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Torres Roldan VD, Urtecho M, Nayfeh T, Firwana M, Muthusamy K, Hasan B, Abd-Rabu R, Maraboto A, Qoubaitary A, Prokop L, Lieb DC, McCall AL, Wang Z, Murad MH. A Systematic Review Supporting the Endocrine Society Guidelines: Management of Diabetes and High Risk of Hypoglycemia. J Clin Endocrinol Metab 2023; 108:592-603. [PMID: 36477885 DOI: 10.1210/clinem/dgac601] [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: 10/08/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Interventions targeting hypoglycemia in people with diabetes are important for improving quality of life and reducing morbidity and mortality. OBJECTIVE To support development of the Endocrine Society Clinical Practice Guideline for management of individuals with diabetes at high risk for hypoglycemia. METHODS We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence. RESULTS We included 149 studies reporting on 43 344 patients. Continuous glucose monitoring (CGM) reduced episodes of severe hypoglycemia in patients with type 1 diabetes (T1D) and reduced the proportion of patients with hypoglycemia (blood glucose [BG] levels <54 mg/dL). There were no data on use of real-time CGM with algorithm-driven insulin pumps vs multiple daily injections with BG testing in people with T1D. CGM in outpatients with type 2 diabetes taking insulin and/or sulfonylureas reduced time spent with BG levels under 70 mg/dL. Initiation of CGM in hospitalized patients at high risk for hypoglycemia reduced episodes of hypoglycemia with BG levels lower than 54 mg/dL and time spent under 54 mg/dL. The proportion of patients with hypoglycemia with BG levels lower than 70 mg/dL and lower than 54 mg/dL detected by CGM was significantly higher than point-of-care BG testing. We found no data evaluating continuation of personal CGM in the hospital. Use of an inpatient computerized glycemic management program utilizing electronic health record data was associated with fewer patients with and episodes of hypoglycemia with BG levels lower than 70 mg/dL and fewer patients with severe hypoglycemia compared with standard care. Long-acting basal insulin analogs were associated with less hypoglycemia. Rapid-acting insulin analogs were associated with reduced severe hypoglycemia, though there were more patients with mild to moderate hypoglycemia. Structured diabetes education programs reduced episodes of severe hypoglycemia and time below 54 mg/dL in outpatients taking insulin. Glucagon formulations not requiring reconstitution were associated with longer times to recovery from hypoglycemia, although the proportion of patients who recovered completely from hypoglycemia was not different between the 2 groups. CONCLUSION This systematic review summarized the best available evidence about several interventions addressing hypoglycemia in people with diabetes. This evidence base will facilitate development of clinical practice guidelines by the Endocrine Society.
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Affiliation(s)
| | - Meritxell Urtecho
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Mohammed Firwana
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | | | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Rami Abd-Rabu
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Andrea Maraboto
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Amjad Qoubaitary
- College of Arts and Science, University of San Francisco, San Francisco, CA 94117, USA
| | - Larry Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN 55902, USA
| | - David C Lieb
- Division of Endocrine and Metabolic Disorders, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23501-1980, USA
| | - Anthony L McCall
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
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2
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Brøsen JMB, Agesen RM, Kristensen PL, Alibegovic AC, Andersen HU, Beck-Nielsen H, Gustenhoff P, Hansen TK, Hedetoft C, Jensen T, Stolberg CR, Juhl CB, Lerche SS, Nørgaard K, Parving HH, Tarnow L, Thorsteinsson B, Pedersen-Bjergaard U. Effect of insulin degludec versus insulin glargine U100 on nocturnal glycaemia assessed by plasma glucose profiles in people with type 1 diabetes prone to nocturnal severe hypoglycaemia. Diabetes Obes Metab 2023; 25:1557-1565. [PMID: 36749303 DOI: 10.1111/dom.15003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
AIM To compare nocturnal glucose profiles according to hourly plasma glucose measurements during treatment with insulin degludec and insulin glargine U100 in a cohort of people with type 1 diabetes prone to nocturnal severe hypoglycaemia. MATERIALS AND METHODS The HypoDeg trial is a 2-year investigator-initiated, randomized, controlled crossover trial in 149 participants randomized to treatment with insulin degludec and insulin glargine U100 for 12 months each. The 51 participants in this predefined substudy stayed at least one night in hospital during each treatment arm for plasma glucose samples to be taken. Endpoints were glucose profiles, including mean plasma glucose, glycaemic variability and risk of hypoglycaemia. RESULTS There were no differences between treatments regarding mean plasma glucose. We saw a flatter glucose profile during insulin degludec compared with insulin glargine U100 treatment, which had a nadir at 4:00 AM, with a subsequent rise. During treatment with insulin degludec, the participants had lower glycaemic variability, with an estimated treatment difference of -4.3% (95% confidence interval [CI] -8.1 to -0.5; P < 0.05). Participants treated with insulin degludec were less likely to experience nocturnal hypoglycaemia below 3.0 mmol/L (hazard ratio 0.36 [95% CI 0.17-0.73; P < 0.05]). CONCLUSION Based on nocturnal plasma glucose measurements, treatment with insulin degludec compared with insulin glargine U100 administered in the evening results in lower glycaemic variability and lower risk of nocturnal hypoglycaemia without differences in mean plasma glucose.
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Affiliation(s)
- Julie Maria Bøggild Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rikke Mette Agesen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lommer Kristensen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Henrik Ullits Andersen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Henning Beck-Nielsen
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Faculty of Health and Sciences, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | - Troels Krarup Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus, Denmark
| | | | - Tonny Jensen
- Department of Medical Endocrinology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Røn Stolberg
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Faculty of Health and Sciences, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, University Hospital South West Jutland, Esbjerg, Denmark
| | - Claus Bogh Juhl
- Faculty of Health and Sciences, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, University Hospital South West Jutland, Esbjerg, Denmark
- Steno Diabetes Center Odense, Odense, Denmark
| | - Susanne Søgaard Lerche
- Department of Diabetes and Hormonal Diseases, Lillebaelt Hospital Kolding, Kolding, Denmark
| | - Kirsten Nørgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Endocrinology, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Hans-Henrik Parving
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Medical Endocrinology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Lise Tarnow
- Steno Diabetes Center Sjaelland, Holbaek, Denmark
- Department of Clinical Research, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
| | - Birger Thorsteinsson
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-Nordsjaelland, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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3
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Lechleitner M, Kaser S, Hoppichler F, Roden M, Weitgasser R, Ludvik B, Fasching P, Winhofer Y, Kautzky-Willer A, Schernthaner G, Prager R, Wascher TC, Clodi M. [Diagnosis and insulin therapy of type 1 diabetes mellitus (Update 2023)]. Wien Klin Wochenschr 2023; 135:98-105. [PMID: 37101030 PMCID: PMC10133075 DOI: 10.1007/s00508-023-02182-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/28/2023]
Abstract
This guideline summarizes diagnosis of type 1 diabetes, including accompanying autoimmune disorders, insulin therapy regimens and glycemic target values.
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Affiliation(s)
- Monika Lechleitner
- Avomed - Arbeitskreis für Vorsorgemedizin zbd Gesundheitsförderung in Tirol, Innsbruck, Österreich
| | - Susanne Kaser
- Department für Innere Medizin 1, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Friedrich Hoppichler
- Abteilung für Innere Medizin, Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Österreich
| | - Michael Roden
- Klinik für Endokrinologie und Diabetologie, Medizinische Fakultät, Heinrich-Heine-Universität, Düsseldorf, Deutschland
- Institut für Klinische Diabetologie, Deutsches Diabetes-Zentrum (DDZ), Leibniz-Zentrum für Diabetesforschung, Düsseldorf, Deutschland
- Deutsches Zentrum für Diabetesforschung (DZD e. V.), München-Neuherberg, Deutschland
| | - Raimund Weitgasser
- Abteilung für Innere Medizin, Privatklinik Wehrle-Diakonissen, Salzburg, Österreich
- Universitätsklinik für Innere Medizin I, LKH Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Bernhard Ludvik
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Peter Fasching
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Wilhelminenspital der Stadt Wien, Wien, Österreich
| | - Yvonne Winhofer
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Alexandra Kautzky-Willer
- Gender Medicine Unit, Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Guntram Schernthaner
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Department für Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - Rudolf Prager
- 3. Medizinische Abteilung mit Stoffwechselerkrankungen und Nephrologie, Krankenhaus Hietzing, Wien, Österreich
- Karl Landsteiner Institut für Stoffwechselerkrankungen und Nephrologie, Wien, Österreich
| | - Thomas C Wascher
- 1. Medizinische Abteilung, Hanusch-Krankenhaus, Wien, Österreich
| | - Martin Clodi
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
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Brøsen JMB, Agesen RM, Alibegovic AC, Ullits Andersen H, Beck-Nielsen H, Gustenhoff P, Krarup Hansen T, Hedetoft CGR, Jensen TJ, Stolberg CR, Bogh Juhl C, Lerche SS, Nørgaard K, Parving HH, Tarnow L, Thorsteinsson B, Pedersen-Bjergaard U. Continuous Glucose Monitoring-Recorded Hypoglycemia with Insulin Degludec or Insulin Glargine U100 in People with Type 1 Diabetes Prone to Nocturnal Severe Hypoglycemia. Diabetes Technol Ther 2022; 24:643-654. [PMID: 35467938 DOI: 10.1089/dia.2021.0567] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background and Aims: Nocturnal hypoglycemia is mainly a consequence of inappropriate basal insulin therapy in type 1 diabetes (T1D) and may compromise optimal glycemic control. Insulin degludec is associated with a lower risk of nocturnal hypoglycemia in T1D. As nocturnal hypoglycemia is often asymptomatic, we applied continuous glucose monitoring (CGM) to detect a more precise occurrence of nocturnal hypoglycemia in the HypoDeg trial, comparing insulin degludec with insulin glargine U100 in people with T1D and previous nocturnal severe hypoglycemia. Materials and Methods: In the HypoDeg trial, 149 people with T1D were included in an open-label randomized cross-over trial. Sixty-seven participants accepted optional participation in the predefined substudy of 4 × 6 days of blinded CGM requiring completion of at least one CGM period in each treatment arm. CGM data were reviewed for hypoglycemic events. Results: Treatment with insulin degludec resulted in a relative rate reduction (RRR) of 36% (95% confidence interval [CI]: 10%-54%; P < 0.05) in nocturnal CGM-recorded hypoglycemia (≤3.9 mmol/L), corresponding to an absolute rate reduction (ARR) of 0.85 events per person-week. In nocturnal CGM-recorded hypoglycemia (≤3.0 mmol/L), we found an RRR of 53% (95% CI: 36%-65%; P < 0.001), corresponding to an ARR of 0.75 events per person-week. At the lower detection limit of the CGM (≤2.2 mmol/L), treatment with insulin degludec resulted in a significant RRR of 58% (95% CI: 23%-77%; P = 0.005). The reductions were primarily due to significant RRRs in asymptomatic hypoglycemia. Conclusion: In people with T1D, prone to nocturnal severe hypoglycemia, insulin degludec compared with insulin glargine U100 significantly reduces nocturnal CGM-recorded hypoglycemia. www.clinicaltrials.gov (#NCT02192450).
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Affiliation(s)
- Julie Maria Bøggild Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical & Sciences, University of Copenhagen, Denmark
| | - Rikke Mette Agesen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical & Sciences, University of Copenhagen, Denmark
- Department of Medical & Science, Novo Nordisk A/S, Søborg, Denmark
| | - Amra Ciric Alibegovic
- Department of Medical & Science, Novo Nordisk A/S, Søborg, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Henrik Ullits Andersen
- Department of Clinical Medicine, Faculty of Health and Medical & Sciences, University of Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Henning Beck-Nielsen
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, Faculty of Health and Sciences, University of Southern Denmark, Odense, Denmark
| | | | - Troels Krarup Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus, Denmark
| | | | - Tonny Joran Jensen
- Department of Clinical Medicine, Faculty of Health and Medical & Sciences, University of Copenhagen, Denmark
- Department of Medical Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Røn Stolberg
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Department of Medicine, University Hospital South West Jutland, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Claus Bogh Juhl
- Department of Medicine, University Hospital South West Jutland, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Odense, Odense, Denmark
| | | | - Kirsten Nørgaard
- Department of Clinical Medicine, Faculty of Health and Medical & Sciences, University of Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Endocrinology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Hans-Henrik Parving
- Department of Clinical Medicine, Faculty of Health and Medical & Sciences, University of Copenhagen, Denmark
- Department of Medical Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lise Tarnow
- Department of Clinical Research, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Steno Diabetes Center Zealand, Holbæk, Denmark
| | - Birger Thorsteinsson
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical & Sciences, University of Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical & Sciences, University of Copenhagen, Denmark
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5
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Pedersen‐Bjergaard U, Agesen RM, Brøsen JMB, Alibegovic AC, Andersen HU, Beck‐Nielsen H, Gustenhoff P, Hansen TK, Hedetoft C, Jensen TJ, Juhl CB, Jensen AK, Lerche SS, Nørgaard K, Parving H, Sørensen AL, Tarnow L, Thorsteinsson B. Comparison of treatment with insulin degludec and glargine U100 in patients with type 1 diabetes prone to nocturnal severe hypoglycaemia: The HypoDeg randomized, controlled, open-label, crossover trial. Diabetes Obes Metab 2022; 24:257-267. [PMID: 34643020 PMCID: PMC9298237 DOI: 10.1111/dom.14574] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/04/2021] [Accepted: 10/10/2021] [Indexed: 11/27/2022]
Abstract
AIM To investigate whether the long-acting insulin analogue insulin degludec compared with insulin glargine U100 reduces the risk of nocturnal symptomatic hypoglycaemia in patients with type 1 diabetes (T1D). METHODS Adults with T1D and at least one episode of nocturnal severe hypoglycaemia during the last 2 years were included in a 2-year prospective, randomized, open, multicentre, crossover trial. A total of 149 patients were randomized 1:1 to basal-bolus therapy with insulin degludec and insulin aspart or insulin glargine U100 and insulin aspart. Each treatment period lasted 1 year and consisted of 3 months of run-in or crossover followed by 9 months of maintenance. The primary endpoint was the number of blindly adjudicated nocturnal symptomatic hypoglycaemic episodes. Secondary endpoints included the occurrence of severe hypoglycaemia. We analysed all endpoints by intention-to-treat. RESULTS Treatment with insulin degludec resulted in a 28% (95% CI: 9%-43%; P = .02) relative rate reduction (RRR) of nocturnal symptomatic hypoglycaemia at level 1 (≤3.9 mmol/L), a 37% (95% CI: 16%-53%; P = .002) RRR at level 2 (≤3.0 mmol/L), and a 35% (95% CI: 1%-58%; P = .04) RRR in all-day severe hypoglycaemia compared with insulin glargine U100. CONCLUSIONS Patients with T1D prone to nocturnal severe hypoglycaemia have lower rates of nocturnal symptomatic hypoglycaemia and all-day severe hypoglycaemia with insulin degludec compared with insulin glargine U100.
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Affiliation(s)
- Ulrik Pedersen‐Bjergaard
- Department of Endocrinology and NephrologyNordsjællands HospitalHillerødDenmark
- Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Rikke M. Agesen
- Department of Endocrinology and NephrologyNordsjællands HospitalHillerødDenmark
- Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Julie M. B. Brøsen
- Department of Endocrinology and NephrologyNordsjællands HospitalHillerødDenmark
- Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | | | | | - Henning Beck‐Nielsen
- Department of Endocrinology MOdense University HospitalOdense CDenmark
- Faculty of Health SciencesUniversity of Southern DenmarkOdense CDenmark
| | - Peter Gustenhoff
- Department of EndocrinologyAalborg University HospitalAalborgDenmark
| | - Troels K. Hansen
- Steno Diabetes Center AarhusAarhus NDenmark
- Health, University of AarhusAarhus CDenmark
| | | | - Tonny J. Jensen
- Department of Medical EndocrinologyCopenhagen University Hospital (Rigshospitalet)CopenhagenDenmark
| | - Claus B. Juhl
- Department of MedicineSydvestjysk SygehusEsbjergDenmark
| | - Andreas K. Jensen
- Department of Public Health, Section of BiostatisticsUniversity of CopenhagenCopenhagenDenmark
- Department of Clinical ResearchNordsjællands HospitalHillerødDenmark
| | - Susanne S. Lerche
- Department of Diabetes and Hormonal DiseasesLillebælt Hospital KoldingKoldingDenmark
| | - Kirsten Nørgaard
- Department of Endocrinology and NephrologyNordsjællands HospitalHillerødDenmark
- Steno Diabetes Center CopenhagenGentofteDenmark
- Department of EndocrinologyHvidovre University HospitalHvidovreDenmark
| | - Hans‐Henrik Parving
- Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
- Department of Medical EndocrinologyCopenhagen University Hospital (Rigshospitalet)CopenhagenDenmark
| | - Anne L. Sørensen
- Department of Public Health, Section of BiostatisticsUniversity of CopenhagenCopenhagenDenmark
| | - Lise Tarnow
- Department of Clinical ResearchNordsjællands HospitalHillerødDenmark
- Steno Diabetes Center SjællandHolbækDenmark
| | - Birger Thorsteinsson
- Department of Endocrinology and NephrologyNordsjællands HospitalHillerødDenmark
- Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
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6
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Pedersen-Bjergaard U, Fabricius TW, Thorsteinsson B. Synthetic long-acting insulin analogs for the management of type 1 diabetes: an update. Expert Opin Pharmacother 2021; 22:2251-2259. [PMID: 34467826 DOI: 10.1080/14656566.2021.1970136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Type 1 diabetes is characterized by insulin deficiency and requires near-physiological insulin replacement. In most patients, this is accomplished by basal bolus therapy consisting of a long-acting basal insulin administered once or twice daily and short-acting insulin with main meals. Several long-acting insulin analogs have been developed to optimize basal insulin therapy. AREAS COVERED This paper reviews the design of - and data from - randomized controlled trials (RCTs) to assess glucose lowering efficacy and safety of long-acting insulin analogs for the treatment of type 1 diabetes. EXPERT OPINION Due to the non-inferiority treat-to-target design of insulin, RCTs treatment differences primarily appear as differences in hypoglycemia risk. Data suggest that the first generation long-acting insulin analogs insulin glargine U100 and insulin detemir have a similar glucose lowering efficacy compared to NPH insulin but a lower risk of hypoglycemia, particularly during nighttime. The newer analogs insulin glargine U300 and insulin degludec provide non-inferior efficacy, although insulin glargine U300 is less potent unit-to-unit. Insulin degludec reduces hypoglycemia risk compared to insulin glargine U100. Future studies should explore the potential for further improvement of treatment results in type 1 diabetes by a structured approach to personalization of basal insulin therapy.
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Affiliation(s)
- Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Therese W Fabricius
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - Birger Thorsteinsson
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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7
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Hemmingsen B, Metzendorf MI, Richter B. (Ultra-)long-acting insulin analogues for people with type 1 diabetes mellitus. Cochrane Database Syst Rev 2021; 3:CD013498. [PMID: 33662147 PMCID: PMC8094220 DOI: 10.1002/14651858.cd013498.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND People with type 1 diabetes mellitus (T1DM) need treatment with insulin for survival. Whether any particular type of (ultra-)long-acting insulin provides benefit especially regarding risk of diabetes complications and hypoglycaemia is unknown. OBJECTIVES To compare the effects of long-term treatment with (ultra-)long-acting insulin analogues to NPH insulin (neutral protamine Hagedorn) or another (ultra-)long-acting insulin analogue in people with type 1 diabetes mellitus. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We explored the US Food and Drug Administration (FDA) and European Medical Agency (EMA) web pages. We asked pharmaceutical companies, EMA and investigators for additional data and clinical study reports (CSRs). The date of the last search of all databases was 24 August 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) with a duration of 24 weeks or more comparing one (ultra-)long-acting insulin to NPH insulin or another (ultra-)long-acting insulin in people with T1DM. DATA COLLECTION AND ANALYSIS Two review authors assessed risk of bias using the new Cochrane 'Risk of bias' 2 (RoB 2) tool and extracted data. Our main outcomes were all-cause mortality, health-related quality of life (QoL), severe hypoglycaemia, non-fatal myocardial infarction/stroke (NFMI/NFS), severe nocturnal hypoglycaemia, serious adverse events (SAEs) and glycosylated haemoglobin A1c (HbA1c). We used a random-effects model to perform meta-analyses and calculated risk ratios (RRs) and odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) and 95% prediction intervals for effect estimates. We evaluated the certainty of the evidence applying the GRADE instrument. MAIN RESULTS We included 26 RCTs. Two studies were unpublished. We obtained CSRs, clinical study synopses or both as well as medical reviews from regulatory agencies on 23 studies which contributed to better analysis of risk of bias and improved data extraction. A total of 8784 participants were randomised: 2428 participants were allocated to NPH insulin, 2889 participants to insulin detemir, 2095 participants to insulin glargine and 1372 participants to insulin degludec. Eight studies contributing 21% of all participants comprised children. The duration of the intervention varied from 24 weeks to 104 weeks. Insulin degludec versus NPH insulin: we identified no studies comparing insulin degludec with NPH insulin. Insulin detemir versus NPH insulin (9 RCTs): five deaths reported in two studies including adults occurred in the insulin detemir group (Peto OR 4.97, 95% CI 0.79 to 31.38; 9 studies, 3334 participants; moderate-certainty evidence). Three studies with 870 participants reported QoL showing no true beneficial or harmful effect for either intervention (low-certainty evidence). There was a reduction in severe hypoglycaemia in favour of insulin detemir: 171/2019 participants (8.5%) in the insulin detemir group compared with 138/1200 participants (11.5%) in the NPH insulin group experienced severe hypoglycaemia (RR 0.69, 95% CI 0.52 to 0.92; 8 studies, 3219 participants; moderate-certainty evidence). The 95% prediction interval ranged between 0.34 and 1.39. Only 1/331 participants in the insulin detemir group compared with 0/164 participants in the NPH insulin group experienced a NFMI (1 study, 495 participants; low-certainty evidence). No study reported NFS. A total of 165/2094 participants (7.9%) in the insulin detemir group compared with 102/1238 participants (8.2%) in the NPH insulin group experienced SAEs (RR 0.95, 95% CI 0.75 to 1.21; 9 studies, 3332 participants; moderate-certainty evidence). Severe nocturnal hypoglycaemia was observed in 70/1823 participants (3.8%) in the insulin detemir group compared with 60/1102 participants (5.4%) in the NPH insulin group (RR 0.67, 95% CI 0.39 to 1.17; 7 studies, 2925 participants; moderate-certainty evidence). The MD in HbA1c comparing insulin detemir with NPH insulin was 0.01%, 95% CI -0.1 to 0.1; 8 studies, 3122 participants; moderate-certainty evidence. Insulin glargine versus NPH insulin (9 RCTs): one adult died in the NPH insulin group (Peto OR 0.14, 95% CI 0.00 to 6.98; 8 studies, 2175 participants; moderate-certainty evidence). Four studies with 1013 participants reported QoL showing no true beneficial effect or harmful effect for either intervention (low-certainty evidence). Severe hypoglycaemia was observed in 122/1191 participants (10.2%) in the insulin glargine group compared with 145/1159 participants (12.5%) in the NPH insulin group (RR 0.84, 95% CI 0.67 to 1.04; 9 studies, 2350 participants; moderate-certainty evidence). No participant experienced a NFMI and one participant in the NPH insulin group experienced a NFS in the single study reporting this outcome (585 participants; low-certainty evidence). A total of 109/1131 participants (9.6%) in the insulin glargine group compared with 110/1098 participants (10.0%) in the NPH insulin group experienced SAEs (RR 1.08, 95% CI 0.63 to 1.84; 8 studies, 2229 participants; moderate-certainty evidence). Severe nocturnal hypoglycaemia was observed in 69/938 participants (7.4%) in the insulin glargine group compared with 83/955 participants (8.7%) in the NPH insulin group (RR 0.83, 95% CI 0.62 to 1.12; 6 studies, 1893 participants; moderate-certainty evidence). The MD in HbA1c comparing insulin glargine with NPH insulin was 0.02%, 95% CI -0.1 to 0.1; 9 studies, 2285 participants; moderate-certainty evidence. Insulin detemir versus insulin glargine (2 RCTs),insulin degludec versus insulin detemir (2 RCTs), insulin degludec versus insulin glargine (4 RCTs): there was no evidence of a clinically relevant difference for all main outcomes comparing (ultra-)long-acting insulin analogues with each other. For all outcomes none of the comparisons indicated differences in tests of interaction for children versus adults. AUTHORS' CONCLUSIONS Comparing insulin detemir with NPH insulin for T1DM showed lower risk of severe hypoglycaemia in favour of insulin detemir (moderate-certainty evidence). However, the 95% prediction interval indicated inconsistency in this finding. Both insulin detemir and insulin glargine compared with NPH insulin did not show benefits or harms for severe nocturnal hypoglycaemia. For all other main outcomes with overall low risk of bias and comparing insulin analogues with each other, there was no true beneficial or harmful effect for any intervention. Data on patient-important outcomes such as QoL, macrovascular and microvascular diabetic complications were sparse or missing. No clinically relevant differences were found between children and adults.
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Affiliation(s)
- Bianca Hemmingsen
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Bernd Richter
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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8
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Jensen MH, Hejlesen O, Vestergaard P. Association of insulin regimens with severe hypoglycaemia in patients with type 1 diabetes: A Danish case-control study. Br J Clin Pharmacol 2020; 86:1560-1566. [PMID: 32086824 PMCID: PMC8176963 DOI: 10.1111/bcp.14263] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/24/2019] [Accepted: 02/14/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS To evaluate the risk of severe hypoglycaemia for patients with Type 1 diabetes (T1D) when exposed to insulin regimens including human insulin only or insulin analogues. METHODS A total of 19 896 patients with T1D were extracted from the Danish National Patient Register. Of these, 6379 T1D patients experiencing 1 of more severe hypoglycaemic episodes (total of 17 242 episodes) were matched 1:1 with T1D patients without severe hypoglycaemia. A logistic regression model with last insulin regimen used as exposure was constructed to analyse the effect on severe hypoglycaemia. RESULTS People on a basal-bolus regimen with insulin analogues had a reduced risk of severe hypoglycaemia of 39% (odds ratio: 0.61, 95% confidence interval: 0.54-0.68) compared to patients on a basal-bolus human insulin only regimen. Furthermore, patients on a premixed regimen containing an insulin analogue had a 58% (odds ratio: 0.42, 95% confidence interval: 0.36-0.49) reduced risk of severe hypoglycaemia compared to patients on premixed human insulin only. CONCLUSION This study indicates that use of a basal-bolus insulin regimen with an insulin analogue is safer with respect to severe hypoglycaemia in patients with T1D than the use of a basal-bolus human insulin only regimen.
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Affiliation(s)
- Morten Hasselstrøm Jensen
- Steno Diabetes Center North DenmarkAalborg University HospitalAalborgDenmark
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Ole Hejlesen
- Department of Health Science and TechnologyAalborg UniversityAalborgDenmark
| | - Peter Vestergaard
- Steno Diabetes Center North DenmarkAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg University HospitalAalborgDenmark
- Department of EndocrinologyAalborg University HospitalAalborgDenmark
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9
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Agesen RM, Alibegovic AC, Andersen HU, Beck-Nielsen H, Gustenhoff P, Hansen TK, Hedetoft C, Jensen T, Juhl CB, Lerche SS, Nørgaard K, Parving HH, Tarnow L, Thorsteinsson B, Pedersen-Bjergaard U. The effect of insulin degludec on risk of symptomatic nocturnal hypoglycaemia in adults with type 1 diabetes and high risk of nocturnal severe hypoglycaemia (the HypoDeg trial): study rationale and design. BMC Endocr Disord 2019; 19:78. [PMID: 31337371 PMCID: PMC6652000 DOI: 10.1186/s12902-019-0408-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/15/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Hypoglycaemia, especially nocturnal, remains the main limiting factor of achieving good glycaemic control in type 1 diabetes. The effect of first generation long-acting insulin analogues in reducing nocturnal hypoglycaemia is well documented in patient with type 1 diabetes. The effect of the newer long-acting insulin degludec on risk of nocturnal hypoglycaemia remains undocumented in patients with type 1 diabetes and recurrent severe nocturnal hypoglycaemia. The HypoDeg trial is designed to investigate whether insulin degludec in comparison with insulin glargine U100 is superior in limiting the occurrence of nocturnal hypoglycaemia in patients with recurrent nocturnal severe hypoglycaemia. This paper reports the study design of the HypoDeg trial. METHODS/DESIGN A Danish investigator-initiated, prospective, randomised, open, blinded endpoint (PROBE), multicentre, two-year cross-over study investigating the effect of insulin degludec versus insulin glargine U100 on frequency of nocturnal hypoglycaemia in patients with type 1 diabetes and one or more episodes of nocturnal severe hypoglycaemia during the preceding two years as the major inclusion criteria. Patients are randomised (1:1) to basal therapy with insulin degludec or insulin glargine. Insulin aspart is used as bolus therapy in both treatment arms. DISCUSSION In contrast to most other insulin studies the HypoDeg trial includes only patients at high risk of hypoglycaemia. The HypoDeg trial will compare treatment with insulin degludec to insulin glargine U100 in terms of risk of nocturnal hypoglycaemic episodes in patients with type 1 diabetes with the greatest potential to benefit from near-physiological insulin replacement therapy. www.clinicaltrials.gov : NCT02192450.
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Affiliation(s)
- Rikke Mette Agesen
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Dyrehavevej 29, DK-3400 Hillerød, Denmark
| | | | | | - Henning Beck-Nielsen
- Department of Endocrinology M, Odense University Hospital, Søndre Boulevard 29, DK-5000 Odense C, Denmark
- Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, DK-5000 Odense C, Denmark
| | - Peter Gustenhoff
- Department of Endocrinology, Aalborg University Hospital, Mølleparkvej 4, DK-9000, Aalborg, Denmark
| | - Troels Krarup Hansen
- Steno Diabetes Center Aarhus, Hedeager 3, DK-8200 Aarhus N, Denmark
- Health, University of Aarhus, Nordre Ringgade 1, DK-8000 Aarhus C, Denmark
| | - Christoffer Hedetoft
- Department of Internal Medicine, Køge Sygehus, Lykkebækvej 1, DK-4600 Køge, Denmark
| | - Tonny Jensen
- Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet), Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Claus Bogh Juhl
- Department of Medicine, Sydvestjysk Sygehus, Finsensgade 35, DK-6700 Esbjerg, Denmark
| | - Susanne Søgaard Lerche
- Department of Diabetes and Hormonal Diseases, Lillebælt Hospital Kolding, Sygehusvej 24, DK-6000 Kolding, Denmark
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, DK-2820 Gentofte, Denmark
- Department of Endocrinology, Hvidovre University Hospital, Kettegaards Alle 30, DK-2650 Hvidovre, Denmark
| | - Hans-Henrik Parving
- Health, University of Aarhus, Nordre Ringgade 1, DK-8000 Aarhus C, Denmark
- Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet), Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Lise Tarnow
- Health, University of Aarhus, Nordre Ringgade 1, DK-8000 Aarhus C, Denmark
- Department of Clinical Research, Nordsjællands Hospital, Hillerød, Dyrehavevej 29, DK-3400 Hillerød, Denmark
- Steno Diabetes Center Sjaelland, Akacievej 7, DK-4300 Holbaek, Denmark
| | - Birger Thorsteinsson
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Dyrehavevej 29, DK-3400 Hillerød, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Dyrehavevej 29, DK-3400 Hillerød, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
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10
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Lechleitner M, Kaser S, Hoppichler F, Roden M, Weitgasser R, Ludvik B, Fasching P, Winhofer-Stöckl Y, Kautzky-Willer A, Schernthaner G, Prager R, Wascher TC, Clodi M. [Diagnosis and insulin therapy of type 1 diabetes mellitus (Update 2019)]. Wien Klin Wochenschr 2019; 131:77-84. [PMID: 30980145 DOI: 10.1007/s00508-019-1493-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This guideline summarizes diagnosis of type 1 diabetes, including accompanying autoimmune disorders, insulin therapy regimens and glycemic target values.
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Affiliation(s)
- Monika Lechleitner
- Interne Abteilung, Landeskrankenhaus Hochzirl - Natters, Hochzirl, 6170, Zirl, Österreich.
| | - Susanne Kaser
- Department für Innere Medizin 1, Medizinische Universität Innsbruck, Innsbruck, Österreich
- Christian Doppler Labor für Insulinresistenz, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Friedrich Hoppichler
- Abteilung für Innere Medizin, Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Österreich
| | - Michael Roden
- Klinik für Endokrinologie und Diabetologie, Medizinische Fakultät, Heinrich-Heine-Universität, Düsseldorf, Deutschland
- Institut für Klinische Diabetologie, Deutsches Diabetes-Zentrum (DDZ), Leibniz-Zentrum für Diabetesforschung, Düsseldorf, Deutschland
- Deutsches Zentrum für Diabetesforschung (DZD e. V.), München-Neuherberg, Deutschland
| | - Raimund Weitgasser
- Abteilung für Innere Medizin, Privatklinik Wehrle-Diakonissen, Salzburg, Österreich
- Universitätsklinik für Innere Medizin I, LKH Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Bernhard Ludvik
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - Peter Fasching
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Wilhelminenspital der Stadt Wien, Wien, Österreich
| | - Yvonne Winhofer-Stöckl
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Alexandra Kautzky-Willer
- Gender Medicine Unit, Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Guntram Schernthaner
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Department für Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - Rudolf Prager
- 3. Medizinische Abteilung mit Stoffwechselerkrankungen und Nephrologie, Krankenhaus Hietzing, Wien, Österreich
- Karl Landsteiner Institut für Stoffwechselerkrankungen und Nephrologie, Wien, Österreich
| | - Thomas C Wascher
- 1. Medizinische Abteilung, Hanusch-Krankenhaus, Wien, Österreich
| | - Martin Clodi
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
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11
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Pedersen‐Bjergaard U, Alsifri S, Aronson R, Berković MC, Galstyan G, Gydesen H, Lekdorf JB, Ludvik B, Moberg E, Ramachandran A, Khunti K. Comparison of the HAT study, the largest global hypoglycaemia study to date, with similar large real-world studies. Diabetes Obes Metab 2019; 21:844-853. [PMID: 30456887 PMCID: PMC6590793 DOI: 10.1111/dom.13588] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 11/30/2022]
Abstract
AIMS Optimal diabetes care requires clear understanding of the incidence of hypoglycaemia in real-world clinical practice. Current data on hypoglycaemia are generally limited to those reported from randomised controlled clinical trials. The Hypoglycaemia Assessment Tool (HAT) study, a non-interventional real-world study of hypoglycaemia, assessed hypoglycaemia in 27 585 individuals across 24 countries. The present study compared the incidence of hypoglycaemia from the HAT study with other similarly designed, large, real-world studies. MATERIALS AND METHODS A literature search of PubMed (1995-2017) for population-based studies of insulin-treated patients with type 1 or type 2 diabetes (T1D, T2D), excluding clinical trials and reviews, identified comparable population-based studies reporting the incidence of hypoglycaemia. RESULTS The 24 comparative studies, including more than 24 000 participants with T1D and more than 160 000 participants with T2D, varied in design, size, inclusion criteria, definitions of hypoglycaemia and method of recording hypoglycaemia. Reported rates (events per patient-year [PPY]) of hypoglycaemia were higher in patients with T1D than in those with T2D (overall T1D, 21.8-73.3 and T2D, 1.3-37.7; mild/non-severe T1D, 29.0-126.7 and T2D, 1.3-41.5; severe T1D, 0.7-5.8 and T2D, 0.0-2.5; nocturnal T1D, 2.6-11.3 and T2D, 0.38-9.7) and were similar to the ranges found in the HAT study. CONCLUSIONS The HAT data on hypoglycaemia incidence were comparable with those from other real-world studies and indicate a high incidence of hypoglycaemia among insulin-treated patients. Differences in rates among studies are mostly explained by differences in patient populations and study methodology. The goal of reducing hypoglycaemia should be a target for continued educational and evidence-based pharmacological interventions.
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Affiliation(s)
| | | | - Ronnie Aronson
- Endocrinology and MetabolismLMC Diabetes and EndocrinologyTorontoOntarioCanada
| | | | | | | | | | - Bernhard Ludvik
- Division of Endocrinology and MetabolismRudolfstiftung Hospital and Karl‐Landsteiner InstituteViennaAustria
| | | | | | - Kamlesh Khunti
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
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12
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Smith L, Chakraborty D, Bhattacharya P, Sarmah D, Koch S, Dave KR. Exposure to hypoglycemia and risk of stroke. Ann N Y Acad Sci 2018; 1431:25-34. [PMID: 29917249 DOI: 10.1111/nyas.13872] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/23/2018] [Accepted: 05/08/2018] [Indexed: 12/25/2022]
Abstract
In the treatment of both type 1 and type 2 diabetes mellitus, maintaining a euglycemic state represents one of the key challenges. Improper dosing and administration of glucose-lowering drugs is associated with an increased risk of recurrent hypoglycemia episodes. In addition, the risk of adverse cardiovascular events in diabetic patients, particularly myocardial infarctions and strokes, is well established. Current research indicates a potential link between the baseline risk of cardio/cerebrovascular events in diabetic patients and exposure to hypoglycemia. In this review of the literature, we aim to determine if a relationship exists between recurrent hypoglycemia and adverse neurovascular events.
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Affiliation(s)
- Logan Smith
- Cerebral Vascular Disease Research Laboratories, University of Miami, Miami, Florida.,Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Diya Chakraborty
- Cerebral Vascular Disease Research Laboratories, University of Miami, Miami, Florida.,Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Pallab Bhattacharya
- National Institute of Pharmaceutical Education and Research, Ahmedabad, Gujarat, India.,Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepaneeta Sarmah
- National Institute of Pharmaceutical Education and Research, Ahmedabad, Gujarat, India
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida
| | - Kunjan R Dave
- Cerebral Vascular Disease Research Laboratories, University of Miami, Miami, Florida.,Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida.,Neuroscience Program, University of Miami Miller School of Medicine, Miami, Florida
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13
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Pathan MF, Fariduddin M, Nazimuddin K, Mollah AS, Islam Siddiqui MN, Hassan KA, Ferdous HS, Rahman MH, Ashrafuzzaman SM, Sobhan MJ, E-Tanvir Haider MR, Amin MF. The Incidence of Hypoglycemia among Insulin-Treated Patients with Type 1 or Type 2 Diabetes: Bangladeshi Cohort of International Operations-Hypoglycemia Assessment Tool Study. Indian J Endocrinol Metab 2018; 22:379-386. [PMID: 30090731 PMCID: PMC6063185 DOI: 10.4103/ijem.ijem_545_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The objective of this study was to assess the incidence of hypoglycemia in patients with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) in Bangladeshi cohort of the International Operations-Hypoglycemia Assessment Tool study. MATERIALS AND METHODS Patients diagnosed with either T1DM or T2DM, aged ≥18 years, treated with insulin (any regimen) for >12 months, and completed self-assessment questionnaires (SAQs) to record demography, treatment information, and hypoglycemia during the 6-month retrospective and 4-week prospective periods (a total of 7 months) were enrolled in the study. RESULTS A total of 1179 patients were enrolled and completed the SAQ1 (T1DM, n = 25; T2DM, n = 1154). Almost all patients (T1DM: 100.0% [95% confidence interval (CI): 86.3%, 100.0%] and T2DM: 97.0% [95% CI: 95.9%, 97.9%]) experienced at least 1 hypoglycemic event prospectively. The estimated rates of any and severe hypoglycemia were 26.6 (95% CI: 19.8, 35.0) and 14.1 (95% CI: 9.3, 20.4) events per patient-per year (PPY), respectively, for patients with T1DM and 18.3 (95% CI: 17.4, 19.2) and 12.1 (95% CI: 11.4, 12.9) events PPY, respectively, for patients with T2DM during the prospective period. At baseline, mean glycated hemoglobin (HbA1c) (±standard deviation) was 8.1 (±1.8%) for T1DM and 8.8 (±1.8%) for T2DM. Hypoglycemic rate was independent of HbA1c levels and types of insulin. CONCLUSIONS This is the first patient dataset of self-reported hypoglycemia in Bangladesh; results confirm that hypoglycemia is underreported.
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Affiliation(s)
- Md. Faruque Pathan
- Department of Medicine and Endocrinology, BIRDEM General Hospital, Chittagong, Bangladesh
| | - M. Fariduddin
- Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Chittagong, Bangladesh
| | - Khwaja Nazimuddin
- Department of Medicine, Bangladesh University of Health Sciences, Dhaka, Bangladesh
| | - Abdus Saleque Mollah
- Department of Endocrinology, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | | | - Kazi Ali Hassan
- Department of Endocrinology, Square Hospital, Dhaka, Bangladesh
| | - H. S. Ferdous
- Department of Endocrinology, Popular Medical College Hospital, Dhaka, Bangladesh
| | | | | | - Md. Javed Sobhan
- Department of Clinical, Medical, Regulatory & Quality, Novo Nordisk Pharma (Private) Limited, Dhaka, Bangladesh
| | - Md. Reza E-Tanvir Haider
- Department of Clinical, Medical, Regulatory & Quality, Novo Nordisk Pharma (Private) Limited, Dhaka, Bangladesh
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15
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Agesen RM, Kristensen PL, Beck-Nielsen H, Nørgaard K, Perrild H, Jensen T, Parving HH, Thorsteinsson B, Tarnow L, Pedersen-Bjergaard U. Effect of Insulin Analogs on Frequency of Non-Severe Hypoglycemia in Patients with Type 1 Diabetes Prone to Severe Hypoglycemia: Much Higher Rates Detected by Continuous Glucose Monitoring than by Self-Monitoring of Blood Glucose-The HypoAna Trial. Diabetes Technol Ther 2018; 20:247-256. [PMID: 29565719 DOI: 10.1089/dia.2017.0372] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypoglycemia is an increasingly important endpoint in clinical diabetes trials. The assessment of hypoglycemia should therefore be as complete as possible. Blinded continuous glucose monitoring (CGM) provides an improved opportunity to capture asymptomatic and nocturnal events. Here we report results from the HypoAna trial comparing all-analog-insulin therapy (aspart/detemir) with all-human-insulin therapy (neutral protamine Hagedorn/regular) on non-severe hypoglycemia (symptomatic and asymptomatic hypoglycemia) as assessed by blinded CGM and compared with data obtained by self-monitoring of blood glucose (SMBG) in patients with type 1 diabetes and recurrent severe hypoglycemia. METHODS Fifty-three patients completed a substudy of 4 × 3 days of blinded CGM. CGM traces were reviewed for hypoglycemic events lasting 15 min or longer. RESULTS At the threshold ≤3.9 mmol/L, the per-protocol analysis demonstrated a 40% rate reduction (95% confidence interval [CI] 20%-60%; P = 0.002) in nocturnal non-severe hypoglycemia during analog treatment, mainly due to a 40% rate reduction (95% CI 0%-70%; P = 0.03) of nocturnal asymptomatic hypoglycemia. Similar nonsignificant trends were seen at the glucose threshold ≤3.0 mmol/L. Overall CGM-detected that nocturnal asymptomatic hypoglycemia ≤3.9 mmol/L was ∼17 times more frequent than SMBG-detected episodes (52 vs. 3 events/patient-year). This translates into a time needed to treat one patient with insulin analogs to prevent one episode that is 34 times shorter using CGM data than SMBG data (1.4 vs. 47 weeks). CONCLUSIONS Capturing hypoglycemic events by the conventional method of SMBG in patients with impaired awareness reveals only a limited number of events. Blinded CGM can provide more complete data, particularly in terms of asymptomatic and nocturnal events.
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Affiliation(s)
- Rikke Mette Agesen
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | - Peter Lommer Kristensen
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 3 Clinical Research Unit, Steno Diabetes Center , Gentofte, Denmark
| | - Henning Beck-Nielsen
- 4 Department of Endocrinology M, Odense University Hospital , Odense, Denmark
- 5 Faculty of Health Sciences, University of Southern Denmark , Odense, Denmark
| | - Kirsten Nørgaard
- 6 Department of Endocrinology, Hvidovre Hospital , Hvidovre, Denmark
| | - Hans Perrild
- 7 Department of Internal Medicine, Bispebjerg Hospital , Copenhagen, Denmark
| | - Tonny Jensen
- 8 Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet) , Copenhagen, Denmark
| | - Hans-Henrik Parving
- 8 Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet) , Copenhagen, Denmark
- 9 Health, University of Aarhus , Aarhus, Denmark
| | - Birger Thorsteinsson
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | - Lise Tarnow
- 3 Clinical Research Unit, Steno Diabetes Center , Gentofte, Denmark
- 9 Health, University of Aarhus , Aarhus, Denmark
- 10 Department of Clinical Research, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
| | - Ulrik Pedersen-Bjergaard
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
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16
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Emral R, Pathan F, Cortés CAY, El-Hefnawy MH, Goh SY, Gómez AM, Murphy A, Abusnana S, Rudijanto A, Jain A, Ma Z, Mirasol R. Self-reported hypoglycemia in insulin-treated patients with diabetes: Results from an international survey on 7289 patients from nine countries. Diabetes Res Clin Pract 2017; 134:17-28. [PMID: 28951336 DOI: 10.1016/j.diabres.2017.07.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 07/05/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
Abstract
AIMS Hypoglycemia constitutes a significant barrier to achieving glycemic control with insulin in both type 1 and type 2 diabetes. Historically, it has been difficult to accurately verify the rates of hypoglycemia within a clinical setting and there is a need for high-quality, real-world data to ascertain the true rates of hypoglycemia in clinical practice. The global Hypoglycemia Assessment Tool (HAT) study was designed to assess the global incidence of hypoglycemia in patients with insulin-treated diabetes, and the results have indicated that the overall incidence of hypoglycemia is high, with large variations between geographical regions. METHODS The International Operations HAT (IO HAT) study retrospectively and prospectively assessed the incidence of hypoglycemia in patients with insulin-treated diabetes in Bangladesh, Colombia, Egypt, Indonesia, Philippines, Singapore, South Africa, Turkey, and United Arab Emirates. RESULTS During the prospective period, hypoglycemic events were reported by 97.4% of patients with type 1 diabetes and 95.3% of those with type 2 diabetes, with an estimated rate of 6.86 events per patient per month (PPPM) for patients with type 1 diabetes and 2.37 events PPPM for patients with type 2 diabetes. CONCLUSIONS These results represent the first patient-reported dataset on hypoglycemia in the participating countries and confirm that hypoglycemia is under-reported and more widespread than previously believed. Although the incidence of hypoglycemia was variable among patients on different treatment regimens, there were substantial impacts on both productivity and healthcare utilization following an episode of hypoglycemia. This trial is registered at clinicaltrials.gov: NCT02306681.
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Affiliation(s)
- Rifat Emral
- Ankara University, Faculty of Medicine, Department of Endocrinology and Metabolic Diseases, Ankara, Turkey.
| | | | - Carlos Augusto Yepes Cortés
- Department of Internal Medicine and Endocrinology, Hospital Universitario Clínica San Rafael, Bogotá, Colombia.
| | | | | | - Ana Maria Gómez
- Department of Internal Medicine and Endocrinology, Medical Faculty of Javeriana University, Head of Endocrinology Unit, San Ignacio Hospital, Bogotá, Colombia.
| | - Angela Murphy
- Sunward Park Centre for Diabetes Excellence, Boksburg, South Africa.
| | - Salah Abusnana
- Rashid Center for Diabetes and Research, Al Jurf Ajman, Ajman, United Arab Emirates.
| | - Achmad Rudijanto
- Department of Internal Medicine, Medical Faculty of Brawijaya University, Kota Malang, Jawa Timur 65145, Indonesia.
| | - Anand Jain
- Novo Nordisk Region International Operations AG, Zurich, Switzerland.
| | - Zhulin Ma
- Novo Nordisk Region International Operations AG, Zurich, Switzerland.
| | - Roberto Mirasol
- Section of Endocrinology, Diabetes and Metabolism, St. Luke's Medical Center, Quezon City, Philippines.
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17
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Lane W, Bailey TS, Gerety G, Gumprecht J, Philis-Tsimikas A, Hansen CT, Nielsen TSS, Warren M. Effect of Insulin Degludec vs Insulin Glargine U100 on Hypoglycemia in Patients With Type 1 Diabetes: The SWITCH 1 Randomized Clinical Trial. JAMA 2017; 318:33-44. [PMID: 28672316 PMCID: PMC5817477 DOI: 10.1001/jama.2017.7115] [Citation(s) in RCA: 158] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 06/12/2017] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Hypoglycemia, common in patients with type 1 diabetes, is a major barrier to achieving good glycemic control. Severe hypoglycemia can lead to coma or death. OBJECTIVE To determine whether insulin degludec is noninferior or superior to insulin glargine U100 in reducing the rate of symptomatic hypoglycemic episodes. DESIGN, SETTING, AND PARTICIPANTS Double-blind, randomized, crossover noninferiority trial involving 501 adults with at least 1 hypoglycemia risk factor treated at 84 US and 6 Polish centers (January 2014-January 12, 2016) for two 32-week treatment periods, each with a 16-week titration and a 16-week maintenance period. INTERVENTIONS Patients were randomized 1:1 to receive once-daily insulin degludec followed by insulin glargine U100 (n = 249) or to receive insulin glargine U100 followed by insulin degludec (n = 252) and randomized 1:1 to morning or evening dosing within each treatment sequence. MAIN OUTCOMES AND MEASURES The primary end point was the rate of overall severe or blood glucose-confirmed (<56 mg/dL) symptomatic hypoglycemic episodes during the maintenance period. Secondary end points included the rate of nocturnal symptomatic hypoglycemic episodes and proportion of patients with severe hypoglycemia during the maintenance period. The noninferiority criterion for the primary end point and for the secondary end point of nocturnal hypoglycemia was defined as an upper limit of the 2-sided 95% CI for a rate ratio of 1.10 or lower; if noninferiority was established, 2-sided statistical testing for superiority was conducted. RESULTS Of the 501 patients randomized (mean age, 45.9 years; 53.7% men), 395 (78.8%) completed the trial. During the maintenance period, the rates of overall symptomatic hypoglycemia were 2200.9 episodes per 100 person-years' exposure (PYE) in the insulin degludec group vs 2462.7 episodes per 100 PYE in the insulin glargine U100 group for a rate ratio (RR) of 0.89 (95% CI, 0.85-0.94; P < .001 for noninferiority; P < .001 for superiority; rate difference, -130.31 episodes per 100 PYE; 95% CI, -193.5 to -67.16). The rates of nocturnal symptomatic hypoglycemia were 277.1 per 100 PYE in the insulin degludec group vs 428.6 episodes per 100 PYE in the insulin glargine U100 group, for an RR of 0.64 (95% CI, 0.56-0.73; P < .001 for noninferiority; P < .001 for superiority; rate difference, -61.94 episodes per 100 PYE; 95% CI, -83.85 to -40.03). A lower proportion of patients in the insulin degludec than in the insulin glargine U100 group experienced severe hypoglycemia during the maintenance period (10.3%, 95% CI, 7.3%-13.3% vs 17.1%, 95% CI, 13.4%-20.8%, respectively; McNemar P = .002; risk difference, -6.8%; 95% CI, -10.8% to -2.7%). CONCLUSIONS AND RELEVANCE Among patients with type 1 diabetes and at least 1 risk factor for hypoglycemia, 32 weeks' treatment with insulin degludec vs insulin glargine U100 resulted in a reduced rate of overall symptomatic hypoglycemic episodes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02034513.
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Affiliation(s)
- Wendy Lane
- Mountain Diabetes and Endocrine Center, Asheville, North Carolina
| | | | | | | | | | | | - Thor S. S. Nielsen
- Biostatistics Insulin & Diabetes Outcomes, Novo Nordisk A/S, Søborg, Denmark
| | - Mark Warren
- Physicians East PA, Greenville, North Carolina
- School of Osteopathic Medicine, Campbell University, Lillington, North Carolina
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18
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Kristensen PL, Tarnow L, Bay C, Nørgaard K, Jensen T, Parving HH, Perrild H, Beck-Nielsen H, Christiansen JS, Thorsteinsson B, Pedersen-Bjergaard U. Comparing effects of insulin analogues and human insulin on nocturnal glycaemia in hypoglycaemia-prone people with Type 1 diabetes. Diabet Med 2017; 34:625-631. [PMID: 28099755 DOI: 10.1111/dme.13317] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2017] [Indexed: 12/17/2022]
Abstract
AIMS To assess the difference between analogue and human insulin with regard to nocturnal glucose profiles and risk of hypoglycaemia in people with recurrent severe hypoglycaemia. METHODS A total of 72 people [46 men, mean ± sd age 54 ± 12 years, mean ± sd HbA1c 65 ± 12 mmol/mol (8.1 ± 1.1%), mean ± sd duration of diabetes 30 ± 14 years], who participated in a 2-year randomized, crossover trial of basal-bolus therapy with insulin detemir/insulin aspart or human NPH insulin/human regular insulin (the HypoAna trial) were studied for 2 nights during each treatment. Venous blood was drawn hourly during sleep. Primary endpoints were nocturnal glucose profiles and occurrence of hypoglycaemia (blood glucose ≤ 3.9 mmol/l). RESULTS During insulin analogue treatment, the mean nocturnal plasma glucose level was significantly higher than during treatment with human insulin (10.6 vs 8.1 mmol/l). The fasting plasma glucose level was similar between the treatments. Nocturnal hypoglycaemia was registered during 41/101 nights (41%) in the human insulin arm and 19/117 nights (16%) in the insulin analogue arm, corresponding to a hazard ratio of 0.26 (95% CI 0.14 to 0.45; P < 0.0001) with insulin analogue. CONCLUSIONS Treatment with insulin analogue reduces the occurrence of nocturnal hypoglycaemia assessed by nocturnal glucose profiles in people with Type 1 diabetes prone to severe hypoglycaemia. Nocturnal glucose profiles provide a more comprehensive assessment of clinical benefit of insulin regimens as compared to conventional recording of hypoglycaemia.
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Affiliation(s)
- P L Kristensen
- Nordsjaellands Hospital Hillerød, Department of Cardiology, Nephrology and Endocrinology, Hillerød, Denmark
| | - L Tarnow
- Steno Diabetes Centre, Department of Clinical Research, Gentofte, Denmark
- Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Research, Nordsjaellands Hospital Hillerød, Hillerød, Denmark
| | - C Bay
- Nordsjaellands Hospital Hillerød, Department of Cardiology, Nephrology and Endocrinology, Hillerød, Denmark
- Department of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - K Nørgaard
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
| | - T Jensen
- Department of Endocrinology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - H-H Parving
- Health, Aarhus University, Aarhus, Denmark
- Department of Endocrinology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - H Perrild
- Department of Endocrinology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - H Beck-Nielsen
- Department of Endocrinology M, Odense University Hospital, Odense, Denmark
| | - J S Christiansen
- Health, Aarhus University, Aarhus, Denmark
- Department of Endocrinology M, Aarhus University Hospital, Aarhus, Denmark
| | - B Thorsteinsson
- Nordsjaellands Hospital Hillerød, Department of Cardiology, Nephrology and Endocrinology, Hillerød, Denmark
- Department of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - U Pedersen-Bjergaard
- Nordsjaellands Hospital Hillerød, Department of Cardiology, Nephrology and Endocrinology, Hillerød, Denmark
- Department of Dermatology, Bispebjerg University Hospital, Copenhagen, Denmark
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19
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Hoskins N, Tikkanen CK, Pedersen-Bjergaard U. The economic impact of insulin-related hypoglycemia in Denmark: an analysis using the Local Impact of Hypoglycemia Tool. J Med Econ 2017; 20:363-370. [PMID: 27926814 DOI: 10.1080/13696998.2016.1269774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIMS To estimate the direct cost of hypoglycemia in insulin-treated adults with type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in Denmark. MATERIALS AND METHODS The Local Impact of Hypoglycemia Tool (LIHT) was used to estimate the costs associated with insulin-related hypoglycemia. Average utilization of healthcare resources, including the costs of pre-hospitalization, hospital admission, healthcare professional contact and follow-up, glucose/glucagon, and extra SMBG tests to monitor blood glucose following an episode, was used to calculate an average cost per severe and per non-severe hypoglycemic episode. The cost per episode was then applied to the rates of severe and non-severe hypoglycemia in people with T1DM and T2DM in Denmark. RESULTS The direct cost of insulin-related hypoglycemia in Denmark is DKK 96.2 million per year, which equates to EUR 12.9 million. For people with T1DM prone to severe hypoglycemia (defined as having ≥2 severe episodes in the past year), the cost per person per year increases by DKK 4,155 compared with the T1DM population average, and for people with T2DM prone to non-severe hypoglycemia (defined as having ≥1 non-severe episode in the last 4 weeks), the cost increases by DKK 647 per person per year compared with the T2DM population average. CONCLUSIONS The LIHT highlights the substantial economic burden of insulin-related hypoglycemia in Denmark, and provides a means to estimate the savings that could be made by lowering hypoglycemia rates. For example, the costs associated with using a new insulin or introducing a patient education program could be offset with the cost saving from reducing hypoglycemia.
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Affiliation(s)
| | | | - Ulrik Pedersen-Bjergaard
- c Department of Cardiology, Nephrology & Endocrinology , Nordsjællands Hospital Hillerød , Denmark
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20
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Cichosz SL, Frystyk J, Tarnow L, Fleischer J. Are Changes in Heart Rate Variability During Hypoglycemia Confounded by the Presence of Cardiovascular Autonomic Neuropathy in Patients with Diabetes? Diabetes Technol Ther 2017; 19:91-95. [PMID: 28118049 DOI: 10.1089/dia.2016.0342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND We have recently shown how the combination of information from continuous glucose monitor (CGM) and heart rate variability (HRV) measurements can be used to construct an algorithm for prediction of hypoglycemia in both bedbound and active patients with type 1 diabetes (T1D). Questions remain on how cardiovascular autonomic neuropathy (CAN) influences these measurable changes. This study aims to examine if changes in HRV during hypoglycemia are confounded by the presence of CAN. METHODS Twenty-one adults (hereof 13 men) with T1D prone to hypoglycemia were recruited and monitored with CGM and a Holter device while they performed normal daily activities. CAN was diagnosed using two cardiac reflex tests: (1) deep breathing and (2) orthostatic hypotension and end organ symptoms. Early CAN was defined as the presence of one abnormal reflex test and severe CAN was defined as two abnormal tests or one abnormal test combined with symptoms of autonomic neuropathy. RESULTS A total of 19 hypoglycemic and corresponding euglycemia periods were identified among the 21 patients. Eleven patients were diagnosed with CAN, hereof five with severe CAN. The HRV parameter low frequency (LF) was significantly (P = 0.029) reduced during hypoglycemia. Changes in LF during hypoglycemia were not different between patients with and without CAN, -0.64 versus -0.48 log(LF) (P = 0.74). CONCLUSIONS Our data show that there are measurable changes in HRV during hypoglycemia, and present in both patients with and without CAN.
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Affiliation(s)
- Simon Lebech Cichosz
- 1 Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Medical Research Laboratory, Institute of Clinical Research, Aarhus University , Aarhus, Denmark
- 2 Department of Health Science and Technology, Aalborg University , Aalborg, Denmark
| | - Jan Frystyk
- 1 Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Medical Research Laboratory, Institute of Clinical Research, Aarhus University , Aarhus, Denmark
| | - Lise Tarnow
- 3 Steno Diabetes Center, Department of Clinical Epidemiology, Aarhus University and Nordsjaellands Hospitaler Hilleroed , Hillerød, Denmark
| | - Jesper Fleischer
- 1 Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Medical Research Laboratory, Institute of Clinical Research, Aarhus University , Aarhus, Denmark
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21
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Pedersen-Bjergaard U, Kristensen PL, Nørgaard K, Perrild H, Jensen T, Thorsteinsson B, Nikolajsen A, Tarnow L. Short-term cost-effectiveness of insulin detemir and insulin aspart in people with type 1 diabetes who are prone to recurrent severe hypoglycemia. Curr Med Res Opin 2016; 32:1719-1725. [PMID: 27326862 DOI: 10.1080/03007995.2016.1205006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Based on the data of the HypoAna trial (ClinicalTrials.gov NCT00346996), a short-term cost-effectiveness analysis was conducted comparing an all insulin analogue regimen with an all human insulin regimen in people with type 1 diabetes who are prone to recurrent severe hypoglycemia. METHODS Clinical data from the HypoAna trial and Danish cost data related to the treatment of severe hypoglycemia were used to populate a 1-year cost-effectiveness analysis. Hypoglycemia quality-of-life data were based on previously published utility values, used to calculate the quality-adjusted life-years (QALYs) gained. Sensitivity analyses were conducted to test the robustness of the analysis. The main outcome measure was the incremental cost-effectiveness ratio (ICER). RESULTS The insulin analogue regimen was associated with greater total costs compared with the human insulin regimen (20,418 DKK [1972 GBP] vs. 18,558 DKK [1793 GBP], respectively), primarily driven by the difference in insulin costs. Total costs for corrective actions for hypoglycemic events, however, were lower in the insulin analogue group (927 DKK [89 GBP]) compared with the human insulin group (1311 DKK [127 GBP]), primarily due to a lower event rate. QALYs were higher with insulin analogues vs. human insulin (difference 0.0672). The resulting ICER was 27,685 DKK (2674 GBP) per QALY gained, which is well below the generally accepted cost-effectiveness threshold. CONCLUSIONS The analysis shows that treating people with type 1 diabetes who are prone to recurrent severe hypoglycemia with an insulin analogue regimen is cost-effective compared with a human insulin regimen.
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Affiliation(s)
- Ulrik Pedersen-Bjergaard
- a Department of Cardiology, Nephrology and Endocrinology , Nordsjællands University Hospital-Hillerød , Hillerød , Denmark
- b Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | - Peter Lommer Kristensen
- a Department of Cardiology, Nephrology and Endocrinology , Nordsjællands University Hospital-Hillerød , Hillerød , Denmark
| | - Kirsten Nørgaard
- c Department of Endocrinology , Hvidovre University Hospital , Hvidovre , Denmark
| | - Hans Perrild
- d Department of Endocrinology and Gastroenterology , Bispebjerg University Hospital , Copenhagen , Denmark
| | - Tonny Jensen
- e Department of Endocrinology , Copenhagen University Hospital (Rigshospitalet) , Copenhagen , Denmark
| | - Birger Thorsteinsson
- a Department of Cardiology, Nephrology and Endocrinology , Nordsjællands University Hospital-Hillerød , Hillerød , Denmark
- b Health and Medical Sciences , University of Copenhagen , Copenhagen , Denmark
| | | | - Lise Tarnow
- g Department of Clinical Medicine - Department of Clinical Epidemiology , University of Aarhus , Aarhus , Denmark
- h Clinical Research Unit, Steno Diabetes Center , Gentofte , Denmark
- i Department of Clinical Research , Nordsjællands University Hospital-Hillerød , Hillerød , Denmark
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