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Laugesen C, Ranjan AG, Schmidt S, Nørgaard K. Pen-administered low-dose dasiglucagon vs usual care for prevention and treatment of non-severe hypoglycaemia in people with type 1 diabetes during free-living conditions: a Phase II, randomised, open-label, two-period crossover trial. Diabetologia 2023; 66:1208-1217. [PMID: 37037948 PMCID: PMC10244275 DOI: 10.1007/s00125-023-05909-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/31/2023] [Indexed: 04/12/2023]
Abstract
AIMS/HYPOTHESIS Consumption of excess carbohydrates to manage hypoglycaemia can lead to rebound hyperglycaemia and promote weight gain. The objective of this trial was to evaluate the efficacy, safety and feasibility of pen-administered low-dose dasiglucagon for prevention and treatment of non-severe hypoglycaemia in people with type 1 diabetes during free-living conditions. METHODS Twenty-four adults with insulin pump-treated type 1 diabetes (HbA1c ≤70 mmol/mol [8.5%]) completed a randomised, open-label, two-period crossover study with 2 week periods. During the usual care and dasiglucagon intervention (DASI) periods, participants managed impending and manifested episodes of hypoglycaemia with regular carbohydrate consumption or pen-administered low-dose (80 μg) s.c. dasiglucagon, respectively. Glycaemic control was evaluated using continuous glucose monitoring (Dexcom G6) and event registration of prevention and treatment episodes. RESULTS Compared with usual care, the mean difference (95% CI) in the DASI period for time in (3.9-10.0 mmol/l) and below (<3.9 mmol/l) range was 2.4 %-points (-0.7, 5.5) and -0.5 %-points (-1.2, 0.2), respectively. In the DASI period, recovery rate (time from hypoglycaemia treatment to euglycaemia) was 44% (11, 87) faster while total daily carbohydrate intake was reduced by 11% (-18, -3). Dasiglucagon use was safe and well tolerated with mild nausea being the most frequent adverse effect. Among the participants, 96% (p<0.0001) were likely to include dasiglucagon in their future routine management of hypoglycaemia. CONCLUSIONS/INTERPRETATION Use of low-dose dasiglucagon to prevent and treat non-severe hypoglycaemia during free-living conditions was safe, fast and efficacious while significantly reducing the total daily carbohydrate intake and yielding high treatment satisfaction. TRIAL REGISTRATION ClinicalTrials.gov NCT04764968 FUNDING: The study was an investigator-initiated trial. Zealand Pharma supplied the investigational drug and device and provided financial support for the conduct of the trial.
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Affiliation(s)
| | - Ajenthen G Ranjan
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - Signe Schmidt
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Kirsten Nørgaard
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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2
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Kim CR, Han JH, Kim MJ, Kim MJ, Kim S, Cho YC, Ji HB, Min CH, Lee C, Choy YB. Implantable device with magnetically rotating disk for needle‐free administrations of emergency drug. Bioeng Transl Med 2023; 8:e10479. [DOI: 10.1002/btm2.10479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Cho Rim Kim
- Interdisciplinary Program in Bioengineering College of Engineering, Seoul National University Seoul Republic of Korea
| | - Jae Hoon Han
- Interdisciplinary Program in Bioengineering College of Engineering, Seoul National University Seoul Republic of Korea
| | - Min Ji Kim
- Interdisciplinary Program in Bioengineering College of Engineering, Seoul National University Seoul Republic of Korea
| | - Myoung Ju Kim
- Interdisciplinary Program in Bioengineering College of Engineering, Seoul National University Seoul Republic of Korea
| | - Se‐Na Kim
- Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University Seoul Republic of Korea
| | - Yong Chan Cho
- Interdisciplinary Program in Bioengineering College of Engineering, Seoul National University Seoul Republic of Korea
| | - Han Bi Ji
- Interdisciplinary Program in Bioengineering College of Engineering, Seoul National University Seoul Republic of Korea
| | - Chang Hee Min
- Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University Seoul Republic of Korea
| | - Cheol Lee
- Department of Pathology Seoul National University College of Medicine Seoul Republic of Korea
| | - Young Bin Choy
- Interdisciplinary Program in Bioengineering College of Engineering, Seoul National University Seoul Republic of Korea
- Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University Seoul Republic of Korea
- Department of Biomedical Engineering Seoul National University College of Medicine Seoul Republic of Korea
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Flatt AJ, Chen E, Peleckis AJ, Dalton-Bakes C, Nguyen HL, Collins HW, Millar JS, Gallop RJ, Rickels MR. Evaluation of Clinical Metrics for Identifying Defective Physiologic Responses to Hypoglycemia in Long-Standing Type 1 Diabetes. Diabetes Technol Ther 2022; 24:737-748. [PMID: 35758724 PMCID: PMC9529296 DOI: 10.1089/dia.2022.0103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Repeated hypoglycemia exposure leads to impaired awareness of hypoglycemia (IAH) and the development of defective counterregulatory responses. To date, only pancreas or islet transplantation has demonstrated normalization of hypoglycemia awareness and the endogenous glucose production (EGP) response to defend against insulin-induced hypoglycemia in long-standing type 1 diabetes (T1D). This study aims to validate clinical metrics of IAH (Clarke score), hypoglycemia severity (HYPO score), glycemic lability (lability index), and continuous glucose monitoring (CGM) as predictors of absent autonomic symptom (AS) recognition and defective glucose counterregulation during insulin-induced hypoglycemia, thus enabling early identification of individuals with compromised physiologic defense against clinically significant hypoglycemia. Forty-three subjects with mean ± standard deviation age 43 ± 13 years and T1D duration 28 ± 13 years, including 32 with IAH and 11 with hypoglycemia awareness (Aware), and 12 nondiabetic control subjects, underwent single-blinded randomized-paired hyperinsulinemic-euglycemic and hypoglycemic clamp experiments. Receiver operating characteristic (ROC) curves and sensitivity analyses were performed to assess metric prediction of absent AS recognition and defective EGP responses to hypoglycemia. Clarke score and CGM measures of hypoglycemia exposure demonstrated good ability to predict absent AS recognition (area under the curve ≥0.80). A composite threshold of IAH-Clarke ≥4 with ROC curve-derived thresholds for CGM measures of hypoglycemia exposure showed high specificity and predictive value in identifying an absent AS response during the hypoglycemic clamp. Metrics demonstrated poor ability to predict defective glucose counterregulation by the EGP response, which was impaired even in the Aware group. Screening for IAH alongside assessment of CGM data can increase the specificity for identifying individuals with absent hypoglycemia symptom recognition who may benefit from further intervention.
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Affiliation(s)
- Anneliese J. Flatt
- Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth Chen
- Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Amy J. Peleckis
- Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cornelia Dalton-Bakes
- Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Huong-Lan Nguyen
- Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Heather W. Collins
- Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - John S. Millar
- Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Translational Medicine and Human Genetics, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert J. Gallop
- Department of Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Mathematics, West Chester University of Pennsylvania, West Chester, Pennsylvania, USA
| | - Michael R. Rickels
- Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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4
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Laugesen C, Ranjan AG, Schmidt S, Nørgaard K. Low-Dose Dasiglucagon Versus Oral Glucose for Prevention of Insulin-Induced Hypoglycemia in People With Type 1 Diabetes: A Phase 2, Randomized, Three-Arm Crossover Study. Diabetes Care 2022; 45:1391-1399. [PMID: 35475907 DOI: 10.2337/dc21-2304] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 03/18/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the efficacy of low-dose subcutaneous dasiglucagon with oral glucose for prevention of insulin-induced hypoglycemia in people with type 1 diabetes. RESEARCH DESIGN AND METHODS Twenty adults with type 1 diabetes using multiple daily injection or insulin pump therapy completed a phase 2, randomized, three-arm crossover study. On each study visit, an individualized subcutaneous insulin bolus was administered aiming for a plasma glucose (PG) concentration of 3.0 mmol/L (54 mg/dL). When a PG concentration of 4.5 mmol/L (81 mg/dL) was reached, 15 g oral glucose (CHO) from dextrose tablets, 80 µg dasiglucagon (D80), or 120 µg dasiglucagon (D120) was administered. PG was measured frequently for the following 180 min. RESULTS Hypoglycemia (<3.9 mmol/L [70 mg/dL]) occurred in 10 participants after CHO, in 5 after D80, and in 4 after D120 (CHO vs. D80, P = 0.096; CHO vs. D120, P = 0.034). Time spent in hypoglycemia (<3.9 mmol/L [70 mg/dL]) was 14%, 7%, and 6% for CHO, D80, and D120, respectively (P = 0.273). The median time (95% CI) from intervention to first increase in PG of 1.1 mmol/L (20 mg/dL) was 30 (25-50), 15 (15-20), and 15 (15-20) minutes for CHO, D80, and D120, respectively (CHO vs. D80, P = 0.006; CHO vs. D120, P = 0.003). Episodes of nausea were numerically, but not significantly, higher after dasiglucagon administration. No significant differences in visual analog scale-assessed adverse effects were observed between interventions. CONCLUSIONS Low-dose dasiglucagon safely and effectively prevented insulin-induced hypoglycemia with a faster glucose-elevating profile than oral glucose.
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Affiliation(s)
| | - Ajenthen G Ranjan
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Danish Diabetes Academy, Odense, Denmark
| | - Signe Schmidt
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Boeder SC, Gregory JM, Giovannetti ER, Pettus JH. SGLT2 Inhibition Increases Fasting Glucagon but Does Not Restore the Counterregulatory Hormone Response to Hypoglycemia in Participants With Type 1 Diabetes. Diabetes 2022; 71:511-519. [PMID: 34857545 PMCID: PMC8893946 DOI: 10.2337/db21-0769] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022]
Abstract
Individuals with type 1 diabetes have an impaired glucagon counterregulatory response to hypoglycemia. Sodium-glucose cotransporter (SGLT) inhibitors increase glucagon concentrations. We evaluated whether SGLT inhibition restores the glucagon counterregulatory hormone response to hypoglycemia. Adults with type 1 diabetes (n = 22) were treated with the SGLT2 inhibitor dapagliflozin (5 mg daily) or placebo for 4 weeks in a randomized, double-blind, crossover study. After each treatment phase, participants underwent a hyperinsulinemic-hypoglycemic clamp. Basal glucagon concentrations were 32% higher following dapagliflozin versus placebo, with a median within-participant difference of 2.75 pg/mL (95% CI 1.38-12.6). However, increased basal glucagon levels did not correlate with decreased rates of hypoglycemia and thus do not appear to be protective in avoiding hypoglycemia. During hypoglycemic clamp, SGLT2 inhibition did not change counterregulatory hormone concentrations, time to recovery from hypoglycemia, hypoglycemia symptoms, or cognitive function. Thus, despite raising basal glucagon concentrations, SGLT inhibitor treatment did not restore the impaired glucagon response to hypoglycemia. We propose that clinical reduction in hypoglycemia associated with these agents is a result of changes in diabetes care (e.g., lower insulin doses or improved glycemic variability) as opposed to a direct, physiologic effect of these medications on α-cell function.
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Affiliation(s)
- Schafer C. Boeder
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Diego, La Jolla, CA
- Corresponding author: Schafer C. Boeder,
| | - Justin M. Gregory
- Ian M. Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
| | - Erin R. Giovannetti
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Diego, La Jolla, CA
| | - Jeremy H. Pettus
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Diego, La Jolla, CA
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Grassi B, Onetto MT, Zapata Y, Jofré P, Echeverría G. Lower versus standard sucrose dose for treating hypoglycemia in patients with type 1 diabetes mellitus in therapy with predictive low glucose suspend (PLGS) augmented insulin pumps: A randomized crossover trial in Santiago, Chile. Diabetes Metab Syndr 2021; 15:695-701. [PMID: 33813244 DOI: 10.1016/j.dsx.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS Recommended hypoglycemia treatment in adults with T1D consists of 15 g of rapid absorption carbohydrates. We aimed to evaluate the response to fewer carbohydrates for treating hypoglycemia in patients with T1D on insulin pumps with predictive suspension technology (PLGS). METHODS T1D patients on insulin pumps with PLGS were randomized to receive 10 or 15 g of sucrose per hypoglycemia for two weeks (S10 and S15 groups, respectively) when capillary blood glucose (BG) was <70 mg/dL, with crossover after two weeks. Evolution of capillary BG, active insulin, and suspension time were assessed. RESULTS 59 hypoglycemic episodes were analyzed, 33 in S10 and 26 in S15. Baseline BG in S10 was 54.3 ± 7.7 mg/dL versus 56.9 ± 8.8 in S15 (p = 0,239). Active insulin, present in 85% of the episodes, and PLGS suspension time were similar between groups. BG at 15 min was 77 mg/dL in S10 and 95 mg/dL in S15 (p = 0.0007). In S10, 21% of the episodes required to repeat the treatment after 15 min compared with none on S15, with a RR of 0,79 (95% CI 0.66, 0.940, p = 0,014) for successfully treating the episode. Sensor glucose was significantly different from BG at the moment of the hypoglycemia and control 15 min after treatment. No severe hypoglycemia and no rebound hyperglycemia occurred in neither group. CONCLUSIONS A hypoglycemia treatment protocol with a lower dose of sucrose might be insufficient despite PLGS technology. Our data suggest that standard doses of sucrose should still be recommended.
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Affiliation(s)
- Bruno Grassi
- Departament of Nutrition, Diabetes and Metabolism, School of Medicine. Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - María Teresa Onetto
- Departament of Nutrition, Diabetes and Metabolism, School of Medicine. Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Yazmín Zapata
- Departament of Nutrition, Diabetes and Metabolism, School of Medicine. Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paulina Jofré
- Departament of Nutrition, Diabetes and Metabolism, School of Medicine. Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Guadalupe Echeverría
- Departament of Nutrition, Diabetes and Metabolism, School of Medicine. Pontificia Universidad Católica de Chile, Santiago, Chile; Center of Molecular Nutrition and Chronic Diseases. School of Medicine. Pontificia Universidad Católica de Chile, Santiago, Chile
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Laugesen C, Schmidt S, Holst JJ, Nørgaard K, Ranjan AG. The effect of preceding glucose decline rate on low-dose glucagon efficacy in individuals with type 1 diabetes: A randomized crossover trial. Diabetes Obes Metab 2021; 23:1057-1062. [PMID: 33336888 DOI: 10.1111/dom.14301] [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: 11/03/2020] [Revised: 12/04/2020] [Accepted: 12/13/2020] [Indexed: 11/30/2022]
Abstract
Identifying determinants of low-dose glucagon efficacy is important to optimise its utilization for prevention and treatment of hypoglycaemia in individuals with type 1 diabetes. The study objective was to investigate whether the preceding glucose decline rate affects glucose response to low-dose glucagon administration. Ten adults with insulin pump-treated type 1 diabetes were included in this randomized, single-blind, two-way crossover study. Using a hyperinsulinaemic clamp technique, plasma glucose levels were reduced with either a rapid or slow decline rate while maintaining fixed insulin levels. When the plasma glucose level reached 3.9 mmoL/L, insulin and glucose infusions were discontinued and 150 μg subcutaneous glucagon was administered, followed by 120 minutes of plasma glucose monitoring. The positive incremental area under the glucose curve after administration of low-dose glucagon did not differ between the rapid-decline and slow-decline visits (mean ± SEM: 220 ± 49 vs. 174 ± 31 mmoL/L x min; P = 0.21). Similarly, no differences in total area under the glucose curve, peak plasma glucose, incremental peak plasma glucose, time-to-peak plasma glucose or end plasma glucose were observed. Thus, preceding glucose decline rate did not significantly affect the glucose response to low-dose glucagon.
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Affiliation(s)
| | - Signe Schmidt
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Jens Juul Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Ajenthen G Ranjan
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Danish Diabetes Academy, Odense, Denmark
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Gómez AM, Imitola A, Henao D, García-Jaramillo M, Giménez M, Viñals C, Grassi B, Torres M, Zuluaga I, Muñoz OM, Rondón M, León-Vargas F, Conget I. Factors associated with clinically significant hypoglycemia in patients with type 1 diabetes using sensor-augmented pump therapy with predictive low-glucose management: A multicentric study on iberoamerica. Diabetes Metab Syndr 2021; 15:267-272. [PMID: 33477103 DOI: 10.1016/j.dsx.2021.01.002] [Citation(s) in RCA: 2] [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] [Received: 06/01/2020] [Revised: 01/01/2021] [Accepted: 01/02/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Despite using sensor-augmented pump therapy (SAPT) with predictive low-glucose management (PLGM), hypoglycemia is still an issue in patients with type 1 Diabetes (T1D). Our aim was to determine factors associated with clinically significant hypoglycemia (<54 mg/dl) in persons with T1D treated with PLGM-SAPT. METHOD ology: This is a multicentric prospective real-life study performed in Colombia, Chile and Spain. Patients with T1D treated with PLGM-SAPT, using sensor ≥70% of time, were included. Data regarding pump and sensor use patterns and carbohydrate intake from 28 consecutive days were collected. A bivariate and multivariate Poisson regression analysis was carried out, to evaluate the association between the number of events of <54 mg/dl with the clinical variables and patterns of sensor and pump use. RESULTS 188 subjects were included (41 ± 13.8 years-old, 23 ± 12 years disease duration, A1c 7.2% ± 0.9). The median of events <54 mg/dl was four events/patient/month (IQR 1-10), 77% of these events occurred during day time. Multivariate analysis showed that the number of events of hypoglycemia were higher in patients with previous severe hypoglycemia (IRR1.38; 95% CI 1.19-1.61; p < 0.001), high glycemic variability defined as Coefficient of Variation (CV%) > 36% (IRR 2.09; 95%CI 1.79-2.45; p < 0.001) and hypoglycemia unawareness. A protector effect was identified for adequate sensor calibration (IRR 0.77; 95%CI 0.66-0.90; p:0.001), and the use of bolus wizard >60% (IRR 0.74; 95%CI 0.58-0.95; p:0.017). CONCLUSION In spite of using advanced SAPT, clinically significant hypoglycemia is still a non-negligible risk. Only the identification and intervention of modifiable factors could help to prevent and reduce hypoglycemia in clinical practice.
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Affiliation(s)
- Ana M Gómez
- Pontificia Universidad Javeriana, Carrera 7 No. 40-62, Bogotá, Colombia; Hospital Universitario San Ignacio, Endocrinology Unit, Carrera 7 No. 40-62, Bogotá, Colombia.
| | - Angelica Imitola
- Pontificia Universidad Javeriana, Carrera 7 No. 40-62, Bogotá, Colombia; Hospital Universitario San Ignacio, Endocrinology Unit, Carrera 7 No. 40-62, Bogotá, Colombia.
| | - Diana Henao
- Pontificia Universidad Javeriana, Carrera 7 No. 40-62, Bogotá, Colombia; Hospital Universitario San Ignacio, Endocrinology Unit, Carrera 7 No. 40-62, Bogotá, Colombia.
| | | | - Marga Giménez
- Diabetes Unit, Endocrinology and Nutrition Department, IDIBAPS (Institut D'investigacions Biomèdiques August Pi i Sunyer), CIBERDEM (Centro de Investigaciones Biomédicas en Red Sobre Diabetes y Enfermedades Metabólicas), Barcelona, Spain.
| | - Clara Viñals
- Diabetes Unit, Endocrinology and Nutrition Department, IDIBAPS (Institut D'investigacions Biomèdiques August Pi i Sunyer), CIBERDEM (Centro de Investigaciones Biomédicas en Red Sobre Diabetes y Enfermedades Metabólicas), Barcelona, Spain.
| | - Bruno Grassi
- Pontificia Universidad Católica de Chile, Chile.
| | - Mariana Torres
- Pontificia Universidad Javeriana, Carrera 7 No. 40-62, Bogotá, Colombia.
| | - Isabella Zuluaga
- Pontificia Universidad Javeriana, Carrera 7 No. 40-62, Bogotá, Colombia.
| | - Oscar Mauricio Muñoz
- Pontificia Universidad Javeriana, Carrera 7 No. 40-62, Bogotá, Colombia; Hospital Universitario San Ignacio, Department of Internal Medicine, Bogotá, Colombia; Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Carrera 7 No. 40-62, Bogotá, Colombia.
| | - Martin Rondón
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Carrera 7 No. 40-62, Bogotá, Colombia.
| | | | - Ignacio Conget
- Diabetes Unit, Endocrinology and Nutrition Department, IDIBAPS (Institut D'investigacions Biomèdiques August Pi i Sunyer), CIBERDEM (Centro de Investigaciones Biomédicas en Red Sobre Diabetes y Enfermedades Metabólicas), Barcelona, Spain.
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Jernelv IL, Hjelme DR, Aksnes A. Infrared measurements of glucose in peritoneal fluid with a tuneable quantum cascade laser. BIOMEDICAL OPTICS EXPRESS 2020; 11:3818-3829. [PMID: 33014568 PMCID: PMC7510913 DOI: 10.1364/boe.393617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/29/2020] [Accepted: 05/01/2020] [Indexed: 06/11/2023]
Abstract
Fast and accurate continuous glucose monitoring is needed in future systems for control of blood glucose levels in type 1 diabetes patients. Direct spectroscopic measurement of glucose in the peritoneal cavity is an attractive alternative to conventional electrochemical sensors placed subcutaneously. We demonstrate the feasibility of fast glucose measurements in peritoneal fluid using a fibre-coupled tuneable mid-infrared quantum cascade laser. Mid-infrared spectra (1200-925 cm-1) of peritoneal fluid samples from pigs with physiological glucose levels (32-426 mg/dL, or 1.8-23.7 mmol/L) were acquired with a tuneable quantum cascade laser employing both transmission and attenuated total reflection (ATR) spectroscopy. Using partial least-squares regression, glucose concentrations were predicted with mean absolute percentage errors (MAPEs) of 8.7% and 12.2% in the transmission and ATR configurations, respectively. These results show that highly accurate concentration predictions are possible with mid-infrared spectroscopy of peritoneal fluid, and represent a first step towards a miniaturised optical sensor for intraperitoneal continuous glucose monitoring.
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Affiliation(s)
| | - Dag Roar Hjelme
- Department of Electronic Systems, Norwegian University of Science and Technology (NTNU), O.S. Bragstads plass 2A, 7491 Trondheim, Norway
| | - Astrid Aksnes
- Department of Electronic Systems, Norwegian University of Science and Technology (NTNU), O.S. Bragstads plass 2A, 7491 Trondheim, Norway
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10
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Zahed K, Sasangohar F, Mehta R, Erraguntla M, Qaraqe K. Diabetes Management Experience and the State of Hypoglycemia: National Online Survey Study. JMIR Diabetes 2020; 5:e17890. [PMID: 32442145 PMCID: PMC7330735 DOI: 10.2196/17890] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/24/2020] [Accepted: 04/03/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Hypoglycemia, or low blood sugar levels, in people with diabetes can be a serious life-threatening condition, and serious outcomes can be avoided if low levels of blood sugar are proactively detected. Although technologies exist to detect the onset of hypoglycemia, they are invasive or costly or exhibit a high incidence of false alarms. Tremors are commonly reported symptoms of hypoglycemia and may be used to detect hypoglycemic events, yet their onset is not well researched or understood. OBJECTIVE This study aimed to understand diabetic patients' perceptions of hypoglycemic tremors, as well as their user experiences with technology to manage diabetes, and expectations from a self-management tool to ultimately inform the design of a noninvasive and cost-effective technology that detects tremors associated with hypoglycemia. METHODS A cross-sectional internet panel survey was administered to adult patients with type 1 diabetes using the Qualtrics platform in May 2019. The questions focused on 3 main constructs: (1) perceived experiences of hypoglycemia, (2) experiences and expectations about a diabetes management device and mobile app, and (3) beliefs and attitudes regarding intention to use a diabetes management device. The analysis in this paper focuses on the first two constructs. Nonparametric tests were used to analyze the Likert scale data, with a Mann-Whitney U test, Kruskal-Wallis test, and Games-Howell post hoc test as applicable, for subgroup comparisons to highlight differences in perceived frequency, severity, and noticeability of hypoglycemic tremors across age, gender, years living with diabetes, and physical activity. RESULTS Data from 212 respondents (129 [60.8%] females) revealed statistically significant differences in perceived noticeability of tremors by gender, whereby males noticed their tremors more (P<.001), and age, with the older population reporting lower noticeability than the young and middle age groups (P<.001). Individuals living longer with diabetes noticed their tremors significantly less than those with diabetes for ≤1 year but not in terms of frequency or severity. Additionally, the majority of our participants (150/212, 70.7%) reported experience with diabetes-monitoring devices. CONCLUSIONS Our findings support the need for cost-efficient and noninvasive continuous monitoring technologies. Although hypoglycemic tremors were perceived to occur frequently, such tremors were not found to be severe compared with other symptoms such as sweating, which was the highest rated symptom in our study. Using a combination of tremor and galvanic skin response sensors may show promise in detecting the onset of hypoglycemic events.
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Affiliation(s)
- Karim Zahed
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, United States
| | - Farzan Sasangohar
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, United States
- Center for Outcomes Research, Houston Methodist Hospital, Houston, TX, United States
| | - Ranjana Mehta
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, United States
| | - Madhav Erraguntla
- Department of Industrial and Systems Engineering, Texas A&M University, College Station, TX, United States
| | - Khalid Qaraqe
- Department of Electrical and Computer Engineering, Texas A&M University at Qatar, Doha, Qatar
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11
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Lei H, Gruetter R. Metabolic and perfusion responses to acute hypoglycemia in the rat cortex: A non-invasive magnetic resonance approach. J Neurochem 2020; 154:71-83. [PMID: 32306383 DOI: 10.1111/jnc.15028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022]
Abstract
Hypoglycemia is critical condition during diabetic treatment that involves intensive insulin therapy, and it may impair brain function. We aimed to compare cortical responses of three hypoglycemic phases and the restoration of glycemia to control levels after a severe episode in rats using non-invasive perfusion magnetic resonance (MR) imaging and localized 1 H MR spectroscopy. Under light α-chloralose anesthesia, cortical blood flow (cCBF) was 42 ± 3 ml/100 g/min at euglycemia (~ 5 mM plasma glucose), was not altered at mild hypoglycemia I (42 ± 4 ml/100 g/min, 2-3.5 mM), increased to 60 ± 8 ml/100 g/min under moderate hypoglycemia II (1-2 mM) and amplified to 190 ± 35 ml/100 g/min at severe hypoglycemia III (< 1 mM). 1 H MRS revealed metabolic changes at hypoglycemia I without any perfusion alteration. At hypoglycemia III, glutamine and glutamate decreased, whereas aspartate increased. When animals subsequently regained glycemic control, not all metabolites returned to their control levels, for example, glutamine. Meanwhile, ascorbate was increased with amplified hypoglycemic severity, whereas glutathione was reduced; these compounds did not return to normal levels upon the restoration of glycemia. Our study is the first to report cCBF and neurochemical changes in cortex upon five glycemic stages. The cortical responses of different hypoglycemic phases would explain variable neuronal damages after hypoglycemia and might help identify the degrees of hypoglycemic insults and further improve alternative therapies.
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Affiliation(s)
- Hongxia Lei
- Animal Imaging Technology (AIT), Center for Biomedical Imaging Research (CIBM), Ecole Polytechnique Federale de Lausanne, Lausanne, Switzerland
| | - Rolf Gruetter
- Animal Imaging Technology (AIT), Center for Biomedical Imaging Research (CIBM), Ecole Polytechnique Federale de Lausanne, Lausanne, Switzerland.,Wuhan United Imaging Life Science Instruments Ltd., Wuhan, P.R.China.,Laboratory of Functional and Metabolic Imaging (LIFMET), Ecole Polytechnique Federale de Lausanne, Lausanne, Switzerland.,Department of Radiology, University of Geneva, Geneva, Switzerland
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12
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Reeve C, Cummings E, McLaughlin E, Smith S, Gadbois S. An Idiographic Investigation of Diabetic Alert Dogs' Ability to Learn From a Small Sample of Breath Samples From People With Type 1 Diabetes. Can J Diabetes 2019; 44:37-43.e1. [PMID: 31477521 DOI: 10.1016/j.jcjd.2019.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/22/2019] [Accepted: 04/30/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE There is a growing market for diabetes-alert dogs but little has been published regarding their ability to reliably detect hypoglycemia. We aimed to determine whether 2 dogs could detect hypoglycemic breath samples from people with type 1 diabetes (T1D) and then transfer detection to novel hypoglycemic breath samples. METHODS Breath samples were collected from individuals with T1D during times of normo-, hypo- and hyperglycemia. Two dogs, previously trained (3 alternative forced choice) with breath samples from 3 different individuals with T1D, were presented with 3 breath samples from the same individual: 1 hypoglycemic, 1 normoglycemic and 1 hyperglycemic, and trained to identify the hypoglycemic sample using a "yes/no" procedure. The dogs' ability to transfer detection was then tested by presenting them with a novel sample set from the same individual. Then we tested whether 1 dog could transfer detection of the odour of hypoglycemia by presenting new samples from a different individual. RESULTS One dog was able to transfer detection of the odour of hypoglycemia to samples from the same individual (specificity 89%, sensitivity 62%), but a second dog was not. Results were inconclusive regarding the ability of 1 dog to transfer detection of the odour of hypoglycemia across 2 individuals. CONCLUSIONS The results suggest that some dogs can be trained to detect hypoglycemic breath of an individual with T1D, but detection may not transfer to novel samples from other individuals. Results should be interpreted with caution, as the dogs were trained with only a small number of breath samples before testing.
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Affiliation(s)
- Catherine Reeve
- Animal Welfare and Behaviour, School of Psychology, Queen's University Belfast, Belfast, Northern Ireland; Canid and Reptile Behaviour and Olfaction Team, Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Elizabeth Cummings
- IWK Health Centre, Dalhousie University Department of Pediatrics, Division of Endocrinology, Halifax, Nova Scotia, Canada
| | | | - Sonia Smith
- Canid and Reptile Behaviour and Olfaction Team, Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Educational Psychology and Special Education, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Simon Gadbois
- Canid and Reptile Behaviour and Olfaction Team, Department of Psychology and Neuroscience, Dalhousie University, Halifax, Nova Scotia, Canada
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13
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Anfinogenova Y, Grakova EV, Shvedova M, Kopieva KV, Teplyakov AT, Popov SV. Interdisciplinary approach to compensation of hypoglycemia in diabetic patients with chronic heart failure. Heart Fail Rev 2017; 23:481-497. [PMID: 28849410 DOI: 10.1007/s10741-017-9647-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Diabetes mellitus is a chronic disease requiring lifelong control with hypoglycemic agents that must demonstrate excellent efficacy and safety profiles. In patients taking glucose-lowering drugs, hypoglycemia is a common cause of death associated with arrhythmias, increased thrombus formation, and specific effects of catecholamines due to sympathoadrenal activation. Focus is now shifting from merely glycemic control to multifactorial approach. In the context of individual drugs and classes, this article reviews interdisciplinary strategies evaluating metabolic effects of drugs for treatment of chronic heart failure (CHF) which can mask characteristic hypoglycemia symptoms. Hypoglycemia unawareness and cardiac autonomic neuropathy are discussed. Data suggesting that hypoglycemia modulates immune response are reviewed. The potential role of gut microbiota in improving health of patients with diabetes and CHF is emphasized. Reports stating that nondiabetic CHF patients can have life-threatening hypoglycemia associated with imbalance of thyroid hormones are discussed. Regular glycemic control based on HbA1c measurements and adequate pharmacotherapy remain the priorities in diabetes management. New antihyperglycemic drugs with safer profiles should be preferred in vulnerable CHF patients. Multidrug interactions must be considered. Emerging therapies with reduced hypoglycemia risk, telemedicine, sensor technologies, and genetic testing predicting hypoglycemia risk may help solving the challenges of hypoglycemia in CHF patients with diabetes. Interdisciplinary work may involve cardiologists, diabetologists/endocrinologists, immunologists, gastroenterologists, microbiologists, nutritionists, imaging specialists, geneticists, telemedicine experts, and other relevant specialists. This review emphasizes that systematic knowledge on pathophysiology of hypoglycemia in diabetic patients with CHF is largely lacking and the gaps in our understanding require further discoveries.
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Affiliation(s)
- Yana Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012. .,National Research Tomsk Polytechnic University, 30 Lenin Avenue, Tomsk, Russia, 634050.
| | - Elena V Grakova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012
| | - Maria Shvedova
- Cardiovascular Research Center (CVRC), Massachusetts General Hospital, 149 13th Street, Charlestown, MA, 02129, USA
| | - Kristina V Kopieva
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012
| | - Alexander T Teplyakov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012
| | - Sergey V Popov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111-a Kievskaya Street, Tomsk, Russia, 634012
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14
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Naik S, Belfort-DeAguiar R, Sejling AS, Szepietowska B, Sherwin RS. Evaluation of the counter-regulatory responses to hypoglycaemia in patients with type 1 diabetes during opiate receptor blockade with naltrexone. Diabetes Obes Metab 2017; 19:615-621. [PMID: 27987236 PMCID: PMC6015737 DOI: 10.1111/dom.12855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/30/2016] [Accepted: 12/12/2016] [Indexed: 12/16/2022]
Abstract
AIMS Hypoglycaemia is the major limiting factor in achieving optimal glycaemic control in people with type 1 diabetes (T1DM), especially intensively treated patients with impaired glucose counter-regulation during hypoglycaemia. Naloxone, an opiate receptor blocker, has been reported to enhance the acute counter-regulatory response to hypoglycaemia when administered intravenously in humans. The current study was undertaken to investigate the oral formulation of the long-acting opiate antagonist, naltrexone, and determine if it could have a similar effect, and thus might be useful therapeutically in treatment of T1DM patients with a high risk of hypoglycaemia. MATERIALS AND METHODS We performed a randomized, placebo-controlled, double-blinded, cross-over study in which 9 intensively treated subjects with T1DM underwent a 2-step euglycaemic-hypoglycaemic-hyperinsulinaemic clamp on 2 separate occasions. At 12 hours and at 1 hour before the clamp study, participants received 100 mg of naltrexone or placebo orally. Counter-regulatory hormonal responses were assessed at baseline and during each step of the hyperinsulinaemic-clamp. RESULTS Glucose and insulin levels did not differ significantly between the naltrexone and placebo visits; nor did the glucose infusion rates required to keep glucose levels at target. During hypoglycaemia, naltrexone, in comparison with the placebo group, induced an increase in epinephrine levels ( P = .05). However, no statistically significant differences in glucagon, cortisol and growth hormone responses were observed. CONCLUSION In contrast to the intravenous opiate receptor blocker naloxone, overnight administration of the oral long-acting opiate receptor blocker, naltrexone, at a clinically used dose, had a limited effect on the counter-regulatory response to hypoglycaemia in intensively treated subjects with T1DM.
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MESH Headings
- Adult
- Blood Glucose/analysis
- Connecticut/epidemiology
- Cross-Over Studies
- Delayed-Action Preparations/adverse effects
- Delayed-Action Preparations/therapeutic use
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/drug therapy
- Double-Blind Method
- Drug Monitoring
- Epinephrine/blood
- Epinephrine/metabolism
- Female
- Glucose Clamp Technique
- Glycated Hemoglobin/analysis
- Humans
- Hypoglycemia/chemically induced
- Hypoglycemia/epidemiology
- Hypoglycemia/prevention & control
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/blood
- Hypoglycemic Agents/pharmacokinetics
- Hypoglycemic Agents/therapeutic use
- Insulin, Regular, Human/adverse effects
- Insulin, Regular, Human/blood
- Insulin, Regular, Human/pharmacokinetics
- Insulin, Regular, Human/therapeutic use
- Male
- Naltrexone/adverse effects
- Naltrexone/therapeutic use
- Nausea/chemically induced
- Risk
- Sensory System Agents/adverse effects
- Sensory System Agents/therapeutic use
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Affiliation(s)
- Sarita Naik
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Department of Diabetes and Endocrinology, University College Hospital, London, UK
| | - Renata Belfort-DeAguiar
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Anne-Sophie Sejling
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Department of Cardiology, Nephrology and Endocrinology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Barbara Szepietowska
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
- Heart Research Follow-Up Program, University of Rochester Medical Center, Rochester, New York
| | - Robert S Sherwin
- Department of Internal Medicine and Endocrinology, Yale University School of Medicine, New Haven, Connecticut
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15
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Butalia S, Patel AB, Johnson JA, Ghali WA, Rabi DM. Geographic Clustering of Acute Complications and Sociodemographic Factors in Adults with Type 1 Diabetes. Can J Diabetes 2016; 41:132-137. [PMID: 27887926 DOI: 10.1016/j.jcjd.2016.08.224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 03/18/2016] [Accepted: 08/24/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To assess the geographic distribution of acute complications in patients with type 1 diabetes in a large urban centre; and to assess the association between acute complications and community-level sociodemographic factors. METHODS Adults (aged ≥18 years old) with type 1 diabetes and acute complications were identified between 2004 and 2008 by using a diabetes centre clinical database or discharge abstracts for acute complications (diabetic ketoacidosis or hypoglycemia). Using a geographic information system, hot-spot analysis was used to identify spatial clusters of acute complications in a large urban centre. The association between acute complications and community-level sociodemographic factors were assessed by Spearman rank correlation. RESULTS We identified 1779 patients with type 1 diabetes, of whom 456 had been hospitalized for acute complications. The mean age of patients was 40.9±16.0 years, and men were more likely to have acute complications (59.2% vs. 52.3%; p<0.01). Spatial clusters of high values and low values were identified. Higher median family income (r=-0.36; p<0.0001) and higher education levels (r=-0.30; p<0.0001) were associated with lower rates of acute complications. CONCLUSIONS This study demonstrated geographic clusters of hospitalizations for acute complications and important community sociodemographic factors. Prevention strategies and interventions targeting these geographic and sociodemographic disparities need to be explored as a means of minimizing hospitalizations for acute complications.
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Affiliation(s)
- Sonia Butalia
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.
| | - Alka B Patel
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey A Johnson
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - William A Ghali
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Doreen M Rabi
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Department of Cardiac Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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16
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Gregory JM, Kraft G, Scott MF, Neal DW, Farmer B, Smith MS, Hastings JR, Allen EJ, Donahue EP, Rivera N, Winnick JJ, Edgerton DS, Nishimura E, Fledelius C, Brand CL, Cherrington AD. Insulin Delivery Into the Peripheral Circulation: A Key Contributor to Hypoglycemia in Type 1 Diabetes. Diabetes 2015; 64:3439-51. [PMID: 26085570 PMCID: PMC4587648 DOI: 10.2337/db15-0071] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 06/10/2015] [Indexed: 12/25/2022]
Abstract
Hypoglycemia limits optimal glycemic control in type 1 diabetes mellitus (T1DM), making novel strategies to mitigate it desirable. We hypothesized that portal (Po) vein insulin delivery would lessen hypoglycemia. In the conscious dog, insulin was infused into the hepatic Po vein or a peripheral (Pe) vein at a rate four times of basal. In protocol 1, a full counterregulatory response was allowed, whereas in protocol 2, glucagon was fixed at basal, mimicking the diminished α-cell response to hypoglycemia seen in T1DM. In protocol 1, glucose fell faster with Pe insulin than with Po insulin, reaching 56 ± 3 vs. 70 ± 6 mg/dL (P = 0.04) at 60 min. The change in area under the curve (ΔAUC) for glucagon was similar between Pe and Po, but the peak occurred earlier in Pe. The ΔAUC for epinephrine was greater with Pe than with Po (67 ± 17 vs. 36 ± 14 ng/mL/180 min). In protocol 2, glucose also fell more rapidly than in protocol 1 and fell faster in Pe than in Po, reaching 41 ± 3 vs. 67 ± 2 mg/dL (P < 0.01) by 60 min. Without a rise in glucagon, the epinephrine responses were much larger (ΔAUC of 204 ± 22 for Pe vs. 96 ± 29 ng/mL/180 min for Po). In summary, Pe insulin delivery exacerbates hypoglycemia, particularly in the presence of a diminished glucagon response. Po vein insulin delivery, or strategies that mimic it (i.e., liver-preferential insulin analogs), should therefore lessen hypoglycemia.
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Affiliation(s)
- Justin M Gregory
- Ian M. Burr Division of Pediatric Endocrinology and Diabetes, Vanderbilt University School of Medicine, Nashville, TN
| | - Guillaume Kraft
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Melanie F Scott
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Doss W Neal
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Ben Farmer
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Marta S Smith
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jon R Hastings
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Eric J Allen
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - E Patrick Donahue
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Noelia Rivera
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Jason J Winnick
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | - Dale S Edgerton
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
| | | | | | | | - Alan D Cherrington
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN
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17
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Franc A, Sabadková D, Neumann D, Pavloková S, Kopecká P, Muselík J. Interdiction of hypoglycemia in diabetic children by multiparticulate dosage form with controlled glucose release. Pharm Dev Technol 2015; 21:867-874. [PMID: 26334252 DOI: 10.3109/10837450.2015.1073741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients tend to evade the occurrence of hypoglycemic episodes by excessive carbohydrate intake. Glucose pellets with delayed release in the time of the maximum effect of insulin can not only prevent hypoglycemia but also eliminate the preventive carbohydrate intake. The pellets can be administered in a mixture with semisolid food. The cores containing glucose in combination with osmotically active agents (croscarmellose sodium, carmellose sodium, polyethylene glycol, or carboxymethyl starch) were prepared by extrusion-spheronization and coated with 15% water ethylcellulose dispersion (Surelease® B NF) in Wurster column (Medipo, Havlíčkův Brod, Czech Republic) into four coating levels (12.5, 25, 35, and 50%). Mean particle size is 0.63-0.73 for cores and 0.82-0.98 for coated pellets. Cores and coated pellets have excellent or good flow properties according to Hausner ratio and Carr index. Aspect ratio ranges from 1.78 to 2.17 for cores and from 1.73 to 2.31 for coated pellets. Dissolution was performed using pH-independent method and method with continual change of pH. The suitable pH-independent release was achieved in the samples containing carboxymethyl starch or polyethylene glycol. Glucose release is enabled by a membrane rupture caused by core swelling. It can be, therefore, assumed that the glucose release profile will not be affected by food or transit time.
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Affiliation(s)
- Aleš Franc
- a Department of Pharmaceutics, Faculty of Pharmacy , University of Veterinary and Pharmaceutical Sciences , Brno , Czech Republic and
| | - Dana Sabadková
- a Department of Pharmaceutics, Faculty of Pharmacy , University of Veterinary and Pharmaceutical Sciences , Brno , Czech Republic and
| | - David Neumann
- b Department of Pediatrics , University Hospital , Hradec Králové , Czech Republic
| | - Sylvie Pavloková
- a Department of Pharmaceutics, Faculty of Pharmacy , University of Veterinary and Pharmaceutical Sciences , Brno , Czech Republic and
| | - Pavlína Kopecká
- a Department of Pharmaceutics, Faculty of Pharmacy , University of Veterinary and Pharmaceutical Sciences , Brno , Czech Republic and
| | - Jan Muselík
- a Department of Pharmaceutics, Faculty of Pharmacy , University of Veterinary and Pharmaceutical Sciences , Brno , Czech Republic and
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18
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Choudhary P, Rickels MR, Senior PA, Vantyghem MC, Maffi P, Kay TW, Keymeulen B, Inagaki N, Saudek F, Lehmann R, Hering BJ. Evidence-informed clinical practice recommendations for treatment of type 1 diabetes complicated by problematic hypoglycemia. Diabetes Care 2015; 38:1016-29. [PMID: 25998294 PMCID: PMC4439532 DOI: 10.2337/dc15-0090] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Problematic hypoglycemia, defined as two or more episodes per year of severe hypoglycemia or as one episode associated with impaired awareness of hypoglycemia, extreme glycemic lability, or major fear and maladaptive behavior, is a challenge, especially for patients with long-standing type 1 diabetes. Individualized therapy for such patients should include a composite target: optimal glucose control without problematic hypoglycemia. Therefore, we propose a tiered, four-stage algorithm based on evidence of efficacy given the limitations of educational, technological, and transplant interventions. All patients with problematic hypoglycemia should undergo structured or hypoglycemia-specific education programs (stage 1). Glycemic and hypoglycemia treatment targets should be individualized and reassessed every 3-6 months. If targets are not met, one diabetes technology-continuous subcutaneous insulin infusion or continuous glucose monitoring-should be added (stage 2). For patients with continued problematic hypoglycemia despite education (stage 1) and one diabetes technology (stage 2), sensor-augmented insulin pumps preferably with an automated low-glucose suspend feature and/or very frequent contact with a specialized hypoglycemia service can reduce hypoglycemia (stage 3). For patients whose problematic hypoglycemia persists, islet or pancreas transplant should be considered (stage 4). This algorithm provides an evidence-informed approach to resolving problematic hypoglycemia; it should be used as a guide, with individual patient circumstances directing suitability and acceptability to ensure the prudent use of technology and scarce transplant resources. Standardized reporting of hypoglycemia outcomes and inclusion of patients with problematic hypoglycemia in studies of new interventions may help to guide future therapeutic strategies.
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Affiliation(s)
| | - Michael R Rickels
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter A Senior
- Department of Medicine, Division of Endocrinology, University of Alberta, Edmonton, Canada
| | - Marie-Christine Vantyghem
- Endocrinology and Metabolism Department, INSERM U1190, European Genomics Institute for Diabetes, Lille University Hospital, Lille Cedex, France
| | - Paola Maffi
- Diabetes Research Institute, Scientific Institute Ospedale San Raffaele, Milan, Italy
| | - Thomas W Kay
- Immunology and Diabetes Unit, St. Vincent's Institute, University of Melbourne, Melbourne, Australia
| | - Bart Keymeulen
- Diabetes Clinic and Research Center, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nobuya Inagaki
- Department of Diabetes and Clinical Nutrition, Kyoto University, Kyoto, Japan
| | - Frantisek Saudek
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Roger Lehmann
- Department of Endocrinology and Diabetology, University of Zurich, Zurich, Switzerland
| | - Bernhard J Hering
- Schulze Diabetes Institute and Department of Surgery, University of Minnesota, Minneapolis, MN
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19
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Thabit H, Elleri D, Leelarathna L, Allen JM, Lubina-Solomon A, Stadler M, Walkinshaw E, Iqbal A, Choudhary P, Wilinska ME, Barnard KD, Heller SR, Amiel SA, Evans ML, Dunger DB, Hovorka R. Unsupervised home use of an overnight closed-loop system over 3-4 weeks: a pooled analysis of randomized controlled studies in adults and adolescents with type 1 diabetes. Diabetes Obes Metab 2015; 17:452-8. [PMID: 25492378 PMCID: PMC4510702 DOI: 10.1111/dom.12427] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/01/2014] [Accepted: 12/04/2014] [Indexed: 12/25/2022]
Abstract
AIMS To compare overnight closed-loop and sensor-augmented pump therapy in patients with type 1 diabetes by combining data collected during free-living unsupervised randomized crossover home studies. METHODS A total of 40 participants with type 1 diabetes, of whom 24 were adults [mean ± standard deviation (s.d.) age 43 ± 12 years and glycated haemoglobin (HbA1c) 8.0 ± 0.9%] and 16 were adolescents (mean ± s.d. age 15.6 ± 3.6 years and HbA1c 8.1 ± 0.8%), underwent two periods of sensor-augmented pump therapy in the home setting, in combination with or without an overnight closed-loop insulin delivery system that uses a model predictive control algorithm to direct insulin delivery. The order of the two interventions was random; each period lasted 4 weeks in adults and 3 weeks in adolescents. The primary outcome was time during which sensor glucose readings were in the target range of 3.9-8.0 mmol/l. RESULTS The proportion of time when sensor glucose was in the target range (3.9-8.0 mmol/l) overnight (between 24:00 and 08:00 hours) was 18.5% greater during closed-loop insulin delivery than during sensor-augmented therapy (p < 0.001). Closed-loop therapy significantly reduced mean overnight glucose levels by 0.9 mmol/l (p < 0.001), with no difference in glycaemic variability, as measured by the standard deviation of sensor glucose. Time spent above the target range was reduced (p = 0.001), as was time spent in hypoglycaemia (<3.9 mmol/l; p = 0.014) during closed-loop therapy. Lower mean overnight glucose levels during closed-loop therapy were brought about by increased overnight insulin delivery (p < 0.001) without changes to the total daily delivery (p = 0.84). CONCLUSION Overnight closed-loop insulin therapy at home in adults and adolescents with type 1 diabetes is feasible, showing improvements in glucose control and reducing the risk of nocturnal hypoglycaemia.
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Affiliation(s)
- H Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
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20
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Olsen SE, Asvold BO, Frier BM, Aune SE, Hansen LI, Bjørgaas MR. Hypoglycaemia symptoms and impaired awareness of hypoglycaemia in adults with Type 1 diabetes: the association with diabetes duration. Diabet Med 2014; 31:1210-7. [PMID: 24824356 DOI: 10.1111/dme.12496] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2014] [Indexed: 11/29/2022]
Abstract
AIMS To examine the association between diabetes duration and hypoglycaemia symptom profiles and the presence of impaired awareness of hypoglycaemia. METHODS A cross-sectional study was performed, using validated methods for recording hypoglycaemia symptoms and assessing hypoglycaemia awareness. The associations between symptom intensity, hypoglycaemia awareness and diabetes duration were examined, and the prevalence of impaired awareness was ascertained for Type 1 diabetes of differing durations. RESULTS Questionnaires were mailed to 636 adults with Type 1 diabetes, of whom 445 (70%) returned them. A total of 440 completed questionnaires were suitable for analysis. Longer diabetes duration was associated with lower intensity of autonomic symptoms (P for trend <0.001), but no association was observed with neuroglycopenic symptoms. The overall prevalence of impaired awareness of hypoglycaemia in this cohort was 17% (95% CI 14-21%) and increased with diabetes duration, from 3% for duration 2-9 years to 28% for duration ≥30 years (P for trend <0.001). Low autonomic symptom scores were not associated with a higher prevalence of impaired awareness. CONCLUSIONS Longer diabetes duration was associated with lower intensity of autonomic symptoms and a higher prevalence of impaired awareness of hypoglycaemia, suggesting that subjective symptoms of hypoglycaemia change over time. These observations underline the need for regular patient education about hypoglycaemia symptomatology and clinical screening for impaired awareness of hypoglycaemia.
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Affiliation(s)
- S E Olsen
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Norway
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Hypoglycemia induced by insulin as a triggering factor of cognitive deficit in diabetic children. ScientificWorldJournal 2014; 2014:616534. [PMID: 24790575 PMCID: PMC3982249 DOI: 10.1155/2014/616534] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 02/18/2014] [Indexed: 12/12/2022] Open
Abstract
This paper provides an overview of insulin-induced hypoglycemia as a triggering factor of cognitive deficit in children with type 1 diabetes mellitus. For this purpose, databases from 1961 to 2013 were used with the objective of detecting the primary publications that address the impact of hypoglycemia on cognitive performance of diabetic children. The results obtained from experimental animals were excluded. The majority of studies demonstrated that the cognitive deficit in diabetic children involves multiple factors including duration, intensity, severity, and frequency of hypoglycemia episodes. Additionally, age at the onset of type 1 diabetes also influences the cognitive performance, considering that early inception of the disease is a predisposing factor for severe hypoglycemia. Furthermore, the results suggest that there is a strong correlation between brain damage caused by hypoglycemia and cognitive deterioration. Therefore, a more cautious follow-up and education are needed to impede and treat hypoglycemia in children with diabetes mellitus.
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22
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Awoniyi O, Rehman R, Dagogo-Jack S. Hypoglycemia in patients with type 1 diabetes: epidemiology, pathogenesis, and prevention. Curr Diab Rep 2013; 13:669-78. [PMID: 23912765 DOI: 10.1007/s11892-013-0411-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hypoglycemia is uncommon in the general, nondiabetic population but occurs frequently in persons with diabetes treated with insulin or insulin secretagogues. Thus, iatrogenic hypoglycemia explains the majority of cases among persons with type 1 diabetes (T1DM). Since T1DM is characterized by absolute insulin dependence, the current imperfections in insulin replacement therapies often lead to a mismatch between caloric supply and circulating insulin levels, thus increasing the risk for glycemic fluctuations. Hypoglycemia is the limiting factor to excellent glycemic control in insulin-treated subjects. Intensification of glycemic control was associated with a 300 % increase in the rate of hypoglycemia in the Diabetes Control and Complications Trial. Recent measurements using continuous glucose monitoring reveal an alarming rate of daytime and nocturnal episodes of hypoglycemia in patients with T1DM. Etiological factors underlying hypoglycemia in T1DM include predictable triggers (skipped meals, exercise, insulin over dosage) as well as defective counterregulation, a component of hypoglycemia-associated autonomic failure.
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Affiliation(s)
- Omodele Awoniyi
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism & Clinical Research Center, University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN, 38163, USA
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Kalra S, Mukherjee JJ, Venkataraman S, Bantwal G, Shaikh S, Saboo B, Das AK, Ramachandran A. Hypoglycemia: The neglected complication. Indian J Endocrinol Metab 2013; 17:819-34. [PMID: 24083163 PMCID: PMC3784865 DOI: 10.4103/2230-8210.117219] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Hypoglycemia is an important complication of glucose-lowering therapy in patients with diabetes mellitus. Attempts made at intensive glycemic control invariably increases the risk of hypoglycemia. A six-fold increase in deaths due to diabetes has been attributed to patients experiencing severe hypoglycemia in comparison to those not experiencing severe hypoglycemia Repeated episodes of hypoglycemia can lead to impairment of the counter-regulatory system with the potential for development of hypoglycemia unawareness. The short- and long-term complications of diabetes related hypoglycemia include precipitation of acute cerebrovascular disease, myocardial infarction, neurocognitive dysfunction, retinal cell death and loss of vision in addition to health-related quality of life issues pertaining to sleep, driving, employment, recreational activities involving exercise and travel. There is an urgent need to examine the clinical spectrum and burden of hypoglycemia so that adequate control measures can be implemented against this neglected life-threatening complication. Early recognition of hypoglycemia risk factors, self-monitoring of blood glucose, selection of appropriate treatment regimens with minimal or no risk of hypoglycemia and appropriate educational programs for healthcare professionals and patients with diabetes are the major ways forward to maintain good glycemic control, minimize the risk of hypoglycemia and thereby prevent long-term complications.
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Affiliation(s)
- Sanjay Kalra
- Bharti Research Institute of Diabetes and Endocrinology, Karnal, Haryana, India
| | - Jagat Jyoti Mukherjee
- Department of Endocrinology and Diabetes, Apollo Gleneagles Hospital, Kolkata, India
| | | | - Ganapathi Bantwal
- Department of Endocrinology, St. John's Medical College, Bangalore, India
| | - Shehla Shaikh
- Department of Endocrinology, Prince Aly Khan Hospital and Saifee Hospital, Mumbai, India
| | - Banshi Saboo
- Department of Diabetology, Dia Care Diabetes Care Centre, Ahmedabad, India
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24
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Crenier L, Abou-Elias C, Corvilain B. Glucose variability assessed by low blood glucose index is predictive of hypoglycemic events in patients with type 1 diabetes switched to pump therapy. Diabetes Care 2013; 36:2148-53. [PMID: 23404296 PMCID: PMC3714507 DOI: 10.2337/dc12-2058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether subgroups of type 1 diabetic patients with different glucose variability indices respond differently to continuous subcutaneous insulin infusion (CSII) in terms of reduced hypoglycemic events. RESEARCH DESIGN AND METHODS We studied 50 adults with long-standing type 1 diabetes switched to CSII because of persistently high A1C or frequent hypoglycemia despite well-managed intensive basal-bolus therapy. We compared A1C, hypoglycemic events, and glucose variability from self-monitoring of blood glucose profiles at baseline and after 6 months of CSII. Regression analysis was performed to identify predictors of response. RESULTS In multivariate analysis, baseline low blood glucose index (LBGI) was the best independent predictor of hypoglycemia outcome on CSII (R(2) = 0.195, P = 0.0013). An ROC curve analysis demonstrated a sensitivity of 70.8% (95% CI 48.9-87.4) and specificity of 73.1% (52.2-88.4) by using the LBGI cutoff of 3.34 as predictor of reduction of hypoglycemia on CSII. By grouping patients by LBGI tertiles, we found a 23.3% reduction in hypoglycemic events (<60 mg/dL [3.3 mmol/L]) in the third tertile (range 4.18-9.34) without change in A1C (P < 0.05). Conversely, the first tertile (range 0.62-2.05) demonstrated the greatest A1C reduction, -0.99% (P = 0.00001), but with increasing hypoglycemia. CONCLUSIONS Baseline LBGI predicts the outcome of type 1 diabetic patients who switch to CSII in terms of hypoglycemia.
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Affiliation(s)
- Laurent Crenier
- Department of Endocrinology, ULB-Erasme Hospital, Brussels, Belgium.
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25
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Hsu PF, Sung SH, Cheng HM, Yeh JS, Liu WL, Chan WL, Chen CH, Chou P, Chuang SY. Association of clinical symptomatic hypoglycemia with cardiovascular events and total mortality in type 2 diabetes: a nationwide population-based study. Diabetes Care 2013; 36:894-900. [PMID: 23223349 PMCID: PMC3609481 DOI: 10.2337/dc12-0916] [Citation(s) in RCA: 179] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Hypoglycemia is associated with serious health outcomes for patients treated for diabetes. However, the outcome of outpatients with type 2 diabetes who have experienced hypoglycemia episodes is largely unknown. RESEARCH DESIGN AND METHODS The study population, derived from the National Health Insurance Research Database released by the Taiwan National Health Research Institutes during 1998-2009, comprised 77,611 patients with newly diagnosed type 2 diabetes. We designed a prospective study consisting of randomly selected hypoglycemic type 2 diabetic patients and matched type 2 diabetic patients without hypoglycemia. We investigated the relationships of hypoglycemia with total mortality and cardiovascular events, including stroke, coronary heart disease, cardiovascular diseases, and all-cause hospitalization. RESULTS There were 1,844 hypoglycemic events (500 inpatients and 1,344 outpatients) among the 77,611 patients. Both mild (outpatient) and severe (inpatient) hypoglycemia cases had a higher percentage of comorbidities, including hypertension, renal diseases, cancer, stroke, and heart disease. In multivariate Cox regression models, including diabetes treatment adjustment, diabetic patients with hypoglycemia had a significantly higher risk of cardiovascular events during clinical treatment periods. After constructing a model adjusted with propensity scores, mild and severe hypoglycemia still demonstrated higher hazard ratios (HRs) for cardiovascular diseases (HR 2.09 [95% CI 1.63-2.67]), all-cause hospitalization (2.51 [2.00-3.16]), and total mortality (2.48 [1.41-4.38]). CONCLUSIONS Symptomatic hypoglycemia, whether clinically mild or severe, is associated with an increased risk of cardiovascular events, all-cause hospitalization, and all-cause mortality. More attention may be needed for diabetic patients with hypoglycemic episodes.
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Affiliation(s)
- Pai-Feng Hsu
- Healthcare and Management Center, Taipei Veterans General Hospital, Taipei, Taiwan
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26
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Whitehead N, White H. Systematic review of randomised controlled trials of the effects of caffeine or caffeinated drinks on blood glucose concentrations and insulin sensitivity in people with diabetes mellitus. J Hum Nutr Diet 2013; 26:111-25. [DOI: 10.1111/jhn.12033] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- N. Whitehead
- Department of Nutrition and Dietetics; Leeds Metropolitan University; Leeds UK
| | - H. White
- Department of Nutrition and Dietetics; Leeds Metropolitan University; Leeds UK
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Coenzyme Q10 prevents peripheral neuropathy and attenuates neuron loss in the db-/db- mouse, a type 2 diabetes model. Proc Natl Acad Sci U S A 2012; 110:690-5. [PMID: 23267110 DOI: 10.1073/pnas.1220794110] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Diabetic peripheral neuropathy (DPN) is the most common complication in both type 1 and type 2 diabetes. Here we studied some phenotypic features of a well-established animal model of type 2 diabetes, the leptin receptor-deficient db(-)/db(-) mouse, and also the effect of long-term (6 mo) treatment with coenzyme Q10 (CoQ10), an endogenous antioxidant. Diabetic mice at 8 mo of age exhibited loss of sensation, hypoalgesia (an increase in mechanical threshold), and decreases in mechanical hyperalgesia, cold allodynia, and sciatic nerve conduction velocity. All these changes were virtually completely absent after the 6-mo, daily CoQ10 treatment in db(-)/db(-) mice when started at 7 wk of age. There was a 33% neuronal loss in the lumbar 5 dorsal root ganglia (DRGs) of the db(-)/db(-) mouse versus controls at 8 mo of age, which was significantly attenuated by CoQ10. There was no difference in neuron number in 5/6-wk-old mice between diabetic and control mice. We observed a strong down-regulation of phospholipase C (PLC) β3 in the DRGs of diabetic mice at 8 mo of age, a key molecule in pain signaling, and this effect was also blocked by the 6-mo CoQ10 treatment. Many of the phenotypic, neurochemical regulations encountered in lumbar DRGs in standard models of peripheral nerve injury were not observed in diabetic mice at 8 mo of age. These results suggest that reactive oxygen species and reduced PLCβ3 expression may contribute to the sensory deficits in the late-stage diabetic db(-)/db(-) mouse, and that early long-term administration of the antioxidant CoQ10 may represent a promising therapeutic strategy for type 2 diabetes neuropathy.
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28
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Lehecka KE, Renukuntla VS, Heptulla RA. Insight into hypoglycemia in pediatric type 1 diabetes mellitus. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2012; 2012:19. [PMID: 22716962 PMCID: PMC3441359 DOI: 10.1186/1687-9856-2012-19] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 04/15/2012] [Indexed: 02/06/2023]
Abstract
Hypoglycemia is a common complication of insulin treatment in type 1 diabetes mellitus and can occur in any patient with diabetes when glucose consumption exceeds supply. Many studies have been done to elucidate those factors that predict severe hypoglycemia: younger age, longer duration of diabetes, lower HgbA1c, higher insulin dose, lower Body Mass Index, male gender, Caucasian race, underinsurance or low socioeconomic status, and the presence of psychiatric disorders. Hypoglycemia can affect patients' relationships, occupation, and daily activities such as driving. However, one of the greatest impacts is patients' fear of severe hypoglycemic events, which is a limiting factor in the optimization of glycemic control. Therefore, the importance of clinicians' ability to identify those patients at greatest risk for hypoglycemic events is two-fold: 1) Patients at greatest risk may be counseled as such and offered newer therapies and monitoring technologies to prevent hypoglycemic events. 2) Patients at lower risk may be reassured and encouraged to improve their glycemic control. Since the risk of long-term complications with poor blood glucose control outweighs the risks of hypoglycemia with good blood glucose control, patients should be encouraged to aim for glucose concentrations in the physiologic range pre- and post-prandially. Advancements in care, including multiple daily injection therapy with analog insulin, continuous subcutaneous insulin infusion, and continuous glucose monitoring, have each subsequently improved glycemic control and decreased the risk of severe hypoglycemia.
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Affiliation(s)
- Kimberly E Lehecka
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas, 77030, USA
| | - Venkat S Renukuntla
- Department of Pediatrics, Division of Pediatric Endocrinology, Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Rubina A Heptulla
- Department of Pediatrics, Division of Pediatric Endocrinology, Albert Einstein College of Medicine/ The Children’s Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY, 10467, USA
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Abstract
Kinnier Wilson coined the term metabolic encephalopathy to describe a clinical state of global cerebral dysfunction induced by systemic stress that can vary in clinical presentation from mild executive dysfunction to deep coma with decerebrate posturing; the causes are numerous. Some mechanisms by which cerebral dysfunction occurs in metabolic encephalopathies include focal or global cerebral edema, alterations in transmitter function, the accumulation of uncleared toxic metabolites, postcapillary venule vasogenic edema, and energy failure. This article focuses on common causes of metabolic encephalopathy, and reviews common causes, clinical presentations and, where relevant, management.
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Affiliation(s)
- Michael J Angel
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
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30
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Xu C, Yogaratnam J, Lua R, Naik S, Khoo CL, Pillai SS, Sim K. Persistent, severe hypoglycemia-induced organic brain syndrome with neurological sequelae: a case report. Gen Hosp Psychiatry 2011; 33:412.e9-412.e11. [PMID: 21762845 DOI: 10.1016/j.genhosppsych.2011.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 05/02/2011] [Accepted: 05/03/2011] [Indexed: 11/16/2022]
Abstract
Hypoglycemia is a biochemical abnormality and often the rate-limiting step in the treatment of both type 1 and type 2 diabetes mellitus. Left uncorrected and prolonged, hypoglycemia can result in neuronal dysfunction and death, with deficits ranging from measurable cognitive impairments to aberrant behavior, seizures and coma. In this case report, hypoglycemia resulted in severe and persistent neurological (slurred speech and gait abnormalities), cognitive (inattention, disorientation and memory deficits) and behavioral manifestations (verbal hostility and irritability). It highlights the potentially severe neuropsychiatric sequelae following hypoglycemia and is timely for clinicians to be reminded that hypoglycemia prevention needs to be more of a focus of diabetes care in general.
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Affiliation(s)
- Changqing Xu
- Institute of Mental Health/Woodbridge Hospital, Singapore 539747, Singapore
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31
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Affiliation(s)
- Natalia Yakubovich
- McMaster University Department of Medicine, Hamilton, Ontario L8N 3Z5, Canada.
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32
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Angel MJ, Chen R, Bryan Young G. Metabolic encephalopathies. HANDBOOK OF CLINICAL NEUROLOGY 2010; 90:115-66. [PMID: 18631820 DOI: 10.1016/s0072-9752(07)01707-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Michael J Angel
- University of Toronto, Division of Neurology, Toronto Western Hospital, Toronto, Ontario, Canada.
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Barnett AH, Cradock S, Fisher M, Hall G, Hughes E, Middleton A. Key considerations around the risks and consequences of hypoglycaemia in people with type 2 diabetes. Int J Clin Pract 2010; 64:1121-9. [PMID: 20236369 DOI: 10.1111/j.1742-1241.2009.02332.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Hypoglycaemia and its consequences represent a significant risk for many people who have type 2 diabetes, and hypoglycaemia is currently under-recognised and commonly avoidable. Current clinical guidelines recommend the targeting of tight glycaemic control and this strategy may also be associated with an increased risk of hypoglycaemia. Hypoglycaemia impacts on morbidity, mortality and quality of life of people with type 2 diabetes, and improved recognition of the symptoms of hypoglycaemia will allow effective treatment and reduce the risk of progression to more severe episodes. A common cause of hypoglycaemia in people with type 2 diabetes is glucose-lowering medication, in particular, those which raise insulin independently of ambient glucose concentration such as sulphonylureas and exogenous insulin. The recently published National Institute for Health and Clinical Excellence guideline recommends the use of Dipeptidyl peptidase-4 inhibitors or thiazolidinediones (glitazones) as alternative second-line therapy instead of a sulphonylurea in those patients who are at significant risk of hypoglycaemia and its consequences.
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Affiliation(s)
- A H Barnett
- Department of Medicine, University of Birmingham and Heart of England National Health Service Foundation Trust (Teaching), Birmingham, UK.
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Nelson PT, Smith CD, Abner EA, Schmitt FA, Scheff SW, Davis GJ, Keller JN, Jicha GA, Davis D, Wang-Xia W, Hartman A, Katz DG, Markesbery WR. Human cerebral neuropathology of Type 2 diabetes mellitus. BIOCHIMICA ET BIOPHYSICA ACTA 2009; 1792:454-69. [PMID: 18789386 PMCID: PMC2834412 DOI: 10.1016/j.bbadis.2008.08.005] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 08/09/2008] [Accepted: 08/14/2008] [Indexed: 12/15/2022]
Abstract
The cerebral neuropathology of Type 2 diabetes (CNDM2) has not been positively defined. This review includes a description of CNDM2 research from before the 'Pubmed Era'. Recent neuroimaging studies have focused on cerebrovascular and white matter pathology. These and prior studies about cerebrovascular histopathology in diabetes are reviewed. Evidence is also described for and against the link between CNDM2 and Alzheimer's disease pathogenesis. To study this matter directly, we evaluated data from University of Kentucky Alzheimer's Disease Center (UK ADC) patients recruited while non-demented and followed longitudinally. Of patients who had come to autopsy (N = 234), 139 met inclusion criteria. These patients provided the basis for comparing the prevalence of pathological and clinical indices between well-characterized cases with (N = 50) or without (N = 89) the premortem diagnosis of diabetes. In diabetics, cerebrovascular pathology was more frequent and Alzheimer-type pathology was less frequent than in non-diabetics. Finally, a series of photomicrographs demonstrates histopathological features (including clinical-radiographical correlation) observed in brains of persons that died after a history of diabetes. These preliminary, correlative, and descriptive studies may help develop new hypotheses about CNDM2. We conclude that more work should be performed on human material in the context of CNDM2.
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Affiliation(s)
- Peter T Nelson
- Department of Pathology, Division of Neuropathology, University of Kentucky Medical Center, Sanders-Brown Center on Aging and Alzheimer's Disease Center, University of Kentucky, Lexington, KY 40536-0230, USA.
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Park MJ, Guest CB, Barnes MB, Martin J, Ahmad U, York JM, Freund GG. Blocking of beta-2 adrenergic receptors hastens recovery from hypoglycemia-associated social withdrawal. Psychoneuroendocrinology 2008; 33:1411-8. [PMID: 18814973 PMCID: PMC2636565 DOI: 10.1016/j.psyneuen.2008.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 08/04/2008] [Accepted: 08/10/2008] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Hypoglycemia is associated with a variety of adverse behaviors including fatigue, confusion and social withdrawal. While these clinical symptoms are well characterized, the mechanism of their cause is not understood. Here we investigated how insulin-induced hypoglycemia causes social withdrawal. RESEARCH DESIGN AND METHODS Male 8-12-week-old C57BL/6J mice were injected intraperitoneally (IP) with or without and/or insulin, norepinephrine (NE) and epinephrine (Epi), terbutaline and butoxamine with subsequent measurement of blood glucose, social withdrawal and plasma catecholamines. RESULTS Insulin generated (0.75h post-injection) significant hypoglycemia with blood glucose nadirs of 64+/-4 and 48+/-5mg/dl for 0.8 and 1.2units/kg of insulin, respectively. Insulin (0.8 or 1.2units/kg) caused near total social withdrawal at 0.75h with full recovery not occurring until 4h (0.8units/kg) or 8h (1.2units/kg) post-insulin injection. Insulin also caused a marked elevation in plasma catecholamines. Basal 12h fasting NE and Epi were 287+/-38 and 350+/-47pg/ml, respectively. Insulin at 0.8units/kg increased plasma NE and Epi to 994+/-73 and 1842+/-473pg/ml, respectively. Administration of exogenous NE or Epi caused social withdrawal similar in magnitude to insulin. Importantly, administration of the beta-2 adrenergic receptor agonist terbutaline also caused social withdrawal while administration of the beta-2 adrenergic receptor antagonist butoxamine blocked NE-induced social withdrawal. Finally, butoxamine blocked insulin-induced social withdrawal. CONCLUSIONS These data demonstrate that hypoglycemia-associated social withdrawal is dependent on catecholamines via a beta-2 receptor-mediated pathway.
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Affiliation(s)
- Min Jung Park
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
- Department of Pathology, Integrative Immunology and Behavior Program, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Christopher B. Guest
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
- Department of Pathology, Integrative Immunology and Behavior Program, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Meredith B. Barnes
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Jonathan Martin
- Department of Pathology, Integrative Immunology and Behavior Program, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Uzma Ahmad
- Department of Pathology, Integrative Immunology and Behavior Program, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Jason M. York
- Department of Pathology, Integrative Immunology and Behavior Program, University of Illinois at Urbana-Champaign, Urbana, IL, USA
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Gregory G. Freund
- Division of Nutritional Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
- Department of Pathology, Integrative Immunology and Behavior Program, University of Illinois at Urbana-Champaign, Urbana, IL, USA
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL, USA
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Dijkgraaf MGW. Unhappy acute lung injury survivors: the case of hypoglycemicly-induced depressive symptoms. Crit Care Med 2008; 36:2931-2. [PMID: 18812794 DOI: 10.1097/ccm.0b013e318187b724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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37
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Systemic Insulin-like Growth Factor-1 Reverses Hypoalgesia and Improves Mobility in a Mouse Model of Diabetic Peripheral Neuropathy. Mol Ther 2008; 16:1400-8. [DOI: 10.1038/mt.2008.115] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Nádas J, Putz Z, Fövényi J, Gaál Z, Gyimesi A, Hídvégi T, Hosszúfalusi N, Neuwirth G, Oroszlán T, Pánczél P, Vándorfi G, Winkler G, Wittmann I, Jermendy G. Cardiometabolic goal attainment during regular care of adult patients with type 1 diabetes mellitus. Orv Hetil 2008; 149:1263-9. [DOI: 10.1556/oh.2008.28328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A kardiometabolikus kockázati tényezők csökkentésével visszaszoríthatók a cardiovascularis események. A kardiometabolikus kockázati tényezők befolyásolásának eredményességéről 1-es típusú diabetes mellitusban szenvedő felnőtt cukorbetegek körében csak kevés adat áll rendelkezésre.
Célkitűzés:
Diabetes-szakrendelésen ellenőrzés céljából megjelenő, 1-es típusú diabetes mellitusban szenvedő felnőtt (életkor ≥ 18 év) cukorbetegek körében adatokat gyűjtöttünk a kardiometabolikus kockázati tényezők előfordulásáról és kezelésük eredményességéről.
Módszerek:
Fél év alatt az ország 11 diabetescentrumában egymást követően megjelent 1-es típusú cukorbetegségben szenvedők (n = 533; 256 férfi, 277 nő; életkor 35,6 ± 11,6 év; diabetestartam 18,0 ± 11,1 év; x ± SD) ellenőrzésekor, az előzményi adatok felvételén túl, antropometriai és laboratóriumi adatokat regisztráltunk. A kardiometabolikus kockázati tényezők kezelési célértékeként a III. Magyar Cardiovascularis Konszenzuskonferencia ajánlásában szereplő adatokat tekintettük mérvadónak.
Eredmények:
A testtömegindex célértékét (< 25 kg/m
2
) a betegek 55,3%-a (férfi: 45,7%, nő: 64,3%) érte el. A haskörfogat nők körében megkívánt értékét (< 80 cm) a betegek 50,5%-a, a férfiak esetében mérvadó értéket (< 94 cm) 63,7% érte el. A HbA
1c
értéke a betegek 8,4%-ában volt 6,5% alatt (20,5%-ban 7,0% alatt). Lipidcsökkentő kezelésben részesült 130 beteg (24,4%), e csoportban a betegek 53,1%-a érte el a triglicerid, 71,5% a HDL-koleszterin és 27,8% az LDL-koleszterin kezelési célértékét. A lipidek szintjére vonatkozó célérték együttes elérése a betegek 17,7%-ában volt sikeres. Hypertonia miatt kezelésben részesült 173 beteg (32,5%), e betegcsoportban a < 130 Hgmm-es szisztolés vérnyomást a betegek 29,5%-a, a diasztolés célértéket (< 80 Hgmm) pedig 34,7% érte el. A betegek 17,7%-a a vizsgálat időpontjában dohányzónak vallotta magát, 19,2% leszokott a dohányzásról, és 63,2% sohasem dohányzott.
Következtetések:
Felnőtt, 1-es típusú diabetes mellitusban szenvedők körében a kardiometabolikus kockázati tényezők napjainkban ajánlott kezelési célértékeit a cukorbeteg-gondozás keretein belül nehéz elérni. További erőfeszítéseket kell tenni a cukorbetegek kardiometabolikus kockázati tényezőinek hatékonyabb csökkentése érdekében.
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Affiliation(s)
- Judit Nádas
- 1 Bajcsy-Zsilinszky Kórház Budapest Maglódi út 89–91. 1106
| | - Zsuzsanna Putz
- 1 Bajcsy-Zsilinszky Kórház Budapest Maglódi út 89–91. 1106
| | | | | | | | | | - Nóra Hosszúfalusi
- 6 Semmelweis Egyetem, Általános Orvostudományi Kar III. Belgyógyászati Klinika Budapest
| | | | | | - Pál Pánczél
- 6 Semmelweis Egyetem, Általános Orvostudományi Kar III. Belgyógyászati Klinika Budapest
| | | | | | - István Wittmann
- 11 Pécsi Tudományegyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Pécs
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39
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Abstract
This paper presents a critical review of continuous glucose monitoring studies that address accuracy, utility in assessing glucose variability, detection of hypoglycemia for improved metabolic control or reduced glucose variability, impact on quality of life, reduced fear of hypoglycemia, and applicability in helping patients to overcome their reluctance to intensify insulin therapy. This analysis can be used to delineate the evidence that is still missing when considering continuous glucose monitoring as an established tool in clinical practice and for reimbursement of the system and services.
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Affiliation(s)
- Gérard Reach
- Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital Assistance Publique-Hôpitaux de Paris, France.
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40
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Abstract
Hypoglycaemia is the commonest side-effect of insulin treatment for diabetes, and is the single greatest barrier to achieving and maintaining good glycaemic control. Severe hypoglycaemia (requiring assistance for recovery) is associated with significant morbidity and is feared by most people with type 1 diabetes and their families. It causes stress and anxiety and may influence self-management and glycaemic control. The annual prevalence of severe hypoglycaemia is around 30% in people with type 1 diabetes, and is higher in those with risk factors such as strict glycaemic control, impaired awareness of hypoglycaemia and increasing duration of diabetes. It is also common during sleep (nocturnal hypoglycaemia). Neurological manifestations include coma, convulsions, transient hemiparesis and stroke, while reduced consciousness and cognitive dysfunction may cause accidents and injuries. Cardiac events may be precipitated such as arrhythmias, myocardial ischaemia and cardiac failure. Hypoglycaemia can affect all aspects of life, including employment, driving, recreational activities involving exercise, and travel, and measures should be taken in all of these situations to avoid this potentially dangerous side-effect of insulin therapy.
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41
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Abstract
Iatrogenic hypoglycemia is the main factor limiting aggressive and optimal diabetes management. Rather than being an inevitable consequence of optimal glycemic control, however, hypoglycemia is avoidable and generally straightforward to manage when it occurs. Professional caregivers, patients, and their families are often fearful of hypoglycemia, even though most episodes are minor and easily self-treated. Understanding the factors contributing to hypoglycemia risk and how to minimize its occurrence is an essential part of diabetes care. Building on the physiologic fundamentals presented in the accompanying review, the incidence, mortality/morbidity, clinical symptoms, severity classification, and psychosocial impact of hypoglycemia are described here. Appropriate selection and titration of therapeutic agents, including insulin analogs with more predictable time-action profiles than human insulin formulations, can reduce hypoglycemia risk. Patient education about hypoglycemia prevention, including symptom recognition and necessity of rapid treatment, behavioral modification, and the importance of frequent blood glucose monitoring should accompany all therapeutic interventions.
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Affiliation(s)
- Patrick J Boyle
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
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