Psychoactive drugs, alcohol, and severe hypoglycemia in insulin-treated diabetes: analysis of 141 cases

Risk factors for hypoglycaemia in people with diabetes admitted to the Emergency Department of a Hospital in French Guiana

AIMS/INTRODUCTION

Strict management of glucose levels in elderly people with diabetes or with comorbidities exposes them to the risk of severe hypoglycaemia (capillary or venous glucose ≤3.3 mmol/L) and the associated morbidity and mortality. We aimed to describe the clinical, laboratory, and epidemiological characteristics of people with diabetes admitted to the Emergency Department in Cayenne, French Guiana for severe hypoglycaemia and identify avoidable behaviours in this population.

MATERIALS AND METHODS

An observational epidemiological study of adults with diabetes who presented to the Emergency Department with severe hypoglycaemia was conducted between 2015 and 2018. Their medical history, clinical and laboratory data were collected. The primary outcome was the association between therapeutic misuse and age ≥65 years.

RESULTS

Overall, 178 admissions were analysed. The main cause of hypoglycaemia was insulin dosing-error or inappropriate glycaemic targets. Among those ≥65 years, 59% had a glycated haemoglobin ≤48 mmol/mol (6.5%), and the median duration of their diabetes was 20 years. Among them, 60% were treated with sulfonylurea, repaglinide, biphasic insulin, or mixed drugs, and 48% were on non-diabetes related treatments that had a hypoglycaemic effect. Furthermore, 23% of the elderly treated with oral antidiabetics had chronic kidney disease.

CONCLUSION

Many avoidable risk factors for severe hypoglycaemia have been highlighted, in particular insulin dosing errors or non-compliance with recommendations for participants ≥ 65 years. Primary care physicians and homecare nurses need to provide preventive interventions and undergo training.

Glucagon for hypoglycaemia treatment in type 1 diabetes

To achieve strict glycaemic control and avoid chronic diabetes complications, individuals with type 1 diabetes (T1D) are recommended to follow an intensive insulin regimen. However, the risk and fear of hypoglycaemia often prevent individuals from achieving the treatment goals. Apart from early insulin suspension in insulin pump users, carbohydrate ingestion is the only option for preventing and treating non-severe hypoglycaemic events. These rescue treatments may give extra calories and cause overweight. As an alternative, the use of low-dose glucagon to counter hypoglycaemia has been proposed as a tool to raise glucose concentrations without adding extra calories. Previously, the commercially available glucagon formulations required reconstitution from powder to a solution before being injected subcutaneously or intramuscularly-making it practical only for treating severe hypoglycaemia. Several companies have developed more stable formulations that do not require the time-consuming reconstitution process before use. As well as treating severe hypoglycaemia, non-severe and impending hypoglycaemia can also be treated with lower doses of glucagon. Once available, low-dose glucagon can be either delivered manually, as an injection, or automatically, by an infusion pump. This review focuses on the role and perspectives of using glucagon to treat and prevent hypoglycaemia in T1D.

Alcohol Use and Clinical Outcomes in Adults in the Type 1 Diabetes Exchange

OBJECTIVES

Alcohol consumption has serious potential consequences for persons with type 1 diabetes. This cross-sectional study examined associations between drinking status and diabetes-related outcomes.

METHODS

Participants included 934 adults at Type 1 Diabetes Exchange Registry clinics who responded to an e-mail invitation to complete an electronic survey with items on alcohol consumption; glycated hemoglobin (A1C) and body mass index (BMI) were extracted from medical charts. Participants were an average 38±16 years of age, 61% were women and 90% were non-Hispanic white; A1C was 7.8%±1.5%. The sample was made up of 11% (n=103) never drinkers, 9% (n=89) former drinkers, 61% (n=567) current (past year) nonbinge drinkers and 19% (n=174) current binge drinkers.

RESULTS

After controlling for covariates, diabetes distress was lower among never drinkers compared with former and nonbinge drinkers (p<0.009). Never drinkers compared with former drinkers had lower odds of past-year severe hypoglycemia (p=0.001) and lower odds of a neuropathy diagnoses (p=0.006). There were omnibus model trends toward associations between drinking status and diabetes self-care (p=0.10) and between drinking status and BMI (p=0.06). Never drinkers did not differ from other groups on daily frequency of blood glucose self-monitoring, A1C or past-year diabetic ketoacidosis (p>0.05).

CONCLUSIONS

These results suggest complex relationships between drinking and diabetes-related distress, and that recent severe hypoglycemia and the presence of neuropathy may motivate some to stop drinking. Prospective studies may improve understanding of these findings.

The Probability of A1C Goal Attainment in Patients With Uncontrolled Type 2 Diabetes in a Large Integrated Delivery System: A Prediction Model

OBJECTIVE

To assess patient characteristics and treatment factors associated with uncontrolled type 2 diabetes (T2D) and the probability of hemoglobin A_1c (A1C) goal attainment.

RESEARCH DESIGN AND METHODS

This was a retrospective cohort study using the electronic health record at Cleveland Clinic. Patients with uncontrolled T2D (A1C >9%) were identified on the index date of 31 December 2016 (n = 6,973) and grouped by attainment (n = 1,653 [23.7%]) or nonattainment (n = 5,320 [76.3%]) of A1C <8% by 31 December 2017, and subgroups were compared on a number of demographic and clinical variables. On the basis of these variables, a nomogram was created for predicting probability of A1C goal attainment.

RESULTS

For the entire population, median age at index date was 57.7 years (53.3% male), and the majority were white (67.2%). Median A1C was 10.2%. Obesity (50.6%), cardiovascular disease (46.9%), and psychiatric disease (61.1%) were the most common comorbidities. Metformin (62.7%) and sulfonylureas (38.7%) were the most common antidiabetes medications. Only 1,653 (23.7%) patients achieved an A1C <8%. Predictors of increased probability of A1C goal attainment were older age, white/non-Hispanic race/ethnicity, Medicare health insurance, lower baseline A1C, higher frequency of endocrinology/primary care visits, dipeptidyl peptidase 4 inhibitor use, thiazolidinedione use, metformin use, glucagon-like peptide 1 receptor agonist use, and fewer classes of antidiabetes drugs. Factors associated with lower probability included insulin use and longer time in the T2D database (both presumed as likely surrogates for duration of T2D).

CONCLUSIONS

A minority of patients with an A1C >9% achieved an A1C <8% at 1 year. While most identified predictive factors are nonmodifiable by the clinician, pursuit of frequent patient engagement and tailored drug regimens may help to improve A1C goal attainment.

Hypoglycemia in Older Patients

Hypoglycemia is a serious problem in older patients with diabetes mellitus. This chapter discusses risk factors associated with hypoglycemia and approaches to mitigation of the risk for hypoglycemia. Specific considerations include selection of glucose lowering agents, comorbid conditions and the implications of declining cognitive dysfunction.

Alcohol and illicit drug use in people with diabetes

As the prevalence of type 1 and type 2 diabetes increases and population-level patterns of alcohol and illicit drug use evolve, clinicians will continue to encounter people with diabetes whose substance use is affecting health outcomes. Substance use contributes substantially to the population-level prevalence of cardiovascular events, cerebrovascular events, cancers, mental health conditions, road trauma, and domestic violence. Alcohol and drug use also have a measurable effect on diabetes incidence and the development of both acute and chronic diabetes-related complications. In this Review, we examine the effect of alcohol and illicit drug use on people with type 1 or type 2 diabetes. We describe evidence for substance use as a risk factor for new-onset diabetes, prevalence of use in people with diabetes, evidence linking substance use with diabetes-related health outcomes, and evidence on the management of these co-occurring conditions.

Effects of Preceding Ethanol Intake on Glucose Response to Low-Dose Glucagon in Individuals With Type 1 Diabetes: A Randomized, Placebo-Controlled, Crossover Study

OBJECTIVE

This study investigated whether preceding ethanol intake impairs glucose response to low-dose glucagon in individuals with type 1 diabetes.

RESEARCH DESIGN AND METHODS

This was a randomized, crossover, placebo-controlled study in 12 insulin pump-treated individuals (median [interquartile range] age, 37 [31-51] years; HbA_1c, 57 [51-59] mmol/mol or 7.3% [6.8-7.5]; and BMI, 23.9 [22-25] kg/m²). During two overnight study visits, a 6 p.m. dinner (1 g carbohydrates/kg) was served with diet drink (placebo) or diet drink and ethanol (0.8 g/kg). After 8-9 h, ethanol was estimated to be metabolized, and a subcutaneous (s.c.) insulin bolus was given to induce mild hypoglycemia. When plasma glucose (PG) was ≤3.9 mmol/L, 100 µg glucagon was given s.c., followed by another s.c. 100 µg glucagon 2 h later. Primary end point was incremental peak PG induced by the first glucagon bolus.

RESULTS

Ethanol was undetectable before insulin administration at both visits. The insulin doses (mean ± SEM: 2.5 ± 0.4 vs. 2.7 ± 0.4 IU) to induce hypoglycemia (3.7 ± 0.1 vs. 3.9 ± 0.1 mmol/L) did not differ and caused similar insulin levels (28.3 ± 4.6 vs. 26.1 ± 4.0 mU/L) before glucagon administration on ethanol and placebo visits (all, P > 0.05). The first glucagon bolus tended to cause lower incremental peak PG (2.0 ± 0.5 vs. 2.9 ± 0.3 mmol/L, P = 0.06), lower incremental area under the curve (87 ± 40 vs. 191 ± 37 mmol/L × min, P = 0.08), and lower 2-h PG level (3.6 ± 1.0 vs. 4.8 ± 0.4 mmol/L, P = 0.05) after ethanol compared with placebo. The second glucagon bolus had similar responses between visits, but PG remained 1.8 ± 0.7 mmol/L lower after ethanol compared with placebo.

CONCLUSIONS

The ability of low-dose glucagon to treat mild hypoglycemia persisted with preceding ethanol intake, although it tended to be attenuated.

Effects of alcohol on plasma glucose and prevention of alcohol-induced hypoglycemia in type 1 diabetes-A systematic review with GRADE

Because ethanol is thought to be a risk factor for severe hypoglycemia, patients with type 1 diabetes (T1D) are recommended to limit ethanol intake. However, little is known on how ethanol affects plasma glucose and how ethanol-induced hypoglycemia can be prevented. In this study, we systematically reviewed the literature for ethanol effects on plasma glucose and for prevention strategies on ethanol-induced hypoglycemia. Electronic searches on PubMed and Google were conducted in February 2017. Randomized clinical trials and observational studies were included. Studies involved patients with T1D with no history of ethanol abuse. The primary aims were changes in plasma glucose after ethanol intake and prevention strategies for ethanol-induced hypoglycemia. Quality of the studies was assessed by GRADE. Additionally, we searched for guidelines from diabetes associations on their suggested prevention strategies. We included 13 studies. Eight studies reported that ethanol, regardless of administration intravenously or orally, were associated with an increased risk of hypoglycemia due to decrease in plasma glucose, impaired counter-regulatory response, awareness of hypoglycemia, and cognitive function. Five studies did not report an increased risk of hypoglycemia. None of the studies investigated prevention strategies for ethanol-induced hypoglycemia. Recommendations from 13 diabetes associations were included. All associations recommend that ethanol should only be consumed with food intake. The majority of included studies showed that ethanol intake increased the risk of hypoglycemia in patients with T1D. However, the evidence for how to prevent ethanol-induced hypoglycemia is sparse, and further investigations are needed to establish evidence-based recommendations.

Alcohol and recreational drug use in young adults with type 1 diabetes

Alcohol and other recreational drug use reaches peak prevalence in young adulthood, including for those with chronic medical conditions such as type 1 diabetes. This review summarises the current literature on the patterns of substance use amongst young adults with type 1 diabetes and the mechanisms through which alcohol and recreational drugs may affect diabetes related health outcomes. These include the direct physical effect of intoxication, as well as the effects of alcohol and drugs on mental health and glucose metabolism. Evidence for increased associated mortality and morbidity is also presented, and current guidelines, management strategies and directions for further research are discussed.

Alcohol Toxicity in Diabetes and Its Complications: A Double Trouble?

BACKGROUND

Eight percent of the U.S. population has been diagnosed with diabetes mellitus (DM), while another large percentage has gone undiagnosed. As the epidemiology of this disease constitutes a larger percentage of the American population, another factor presents a dangerous dilemma that can exacerbate the hazardous effects imposed by DM. Excessive alcohol consumption concerns the health of more than 50% of all adults. When this heavy-alcohol-drinking population overlaps with DM and its complications, the effects can be dangerous. In this review, we term it as "double trouble."

METHODS

We provide evidence of alcohol-induced exacerbation of organ damage in diabetic conditions. In certain cases, we have explained how diabetes and alcohol induce similar pathological effects.

RESULTS

Known exacerbated complications include those related to heart diseases, liver damage, kidney dysfunction, as well as retinal and neurological impairment. Often, pathophysiological damage concludes with end-stage disorders and even mortality. The metabolic, cell signaling, and pathophysiological changes associated with "double trouble" would lead to the identification of novel therapeutic targets.

CONCLUSIONS

This review summarizes the epidemiology, diagnosis, pathophysiology, metabolic, and cell signaling alterations and finally brushes upon issues and strategies to manage the "double trouble."

Alcohol use of diabetes patients: the need for assessment and intervention

It is well known that diabetes self-care behaviors are critical to disease progression. Unfortunately, many patients do not adhere to diabetes self-care recommendations despite their importance. Alcohol use has been identified as a barrier to diabetes self-care adherence. Excessive alcohol consumption not only negatively impacts diabetes self-care adherence but also affects the course of diabetes. Diabetes patients who are at-risk drinkers are likely to have poor diabetes treatment adherence, leading to increased morbidity and mortality. Alcohol consumption by diabetes patients is often inadequately assessed and addressed in their medical care. Brief interventions to reduce at-risk drinking have been well validated in a variety of patient populations and offer the potential to improve diabetes treatment adherence and outcome. Assessment and treatment of at-risk drinking could be readily incorporated into routine diabetes care. Strategies for brief assessment of and intervention for at-risk drinking are offered.

Angiotensin-converting enzyme and angiotensin II receptor subtype 2 genotypes in type 1 diabetes and severe hypoglycaemia requiring emergency treatment: a case cohort study

AIMS

In type 1 diabetes, individual susceptibility to severe hypoglycaemia is likely to be influenced by genetic factors. We have previously reported an association of the deletion (D-) allele of the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism and the A-allele of the angiotensin II receptor subtype 2 (AT2R) 1675 G>A polymorphism with risk of severe hypoglycaemia in such patients. The aim of this study was to test the hypothesis that these alleles are more frequent in patients suffering from the most severe episodes of hypoglycaemia requiring medical emergency treatment.

METHODS

The case cohort study consisted of 108 cases of type 1 diabetic patients with severe hypoglycaemia requiring medical emergency treatment during a 1-year period and 262 consecutive controls without such events. ACE I/D and AT2R 1675G>A genotype distributions were compared between cases and controls.

RESULTS

The proportion of D-allele carriers was higher amongst cases than controls (83 vs. 73%; P=0.032). In contrast, AT2R genotype distribution was similar in cases and controls. In a multiple regression analysis, D-allele carriage remained a significant risk factor for being a case [odds ratio: 1.9 (1.0-3.6)] together with male sex, impaired symptomatic awareness of hypoglycaemia and presence of nephropathy.

CONCLUSION

The D-allele of the ACE gene is associated with severe hypoglycaemia requiring emergency treatment in type 1 diabetic patients with preserved spontaneous ACE activity. This supports the association between high ACE activity and occurrence of severe hypoglycaemia.

At-risk drinking among diabetic patients

Diabetes Mellitus is a serious chronic disease, affecting an increasing number of individuals worldwide. Adherence to diabetes self-care behaviors is key to the successful management of the disease. At-risk drinking is common among diabetic patients and is associated with inferior diabetes treatment adherence and outcomes, resulting in increased mortality and morbidity. Furthermore, individuals with diabetes who engage in at-risk drinking are also in danger of incurring the negative consequences of at-risk drinking found in the general population. Research suggests that alcohol use screening and intervention do not commonly occur during the course of primary care treatment for diabetes. While methods for reducing alcohol use in this population have been largely unexplored to date, brief interventions to reduce at-risk drinking have been well-validated in other patient populations and offer the promise to reduce at-risk drinking among diabetic patients, resulting in improved diabetes treatment adherence and outcomes.

Emergencies in Diabetic Patients in the Primary Care Setting

The diabetic patient poses special problems in the primary care setting. Symptoms that are relatively unimpressive on initial presentation, such as polyuria or dizziness, may actually be the beginning of serious medical complications. With careful evaluation and follow-up, some patients, such as those who have mild hypo- and hyperglycemia and certain infections, can be managed as an outpatients; however, many cardiovascular conditions, such as cardiac ischemia or limb-threatening peripheral vascular disease, require immediate transfer to an acute care facility. In all situations, close monitoring of glucose levels during all phases of care--in the office, in the hospital and at home--is essential to achieving target glycemic control and rapid detection of clinical conditions that often first manifest as alterations in glycemic control.