Clinical diagnosis for dusk phenomenon of diabetes

Insulin Requirements for Basal and Auto-Correction Insulin Delivery in Advanced Hybrid Closed-Loop System: 4193 Days' Real-World Data of Children in Two Different Age Groups

BACKGROUND

The insulin requirements of people with type 1 diabetes (T1D) can vary throughout the day due to factors such as biorhythm, exercise, and food intake. The MiniMed 780G system delivers micro boluses to adjust basal insulin and delivers auto-correction boluses to meet insulin needs when micro bolus increases are insufficient. Through analysis of MiniMed 780G data, this study investigates the variations in insulin requirements throughout the day.

METHODS

4193 days' pump and continuous glucose monitoring (CGM) data of 34 children using MiniMed 780G were collected from Medtronic CareLink. Micro and auto-correction boluses were analyzed on an hourly basis for two age groups: below nine years old and above nine years old. Glycemic metrics were analyzed based on International CGM consensus.

RESULTS

The mean age was 12.3 years and mean duration of diabetes was 6.1 years. The mean time in range (TIR) and glucose management indicator (GMI) were 80.5% and 6.6%, respectively. The micro bolus (basal) ratio between 05.00 and 07.00 was significantly higher than the ratio between 10.00 and 03.00 (P < .01), whereas micro bolus was significantly lower between 19.00 and 21.00 than those between 00.00 and 10.00 (P < .001). The auto-correction ratio between 21.00 and 00.00 was significantly higher than those between 03.00-17.00 (P < .001) and 19.00-21.00 (P = .008), whereas auto-correction was significantly lower between 07.00 and 10.00 than those between 10.00 and 03.00 (P < .001). The micro bolus ratio was significantly higher in children below nine years old than in children above nine years old between 21.00-00.00 (P = .026) and 00.00-03.00 (P = .003).

CONCLUSION

The basal insulin need follows a diurnal pattern with two significantly different periods-high between 00.00 and 10.00 and low between 10.00 and 00.00. The auto-correction rates are low between 05.00 and 10.00 and show an increasing pattern peaking between 21.00 and 00.00. These findings are compatible with the dawn and reverse dawn phenomena.

Relationship Between Time in Range and Dusk Phenomenon in Outpatients with Type 2 Diabetes Mellitus

Purpose

The dusk phenomenon refers to a spontaneous and transient pre-dinner hyperglycemia that affects glucose fluctuation and glycemic control, and the increasing use of continuous glucose monitoring (CGM) has facilitated its diagnosis. We investigated the frequency of the dusk phenomenon and its relationship with the time in range (TIR) in patients with type 2 diabetes mellitus (T2DM).

Patients and Methods

This study involved 102 patients with T2DM who underwent CGM for 14 days. CGM-derived metrics and clinical characteristics were evaluated. A consecutive dusk blood glucose difference (pre-dinner glucose minus 2-hour post-lunch glucose) of ≥ 0 or once-only dusk blood glucose difference of < 0 was diagnosed as the clinical dusk phenomenon (CLDP).

Results

We found that the percentage of CLDP was 11.76% (10.34% in men, 13.64% in women). Compared with the non-CLDP group, the CLDP group tended to be younger and have a lower percentage of TIR (%TIR^3.9-10) and higher percentage of time above range (%TAR^>10 and %TAR^>13.9) (P ≤ 0.05). Adjusted for confounding factors, the binary logistic regression analysis showed a negative association of CLDP with %TIR (odds ratio < 1, P < 0.05). We repeated the correlation analysis based on 70%TIR and found significant differences in hemoglobin A1c, fasting blood glucose, mean blood glucose, standard deviation of the sensor glucose values, glucose coefficient of variation, largest amplitude of glycemic excursions, mean amplitude of glycemic excursions, glucose management indicator, and percentage of CLDP between the two subgroups of TIR ≤ 70% and TIR > 70% (P < 0.05). The negative association between TIR and CLDP still remained after adjustment by the binary logistic regression analysis.

Conclusion

The CLDP was frequently present in patients with T2DM. The TIR was significantly correlated with the CLDP and could serve as an independent negative predictor.

Patients with Type 1 Diabetes Treated with Insulin Pumps Need Widely Heterogeneous Basal Rate Profiles Ranging from Negligible to Pronounced Diurnal Variability

BACKGROUND

Pump-treated patients with type 1 diabetes have widely differing basal insulin infusion profiles. We analyzed consequences of such heterogeneity for glycemic control under fasting conditions.

METHODS

Data from 339 adult patients with type 1 diabetes on insulin pump therapy undergoing a 24-hour fast (basal rate test) were retrospectively analyzed. Hourly programmed basal insulin infusion rates and plasma glucose concentrations as well as their proportions within, below, or above arbitrarily defined target ranges were assessed for specific periods of the day (eg, 1-7 hours, "dawn" period, 16-19 hours, "dusk" period, reference period 20-1 hours/10-14 hours), by tertiles of a predefined "dawn" index (mean basal insulin infusion rate during the "dawn" divided by the reference periods).

RESULTS

The "dawn" index varied interindividually from 0.7 to 4.4. Basal insulin infusion profiles exhibited substantial differences (P = .011), especially overnight. Despite higher insulin infusion rates at 4 and 6.45 hours, patients with the most pronounced "dawn" phenomenon exhibited higher plasma glucose concentrations at those time points (P < .012). Patients with a marked "dawn" phenomenon exhibited a lower probability for low (<4.4 mmol/L) and a higher probability of high values (>7.2 mmol/L) during the dawn period (all P values <.01).

CONCLUSIONS

We observe substantial interindividual heterogeneity in the "dawn" phenomenon. However, widely different empirically derived basal insulin infusion profiles appear appropriate for individual patients, as indicated by similar plasma glucose concentrations, mainly in the target range, during a 24-hour fasting period.

The impact of dusk phenomenon on total glucose exposure in Chinese people with type 2 diabetes

This study was aimed at assessing the impact of the dusk phenomenon on the total glucose exposure in Chinese people with type 2 diabetes.A total of 380 type 2 diabetes who received a retrospective continuous glucose monitoring system (CGMs) for 72 hours were enrolled in our study, 32 of them failed in CGMs. The patients were first divided into 2 groups: dusk phenomenon (n = 95) and non dusk phenomenon group (n = 253). The magnitude of the dusk phenomenon (δDusk) was quantified by pre-dinner glucose minus post-lunch 2 hours glucose. A persistent δDusk ≥ 0 or a once only δDusk < 0 can be diagnosed with the dusk phenomenon. The participants were secondarily matched for the post-lunch 2 hours glucose to assess the impact of the dusk phenomenon on the overall glucose exposure. The impact of the dusk phenomenon was assessed on high-performance liquid chromatography assay (HbA1c) and 24-hour mean glucose.There were 95 of 348 (27.3%) participants with the dusk phenomenon in the overall population, and the median of δDusk level was -0.8 (-1.8, 0.2) mmol/L. The median of glucose differences between the 2 paired groups were 0.4 (-0.4, 1.0)% for HbA1c, 0.9 (0.2, 1.4) mmol/L for 24 hours mean glucose. The correlation analysis showed no relationship between the magnitude of dawn phenomenon and the dusk phenomenon (r = 0.052, P = .472).The incidence of dusk phenomenon is about 27.3% in people with type 2 diabetes. The impacts of dusk phenomenon on HbA1c and 24-hour mean glucose were about 0.4% and 0.9 mmol/L and the dusk phenomenon was not related with the dawn phenomenon.

Twenty-Four Hour Fasting (Basal Rate) Tests to Achieve Custom-Tailored, Hour-by-Hour Basal Insulin Infusion Rates in Patients With Type 1 Diabetes Using Insulin Pumps (CSII)

BACKGROUND

Twenty-four hour fasting periods are being used to scrutinize basal insulin infusion rates for pump-treated patients with type 1 diabetes.

METHODS

Data from 339 consecutive in-patients with adult type 1 diabetes on insulin pump therapy undergoing a 24-hour fast as a basal rate test were retrospectively analyzed. Hourly programmed basal insulin infusion rates and plasma glucose concentrations within, below, or above arbitrarily defined target ranges were assessed for periods of the day of special interest (eg, 01:00-07:00 am, "dawn" period, 04:00-07:00 pm, and "dusk" period). Statistics: χ²-tests, paired t-tests were used.

RESULTS

Basal rates (mean: 0.90 ± 0.02 IU/h) showed circadian variations with peaks corresponding to "dawn" (1.07 ± 0.02 IU/h from 01:00 to 07:00 am) and, less prominently, "dusk" (0.95 ± 0.02 IU/h from 03:00 to 07:00 pm). Individual mean plasma glucose concentrations averaged 6.6 ± 0.1 mmol/L, with 53.1% in the predefined "strict" (4.4-7.2 mmol/L) target range. Interestingly, during the "dawn" period, plasma glucose was significantly higher (by 0.5 ± 0.1 mmol/L [95% confidence interval: 0.3-0.8 mmol/L; P < .0001]) and the odds ratio for hypoglycemia was significantly lower compared to the reference period.

INTERPRETATION

Twenty-four hour fasting periods as basal rate tests frequently unravel periods with inappropriate basal insulin infusion rates potentially responsible for fasting hyper- or hypoglycemia. Notably, the higher basal insulin infusion rate found during the "dawn" period seems to be justified and may need to be accentuated.

Spontaneous and transient hyperglycemia before sleep in a patient with glaucomatous blindness and diabetes: A case reprt

RATIONALE

The peak of blood glucose was during 9 PM to 3 AM. There is a stable, spontaneous and short-term abnormal increase of blood glucose. The pathophysiological mechanism is unknown. It is speculated that the cause might be the imbalance of the glucose-regulating hormone that is caused by the disorder of the biological clock system.

PATIENT CONCERNS

The case was a 73-year old man with bilateral glaucoma (only mild light perception) and was hospitalized to establish a viable hypoglycemic plan. He received 4 shots of insulin enhancement, oral meditation, pre-mixed insulin treatment during the 22 days. However, his blood glucose had been spontaneously increased from 9 PM to 3 AM which was the highest of the day, and then resumed by itself. Insulin intervention was effective.

DIAGNOSIS

Glaucomatous blindness and diabetes, spontaneous and transient hyperglycemia before sleep.

INTERVENTIONS

We used insulin aspart 3u when we found hyperglycemia three times at 9 PM and it was effective. Without intervention, blood sugar will automatically improve in the morning.

OUTCOMES

During the late night and early morning, there is a stable, spontaneous and short-term transit abnormal increase in blood glucose, which suggests the complexity of blood glucose adjustment.

LESSONS

Due to the case specialty, we could not do the systematic review of the study. However, it improves the awareness of the abnormal periodically increase of blood glucose during the special periods, and provides with a reference for clinical research of dawn and dusk phenomenon. Multi-point blood glucose monitoring or dynamic blood glucose monitoring throughout the day is of great significance for the detection of special types of hyperglycemia.