Individual and societal consequences of hypoglycemia: A cross-sectional survey

Intermittently scanned continuous glucose monitoring and hypoglycaemia awareness in drivers with diabetes: Insights from the Association of British Clinical Diabetologists Nationwide audit

AIM

Frequent hypoglycaemia results in disruption to usual hypoglycaemic autonomic responses leading to impaired awareness of hypoglycaemia, which is associated with an increased risk of severe hypoglycaemia requiring third-party assistance (SH). The UK Driving and Vehicle Licensing Agency (DVLA) does not permit car driving if they have either a complete loss of hypoglycaemia awareness or more than one SH event a year.

METHODS

The FreeStyle Libre (FSL) Association of British Clinical Diabetologists (ABCD) Nationwide Audit consists of data collected by clinicians during routine clinical work, submitted into a secure web-based tool held within the National Health Service (NHS) N3 network. Analysis of paired baseline and follow-up data for people with type 1 diabetes who also held a driving licence was undertaken.

RESULTS

The study consisted of 6304 people who had data recorded about driving status from 102 UK specialist diabetes centres, of which 4218 held a driving licence: 4178 a group 1, standard licence, 33 a group 2, large lorries and buses, seven a taxi licence; 1819 did not drive. Paired baseline and follow-up data were available for a sub-cohort of 1606/4218. At a mean follow-up of 6.9 months [95% CI (6.8, 7.1)], the Gold score had improved (2.3 ± 1.5 vs. 2.0 ± 1.3 p < .001), and the number of people who experienced an SH episode was also significantly lower (12.1% vs. 2.7%, p < .001).

CONCLUSION

This study suggests that intermittently scanned continuous glucose monitoring may improve impaired awareness of hypoglycaemia and reduce the number of people with type 1 diabetes with a driving licence experiencing a severe hypoglycaemic episode.

The impact of hypoglycaemia on quality of life among adults with type 1 diabetes: Results from "YourSAY: Hypoglycaemia"

AIMS

Research on hypoglycaemia and quality of life (QoL) has focused mostly on severe hypoglycaemia and psychological outcomes, with less known about other aspects of hypoglycaemia (e.g., self-treated episodes) and impacts on other QoL domains (e.g., relationships). Therefore, we examined the impact of all aspects of hypoglycaemia on QoL in adults with type 1 diabetes (T1DM).

METHODS

Participants completed an online survey, including assessment of hypoglycaemia-specific QoL (using the 12-item Hypoglycaemia Impact Profile). Mann-Whitney U tests examined differences in hypoglycaemia-specific QoL by hypoglycaemia frequency, severity, and awareness. Hierarchical linear regression examined associations with QoL.

RESULTS

Participants were 1028 adults with T1DM (M ± SD age: 47 ± 15 years; diabetes duration: 27 ± 16 years). Severe and self-treated hypoglycaemia and impaired awareness negatively impacted on overall QoL and several QoL domains, including leisure activities, physical health, ability to keep fit/be active, sleep, emotional well-being, spontaneity, independence, work/studies, and dietary freedom. Diabetes distress was most strongly associated with hypoglycaemia-specific QoL, followed by generic emotional well-being, fear of hypoglycaemia, and confidence in managing hypoglycaemia. Hypoglycaemia frequency and awareness were no longer significantly associated with QoL once psychological factors were considered.

CONCLUSIONS

Hypoglycaemia negatively impacts on several QoL domains. Psychological factors supersede the effect of hypoglycaemia frequency and awareness in accounting for this negative impact.

Prevalence and contributing factors of impaired awareness of hypoglycemia in patients with type 2 diabetes: a meta-analysis

AIMS

To conduct a systematic review to summarize the definition, measurement tools, prevalence, and contributing factors of impaired awareness of hypoglycemia (IAH) in type 2 diabetes mellitus (T2DM).

METHODS

A reproducible search strategy was used to identify factors affecting IAH in T2DM in PubMed, MEDLINE, EMBASE, Cochrane, PsycINFO, and CINAHL from inception until 2022. Literature screening, quality evaluation, and information extraction were performed independently by 2 investigators. A meta-analysis of prevalence was performed using Stata 17.0.

RESULTS

The pooled prevalence of IAH in patients with T2DM was 22% (95%CI:14-29%). Measurement tools included the Gold score, Clarke's questionnaire, and the Pedersen-Bjergaard scale. IAH in T2DM was associated with sociodemographic factors (age, BMI, ethnicity, marital status, education level, and type of pharmacy patients visited), clinical disease factors (disease duration, HbAlc, complications, insulin therapy regimen, sulfonylureas use, and the frequency and severity of hypoglycemia), and behavior and lifestyle (smoking and medication adherence).

CONCLUSION

The study found a high prevalence of IAH in T2DM, with an increased risk of severe hypoglycemia, suggesting that medical workers should take targeted measures to address sociodemographic factors, clinical disease, and behavior and lifestyle to reduce IAH in T2DM and thus reduce hypoglycemia in patients.

The Hypoglycemic Fear Syndrome: Understanding and Addressing This Common Clinical Problem in Adults With Diabetes

Although a broad literature on fear of hypoglycemia and its impact on people with type 1 or type 2 diabetes has accumulated over the past three decades, there has been surprisingly little guidance concerning how best to tackle this problem in clinical care. The aim of this article is to begin filling this gap by describing the "hypoglycemic fear syndrome," which we define as hypoglycemic fear that has become so overwhelming that it leads to avoidance behaviors and chronically elevated glucose levels. We begin by presenting several illustrative cases, describing the syndrome and how it is most commonly presented in clinical care, and detailing its most common precipitants. We then offer practical, evidence-based strategies for clinical intervention, based on the literature and our clinical experience.

Epidemiological, Social and Economic Burden of Severe Hypoglycaemia in Patients with Diabetes Mellitus in Portugal: A Structured Literature Review

INTRODUCTION

The aim of this review was to identify and review studies reporting on the epidemiological, social and economic impact associated with severe hypoglycaemia (SH) in people with diabetes mellitus (DM) in Portugal.

METHODS

A structured literature search was carried out in PubMed and Embase using a predefined selection criterion. Studies published in either Portuguese or English, between January 2010 and February 2021 were deemed eligible for inclusion.

RESULTS

Twelve studies including adults (aged ≥ 18 years) with type 1 and/or type 2 diabetes mellitus (T1DM/T2DM) were eligible for inclusion. Epidemiological estimates varied according to the setting and type of data source used. The proportion of patients who experienced ≥ 1 SH episode (SHE) in the previous 6-12 months varied from 3.1% in adults with T2DM to 36.8% in adults with T1DM. In adults with T2DM the prevalence in a community-based study was highest in the insulin and secretagogue combination treated group (9.1%), while in an emergency department setting prevalence was highest in the insulin-based therapy group and the oral hypoglycaemic agent without secretagogues group (32.0% and 20.0%, respectively). The prevalence of SH in other studies in patients with DM ranged from 0.1% (emergency department) to 18.1% (hospital ward). Patients treated with secretagogues had the highest rates of hospitalisations. In patients with T1DM, the annual rate of SHE was higher in those with impaired hypoglycaemia awareness than in those with intact awareness. Mean total cost (direct and indirect) per SHE ranged from €1493.00 in patients with T2DM treated in an emergency setting to €2608.51 in patients with T1DM who were hospitalised.

CONCLUSION

Hypoglycaemic events, especially SHE, have a significant effect on the life of persons living with DM and their caregivers. Studies show that the prevalence of this acute complication of diabetes is not negligible. In addition to the negative impact on the quality of life, the burden of SHE in Portugal translates into a significant impact on the global health expenditure.

New Developments in Glucagon Treatment for Hypoglycemia

Glucagon is essential for endogenous glucose regulation along with the paired hormone, insulin. Unlike insulin, pharmaceutical use of glucagon has been limited due to the unstable nature of the peptide. Glucagon has the potential to address hypoglycemia as a major limiting factor in the treatment of diabetes, which remains very common in the type 1 and type 2 diabetes. Recent developments are poised to change this paradigm and expand the use of glucagon for people with diabetes. Glucagon emergency kits have major limitations for their use in treating severe hypoglycemia. A complicated reconstitution and injection process often results in incomplete or aborted administration. New preparations include intranasal glucagon with an easy-to-use and needle-free nasal applicator as well as two stable liquid formulations in pre-filled injection devices. These may ease the burden of severe hypoglycemia treatment. The liquid preparations may also have a role in the treatment of non-severe hypoglycemia. Despite potential benefits of expanded use of glucagon, undesirable side effects (nausea, vomiting), cost, and complexity of adding another medication may limit real-world use. Additionally, more long-term safety and outcome data are needed before widespread, frequent use of glucagon is recommended by providers.

Cost-Effectiveness Analysis of an Advanced Hybrid Closed-Loop Insulin Delivery System in People with Type 1 Diabetes in Greece

AbstractIntroduction: Usage of automated insulin delivery systems is increasing for the treatment of people with type 1 diabetes (T1D). This study compared long-term cost-effectiveness of the Advanced Hybrid Closed Loop MiniMed 780G (AHCL) system versus sensor augmented pump (SAP) system with predictive low glucose management (PLGM) or multiple daily injections (MDI) plus intermittently scanned continuous glucose monitoring (isCGM) in people with T1D in Greece. Methods: Analyses were performed using the IQVIA CORE Diabetes Model, with clinical input data sourced from various studies. In the AHCL versus SAP plus PLGM analysis, patients were assumed to have 7.5% baseline glycated hemoglobin (HbA1c), when comparing AHCL with MDI plus isCGM baseline HbA1c was assumed to be 7.8%. HbA1c was reduced to 7.0% following AHCL treatment initiation but remained at baseline levels in the comparator arms. Analyses were performed from a societal perspective over a lifetime time horizon. Future costs and clinical outcomes were discounted at 1.5% per annum. Results: AHCL was associated with increased quality-adjusted life expectancy of 0.284 quality-adjusted life years (QALYs) and EUR 10,173 lower mean total lifetime costs with SAP plus PLGM. Compared with MDI plus isCGM, AHCL was associated with increased quality-adjusted life expectancy of 2.708 QALYs, EUR 76,396 higher mean total lifetime costs, and an incremental cost-effectiveness ratio of EUR 29,869 per QALY. Extensive sensitivity analysis confirmed the robustness of results. Conclusions: Over patient lifetime, the MiniMed 780G system is likely to be cost saving compared with the SAP plus PLGM system and cost-effective compared with MDI plus isCGM in people with T1D in Greece.

Cost-Effectiveness of Hybrid Closed Loop Insulin Pumps Versus Multiple Daily Injections Plus Intermittently Scanned Glucose Monitoring in People With Type 1 Diabetes in The Netherlands

INTRODUCTION

Hybrid closed loop (HCL) insulin pump systems and intermittently scanned continuous glucose monitoring (IS-CGM) are increasingly used by individuals with type 1 diabetes (T1D). The aim of the analysis was to compare the long-term cost-effectiveness of the MiniMed 670G HCL system versus IS-CGM plus multiple daily injections of insulin (MDI) or continuous subcutaneous insulin infusion (CSII) in adults with T1D in the Netherlands.

METHODS

The analysis was performed using the IQVIA CORE Diabetes Model with clinical input data sourced from observational studies. Simulated patients were assumed to have a baseline HbA1c of 7.8%. Use of the MiniMed 670G system was assumed to reduce HbA1c by 0.4% and confer a quality-of-life (QoL) benefit through reduced fear of hypoglycemia (FoH). The analysis was performed from a societal perspective over a lifetime time horizon; future costs and clinical outcomes pertaining to the Netherlands were used and discounted at 4% and 1.5% per annum, respectively.

RESULTS

Use of the MiniMed 670G HCL system was projected to improve mean quality-adjusted life expectancy by 2.231 quality-adjusted life years (QALYs) versus IS-CGM. Total mean lifetime costs were EUR 13,683 higher with the MiniMed 670G system resulting in an ICER of EUR 6133 per QALY gained. Sensitivity analyses revealed findings to be sensitive to changes in assumptions around severe hypoglycemic event rates and the (QoL) benefit associated with reduced FoH.

CONCLUSIONS

Over patient lifetimes, for adults with long-standing T1D in the Netherlands, use of the MiniMed 670G system is projected to be cost-effective versus IS-CGM plus MDI or CSII.

Unmet support needs relating to hypoglycaemia among adults with type 1 diabetes: Results of a multi-country web-based qualitative study

OBJECTIVE

Hypoglycaemic episodes and fear of hypoglycaemia can be burdensome for adults with type 1 diabetes. This study explored support needs relating to hypoglycaemia among adults with type 1 diabetes living in Denmark, Germany, the Netherlands and the United Kingdom.

RESEARCH DESIGN AND METHODS

Respondents participated in a web-based qualitative study involving four open-ended questions that asked what they wished other people understood about hypoglycaemia and what other people could do differently to support them with hypoglycaemia. Responses were analyzed using reflexive thematic analysis.

RESULTS

Participants were 219 adults with type 1 diabetes (mean ± SD age 39 ± 13 years; mean ± SD diabetes duration 20 ± 14 years). They described unmet needs relating to: (1) Clinical support, involving access to new diabetes technologies, training on hypoglycaemia prevention, personalised care and psychological support; (2) Practical support, involving family and friends better supporting them with hypoglycaemia management and prevention; (3) Education for other people, involving others becoming more informed about hypoglycaemia; and (4) An appreciation of the burden, involving others recognizing the experience and impact of episodes, and the burden of living with the risk of hypoglycaemia.

CONCLUSIONS

Adults with type 1 diabetes report several unmet support needs relating to hypoglycaemia. Service delivery should be person-centred and prioritise the individual's support needs. Clinical conversations are needed to identify the individual's support needs and develop tailored support plans. People with diabetes and their family members should be offered hypoglycaemia-specific education and training.

The Cost-Effectiveness of an Advanced Hybrid Closed-Loop System in People with Type 1 Diabetes: a Health Economic Analysis in Sweden

INTRODUCTION

Swedish National Diabetes Registry data show a correlation of improved glycemic control in people with type 1 diabetes (T1D) with increased use of diabetes technologies over the past 25 years. However, novel technologies are often associated with a high initial outlay. The aim of the present study was to evaluate the long-term cost-effectiveness of the advanced hybrid closed-loop (AHCL) MiniMed 780G system versus intermittently scanned continuous glucose monitoring (isCGM) plus self-injection of multiple daily insulin (MDI) or continuous subcutaneous insulin infusion (CSII) in people with T1D in Sweden.

METHODS

Outcomes were projected over patients' lifetimes using the IQVIA CORE Diabetes Model (v9.0). Clinical data, including changes in glycated hemoglobin (HbA1c) and hypoglycemia rates, were sourced from observational studies and a randomized crossover trial. Modeled patients were assumed to receive the treatments for their lifetimes, with HbA1c kept constant following the application of treatment effects. Costs were accounted from a societal perspective and expressed in Swedish krona (SEK). Utilities and days off work estimates were taken from published sources.

RESULTS

The MiniMed 780G system was associated with an improvement in life expectancy of 0.16 years and an improvement in quality-adjusted life expectancy of 1.95 quality-adjusted life years (QALYs) versus isCGM plus MDI or CSII. These clinical benefits were due to a reduced incidence and a delayed time to onset of diabetes-related complications. Combined costs were estimated to be SEK 727,408 (EUR 72,741) higher with MiniMed 780G, with treatment costs partially offset by direct cost savings from the avoidance of diabetes-related complications and indirect cost savings from the avoidance of lost workplace productivity. The MiniMed 780G system was associated with an incremental cost-effectiveness ratio of SEK 373,700 per QALY gained.

CONCLUSIONS

Based on a willingness-to-pay threshold of SEK 500,000 per QALY gained, the MiniMed 780G system was projected to be cost-effective versus isCGM plus MDI or CSII for the treatment of T1D in Sweden.

Factors associated with work ability in adults with diabetes

AIMS

The aims of this study were to explore associations between clinical and diabetes-related factors with work ability in a sample of working adults with diabetes.

BACKGROUND

Adults with diabetes may face challenges in the workplace, including managing their diabetes and overall physical and mental health.

METHODS

This was a cross-sectional design with a sample of 101 working adults. Subjects completed valid and reliable surveys assessing depressive symptoms, diabetes self-care, fear of hypoglycemia, diabetes distress, cardiovascular health using American Heart Association's Life's Simple 7 (range 0-7) and work ability. Factors significantly associated with work ability at bivariate level were included in linear and logistic regression.

RESULTS

The majority of the sample was female (65%) (mean age 54.1 ± 10.5), White (74%), non-Hispanic (93%), worked full-time (65%) and had type 2 diabetes (87%) (mean duration 12.4 ± 9.5 years). The majority (55%) had low diabetes distress, but 24% had high distress and 28% had depressive symptoms. The sample achieved 2.5 ± 1.4 ideal AHA heart health indices and 33% rated their work ability as excellent. In linear regression higher depressive scores were associated with lower work ability scores (b = -0.45, p = .002). In logistic regression, scores on heart health (OR = 1.4; 95%CI:1.0-1.9, p = .03) and diabetes distress (OR = 0.6, 95%CI:0.4-0.9, p = .048) were significantly associated with work ability at its best.

CONCLUSION

Both cardiovascular and psychological health may impact work ability in adults with diabetes. Routinely screening for diabetes distress and depression while also promoting ideal cardiovascular health may improve overall health and work ability in this population.

Synthetic long-acting insulin analogs for the management of type 1 diabetes: an update

INTRODUCTION

Type 1 diabetes is characterized by insulin deficiency and requires near-physiological insulin replacement. In most patients, this is accomplished by basal bolus therapy consisting of a long-acting basal insulin administered once or twice daily and short-acting insulin with main meals. Several long-acting insulin analogs have been developed to optimize basal insulin therapy.

AREAS COVERED

This paper reviews the design of - and data from - randomized controlled trials (RCTs) to assess glucose lowering efficacy and safety of long-acting insulin analogs for the treatment of type 1 diabetes.

EXPERT OPINION

Due to the non-inferiority treat-to-target design of insulin, RCTs treatment differences primarily appear as differences in hypoglycemia risk. Data suggest that the first generation long-acting insulin analogs insulin glargine U100 and insulin detemir have a similar glucose lowering efficacy compared to NPH insulin but a lower risk of hypoglycemia, particularly during nighttime. The newer analogs insulin glargine U300 and insulin degludec provide non-inferior efficacy, although insulin glargine U300 is less potent unit-to-unit. Insulin degludec reduces hypoglycemia risk compared to insulin glargine U100. Future studies should explore the potential for further improvement of treatment results in type 1 diabetes by a structured approach to personalization of basal insulin therapy.

'Never again will I be carefree': a qualitative study of the impact of hypoglycemia on quality of life among adults with type 1 diabetes

INTRODUCTION

Achieving glycemic targets and optimizing quality of life (QoL) are important goals of type 1 diabetes care. Hypoglycemia is a common barrier to achieving targets and can be associated with significant distress. However, the impact of hypoglycemia on QoL is not fully understood. The aim of this study was to explore how adults with type 1 diabetes are impacted by hypoglycemia in areas of life that are important to their overall QoL.

RESEARCH DESIGN AND METHODS

Participants responded to a web-based qualitative survey involving a novel 'Wheel of Life' activity. Responses were analyzed using reflexive thematic analysis.

RESULTS

The final sample included 219 adults with type 1 diabetes from Denmark, Germany, the Netherlands, and the UK. They had a mean±SD age of 39±13 years and diabetes duration of 20±14 years. Participants identified eight areas of life important to their overall QoL, including relationships and social life, work and studies, leisure and physical activity, everyday life, sleep, sex life, physical health, and mental health. Participants reported emotional, behavioral, cognitive, and social impacts of hypoglycemia within domains. Across domains, participants described interruptions, limited participation in activities, exhaustion, fear of hypoglycemia, compensatory strategies to prevent hypoglycemia, and reduced spontaneity.

CONCLUSIONS

The findings emphasize the profound impact of hypoglycemia on QoL and diabetes self-care behaviors. Diabetes services should be aware of and address the burden of hypoglycemia to provide person-centered care. Clinicians could ask individuals how hypoglycemia affects important areas of their lives to better understand the personal impact and develop tailored management plans.

Economic burden of diabetes-related hypoglycemia on patients, payors, and employers

The economic and psychological consequences of diabetes-related hypoglycemic events are multifold and shared across various parties, including patients and their family or caregivers, payors, and employers. Hypoglycemic events contribute to increased morbidity, mortality, and a substantial portion of diabetes economic burden. Both severe and non-severe hypoglycemic episodes contribute to economic and psychological burden, and can have short-term consequences, such as emergency services, hospitalization, clinic visits, and increased use of diabetes supplies. Severe hypoglycemic events also generate additional follow-up costs, and are likely to occur again. Left untreated, hypoglycemia can have long-term consequences including, death, cardiovascular events, and cognitive issues. Costs vary geographically based on the treatment protocols which focus on outpatient treatment versus increased in-patient hospitalization. Certain types of medications are also associated with increased hypoglycemia, which requires closer monitoring of the patient, such as with basal insulin initiation. Some individuals with diabetes may be more vulnerable to hypoglycemia, such as the elderly, postoperative bariatric patients, and adolescent females. Measures to mitigate hypoglycemia are essential to ease the economic burden of these events. Medication management, optimal glucose control, lifestyle modifications and frequent glucose monitoring are some interventions which may help prevent hypoglycemia.

The impact of hypoglycaemia on quality of life outcomes among adults with type 1 diabetes: A systematic review

Hypoglycaemia is a common barrier to optimal glycaemic management and often feared among adults with type 1 diabetes. The aim of this systematic review was to summarize current evidence regarding the impact of hypoglycaemia on quality of life (QoL) and related outcomes. Electronic searches of MEDLINE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials were conducted. Peer-reviewed empirical studies investigating the relationship between hypoglycaemia and QoL were eligible for inclusion. Thirty studies met the inclusion criteria. Extracted data was summarized in a narrative synthesis according to Synthesis Without Meta-Analysis guidelines. None of the studies examined the impact of hypoglycaemia on general QoL. There was no association between hypoglycaemia and diabetes-specific QoL in four of the 30 studies. Severe hypoglycaemia was associated with greater fear of hypoglycaemia and diabetes distress, and lower general emotional well-being, but not with depression, anxiety, or health status. Self-treated hypoglycaemia was associated with greater fear of hypoglycaemia. With the exception of fear of hypoglycaemia, this review shows mixed associations between hypoglycaemia and psychological outcomes. Further research is needed to investigate the impact of hypoglycaemia on other domains of QoL.

Effects of continuous glucose monitor-recorded nocturnal hypoglycaemia on quality of life and mood during daily life in type 1 diabetes

AIMS/HYPOTHESIS

The aim of this work was to assess the effect of spontaneous nocturnal hypoglycaemia on quality of life and mood during subsequent days in type 1 diabetes.

METHODS

A total of 153 people with type 1 diabetes participated in 6 days of blinded continuous glucose monitoring while documenting hypoglycaemic symptoms, quality of life and mood, daily. Hypoglycaemia was defined by interstitial glucose ≤3.9 mmol/l (IG_3.9) and ≤ 3.0 mmol/l (IG_3.0) for ≥15 min and was classified as asymptomatic if no hypoglycaemic symptoms were reported.

RESULTS

Self-estimated quality of life assessed by the EQ-5D VAS (but not by the WHO Well-Being Index) was higher the day after asymptomatic (but not after symptomatic) hypoglycaemic nights, as compared with non-hypoglycaemic nights (IG_3.9, p = 0.021; IG_3.0, p = 0.048). The effect increased with lower glucose nadir and longer duration of nocturnal hypoglycaemia (IG_3.9, p = 0.03). The finding was confined to participants with impaired hypoglycaemia awareness. There was no effect of nocturnal hypoglycaemia on mood or self-estimated effectiveness at work the following day.

CONCLUSIONS/INTERPRETATION

Individuals with type 1 diabetes and impaired hypoglycaemia awareness reported higher quality of life on days preceded by nights with asymptomatic (but not symptomatic) hypoglycaemia. The effect was amplified by lower glucose nadir and longer duration of the episodes and may help explain resistance to implementation of interventions to reduce hypoglycaemia in many people with impaired hypoglycaemia awareness.

Compliance with treatment and fear of hypoglycaemia in patients with type 2 diabetes

AIMS

The aim of this study was to determine the compliance with treatment and fear of hypoglycaemia in patients with type 2 diabetes.

BACKGROUND

One of the important problems of patients is the fear of hypoglycaemia and compliance with treatment, which impairs general health and quality of life. It is believed that nurses contribute to the improvement of compliance with treatment in patients with type 2 diabetes, a decrease in hypoglycaemia rates.

DESIGN

This study was conducted as a descriptive study. The STROBE checklist was used.

METHODS

The study was carried out with 376 patients with type 2 diabetes between January and June 2019. The Patient Information Form, Type 2 Diabetes Mellitus Treatment Patient Compliance Scale and Hypoglycemia Fear Survey applied and SAS 9.4 package program was used for statistical analysis. Data were evaluated using descriptive statistics, t test, chi-square and variation analysis.

RESULTS

It was determined that 58.2% of the participants were female, mean age was 62.19 ± 9.60, 57.7% were primary school graduates, 50.3% were using oral antidiabetic, and 34.5% were using oral antidiabetic and insulin. Patients' compliance with treatment was moderate (60.9%). According to the mean score of the Hypoglycemia Fear Survey, the patients had a low level of fear of hypoglycaemia ( X ¯  = 1.20). There was a statistically significant difference between compliance and fear of hypoglycaemia and education, economic status, self-monitoring of blood glucose, physical activity and education about diabetes (p < .05). Patients with type 2 diabetes had decreased compliance with treatment with increased fear of hypoglycaemia (p < .05).

CONCLUSION

The participants' compliance with the treatment was moderate, and the fear of hypoglycaemia mean score was low. Nursing interventions should be planned to increase compliance with treatment and reduce the fear of hypoglycaemia in patients with type 2 diabetes.

RELEVANCE TO CLINICAL PRACTICE

Assessing the fear of hypoglycaemia and the level of compliance with treatment by healthcare professionals, especially nurses, in patients with type 2 diabetes and providing education on this subject can be helpful in reducing the fear of hypoglycaemia, increasing treatment compliance and providing optimal glycaemic control.

Factors Influencing Adherence Among Youth with Type-1-Diabetes Mellitus - The Hungarian Case

Background and Introduction: Due to the increasing prevalence of type-1-diabetes, an increasing number of studies have drawn attention to its psychological effects and long-term consequences. As Type 1 Diabetes Mellitus is a chronic, non-curable, yet maintainable condition, with the affected children and their families facing a lifelong challenge, our research focuses on the factors influencing adherence.

METHODS

The adherence of youth was examined in a sample involving 114 patients treated in the Medical and Health Science Centre at the University of Debrecen by employing a new adherence questionnaire (DAQ abbreviated version, Munkácsi et al. 2019) (DAF 2017; N=114). The influence of socio- demographic variables and those related to the disease (age at the time of diagnosis, the time elapsed since diagnosis, method of treatment, the time elapsed since the use of the pump) was measured by linear regression. Furthermore, the between-group comparisons were made by independent sample t-tests and variance analysis. The investigation was carried out between September 2017 and May 2018.

RESULTS

The effect of using insulin pump as therapy turned out to be significant and positive (0.36. p=0.045). It was observed that the adherence of the patients using insulin pump was higher while the effect of the age at the diagnosis had a significantly negative effect (-.247, p=0.035). Thus, earlier detection of the disease may lead to a higher level of adherence. The effects of the socio-demographic variables (gender, family structure, educational level, type of the settlement, owning sibling and birth order) were not significant (p>0.05). Regarding the between-group comparisons, a significant difference could be pointed out concerning the siblings and birth-order as the adherence of those with siblings was higher (p=0.044). Moreover, concerning insulin pump therapy, the adherence of patients using pump was significantly better (p=0.048). Also, regarding the age of the diagnosis, the adherence of those diagnosed before 12 was seemingly higher (p=0.039). Concerning the other socio-demographical and disease-related variables, no significant differences could be detected.

CONCLUSION

The results suggest that the treatment has an outstanding role in the adherence of the disease. Moreover, the role of the appropriate treatment, living conditions as well as the early diagnosis is relevant.

Conversations and Reactions Around Severe Hypoglycaemia (CRASH): Results from the German Cohort of a Global Survey of People with Type 1 Diabetes or Insulin-Treated Type 2 Diabetes and Caregivers

BACKGROUND

A global cross-sectional survey (CRASH) was designed to provide information about the experiences of people with diabetes (PWD) and their caregivers in relation to severe hypoglycaemic events.

METHODS

Adults with type 1 diabetes or insulin-treated type 2 diabetes who had experienced one or more severe hypoglycaemic events within the past 3 years, and adult caregivers for such people, were recruited from medical research panels using purposive sampling. We present here results from Germany.

RESULTS

Approximately 100 individuals in each of the four participant groups completed a 30-minute online survey. Survey results indicated that the most recent severe hypoglycaemic event made many participants feel scared (80.4%), unprepared (70.4%), and/or helpless (66.5%). Severe hypoglycaemia was discussed by healthcare professionals at every visit with only 20.2% of participants who had ever had this conversation, and 53.5% of participants indicated that their insulin regimen had not changed following their most recent event. 37.1% of PWD/people with diabetes cared for by caregivers owned a glucagon kit at the time of survey completion.

CONCLUSIONS

The survey identified areas for improvement in the prevention and management of severe hypoglycaemic events. For healthcare professionals, these include enquiring more frequently about severe hypoglycaemia and adjusting blood glucose-lowering medication after a severe hypoglycaemic event. For individuals with diabetes and their caregivers, potential improvements include ensuring availability of glucagon at all times. Changes in these areas could lead not only to improved patient wellbeing but also to reduced use of emergency services/hospitalisation and, consequently, lower healthcare costs.

Impact of severe hypoglycaemia on psychological outcomes in adults with Type 2 diabetes: a systematic review

AIM

Hypoglycaemia affects many people with Type 2 diabetes using insulin and other glucose-lowering therapies. This systematic review examined the impact of severe hypoglycaemia (episodes requiring external assistance) on psychological outcomes (e.g. emotional well-being, health status and quality of life) in adults with Type 2 diabetes.

METHODS

MEDLINE Complete, PsycINFO and CINAHL databases were searched for peer-reviewed empirical studies, published in English, reporting the occurrence and severity of hypoglycaemia and its relationship with patient-reported outcomes (PROs) in adults with Type 2 diabetes. Data were extracted from published reports and analysed.

RESULTS

Of 3756 potentially relevant abstracts, 29 studies met the inclusion criteria. Most reported cross-sectional data and sample sizes varied widely (N = 71 to 17 563). Although definitions of mild and severe hypoglycaemia were largely consistent between studies, additional non-standard categorizations (e.g. moderate, very severe) were apparent and recall periods varied. Overall, severe hypoglycaemia was associated with increased fear of hypoglycaemia and decreased emotional well-being, health status and diabetes-specific quality of life. Effect sizes show that the association with fear of hypoglycaemia was stronger than with general health status.

CONCLUSIONS

Notwithstanding the limitations of the empirical studies, these findings indicate that severe hypoglycaemia in adults with Type 2 diabetes (insulin- and non-insulin-treated) is associated with impaired psychological outcomes. Healthcare professionals should address the psychological impact of severe hypoglycaemia during clinical consultations, to support individuals to minimize exposure to, and the psychological consequences of, severe hypoglycaemia.

Hypoglycaemia Awareness Restoration Programme for People with Type 1 Diabetes and Problematic Hypoglycaemia Persisting Despite Optimised Self-care (HARPdoc): protocol for a group randomised controlled trial of a novel intervention addressing cognitions

INTRODUCTION

Severe hypoglycaemia (SH), when blood glucose falls too low to support brain function, is the most feared acute complication of insulin therapy for type 1 diabetes mellitus (T1DM). 10% of people with T1DM contribute nearly 70% of all episodes, with impaired awareness of hypoglycaemia (IAH) a major risk factor. People with IAH may be refractory to conventional approaches to reduce SH, with evidence for cognitive barriers to hypoglycaemia avoidance. This paper describes the protocol for the Hypoglycaemia Awareness Restoration Programme for People with Type 1 Diabetes and Problematic Hypoglycaemia Persisting Despite Optimised Self-care (HARPdoc) study, a trial to assess the impact on hypoglycaemia experience of a novel intervention that addresses cognitive barriers to hypoglycaemia avoidance, compared with an existing control intervention, recommended by the National Institute of Health and Care Excellence.

METHODS AND ANALYSIS

A randomised parallel two-arm trial of two group therapies: HARPdoc versus Blood Glucose Awareness Training, among 96 adults with T1DM and problematic hypoglycaemia, despite attendance at education with or without technology use, in four centres providing specialist T1DM services. The primary outcome will be the SH rate at 12 and/or 24 months after randomisation to either course. Secondary outcomes include rates of SH requiring parenteral therapy, involving unconsciousness or needing emergency services; hypoglycaemia awareness status, overall diabetes control and quality of life measures. An implementation study to evaluate how the interventions are delivered and how implementation impacts on clinical effectiveness is planned as a parallel study, with its own protocol.

ETHICS AND DISSEMINATION

The protocol was approved by the London Dulwich Research Ethics Committee, the Health Research Authority, National Health Service R&D and the Institutional Review Board of the Joslin Diabetes Center in the USA. Study findings will be disseminated to study participants and through peer-reviewed publications and conference presentations, including user groups.

TRIAL REGISTRATION NUMBER

NCY02940873; Pre-results.

Reliability and validity of the Chinese version of the new fear of hypoglycemia scale: FH-15

Objective

This study aimed to evaluate the reliability and validity of the Chinese version of the Fear of Hypoglycemia scale with 15 items (FH-15).

Methods

After obtaining the original author's authorization, the English version of the FH-15 scale was translated, back translated, and culturally debugged to obtain the Chinese version of FH-15. A convenient sampling method was used to extract patients with type 2 diabetes from four tertiary hospitals in Tianjin. A total of 408 patients with type 2 diabetes were investigated in the hospital to test the reliability and validity of Chinese version FH-15 scale.

Results

The content validity index of the scale was 0.92, and the content validity index of each item was 0.8-1.0. The exploratory factor analysis extracted three common factors (fear, avoidance, and interference), which contained 15 items, and the cumulative variance contribution rate was 71.245%. The confirmatory factor analysis results showed that the model fit was better at 1.981 χ ²/df, GFI = 0.901, CGI = 0.962, TLI = 0.952, and RMSEA = 0.070. The cut-off value for the total hypoglycemia fear scale was 30.5. The Cronbach's α coefficient of the three dimensions of the scale was 0.918, the Cronbach's α coefficient of each dimension is 0.876-0.916, the test-retest reliability was 0.903, and the test-retest reliability of each factor was 0.733-0.930.

Conclusion

The Chinese version of the FH-15 scale can be considered reliable and valid. The item expression is concise, clear, and easy to understand. It is suitable for clinical practice as an initial screening tool to identify and evaluate the severity of fear of hypoglycemia in patients with type 2 diabetes.

Women with Type 1 Diabetes Mellitus: Effect of Disease and Psychosocial-Related Correlates on Health-Related Quality of Life

BACKGROUND

This study is aimed at investigating the various disease-specific and health-related psychosocial concepts of HRQOL among insulin-dependent diabetes mellitus (IDDM) and understanding the gender differences in HRQOL among IDDM patients.

METHODS

A cross-sectional observational study was conducted to assess the effect of health-related and psychosocial correlates on HRQOL of IDDM patients in Penang, Malaysia. The participants were recruited from five governmental diabetic clinics. Patients with insulin use only, IDDM diagnosed at least 1 year earlier, were identified from clinical registers. The sample was then age stratified for 20-64 years, and severe complications (e.g., end-stage renal failure, hemodialysis, and liver cirrhosis) were excluded; a total of 1003 participants were enrolled in the study. Multivariate regression analysis was used to predict the response.

RESULTS

A total of 853 (100%) participants were enrolled and completed the study. Women exhibited significantly higher/better mental health (p < 0.013) and health perception scores (p < 0.001) despite high prevalence of impaired role (49.2%), social (24.2%), and physical (40.5%) functionings as compared to men. Women with longer diabetes exposure and uncontrolled glycemic levels (HbA1c) have poorer HRQOL. Availability of social support showed no significant association with either HRQOL or diabetes distress levels. Diabetes distress levels remained not associated with social support. Women also showed significantly higher association with health perception (15% versus 13% men, p < 0.001) and mental health (13% versus 11% men, p < 0.001) in diabetes-specific psychosocial factors. Thus, among women alone, diabetes-related specific and psychosocial factors explained 15% and 13% of variations in HRQOL extents, respectively.

CONCLUSION

Women exhibit extensive and significant patterns with health-related factors and diabetes-specific psychosocial factors (self-efficacy, social support, and DLC) to improve HRQOL. Also, women have significantly high reported distress levels and low social functioning compared to men.

Association of hypoglycaemia severity with clinical, patient-reported and economic outcomes in US patients with type 2 diabetes using basal insulin

AIMS

To evaluate the clinical and patient-reported outcomes and healthcare utilization and costs associated with patient-reported hypoglycaemia in US adults with type 2 diabetes (T2D) treated with basal insulin.

MATERIALS AND METHODS

This was an observational, cross-sectional, survey-based study of adults with T2D on basal insulin ± oral antidiabetes drugs (OADs) or rapid-acting/premixed insulin, who had in the past ever experienced hypoglycaemia, using US data from the National Health and Wellness Survey. Eligible patients were categorized as having no hypoglycaemia (38.7%), non-severe hypoglycaemia (55.1%), or severe hypoglycaemia (6.2%) in the preceding 3 months. Outcomes included health-related quality of life (HRQoL), work productivity and activity impairment, healthcare resource utilization, and estimated direct and indirect costs. Multivariable regression models were performed to control for patient characteristics.

RESULTS

Patients who experienced severe hypoglycaemia had significantly (P < .05) lower HRQoL scores, greater overall impairment of work productivity and activity, greater healthcare resource utilization, and higher costs compared with those who experienced non-severe or no hypoglycaemia. Patients with non-severe hypoglycaemia also reported an impact on the number of provider visits, indirect costs, and HRQoL.

CONCLUSIONS

Patients with T2D using basal insulin ± OADs or rapid-acting/premixed insulin in the United States who experienced severe hypoglycaemia had greater impairment of activity and work productivity, utilized more healthcare resources, and incurred higher associated costs than those with non-severe or no hypoglycaemia. The study also demonstrated the impact that non-severe hypoglycaemic events have on economic and HRQoL outcomes. Reducing the incidence and severity of hypoglycaemia could lead to clinically meaningful improvements in HRQoL and may result in lower healthcare utilization and associated costs.

Association of diabetes therapy-related quality of life and physical activity levels in patients with type 2 diabetes receiving medication therapy: the Diabetes Distress and Care Registry at Tenri (DDCRT 17)

AIM

To examine the association between diabetes therapy-related quality of life (DTR-QOL) and physical activity levels, and identify factors associated with high diabetes therapy-related quality of life.

METHODS

Cross-sectional data from 2970 patients with type 2 diabetes in a Japanese diabetes registry were assessed for independent correlations between DTR-QOL (domains 1-4) and high physical activity levels. Data collected by the International Physical Activity Questionnaire were analyzed by logistic regression and adjusted for potential confounders.

RESULTS

The mean patient age, BMI and HbA1c level were 65.8 years, 24.7 kg/m² and 7.6% (58.7 mmol/mol), respectively. Univariate analysis showed that DTR-QOL domain 1, 2 and 4 scores were significantly associated with physical activity levels (p = 0.0046, p = 0.0004 and p < 0.001, respectively, but domain 3 score was not (p = 0.5073). In a multivariable-adjusted logistic regression model, odds ratios (ORs) of DTR-QOL domains 1, 3 and 4 were independently associated with high physical activity (ORs for 2nd to 4th quartile and p for trend; [domain 1] 1.16, 1.56, 1.22, p = 0.032; [domain 3] 1.45, 1.55, 1.38, p = 0.049; [domain 4] 1.09, 1.30, 1.51, p = 0.001, respectively), but domain 2 was not (ORs for 2nd to 4th quartile and p for trend; 1.19, 1.26, 1.23, p = 0.096).

CONCLUSION

High diabetes therapy-related QOL scores were associated with high levels of physical activity in patients with type 2 diabetes. Because this is a cross-sectional study, further study is needed to evaluate the causal association between therapy-related QOL and physical activity.

A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health Science Network (EAHSN) model

AIMS

We developed a new clinical integrated pathway linking a regional Ambulance Trust with a severe hypoglycaemia (SH) prevention team. We present clinical data from the first 2000 emergency calls taken through this new clinical pathway in the East of England.

METHODS

SH patients attended by Ambulance crew receive written information on SH avoidance, and are contacted for further education through a new regional SH prevention team. All patients are contacted unless they actively decline.

RESULTS

Median age (IQR) was 67 (50-80) years, 23.6% of calls were for patients over 80years old, and patients more than 90years old were more common than 20-25year olds in this population. Most calls were for patients (84.9%) who were insulin treated, even those over 80years (75%). One - third of patients attended after a call were unconscious on attendance. 5.6% of patients in this call population had 3 or more ambulance call outs, and they generated 17.6% of all calls. In total, 728 episodes (36.4%) were repeat calls. Insulin related events were clinically more severe than oral hypoglycaemic related events. Patients conveyed to hospitals (13.8%) were significantly older, with poorer recovery in biochemical hypoglycaemia after ambulance crew attendance. Only 19 (1%) opted out of further contact. Patients were contacted by the SH prevention team after a median 3 (0-6) days. The most common patient self - reported cause for their SH episode was related to perceived errors in insulin management (31.4%).

CONCLUSIONS

This new clinical service is simple, acceptable to patients, and a translatable model for prevention of recurrent SH in this largely elderly insulin treated SH population.

Reporting Severe Hypoglycemia in Type 1 Diabetes: Facts and Pitfalls

PURPOSE OF REVIEW

To describe potential factors influencing reporting of severe hypoglycemia in adult patients with type 1 diabetes and to analyze their effect on reported rates of severe hypoglycemia.

RECENT FINDINGS

Reported rates of severe hypoglycemia defined as need for third party assistance vary between 0.3-3.0 events per patient-year in unselected cohorts, corresponding to a yearly prevalence range of 10-53%. When defined as need for parenteral therapy with glucose or glucagon or need for admission to an emergency unit or hospitalization, incidence and prevalence rates of severe hypoglycemia are 0.02-0.5 events per patient-year and 1-29%, respectively. When subjects with recurrent severe hypoglycemia in the past or suffering from impaired hypoglycemia awareness are excluded from participation in studies, lower rates are reported. Studies applying anonymous reporting or reporting by partners report higher rates of severe hypoglycemia. There is a large variation between studies reporting incidence and prevalence of severe hypoglycemia in patients with type 1 diabetes, mainly explained by definition of severity, methods of reporting, and patient selection. These findings call for consensus about hypoglycemia definition and reporting in future research.

Be Careful What You Ask For: Effects of Benefit Descriptions on Diabetes Patients' Benefit-Risk Tradeoff Preferences

BACKGROUND

As more studies report on patient preferences for diabetes treatment, identifying diabetes outcomes other than glycated hemoglobin (HbA_1c) to describe effectiveness is warranted to understand patient-relevant, benefit-risk tradeoffs.

OBJECTIVE

The aim of the study was to evaluate how preferences differ when effectiveness (glycemic control) is presented as long-term sequela (LTS) risk mitigation rather than an asymptomatic technical marker (HbA_1c).

METHODS

People with type 2 diabetes and using insulin (n = 3160) were randomly assigned to four self-administered, discrete-choice experiments that differed by their presentation of effectiveness. Epidemiologic reviews were conducted to ensure a close approximation of LTS risk relative to HbA_1c levels. The relative importance of treatment benefit-risk characteristics and maximum acceptable risk tradeoffs was estimated using an error-component logit model. Log-likelihood ratio tests were used to compare parameter vectors.

RESULTS

In total, 1031 people responded to the survey. Significantly more severe hypoglycemic events were accepted for a health improvement in terms of LTS mitigation versus HbA_1c improvement (0.7 events per year; 95% confidence interval [CI]: 0.4-1.0 vs. 0.2 events per year 95% CI: -0.02 to 0.5) and avoidance of treatment-related heart attack risk (1.4 severe hypoglycemic events per year; 95% CI: 0.8-1.9 vs. 1 event per year; 95% CI: 0.6-1.3). This finding is supported by a log-likelihood test that rejected at the 0.05 level that respondent preference structures are similar across the different experimental arms of the discrete-choice experiment.

CONCLUSION

We found evidence that benefit descriptions influence elicited preferences for the benefit-risk characteristics of injectable diabetes treatment. These findings argue for using carefully defined effectiveness measures to accurately take account of the patient perspective in benefit-risk assessments.

The economic impact of insulin-related hypoglycemia in Denmark: an analysis using the Local Impact of Hypoglycemia Tool

AIMS

To estimate the direct cost of hypoglycemia in insulin-treated adults with type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in Denmark.

MATERIALS AND METHODS

The Local Impact of Hypoglycemia Tool (LIHT) was used to estimate the costs associated with insulin-related hypoglycemia. Average utilization of healthcare resources, including the costs of pre-hospitalization, hospital admission, healthcare professional contact and follow-up, glucose/glucagon, and extra SMBG tests to monitor blood glucose following an episode, was used to calculate an average cost per severe and per non-severe hypoglycemic episode. The cost per episode was then applied to the rates of severe and non-severe hypoglycemia in people with T1DM and T2DM in Denmark.

RESULTS

The direct cost of insulin-related hypoglycemia in Denmark is DKK 96.2 million per year, which equates to EUR 12.9 million. For people with T1DM prone to severe hypoglycemia (defined as having ≥2 severe episodes in the past year), the cost per person per year increases by DKK 4,155 compared with the T1DM population average, and for people with T2DM prone to non-severe hypoglycemia (defined as having ≥1 non-severe episode in the last 4 weeks), the cost increases by DKK 647 per person per year compared with the T2DM population average.

CONCLUSIONS

The LIHT highlights the substantial economic burden of insulin-related hypoglycemia in Denmark, and provides a means to estimate the savings that could be made by lowering hypoglycemia rates. For example, the costs associated with using a new insulin or introducing a patient education program could be offset with the cost saving from reducing hypoglycemia.

Investigating Hypoglycemic Confidence in Type 1 and Type 2 Diabetes

BACKGROUND

While research designed to understand the concerns about hypoglycemia among patients with diabetes has been primarily focused on the investigation of fear and anxiety, recent evidence suggests a potentially important and conceptually distinct element-hypoglycemic confidence. To investigate this dimension, we developed the Hypoglycemic Confidence Scale (HCS); herein, we describe the construction and validation of the HCS and examine how key patient factors are associated with hypoglycemic confidence.

METHODS

Items were developed from interviews with six type 1 diabetes (T1D) adults, six insulin-using type 2 diabetes (T2D) adults, and seven diabetes healthcare professionals, resulting in nine self-report items. Separate exploratory factor analyses (EFAs) were conducted with T1D adults (N = 326), with T2D adults using both basal and prandial insulins (T2D-BP, N = 145) and with T2D adults using only basal insulin (T2D-BO, N = 82). Construct validity for the HCS was established with overall well-being (World Health Organization-5), diabetes distress (Diabetes Distress Scale), global anxiety (Generalized Anxiety Disorder), hypoglycemic fear (Hypoglycemic Fear Survey-II), and glycemic control (self-reported A1C). Hierarchical regression analyses examined the unique contribution of HCS scores, independent of hypoglycemic fear, on key psychosocial constructs and A1C.

RESULTS

EFAs of the nine HCS items yielded a single factor solution for each of the three subject samples, accounting for 50.8%, 65.1%, and 73.7% of the variance for the T1D, T2D-BP, and T2D-BO groups, respectively. Construct validity was established by significant correlations with criterion variables. The HCS was associated with well-being and diabetes distress in the T1D (in both cases, P < 0.001) and T2D-BP groups (in both cases, P < .05) and for self-reported A1C in the T2D-BP group (P < .05) independent of hypoglycemic fear.

CONCLUSIONS

Hypoglycemic confidence is a unique dimension of patient experience, different from hypoglycemic fear, and is deserving of further study. The HCS is a reliable valid measure of hypoglycemic confidence for adults with T1D and insulin-using T2D.

Long-Term Prediction of Severe Hypoglycemia in Type 1 Diabetes: Is It Really Possible?

BACKGROUND

Prediction of risk of severe hypoglycemia (SH) in patients with type 1 diabetes is important to prevent future episodes, but it is unknown if it is possible to predict the long-term risk of SH. The aim of the study is to assess if long-term prediction of SH is possible in type 1 diabetes.

METHODS

A follow-up study was performed with 98 patients with type 1 diabetes. At baseline and at follow-up, the patients filled in a questionnaire about diabetes history and complications, number of SH in the preceding year and state of awareness, and HbA1c and C-peptide levels were measured.

RESULTS

During the 12 years of follow-up, there was a decrease in HbA1c, C-peptide levels, and incidence of SH (1.1 to 0.4 episodes per patient-year; P < .001). At baseline, the relative rate of SH was 3.6 (P = .001) and 10.9 (P < .0001) in patients with impaired awareness and unawareness of hypoglycemia, respectively, as compared to patients with normal awareness. At follow-up, patients with unawareness at baseline tended to have maintained an increased rate of SH (RR = 3.1; P = .07). Impaired awareness, HbA1c and C-peptide determined at baseline did not correspond with an increased rate of SH at follow-up.

CONCLUSIONS

Long-term prediction of severe hypoglycemia in type 1 diabetes was not possible, although baseline hypoglycemia unawareness tended to remain a predictor for risk of SH at follow-up. Therefore, it is important repeatedly to assess the different risk factors of SH to determine the actual risk.

Saxagliptin for the treatment of diabetes - a focus on safety

INTRODUCTION

The safety of agents used to treat type 2 diabetes (T2D), a chronic disease requiring life-long intervention, is of particular interest. Saxagliptin is a potent and selective DPP-4 inhibitor that has emerged as a therapeutic option for T2D.

AREAS COVERED

Its safety was assessed in a development program of 20 phase 2/3 randomized clinical trials and in SAVOR-TIMI 53 trial that evaluated the cardiovascular outcomes. In order to capture any further safety signals, mainly in the long-term, a post-marketing safety surveillance is ongoing. This paper discusses the tolerability and safety profile of the agent, including cardiovascular, renal, pancreatic, hepatic and bone adverse events.

EXPERT OPINION

Saxagliptin is a safe therapeutic option for patients with T2D, with low risk of hypoglycemia and good tolerability. It demonstrated cardiovascular safety (including in patients with pre-existing cardiovascular disease and/or HF) and safety with respect to all-cause mortality and adverse events of special interest. In SAVOR-TIMI53, saxagliptin was associated with an unexpected increased risk of HF hospitalization, mainly in the first 12 months; a mechanistic explanation for this has not been found. Further research needs to elucidate the effect of antidiabetic drugs on the heart, by including biomarkers and echocardiographic sub-studies within large outcome trials.

Treatment beliefs, health behaviors and their association with treatment outcome in type 2 diabetes

OBJECTIVE

While the prevalence of type 2 diabetes is growing, it is increasingly well recognized that treatment outcomes in primary care practice are often suboptimal. The aim of this study is to examine the extent to which treatment beliefs and health behaviors predict diabetes health outcome as measured by glycated hemoglobin (HbA1c) level, blood pressure, and lipid profile.

RESEARCH DESIGN AND METHODS

This was a large-scale cross-sectional, registry-based study involving a well-defined type 2 diabetes population, in the county of Funen, Denmark. Registry data were combined with a 27-item self-reported survey administered to all insulin-treated people in the registry (n=3160). The survey was constructed to operationalize key concepts of diabetes management, diabetes treatment beliefs, and health behaviors.

RESULTS

In total, 1033 respondents answered the survey. The majority of treatment beliefs and health behaviors examined were predictors of glycemic control and, to a large extent, lipid profile. Absence from, or a low frequency of, self-measured blood glucose, non-adherence to general medical advice and the prescribed treatment, a low primary care utilization, and perceived low treatment efficacy were factors positively associated with HbA1c levels, s-cholesterol, and low-density lipoprotein. Conversely, infrequent self-measured blood glucose was associated with a significantly higher likelihood of having a blood pressure below 130/80 mm Hg. Perceived low treatment efficacy was the only health belief associated with poorer levels of health outcome other than HbA1c.

CONCLUSIONS

Health behaviors were stronger predictors for health outcomes than treatment beliefs. Self-reported adherence to either the treatment regimen or general medical advice most consistently predicted both glycemic control and cardiovascular risk factors.