Hypoglycemia awareness among insulin-treated patients with diabetes in Malaysia: A cohort subanalysis of the HAT study

Hypoglycemia unawareness among insulin-treated diabetic patients in Madinah, Saudi Arabia: prevalence and risk factors

Background

Hypoglycemia unawareness (HU) is associated with significant risks. Screening for impaired awareness of hypoglycemia in patients with diabetes is important to minimize those risks. There are limited data on the prevalence of HU in patients with diabetes in Saudi Arabia (KSA). In the current study, we investigated the frequency of HU and its risk factors among insulin treated diabetic patients in Madinah, KSA.

Methods

A cross-sectional study was conducted in a diabetes center and four primary healthcare centers at Madinha, KSA. Patients ≥14 years old with type 1 or type 2 diabetes treated with insulin for more than a year were included. HU was assessed by Clarke's and modified Pedersen-Bjergaard's scores. The risk factors for HU were determined.

Results

Of the 413 included patients, 60.3% were women, and 60.8% were on insulin alone. One-third of the participants had T1DM, while 68.5% had T2DM, with median ages of 25 and 56 years, diabetes durations of 10 and 15 years, and durations of insulin use of 10 and 5 years, respectively. The prevalence of HU was 25.2% by Clarke's survey. The risk factors for HU were poor knowledge of the patient's latest HbA1c, type of insulin, and dose of insulin. Poor medical follow-up, previous stroke, and ischemic heart disease were the other risk factors for HU. When the modified Pedersen-Bjergaard method was used, the prevalence of HU was 48.9%.

Conclusion

Despite the advances in diabetes management, HU continues to be prevalent among diabetic patients on insulin, and poor diabetes knowledge is a major risk factor. Diabetes education on self-management is of utmost importance to reduce hypoglycemia and HU.

Awareness Level of Hypoglycemia Among Diabetes Mellitus Type 2 Patients in Al Qassim Region

Background Hypoglycemia has a major impact on patient health and glycemic management during insulin therapy for both type 1 (T1DM) and type 2 diabetes mellitus (T2DM). It is the rate-limiting complication in diabetes management that prevents stringent glucose control. Objectives To assess the knowledge and awareness about hypoglycemia as a complication of T2D in adults in Al Qassim, Saudi Arabia. Methods This is a cross-sectional study done among type 2 diabetes patients in Al-Qassim, Kingdom of Saudi Arabia, from January to June 2022. A previously validated online questionnaire was disseminated through social media to gather information from respondents. Participants were chosen via a simple random sampling technique. Data analysis was completed using SPSS (version 23; IBM Corp., Armonk, NY). Results Overall, 213 respondents were included in our study. The majority of them were females (70.9%). The participants' average age was 35.9 + 13.0 years. Our results revealed that the average awareness score of the study population was found to be 3.6 ± 1.1 (by using the Clarke method) and 3.7 ± 2.1 (by using the Gold method). Moreover, we found that impaired awareness of hypoglycemia's prevalence by Clarke's questionnaire was 52.1% and 53.5% by using the Gold questionnaire. In addition, almost half of the respondents reported weakness as a symptom of hypoglycemia over the last six months and unconsciousness over the last 12 months. Hypertension was the most commonly reported chronic disease by our participants. Lastly, factors such as age, gender, educational level, geographic distribution, and history of chronic illness did not show any significant association with impaired awareness of the prevalence of hypoglycemia. Conclusion According to our research, we concluded that patients with type 2 diabetes mellitus in the region of Al-Qassim, Saudi Arabia, had insufficient knowledge about hypoglycemia as a complication of T2D. Moreover, the impaired awareness of hypoglycemia in diabetic patients was found to be high. Hence, there is a need for interventional programs to raise public awareness.

Preliminary studies of Volten VR4® Kaempferia parviflora herb extracts on blood glucose levels in human type-2 diabetes mellitus and its mineral element analysis

Introduction

Volten VR4® capsules containing herb extract of Kaempferia parviflora has been claimed to reduce blood glucose in patients with diabetes.

Objectives

This preliminary study is conducted to evaluate the efficacy of Volten VR4® on healthy individuals and type-2 diabetes mellitus volunteers. The extracts of 400 mg capsules of Kaempferia parviflora (KP) were used to measure the blood glucose level of 2-hour postprandial.

Methods

The healthy group consists of 15 young adults aged 20-30 with no history of serious diseases, while the diabetic group includes 12 individuals aged 35-75 diagnosed with type-2 diabetes mellitus. Data were validated through the Willcoxon and Friedman test statistics and error distribution. The investigation was continued to trace the capsules contents of elements using inductively coupled plasma optical emission spectrometry (ICP-OES) techniques.

Results

It has been shown that KP reducing blood sugar levels has been associated with flavonoids and methoxyflavones components. The result specifically showed that consuming VR4® capsules can significantly reduce blood glucose, either at the state of fasting or postprandially. In the study the content of mineral and heavy metal elements in VR4® capsules has been evaluated.

Conclusion

Volten VR4® Kaempferia parviflora extract is safe to be consumed at a single dose of 400 mg. The study also has shown that the participants are free from adverse reactions and hypoglycaemia.

Prevalence of impaired awareness of hypoglycemia and its risk factors among patients with type 1 diabetes in Saudi Arabia

BACKGROUND AND AIMS

To determine the prevalence of impaired awareness of hypoglycemia (IHA) and self-identification of symptoms in patients with type 1 diabetes (T1D).

METHODS

A cross-sectional study was conducted on 242 patients with T1D at the Diabetes Treatment Center, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia from May 2021 to September 2021. In addition to the demographic data, patients' HbA1c level was also collected. Awareness and symptoms of hypoglycemia were assessed using two validated questionnaire-based methods, namely the Gold and Edinburgh methods.

RESULTS

The prevalence of IAH among patients with T1D was 62.8% and the presence of IAH was significantly associated with the duration of T1D (p = 0.019). Compared to males, females had significantly higher (p < 0.05) levels of warmth, pounding heart, and inability to concentrate. Compared to unmarried, married patients had significantly higher levels of (p < 0.05) drowsiness, dizziness, and blurred vision. Similarly, compared to school educated, college-educated showed a higher hunger level (p < 0.05). Patients with HbA1c ≥ 7% possess a significantly higher level of drowsiness, dizziness, and hunger. Dizziness, warmth, difficulty speaking, pounding heart, and blurred vision were significantly higher among patients with diabetes duration ≥10 yrs. Nausea was significantly higher among smokers than non-smokers (p < 0.05).

CONCLUSION

The prevalence of IAH is high among patients with T1D in Saudi Arabia. Focused and evidence-based interventions are essential to minimize the hypoglycemia risk among patients with T1D.

Pharmacogenetics of sulfonylurea-induced hypoglycemia in Type 2 diabetes patients: the SUCLINGEN study

Aim: This study investigated the incidence of sulfonylurea-induced hypoglycemia and its predictors in Type 2 diabetes (T2D) patients. Patients & methods: In this prospective, observational study, T2D patients on maximal sulfonylurea-metformin therapy >1 year were enrolled. Hypoglycemia was defined as having symptoms or a blood glucose level <3.9 mmol/l. Results: Of the 401 patients, 120 (29.9%) developed sulfonylurea-induced hypoglycemia during the 12-month follow-up. The ABCC8 rs757110, KCNJ11 rs5219, CDKAL1 rs7756992 and KCNQ1 rs2237892 gene polymorphisms were not associated with sulfonylurea-induced hypoglycemia (p > 0.05). Prior history of hypoglycemia admission (odds ratio = 16.44; 95% CI: 1.74-154.33, p = 0.014) independently predicted its risk. Conclusion: Sulfonylurea-treated T2D patients who experienced severe hypoglycemia are at increased risk of future hypoglycemia episodes.

Utilisation Trend of Long-Acting Insulin Analogues including Biosimilars across Europe: Findings and Implications

BACKGROUND

Diabetes mellitus rates and associated costs continue to rise across Europe enhancing health authority focus on its management. The risk of complications is enhanced by poor glycaemic control, with long-acting insulin analogues developed to reduce hypoglycaemia and improve patient convenience. There are concerns though with their considerably higher costs, but moderated by reductions in complications and associated costs. Biosimilars can help further reduce costs. However, to date, price reductions for biosimilar insulin glargine appear limited. In addition, the originator company has switched promotional efforts to more concentrated patented formulations to reduce the impact of biosimilars. There are also concerns with different devices between the manufacturers. As a result, there is a need to assess current utilisation rates for insulins, especially long-acting insulin analogues and biosimilars, and the rationale for patterns seen, among multiple European countries to provide future direction. Methodology. Health authority databases are examined to assess utilisation and expenditure patterns for insulins, including biosimilar insulin glargine. Explanations for patterns seen were provided by senior-level personnel.

RESULTS

Typically increasing use of long-acting insulin analogues across Europe including both Western and Central and Eastern European countries reflects perceived patient benefits despite higher prices. However, activities by the originator company to switch patients to more concentrated insulin glargine coupled with lowering prices towards biosimilars have limited biosimilar uptake, with biosimilars not currently launched in a minority of European countries. A number of activities were identified to address this. Enhancing the attractiveness of the biosimilar insulin market is essential to encourage other biosimilar manufacturers to enter the market as more long-acting insulin analogues lose their patents to benefit all key stakeholder groups.

CONCLUSIONS

There are concerns with the availability and use of insulin glargine biosimilars among European countries despite lower costs. This can be addressed.

Current utilization patterns for long-acting insulin analogues including biosimilars among selected Asian countries and the implications for the future

INTRODUCTION

Prevalence rates for diabetes mellitus continue to rise, which, coupled with increasing costs of complications, has appreciably increased expenditure in recent years. Poor glycaemic control including hypoglycaemia enhances complication rates and associated morbidity, mortality and costs. Consequently, this needs to be addressed. Whilst the majority of patients with diabetes have type-2 diabetes, a considerable number of patients with diabetes require insulin to help control their diabetes. Long-acting insulin analogues were developed to reduce hypoglycaemia associated with insulin and help improve adherence, which can be a concern. However, their considerably higher costs have impacted on their funding and use, especially in countries with affordability issues. Biosimilars can help reduce the costs of long-acting insulin analogues thereby increasing available choices. However, the availability and use of long-acting insulin analogues can be affected by limited price reductions versus originators and limited demand-side initiatives to encourage their use. Consequently, we wanted to assess current utilisation rates for long-acting insulin analogues, especially biosimilars, and the rationale for patterns seen, across multiple Asian countries ranging from Japan (high-income) to Pakistan (lower-income) to inform future strategies.

METHODOLOGY

Multiple approaches including assessing utilization and prices of insulins including biosimilars among six Asian countries and comparing the findings especially with other middle-income countries.

RESULTS

Typically, there was increasing use of long-acting insulin analogues among the selected Asian countries. This was especially the case enhanced by biosimilars in Bangladesh, India, and Malaysia reflecting their perceived benefits. However, there was limited use in Pakistan due to issues of affordability similar to a number of African countries. The high use of biosimilars in Bangladesh, India and Malaysia was helped by issues of affordability and local production. The limited use of biosimilars in Japan and Korea reflects limited price reductions and demand-side initiatives similar to a number of European countries.

CONCLUSIONS

Increasing use of long-acting insulin analogues across countries is welcomed, adding to the range of insulins available, which increasingly includes biosimilars. A number of activities are needed to enhance the use of long-acting insulin analogue biosimilars in Japan, Korea and Pakistan.

Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis

BACKGROUND

Adverse drug reactions (ADRs) represent a major cause of iatrogenic morbidity and mortality in patient care. While a substantial body of work has been undertaken to characterise ADRs in the hospital setting, the overall burden of ADRs in the primary care remains unclear.

OBJECTIVES

To investigate the prevalence of ADRs in the primary care setting and factors affecting the heterogeneity of the estimates.

METHODS

Studies were identified through searching of Medline, Embase, CINAHL and IPA databases. We included observational studies that reported information on the prevalence of ADRs in patients receiving primary care. Disease and treatment specific studies were excluded. Quality of the included studies were assessed using Smyth ADRs adapted scale. A random-effects model was used to calculate the pooled estimate. Potential source of heterogeneity, including age groups, ADRs definitions, ADRs detection methods, study setting, quality of the studies, and sample size, were investigated using sub-group analysis and meta-regression.

RESULTS

Thirty-three studies with a total study population of 1,568,164 individuals were included. The pooled prevalence of ADRs in the primary care setting was 8.32% (95% CI, 7.82, 8.83). The percentage of preventable ADRs ranged from 12.35-37.96%, with the pooled estimate of 22.96% (95% CI, 7.82, 38.09). Cardiovascular system drugs were the most commonly implicated medication class. Methods of ADRs detection, age group, setting, and sample size contributed significantly to the heterogeneity of the estimates.

CONCLUSION

ADRs constitute a significant health problem in the primary care setting. Further research should focus on examining whether ADRs affect subsequent clinical outcomes, particularly in high-risk therapeutic areas. This information may better inform strategies to reduce the burden of ADRs in the primary care setting.

Patient-reported outcomes for diabetes and hypertension care in low- and middle-income countries: A scoping review

INTRODUCTION

Patient-reported outcome measures (PROMs) assess patients' perspectives on their health status, providing opportunities to improve the quality of care. While PROMs are increasingly used in high-income settings, limited data are available on PROMs use for diabetes and hypertension in low-and middle-income countries (LMICs). This scoping review aimed to determine how PROMs are employed for diabetes and hypertension care in LMICs.

METHODS

We searched PubMed, EMBASE, and ClinicalTrials.gov for English-language studies published between August 2009 and August 2019 that measured at least one PROM related to diabetes or hypertension in LMICs. Full texts of included studies were examined to assess study characteristics, target population, outcome focus, PROMs used, and methods for data collection and reporting.

RESULTS

Sixty-eight studies met the inclusion criteria and reported on PROMs for people diagnosed with hypertension and/or diabetes and receiving care in health facilities. Thirty-nine (57%) reported on upper-middle-income countries, 19 (28%) reported on lower-middle-income countries, 4 (6%) reported on low-income countries, and 6 (9%) were multi-country. Most focused on diabetes (60/68, 88%), while 4 studies focused on hypertension and 4 focused on diabetes/hypertension comorbidity. Outcomes of interest varied; most common were glycemic or blood pressure control (38), health literacy and treatment adherence (27), and acute complications (22). Collectively the studies deployed 55 unique tools to measure patient outcomes. Most common were the Morisky Medication Adherence Scale (7) and EuroQoL-5D-3L (7).

CONCLUSION

PROMs are deployed in LMICs around the world, with greatest reported use in LMICs with an upper-middle-income classification. Diabetes PROMs were more widely deployed in LMICs than hypertension PROMs, suggesting an opportunity to adapt PROMs for hypertension. Future research focusing on standardization and simplification could improve future comparability and adaptability across LMIC contexts. Incorporation into national health information systems would best establish PROMs as a means to reveal the effectiveness of person-centered diabetes and hypertension care.

Clinical and genetic predictors of secondary sulfonylurea failure in Type 2 diabetes patients: the SUCLINGEN study

Background: Due to several limitations in the study designs of sulfonylurea pharmacogenomics studies, we investigated the clinical and genetic predictors of secondary sulfonylurea failure in Type 2 diabetes patients. Materials & methods: Patients receiving the maximum sulfonylurea and metformin doses for >1 year were enrolled. Secondary sulfonylurea failure was defined as HbA1c >7.0% (>53 mmol/mol) after a 12-month follow-up. Results: By multivariate analysis, increased insulin resistance (HOMA2-IR), baseline HbA1c >7.0%, residing in eastern Peninsular Malaysia, and the CC genotype of rs757110 ABCC8 gene polymorphism were independent predictors of secondary sulfonylurea failure (p < 0.05) while sulfonylurea-induced hypoglycemia was protective against such failure (p < 0.05). Conclusion: Sulfonylurea does not benefit patients with an increased risk of secondary sulfonylurea failure.

Economic burden of hypoglycemia for type II diabetes mellitus patients in Malaysia

This study mainly aims to identify the direct cost and economic burden of hypoglycemia for patients with type II diabetes mellitus in Malaysia. A cross-sectional study explored the cost incurred for hypoglycemia among patients admitted to University Kebangsaan Malaysia Medical Centre (UKMMC). The study covered patients aged 20-79 years hospitalized with a primary diagnosis of ICD-10 hypoglycemia and discharged between January 2010 and September 2015 according to the casemix database. A costing analysis was done through a step-down approach from the perspective of health providers. Cost data were collected for three levels of cost centers with the help of a hospital-costing template. The costing data from UKMMC were used to estimate the national burden of hypoglycemia among type II diabetics for the whole country. Of 244 diabetes patients admitted primarily for hypoglycemia to UKMMC, 52% were female and 88% were over 50 years old. The cost increased with severity. Managing a hypoglycemic case requires five days (median) of inpatient stay on average, with a range of 2-26 days, and costs RM 8,949 (USD 2,289). Of the total cost, 30% related to ward (final cost center), 16% to ICU, and 15% to pharmacy (secondary-level cost center) services. Considering that 3.2% of all admissions were hypoglycemia related, the total annual cost of hypoglycemia care for adult diabetics in Malaysia is estimated at RM 117.4 (USD 30.0) million, which translates to 0.5% of the Ministry of Health budget. Hypoglycemia imposes a substantial economic impact even without the direct and indirect cost incurred by patients and other cost of complications. Diabetic management needs to include proper diabetic care and health education to reduce episodes of hypoglycemia.

Silymarin Attenuates ELMO-1 and KIM-1 Expression and Oxidative Stress in the Kidney of Rats with Type 2 Diabetes

Chronic diabetes mellitus is accompanied with overexpression of ELMO1 and KIM1 and enhanced oxidative stress. This study was aimed to evaluate the effects of administration of silymarin on oxidative stress markers and ELMO1 and KIM1 expression in the kidney tissue of type 2 diabetic rats. In this experimental study, 36 male Wistar rats were divided into 6 groups: Control, silymarin-treated control (60 and 120 mg/kg/day), diabetic, and silymarin-treated diabetic groups (60 and 120 mg/kg/day). Tissue levels of oxidative stress and biochemical parameters were measured by spectrophotometric methods. Lipid peroxidation levels in the kidney tissue were measured by fluorometric method. Insulin was determined using immunoassay. Gene expression analysis was determined by qPCR technique. The level of expression of ELMO1 and KIM1 in the diabetic groups treated with silymarin was significantly reduced (P < 0.001). Total antioxidant levels and thiol groups contents increased (P < 0.001) dramatically in treated groups. A significant decrease in tissue levels of malondialdehyde and total oxidant were observed in the silymarin treated diabetic rats (P < 0.001). The results showed that the urinary amount of protein in the treatment groups was significantly lower than of diabetic control (P < 0.001). These results indicate that silymarin has a blood glucose lowering effect and, due to its antioxidant properties, increases the antioxidant parameters and reduces the oxidant markers. The administration of silymarin has beneficial effects on kidney of diabetic rats with reduction of ELMO1 and KIM1expression.