C.)
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), 17003 Girona, Spain
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12
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Executive summary: Position document: Evaluation and management of hypoglycemia in the patient with diabetes mellitus 2020. Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition. ACTA ACUST UNITED AC 2021; 68:270-276. [PMID: 33422450 DOI: 10.1016/j.endinu.2020.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/19/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To provide practical recommendations for the evaluation and management of hypoglycemia in patients with diabetes mellitus. PARTICIPANTS Members of the Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition (SEEN). METHODS The recommendations were made based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to establish both the strength of the recommendations and the level of evidence. A systematic search was made in MEDLINE (PubMed) for the available evidence on each subject, and articles written in English and Spanish with an inclusion date up to 28 February 2020 were reviewed. This executive summary takes account of the evidence incorporated since 2013. CONCLUSIONS The document establishes practical evidence-based recommendations regarding the evaluation and management of hypoglycemia in patients with diabetes mellitus.
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13
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Eik Filho W, Wanczinski Ferrari BJ, Masetto Antunes M, Batista Travassos P, Medri de Souza H, Menezes de Souza E, Barbosa Bazotte R. Glycerol Potentiates the Effects of Glucose in Promoting Glucose Recovery During Hypoglycemia: From Basic to Clinical Investigations and Their Therapeutic Application. J Med Food 2020; 24:908-915. [PMID: 33297841 DOI: 10.1089/jmf.2020.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We compared the effect of oral glucose versus oral glucose combined with glycerol (glucose + glycerol) in promoting glucose recovery during hypoglycemia. These studies were carried out in two series of experiments. In the first series of experiments, 16 overnight fasted rats received an intraperitoneal injection of lispro insulin (1 IU/kg), and 25 min later, they received oral water (control), glucose (0.25 g/kg), glycerol (2.5 g/kg), or glucose (0.25 g/kg) + glycerol (2.5 g/kg). In the second series of experiments on 164 eligible type 1 diabetic (T1D) patients, 30 individuals with a history of hypoglycemia were recruited. Five volunteers did not meet the inclusion criteria and two subjects were excluded after starting the clinical investigation; 23 patients concluded the study. All patients with symptoms of hypoglycemia ingested oral glucose (15 g) or glucose (15 g) + glycerol (9.45 g). To treat hypoglycemia in T1D patients, preparations containing glucose alone or glucose + glycerol were used alternately (2 weeks/2 weeks) in a double-blind crossover scheme. Throughout the clinical research (4 weeks), glucose concentrations were assessed with a continuous glucose monitoring device and the results after the use of glucose alone or glucose + glycerol preparations were compared. Oral glucose combined with glycerol was more effective in promoting glucose recovery in comparison with glucose alone, not only in rats but also in T1D patients. Taken together, our experimental and clinical investigations reported the best performance of oral administration of glucose + glycerol in comparison with isolated glucose.
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Affiliation(s)
- Wilson Eik Filho
- Department of Medicine, Endocrinology Unit, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Marina Masetto Antunes
- Post-Graduate Program in Pharmaceutical Sciences, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Helenir Medri de Souza
- Department of Physiological Sciences, State University of Londrina, Londrina, Paraná, Brazil
| | - Eniuce Menezes de Souza
- Post-Graduate Program in Biostatistics, State University of Maringá, Maringá, Paraná, Brazil
| | - Roberto Barbosa Bazotte
- Post-Graduate Program in Pharmaceutical Sciences, State University of Maringá, Maringá, Paraná, Brazil.,Post-Graduate Program in Biological Sciences, State University of Maringá, Maringá, Paraná, Brazil.,Department of Pharmacology and Therapeutics, State University of Maringá, Maringá, Paraná, Brazil
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14
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Malandrucco I, Russo B, Picconi F, Menduni M, Frontoni S. Glycemic Status Assessment by the Latest Glucose Monitoring Technologies. Int J Mol Sci 2020; 21:E8243. [PMID: 33153229 PMCID: PMC7663245 DOI: 10.3390/ijms21218243] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
The advanced and performing technologies of glucose monitoring systems provide a large amount of glucose data that needs to be properly read and interpreted by the diabetology team in order to make therapeutic decisions as close as possible to the patient's metabolic needs. For this purpose, new parameters have been developed, to allow a more integrated reading and interpretation of data by clinical professionals. The new challenge for the diabetes community consists of promoting an integrated and homogeneous reading, as well as interpretation of glucose monitoring data also by the patient himself. The purpose of this review is to offer an overview of the glycemic status assessment, opened by the current data management provided by latest glucose monitoring technologies. Furthermore, the applicability and personalization of the different glycemic monitoring devices used in specific insulin-treated diabetes mellitus patient populations will be evaluated.
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Affiliation(s)
- Ilaria Malandrucco
- Unit of Endocrinology, Diabetes and Metabolism, S. Giovanni Calibita, Fatebenefratelli Hospital, 00186 Rome, Italy; (I.M.); (B.R.); (F.P.)
| | - Benedetta Russo
- Unit of Endocrinology, Diabetes and Metabolism, S. Giovanni Calibita, Fatebenefratelli Hospital, 00186 Rome, Italy; (I.M.); (B.R.); (F.P.)
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Fabiana Picconi
- Unit of Endocrinology, Diabetes and Metabolism, S. Giovanni Calibita, Fatebenefratelli Hospital, 00186 Rome, Italy; (I.M.); (B.R.); (F.P.)
| | - Marika Menduni
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Simona Frontoni
- Unit of Endocrinology, Diabetes and Metabolism, S. Giovanni Calibita, Fatebenefratelli Hospital, 00186 Rome, Italy; (I.M.); (B.R.); (F.P.)
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
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15
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Kushner PR, Kruger DF. The Changing Landscape of Glycemic Targets: Focus on Continuous Glucose Monitoring. Clin Diabetes 2020; 38:348-356. [PMID: 33132504 PMCID: PMC7566931 DOI: 10.2337/cd19-0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Continuous glucose monitoring (CGM) provides comprehensive assessment of daily glucose measurements for patients with diabetes and can reveal high and low blood glucose values that may occur even when a patient's A1C is adequately controlled. Among the measures captured by CGM, the percentage of time in the target glycemic range, or "time in range" (typically 70-180 mg/dL), has emerged as one of the strongest indicators of good glycemic control. This review examines the shift to using CGM to assess glycemic control and guide diabetes treatment decisions, with a focus on time in range as the key metric of glycemic control.
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16
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Riddell MC, Scott SN, Fournier PA, Colberg SR, Gallen IW, Moser O, Stettler C, Yardley JE, Zaharieva DP, Adolfsson P, Bracken RM. The competitive athlete with type 1 diabetes. Diabetologia 2020; 63:1475-1490. [PMID: 32533229 PMCID: PMC7351823 DOI: 10.1007/s00125-020-05183-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022]
Abstract
Regular exercise is important for health, fitness and longevity in people living with type 1 diabetes, and many individuals seek to train and compete while living with the condition. Muscle, liver and glycogen metabolism can be normal in athletes with diabetes with good overall glucose management, and exercise performance can be facilitated by modifications to insulin dose and nutrition. However, maintaining normal glucose levels during training, travel and competition can be a major challenge for athletes living with type 1 diabetes. Some athletes have low-to-moderate levels of carbohydrate intake during training and rest days but tend to benefit, from both a glucose and performance perspective, from high rates of carbohydrate feeding during long-distance events. This review highlights the unique metabolic responses to various types of exercise in athletes living with type 1 diabetes. Graphical abstract.
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Affiliation(s)
- Michael C Riddell
- School of Kinesiology and Health Science, Faculty of Health, Muscle Health Research Centre and Physical Activity & Chronic Disease Unit, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada.
- LMC Diabetes & Endocrinology, Toronto, ON, Canada.
| | - Sam N Scott
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, University of Bern, Bern, Switzerland
- Team Novo Nordisk Professional Cycling Team, Atlanta, GA, USA
| | - Paul A Fournier
- School of Human Sciences, Division Sport Science, Exercise and Health, University of Western Australia, Crawley, WA, Australia
| | - Sheri R Colberg
- Human Movement Sciences Department, Old Dominion University, Norfolk, VA, USA
| | - Ian W Gallen
- Royal Berkshire NHS Foundation Trust Centre for Diabetes and Endocrinology, Royal Berkshire Hospital, Reading, UK
| | - Othmar Moser
- Cardiovascular Diabetology Research Group, Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Stettler
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jane E Yardley
- Augustana Faculty, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, Edmonton, AB, Canada
- Women's and Children's Health Research Institute, Edmonton, AB, Canada
| | - Dessi P Zaharieva
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter Adolfsson
- Department of Pediatrics, The Hospital of Halland, Kungsbacka, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Richard M Bracken
- Applied Sport, Technology, Exercise and Medicine Research Centre (A-STEM), Swansea University, A111 Engineering East, Fabian Way, Crymlyn Burrows, Swansea, SA1 8EN, UK.
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17
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Chen X, Chen S, Shen T, Yang W, Chen Q, Zhang P, You Y, Sun X, Xu H, Tang Y, Mi J, Yang Y, Ling W. Adropin regulates hepatic glucose production via PP2A/AMPK pathway in insulin-resistant hepatocytes. FASEB J 2020; 34:10056-10072. [PMID: 32579277 DOI: 10.1096/fj.202000115rr] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/08/2020] [Accepted: 05/09/2020] [Indexed: 11/11/2022]
Abstract
Adropin as a secretory peptide has shown a protective role on the disorders of glucose and lipid metabolism. However, the role and mechanism of this peptide on the hepatic glucose production has remained unclear. Adropin knockout (KO) mice were generated to explore its effects on the enhanced hepatic glucose production in obesity. We found that compared to wild-type (WT) mice, adropin-KO mice developed the unbalanced enhanced hepatic glucose production in advance of the whole-body insulin resistance (IR) by high-fat diet (HFD). Mechanistically, adropin dissociated CREB-CRTC2 and FoxO1-PGC1α complex and reduced their binding to the promoters of G6Pase and PEPCK to decrease glucose production in IR. However, these effects were not observed in insulin-sensitive hepatocytes. Furthermore, in IR hepatocytes, dampened AMPK signaling was re-activated by adropin treatment via inhibition of PP2A. To further authenticate AMPK role in vivo, we administrated HFD-fed mice with AAV8-CA AMPKα and found that AMPK activation functionally restored the aberrant glucose production and IR induced by adropin-deficiency. This study provides evidence that adropin activates the AMPK pathway via inhibition of PP2A and decreases the liver glucose production in IR context. Therefore, adropin may represent a novel target for the prevention and treatment of diabetes.
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Affiliation(s)
- Xu Chen
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China
| | - Shen Chen
- Department of Toxicology, School of Public Health, Sun Yat-sen University, Guangzhou, PR China
| | - Tianran Shen
- Department of Nutrition, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, PR China
| | - Wenqi Yang
- Laboratory Center for Sport Science and Medicine, Guangzhou Institute of Physical Education, Guangzhou, PR China
| | - Qian Chen
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China.,Department of Cardiology, Sun Yat-sen Memorial Hospital, Guangzhou, PR China
| | - Peiwen Zhang
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China
| | - Yiran You
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China
| | - Xiaoyuan Sun
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China
| | - Huihui Xu
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China
| | - Yi Tang
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China
| | - Jiaxin Mi
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China
| | - Yan Yang
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China.,School of Public Health (Shenzhen), Sun Yat-sen University, Guangzhou, PR China
| | - Wenhua Ling
- Department of Nutrition, School of Public Health, Sun Yat-sen University, Guangzhou, PR China.,Guangdong Provincial Key Laboratory of Food, Nutrition and Health, Guangzhou, PR China
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18
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Pontiroli AE, Tagliabue E. Therapeutic Use of Intranasal Glucagon: Resolution of Hypoglycemia. Int J Mol Sci 2019; 20:E3646. [PMID: 31349701 PMCID: PMC6695717 DOI: 10.3390/ijms20153646] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 02/06/2023] Open
Abstract
Episodes of hypoglycemia are frequent in patients with diabetes treated with insulin or sulphonylureas. Hypoglycemia can lead to severe acute complications, and, as such, both prevention and treatment of hypoglycemia are important for the well-being of patients with diabetes. The experience of hypoglycemia also leads to fear of hypoglycemia, that in turn can limit optimal glycemic control in patients, especially with type 1 diabetes. Treatment of hypoglycemia is still based on administration of carbohydrates (oral or parenteral according to the level of consciousness) or of glucagon (intramuscular or subcutaneous injection). In 1983, it was shown for the first time that intranasal (IN) glucagon drops (with sodium glycocholate as a promoter) increase blood glucose levels in healthy volunteers. During the following decade, several authors showed the efficacy of IN glucagon (drops, powders, and sprays) to resolve hypoglycemia in normal volunteers and in patients with diabetes, both adults and children. Only in 2010, based on evaluation of patients' beliefs and patients' expectations, a canadian pharmaceutical company (Locemia Solutions, Montreal, Canada) reinitiated efforts to develop glucagon for IN administration. The project has been continued by Eli Lilly, that is seeking to obtain registration in order to make IN glucagon available to insulin users (children and adolescents) worldwide. IN glucagon is as effective as injectable glucagon, and devoid of most of the technical difficulties associated with administration of injectable glucagon. IN glucagon appears to represent a major breakthrough in the treatment of severe hypoglycemia in insulin-treated patients with diabetes, both children and adults.
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Affiliation(s)
- Antonio E Pontiroli
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Ospedale San Paolo, Via Antonio di Rudinì 8, 20142 Milan, Italy.
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19
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Demir G, Özen S, Çetin H, Darcan Ş, Gökşen D. Effect of Education on Impaired Hypoglycemia Awareness and Glycemic Variability in Children and Adolescents with Type 1 Diabetes Mellitus. J Clin Res Pediatr Endocrinol 2019; 11:189-195. [PMID: 30701953 PMCID: PMC6571530 DOI: 10.4274/jcrpe.galenos.2019.2019.0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine the prevalence of impaired hypoglycemia awareness (IHA) in children and adolescents with type 1 diabetes mellitus using a professional continuous glucose monitoring (CGM) system and to show the effect of structured education on glycemic variability (GV) in children and adolescents with IHA. METHODS Forty type 1 diabetic children and adolescents with a diabetes duration of at least five years were eligible for inclusion in this prospective, quantitative study. All subjects were asked about their history of being aware of the symptoms of hypoglycemia using a questionnaire. Professional CGM was conducted in all of the patients for six days. The frequency of IHA detected by comparison of CGM and logbook reports were analyzed. Patients with identified IHA underwent a structured training program. After three months, CGM was re-applied to patients with IHA. RESULTS The study was completed by 37 diabetic children and adolescents. After the initial CGM, nine patients (24.3%) were found to have had episodes of IHA. Area under the curve (AUC) for hypoglycemia and number of low excursions were; 1.81±0.95 and 8.33±3.60 for the IHA group at the beginning of the study. AUC for hypoglycemia was 0.43±0.47 after three months of structured education the IHA patients (p=0.01). Coefficient of variation which shows primary GV decreased significantly although unstable at the end of education in IHA patients (p=0.03). CONCLUSION CGM is a valuable tool to diagnose IHA. IHA, GV and time in range can be improved by education-based intervention.
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Affiliation(s)
- Günay Demir
- Ege University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, İzmir, Turkey
| | - Samim Özen
- Ege University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, İzmir, Turkey,* Address for Correspondence: Ege University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, İzmir, Turkey Phone: +90 232 390 12 30 E-mail:
| | - Hafize Çetin
- Ege University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, İzmir, Turkey
| | - Şükran Darcan
- Ege University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, İzmir, Turkey
| | - Damla Gökşen
- Ege University Faculty of Medicine, Department of Pediatric Endocrinology and Diabetes, İzmir, Turkey
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20
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Lucidi P, Porcellati F, Bolli GB, Fanelli CG. Real-time continuous glucose monitoring decreases the risk of severe hypoglycemia in people with type 1 diabetes and impaired awareness of hypoglycemia. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:S97. [PMID: 30740418 DOI: 10.21037/atm.2018.11.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Paola Lucidi
- Department of Medicine, Section of Endocrinology & Metabolism, Perugia University School of Medicine, Perugia, Italy
| | - Francesca Porcellati
- Department of Medicine, Section of Endocrinology & Metabolism, Perugia University School of Medicine, Perugia, Italy
| | - Geremia B Bolli
- Department of Medicine, Section of Endocrinology & Metabolism, Perugia University School of Medicine, Perugia, Italy
| | - Carmine G Fanelli
- Department of Medicine, Section of Endocrinology & Metabolism, Perugia University School of Medicine, Perugia, Italy
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