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Macon EL, Devore MH, Lin YK, Music MB, Wooten M, McMullen CA, Woodcox AM, Marksbury AR, Beckner Z, Patel BV, Schoeder LA, Iles AN, Fisher SJ. Current and future therapies to treat impaired awareness of hypoglycemia. Front Pharmacol 2023; 14:1271814. [PMID: 37942482 PMCID: PMC10628050 DOI: 10.3389/fphar.2023.1271814] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/05/2023] [Indexed: 11/10/2023] Open
Abstract
In order to achieve optimal glycemic control, intensive insulin regimes are needed for individuals with Type 1 Diabetes (T1D) and insulin-dependent Type 2 Diabetes (T2D). Unfortunately, intensive glycemic control often results in insulin-induced hypoglycemia. Moreover, recurrent episodes of hypoglycemia result in both the loss of the characteristic warning symptoms associated with hypoglycemia and an attenuated counterregulatory hormone responses. The blunting of warning symptoms is known as impaired awareness of hypoglycemia (IAH). Together, IAH and the loss of the hormonal response is termed hypoglycemia associated autonomic failure (HAAF). IAH is prevalent in up to 25% in people with T1D and up to 10% in people with T2D. IAH and HAAF increase the risk of severe hypoglycemia 6-fold and 25-fold, respectively. To reduce this risk for severe hypoglycemia, multiple different therapeutic approaches are being explored that could improve awareness of hypoglycemia. Current therapies to improve awareness of hypoglycemia include patient education and psychoeducation, the use of novel glycemic control technology, pancreas/islet transplantation, and drug therapy. This review examines both existing therapies and potential therapies that are in pre-clinical testing. Novel treatments that improve awareness of hypoglycemia, via improving the counterregulatory hormone responses or improving hypoglycemic symptom recognition, would also shed light on the possible neurological mechanisms that lead to the development of IAH. To reduce the risk of severe hypoglycemia in people with diabetes, elucidating the mechanism behind IAH, as well as developing targeted therapies is currently an unmet need for those that suffer from IAH.
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Affiliation(s)
- Erica L. Macon
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Micah H. Devore
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Yu Kuei Lin
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Megan B. Music
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Mason Wooten
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Colleen A. McMullen
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Andrea M. Woodcox
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Ashlee R. Marksbury
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Zachary Beckner
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Bansi V. Patel
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Lily A. Schoeder
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Ashley N. Iles
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Simon J. Fisher
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
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Meloni M, Andreadi A, Ruotolo V, Romano M, Bellizzi E, Giurato L, Bellia A, Uccioli L, Lauro D. Hospital Readmission in Patients With Diabetic Foot Ulcers: Prevalence, Causes, and Outcomes. INT J LOW EXTR WOUND 2023:15347346231207747. [PMID: 37849322 DOI: 10.1177/15347346231207747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
The aim of the current study was to evaluate the rate of readmission in patients affected by diabetes and foot ulcers (DFUs), and causes and outcomes of patients requiring a new hospitalization. The current study is a retrospective observational study including patients who have required hospitalization since January 2019 to September 2022 due to a DFU. Once patients were discharged, they were regularly followed as outpatients. Within 6 months of follow-up, the rate of hospital readmission for a diabetic foot problem was recorded. According to the readmission or not, patients were divided into 2 groups, readmitted and not readmitted patients, respectively. Hence, all patients were followed for 6 months more and outcomes of the 2 groups were analyzed and compared. Overall, 310 patients were included. The mean age was 68 ± 12 years, the majority of patients reported type 2 diabetes (>90%), and the mean diabetes duration was approximately 20 years. Sixty-eight (21.9%) patients were readmitted. The main reason for hospital readmission was the presence of critical limb ischemia (CLI) in the contralateral limb (6.1%), the recurrence of CLI in the previous treated limb (4.5%), and the onset of new infected DFU in the contralateral foot (4.5%). Readmitted patients reported lower rate of healing (51.5% vs 89.2%, P < .0001) and higher rate of major amputation (10.3% vs 4.5%, P = .2) in comparison to not readmitted patients. Critical limb ischemia resulted in the only independent predictor of hospital readmission. Hospital readmission is a frequent issue among patients with DFUs, and readmitted patients showed a lower chance of wound healing. Critical limb ischemia resulted in the main cause of new hospitalization.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Aikaterini Andreadi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Valeria Ruotolo
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Maria Romano
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Ermanno Bellizzi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Laura Giurato
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Luigi Uccioli
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- University Hospital Fondazione Policlinico Tor Vergata, Rome, Italy
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Li CX, Liu TT, Zhang Q, Xie Q, Geng XH, Man CX, Li JY, Mao XY, Qiao Y, Liu H. Safety of sodium-glucose transporter 2 (SGLT-2) inhibitors in patients with type 2 diabetes: a meta-analysis of cohort studies. Front Pharmacol 2023; 14:1275060. [PMID: 37905204 PMCID: PMC10613530 DOI: 10.3389/fphar.2023.1275060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/21/2023] [Indexed: 11/02/2023] Open
Abstract
Aims: This study aimed to investigate the association between the use of sodium-glucose transporter 2 inhibitors (SGLT-2i) and the risk of diabetic ketoacidosis (DKA), lower limb amputation (LLA), urinary tract infections (UTI), genital tract infections (GTI), bone fracture, and hypoglycemia in cohort studies. Methods: A systematic search was conducted in the PubMed and Embase databases to identify cohort studies comparing the safety of SGLT-2i versus other glucose-lowering drugs (oGLD) in patients with type 2 diabetes mellitus (T2DM). The quality of the studies was assessed using the Newcastle-Ottawa Scale. Primary endpoints were DKA and LLA, while secondary endpoints included UTI, GTI, bone fracture, and hypoglycemia. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated. Results: A total of 9,911,454 patients from 40 cohort studies were included in the analysis. SGLT-2i use was associated with a higher risk of DKA (HR: 1.21, 95% CI: 1.07-1.38, p = 0.003) and GTI (HR: 2.72, 95% CI: 2.48-2.98, p < 0.01). However, it was not associated with an increased risk of LLA (HR: 1.06, 95% CI: 0.92-1.23, p = 0.42), UTI (HR: 0.99, 95% CI: 0.89-1.10, p = 0.83), or bone fracture (HR: 0.99, 95% CI: 0.94-1.04, p = 0.66). Furthermore, SGLT-2i was associated with a reduced risk of hypoglycemia. Furthermore, compared to dipeptidyl peptidase 4 inhibitors, SGLT-2i as a class and individually was associated with an increased risk of DKA. Canagliflozin specifically increased the risk of LLA (HR: 1.19, 95% CI: 1.04-1.36, p = 0.01). The subgroup analysis suggested that SGLT-2i increased the risk of LLA among patients with a history of cardiovascular disease. Conclusion: SGLT-2i versus oGLD was associated with a similar occurrence of LLA, UTI, and bone fracture. However, SGLT-2i was associated with a higher risk of DKA and GTI than oGLD. These findings provide valuable information on the safety profile of SGLT-2i in patients with T2DM and can help inform clinical decision-making.
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Affiliation(s)
- Chun Xing Li
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Tian Tian Liu
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Qian Zhang
- College of Pharmacy, Hebei Medical University, Shijiazhuang, China
| | - Qing Xie
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Xu Hua Geng
- Aerospace School of Clinical Medicine, Peking University, Beijing, China
| | - Chun Xia Man
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Jia Yi Li
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Xin Ying Mao
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Yue Qiao
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
| | - Hua Liu
- Department of Pharmacy, Aerospace Center Hospital, Beijing, China
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Sinclair JE, Austin MA, Leduc S, Dionne R, Froats M, Marchand J, Vaillancourt C. Patient and Prehospital Predictors of Hospital Admission for Patients With and Without Histories of Diabetes Treated by Paramedics for Hypoglycemia: A Health Record Review Study. PREHOSP EMERG CARE 2022; 27:955-966. [PMID: 36264569 DOI: 10.1080/10903127.2022.2137863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/29/2022] [Accepted: 10/15/2022] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The objectives of this study were to describe the characteristics, management, and outcomes of patients treated by paramedics for hypoglycemia, and to determine the predictors of hospital admission for these patients within 72 hours of the initial hypoglycemia event. METHODS We performed a health record review of paramedic call reports and emergency department records over a 12-month period. We queried prehospital databases to identify cases, which included all patients ⩾18 years with prehospital glucose readings of <72 mg/dl (<4.0 mmol/L) and excluded terminally ill and cardiac arrest patients. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions before initiation of data extraction by trained investigators. Data analyses included descriptive statistics univariate and logistic regression presented as adjusted odds ratios (aOR) with 95% confidence intervals (95%CI). RESULTS There were 791 patients with the following characteristics: mean age 56.2, male 52.3%, type 1 diabetes 11.6%, on insulin 43.3%, median initial glucose 54.0 mg/dl (3.0 mmol/L), from home 56.4%. They were treated by advanced care paramedics 80.1%, received intravenous D50 37.8%, intramuscular glucagon 17.8%, oral complex carbs/protein 25.7%, and accepted transport to hospital 70.2%. Among those transported, 134 (24.3%) were initially admitted and four more were admitted within 72 hours. One patient was admitted, discharged, and admitted again within 72 hours. Patients without documented histories of diabetes (aOR 2.35, CI 1.13-4.86), with cardiovascular disease (aOR 1.81, CI 1.10-3.00), on corticosteroids (aOR 4.63, CI 2.15-9.96), on oral hypoglycemic agent(s) (aOR 1.92, CI 1.02-3.62), or those given glucagon (aOR 1.77, CI 1.07-2.93) on scene were more likely to be admitted to hospital, whereas patients on insulin (aOR 0.49, CI 0.27-0.91), able to tolerate complex oral carbs/protein (aOR 0.22, CI 0.10-0.48), with final GCS scores of 15 (aOR 0.53, CI 0.34-0.83), or from public locations (aOR 0.40, CI 0.21-0.75) were less likely to be admitted. CONCLUSIONS There are several patient and prehospital management characteristics which, in combination, could be incorporated into a safe clinical decision tool for patients who present with hypoglycemia.
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Affiliation(s)
| | - Michael A Austin
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario
- Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Shannon Leduc
- Ottawa Hospital Research Institute, Ottawa, Ontario
- Ottawa Paramedic Service, Ottawa, Ontario
| | - Richard Dionne
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario
| | - Mark Froats
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
- Department of Emergency Medicine, Queen's University, Kingston, Ontario
| | - Jane Marchand
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
| | - Christian Vaillancourt
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario
- Ottawa Hospital Research Institute, Ottawa, Ontario
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Andreano A, Bosio M, Russo AG. Emergency attendance for acute hyper- and hypoglycaemia in the adult diabetic population of the metropolitan area of Milan: quantifying the phenomenon and studying its predictors. BMC Endocr Disord 2020; 20:72. [PMID: 32429960 PMCID: PMC7238653 DOI: 10.1186/s12902-020-0546-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/06/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We quantified, among diabetic adults, the frequency, costs, and factors associated with visits to the emergency department (EDs) and subsequent hospitalizations for acute hypoglycaemic and hyperglycaemic events. METHODS We included adults with diabetes residing in the Milan Agency for Health Protection between 2015 and 2017. From healthcare databases, we identified demographic variables, comorbidities, type of treatment, insulin treatment duration, previous ED attendances for acute glycaemic events, and two indicators of glycaemic monitoring. Using a validated ICD-9-CM coding algorithm, we identified all ED attendances for acute glycaemic events from the ED database and calculated their incidence. We computed the direct costs from health databases and presented them as average annual mean costs for those having had at least an ED attendance. The analysis of the association between the number of ED attendances and potential determinants was performed using zero-inflated negative binomial regression models. These two-part models concomitantly estimate two sets of parameters: the odds-ratios (ORs) of having no attendances and the incidence rate ratios (IRRs) of attendance. RESULTS The cohort included 168,285 subjects, 70% of subjects were older than 64 years, 56% were males, and 26% were treated with insulin. The incidence of acute glycaemic events for those attending the ED was 7.0 per 1000 patient-years, followed by hospitalization 26.0% of the time. The total annual direct cost for ED attendances due to acute glycaemic events was 174,000 €. Type of antidiabetic treatment had the strongest association with ED attendances for hypoglycaemia. Patients assuming insulin only had a lower probability of having no attendances (OR compared to those who assumed non-insulin antidiabetic drugs =0.01, 95% CI = 0.00-0.02). These patients also had the highest rate of hyperglycaemic episodes (IRR = 7.7, 95% CI = 5.1-11.7 for insulin only vs. non-insulin antidiabetic drugs). Subjects having had a previous episode of the same type leading to an ED visit had a higher rate of subsequent attendances (IRR for hypoglycaemia = 5.3, 95% CI = 3.9-7.3 and IRR for hyperglycaemia = 3.7, 95% CI = 1.3-10.2). CONCLUSION Insulin treatment and having had a prior acute glycaemic event leading to an ED visit were major predictors of ED attendance for hyper and hypoglycaemia in a population of adults with diabetes.
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Affiliation(s)
- Anita Andreano
- Epidemiology Unit, Agency for Health Protection (ATS) of Milan, C.so Italia, 19, 20122 Milano, Milan, (MI) Italy
| | - Marco Bosio
- General Directorate, Agency for Health Protection (ATS) of Milan, Milan, Italy
| | - Antonio Giampiero Russo
- Epidemiology Unit, Agency for Health Protection (ATS) of Milan, C.so Italia, 19, 20122 Milano, Milan, (MI) Italy
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Almalki ZS, Albassam AA, Alnakhli MA, Alnusyan MF, Alanazi FN, Alqurashi MS. National rates of emergency department visits associated with diabetes in Saudi Arabia, 2011-2015. Ann Saudi Med 2019; 39:71-76. [PMID: 30955014 PMCID: PMC6464666 DOI: 10.5144/0256-4947.2019.71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Despite the fact that diabetes is an important component of the burden of disease on the individual and on the national healthcare systems in Saudi Arabia, knowledge of the volume of emergency department (ED) visits for diabetes is unclear. OBJECTIVE Examine changes in ED visit rates associated with diabetes. DESIGN Retrospective. SETTINGS Governmental hospitals. METHODS Publicly available records of health statistics published by the Saudi Ministry of Health from 2011 through 2015 were used to extract data on ED visits related to diabetes. ED visits associated with diabetes were compared over time and by gender. We calculated diabetes-specific rates per 10000 persons for each sex category by dividing the total number of diabetes-associated ED visits in that category by the sex-specific population. We calculated the rate difference (RD) with 95% CI between 2011 and 2015. MAIN OUTCOME MEASURES Diabetes-specific rates per 10000 persons for each sex category. RESULTS Total annual visits to the ED for management of diabetes increased from 617683 cases in 2011 to 748605 in 2015. The annual number of ED visits associated with diabetes increased by 21% over the study period (20% for males and 23% for females). Compared to males, females had a larger increase in visit rates from 240.5 to 249.8 visits per 10000 women over the study years (RD, 9.6 per 10000 persons, 95% CI -16.4 to 26.6 versus 5.7 per 10 000 persons, 95% CI-13.6 to 18.3 ; P=.01). CONCLUSION Although diabetes-associated ED visit rates dramatically increased in 2012, they remained relatively stable after 2012 to the end of the study period. More effective preventive diabetes programs that prevent the use of ED visits and other expensive healthcare resources among people with diabetes are needed. LIMITATIONS We had no information on the specific indications for the reported ED visits. These estimates may represent a lower bound on ED visits associated with diabetes since the private sector was not included. CONFLICT OF INTEREST None.
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Affiliation(s)
- Ziyad Saeed Almalki
- Dr. Ziyad Almalki Department of Clinical Pharmacy, College of Pharmacy,, Prince Sattam bin Abdulaziz University,, Al Kharj, Saudi Arabia 11942, T: +966 11 588 6059, , ORCID: https://orcid.org/00000003-1618-4142
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