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Arshad MF, Walkinshaw E, Solomon AL, Bernjak A, Rombach I, Leelarathna L, Little SA, Evans M, Shaw JAM, Heller SR, Iqbal A. Diabetic autonomic neuropathy does not impede improvement in hypoglycaemia awareness in adults: Sub-study results from the HypoCOMPaSS trial. Diabet Med 2024; 41:e15340. [PMID: 38741266 DOI: 10.1111/dme.15340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/22/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
AIMS Impaired awareness of hypoglycaemia (IAH) increases the risk of severe hypoglycaemia in people with type 1 diabetes mellitus (T1DM). IAH can be reversed through meticulous avoidance of hypoglycaemia. Diabetic autonomic neuropathy (DAN) has been proposed as an underlying mechanism contributing to IAH; however, data are inconsistent. The aim of this study was to examine the effects of cardiac autonomic neuropathy (CAN) on IAH reversibility inT1DM. METHODS Participants with T1DM and IAH (Gold score ≥4) recruited to the HypoCOMPaSS (24-week 2 × 2 factorial randomised controlled) trial were included. All underwent screening for cardiac autonomic function testing at baseline and received comparable education and support aimed at avoiding hypoglycaemia and improving hypoglycaemia awareness. Definite CAN was defined as the presence of ≥2 abnormal cardiac reflex tests. Participants were grouped according to their CAN status, and changes in Gold score were compared. RESULTS Eighty-three participants (52 women [62.7%]) were included with mean age (SD) of 48 (12) years and mean HbA1c of 66 (13) mmol/mol (8.2 [3.3] %). The mean duration of T1DM was 29 (13) years. The prevalence of CAN was low with 5/83 (6%) participants having definite autonomic neuropathy with 11 (13%) classified with possible/early neuropathy. All participants, regardless of the autonomic function status, showed a mean improvement in Gold score of ≥1 (mean improvement -1.2 [95% CI -0.8, -1.6]; p < 0.001). CONCLUSIONS IAH can be improved in people with T1DM, and a long duration of disease, with and without cardiac autonomic dysfunction. These data suggest that CAN is not a prime driver for modulating IAH reversibility.
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Affiliation(s)
- Muhammad Fahad Arshad
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Emma Walkinshaw
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | | | | | | | - Lala Leelarathna
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London
| | - Stuart A Little
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Mark Evans
- MRC Institute of Metabolic Science, University of Cambridge, Cambridge, London
| | - James A M Shaw
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Simon R Heller
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Ahmed Iqbal
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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Lai HH, Walker D, Elsouda D, Lockefeer A, Gallington K, Bacci ED. Sleep Disturbance Among Adults With Overactive Bladder: A Cross-sectional Survey. Urology 2023; 179:23-31. [PMID: 37356462 DOI: 10.1016/j.urology.2023.06.014] [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: 03/21/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To examine differences in sleep disturbance, nocturia, and depression among adults with overactive bladder (OAB) by treatment type. METHODS A cross-sectional survey of adults with OAB assessed sleep disturbance, nocturia, and depression using patient-reported outcome measures, including the Patient Reported Outcomes Measurement Information System (PROMIS)-29 Profile v2.1 (Sleep Disturbance and Depression domains), Lower Urinary Tract Dysfunction Research Network Symptom Index-10, and PROMIS Sleep Disturbance Short Form 8B. Treatment groups included antimuscarinics, β-3 adrenergic agonists, and no treatment. Analysis of covariance (ANCOVA) was used to test for differences in study endpoints; Bonferroni-adjusted pairwise tests (P < .05/3) were performed to compare differences in least squares means between groups. RESULTS One hundred participants were included per treatment group. The overall mean (standard deviation) age across all groups was 47.8 (11.8) years. Symptom scores across all PROMIS domains in all three treatment groups were higher than the US general population. There were no statistically significant differences in outcomes across treatment groups. CONCLUSION Adults with OAB reported being affected by sleep disturbance and depression, regardless of treatment. The mirabegron group trended toward the lowest symptom impact across all outcomes, however, comparisons were not significant. Future research should examine temporal associations between OAB treatment, sleep disturbance, and outcomes.
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Affiliation(s)
- H H Lai
- Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - D Walker
- Astellas Global Pharma Development, Inc., Northbrook, IL.
| | - D Elsouda
- Astellas Global Pharma Development, Inc., Northbrook, IL
| | - A Lockefeer
- Astellas Global Pharma Development, Inc., Northbrook, IL
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3
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Hassanein M, Malek R, Shaltout I, Sahay RK, Buyukbese MA, Djaballah K, Pilorget V, Coudert M, Al Sifri S. Real-world safety and effectiveness of iGlarLixi in people with type 2 diabetes who fast during Ramadan: The SoliRam observational study. Diabetes Metab Syndr 2023; 17:102707. [PMID: 36680967 DOI: 10.1016/j.dsx.2023.102707] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIMS To evaluate the safety and effectiveness of iGlarLixi in adults with type 2 diabetes (T2D) fasting during Ramadan. METHODS SoliRam was a multinational, prospective, single-arm, real-world observational study conducted during Ramadan 2020 and 2021 in adults with T2D treated with iGlarLixi ≥3 months at study entry. The primary endpoint was the percentage of participants experiencing ≥1 episode of severe and/or symptomatic documented hypoglycemia (<70 mg/dL [<3.9 mmol/L]). RESULTS Among the 409 eligible participants followed during Ramadan, 96.8% fasted for ≥25 days and 92.4% did not break fasting during Ramadan. Four participants broke their fast due to hypoglycemia. Minimal adjustments were seen in antihyperglycemic therapies from pre to during Ramadan. Documented symptomatic hypoglycemia was experienced by 1.0%, 2.3%, and 0.3% of participants, respectively, during the last month of pre-Ramadan, Ramadan, and first month post-Ramadan. Mean change in HbA1c from pre-to post-Ramadan periods was -0.75% (-8.2 mmol/mol), and participants with HbA1c <7% (<53 mmol/mol) increased from 7.9% pre-Ramadan to 28.6% post-Ramadan. CONCLUSIONS iGlarLixi is an effective and well-tolerated therapy for people with T2D, including those who intend to fast during Ramadan, and is associated with a low risk of hypoglycemia; benefits were observed both during and after Ramadan.
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Affiliation(s)
- Mohamed Hassanein
- Dubai Hospital, Al Khaleej Street, Al Baraha, Dubai, United Arab Emirates.
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4
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Siamashvili M, Davis HA, Davis SN. Nocturnal hypoglycemia in type 1 and type 2 diabetes: an update on prevalence, prevention, pathophysiology and patient awareness. Expert Rev Endocrinol Metab 2021; 16:281-293. [PMID: 34525888 DOI: 10.1080/17446651.2021.1979391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Despite considerable progress in diabetes treatment, prevalence of nocturnal hypoglycemia in type 1 diabetes mellitus (T1DM) and advanced insulin treated type 2 diabetes mellitus (T2DM) remains high. AREAS COVERED The present manuscript describes the prevalence of night-time hypoglycemia as reported in observational and randomized controlled trials. Factors that affect the risk of hypoglycemia are highlighted. The authors also describe impaired awareness of hypoglycemia and available preventive methods. EXPERT OPINION Prevention of nocturnal hypoglycemia includes behavioral, dietary and pharmacologic interventions. The most recent development with the lowest rate of hypoglycemia is sensor-augmented pumps with predictive low glucose suspend technology. These pumps combine continuous subcutaneous insulin infusion with continuous glucose monitoring and use various algorithms to predict and stop hypoglycemia before it develops.
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Affiliation(s)
- Maka Siamashvili
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Hugh A Davis
- Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, United States
| | - Stephen N Davis
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
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Au NH, Ratzki-Leewing A, Zou G, Ryan BL, Webster-Bogaert S, Reichert SM, Brown JB, Harris SB. Real-World Incidence and Risk Factors for Daytime and Nocturnal Non-Severe Hypoglycemia in Adults With Type 2 Diabetes Mellitus on Insulin and/or Secretagogues (InHypo-DM Study, Canada). Can J Diabetes 2021; 46:196-203.e2. [DOI: 10.1016/j.jcjd.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 10/20/2022]
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Shi L, Fonseca V, Childs B. Economic burden of diabetes-related hypoglycemia on patients, payors, and employers. J Diabetes Complications 2021; 35:107916. [PMID: 33836965 DOI: 10.1016/j.jdiacomp.2021.107916] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Lizheng Shi
- 1440 Canal Street Suite 1900, New Orleans, LA 70112, United States of America.
| | - Vivian Fonseca
- Tullis Tulane Alumni Chair in Diabetes, Section of Endocrinology, Tulane University Health Sciences Center, 1430 Tulane Avenue - SL 53, New Orleans, LA 70112, United States of America.
| | - Belinda Childs
- Great Plains Diabetes, 834 N. Socora, Suite 4, Wichita, KS 67212, United States of America.
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Farrell CM, McCrimmon RJ. Clinical approaches to treat impaired awareness of hypoglycaemia. Ther Adv Endocrinol Metab 2021; 12:20420188211000248. [PMID: 33796253 PMCID: PMC7968015 DOI: 10.1177/20420188211000248] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/12/2021] [Indexed: 01/25/2023] Open
Abstract
Impaired awareness of hypoglycaemia (IAH) affects between 25% and 30% of all people with type 1 diabetes (T1D) and markedly increases risk of severe hypoglycaemia. This greatly feared complication of T1D impairs quality of life and has a recognised morbidity. People with T1D have an increased propensity to hypoglycaemia as a result of fundamental physiological defects in their ability to respond appropriately to a fall in blood glucose levels. With repeated exposure to low glucose, many then develop a condition referred to as IAH, where there is a reduced ability to perceive the onset of hypoglycaemia and take appropriate corrective action. The management of individuals with IAH relies initially on its identification in the clinic through a detailed exploration of the frequency of hypoglycaemia and an assessment of the individual's ability to recognise these episodes. In this review article, we will address the clinical strategies that may help in the management of the patient with IAH once identified, who may or may not also suffer from problematic hypoglycaemia. The initial focus is on how to identify such patients and then on the variety of approaches involving educational programmes and technological approaches that may be taken to minimise hypoglycaemia risk. No single approach can be advocated for all patients, and it is the role of the health care professional to identify the clinical strategy that best enables their patient to achieve this goal.
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Affiliation(s)
- Catriona M. Farrell
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
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Rechenberg K, Griggs S, Jeon S, Redeker N, Yaggi HK, Grey M. Sleep and Glycemia in Youth With Type 1 Diabetes. J Pediatr Health Care 2020; 34:315-324. [PMID: 32171612 PMCID: PMC7311270 DOI: 10.1016/j.pedhc.2019.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/03/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Short sleep duration and quality are problems for many youth, and are associated with difficulties in executive function. Our purpose was to describe subjective and objective sleep characteristics and their associations with executive function, stress and coping, adjustment, and self-management in youth with type 1 diabetes (T1D). METHOD Youth with T1D (N = 40; mean age, 13.4 ± 1.9 years; 60% female; 77.1% non-Hispanic white; diabetes duration, 7.1 ± 4.6 years; and hemoglobin A1c, 8.2 ± 1.2%) wore an actigraph and a continuous glucose monitor for 3-7 days and completed questionnaires. Descriptive and bivariate analyses were conducted. RESULTS Sleep variability was associated with stress and depressive symptoms, as well as more glucose variability. Consistent rest-activity rhythm timing was associated with fewer trait anxiety symptoms. Robust rhythms were associated with better diabetes self-management. DISCUSSION Providers should routinely assess sleep habits in youth, especially those with T1D. Improving consistency in sleep timing and sleep duration may be a potential therapeutic target to improve diabetes clinical outcomes.
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9
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Wang JS, Chen H, Tang F, Sheu WHH. Associations of fear of hypoglycemia with second-line use of insulin secretagogues or insulin and subsequent glycemic control in patients with type 2 diabetes: An analysis using data from the DISCOVER study. Int J Clin Pract 2020; 74:e13485. [PMID: 32003099 DOI: 10.1111/ijcp.13485] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/26/2019] [Accepted: 01/29/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Associations of fear of hypoglycemia with prescription of second-line insulin secretagogues (IS) or insulin and subsequent glycemic control in patients with type 2 diabetes were analysed using data from the DISCOVER study-a large, prospective, observational study. METHODS Patients with type 2 diabetes initiating a second-line treatment after a first-line oral therapy were enrolled. Fear of hypoglycemia was assessed using baseline Hypoglycemia Fear Survey (HFS) worry score. Glycemic control was assessed using glycated haemoglobin (HbA1c) levels at 6-month and 1-year follow-up, and HbA1c change from baseline was analysed. To examine the association of baseline HFS worry scores with second-line use of IS or insulin, a hierarchical logistic model with country as random effect was used. RESULTS A total of 6217 patients were analysed. The mean HFS worry score was 6.9 ± 11.4, while patients in the upper quartile had an HFS worry score ≥9. We divided patients into three groups according to their baseline HFS worry score (0, 1-8, ≥9). HFS worry score was associated with the use of first-line IS, but not the second-line treatment. Compared to treatments with no IS and insulin, a better HbA1c response to second-line IS or insulin was noted in patients with a baseline HFS worry score of 0 or 1-8, but not in patients with a baseline HFS worry score ≥9. CONCLUSION HFS worry score was associated with the use of first-line IS and glycemic response to second-line IS or insulin in patients with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT02322762. Registered 23 December 2014.
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Affiliation(s)
- Jun-Sing Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Medical Technology, College of Life Science, National Chung-Hsing University, Taichung, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
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10
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Andersen A, Jørgensen PG, Knop FK, Vilsbøll T. Hypoglycaemia and cardiac arrhythmias in diabetes. Ther Adv Endocrinol Metab 2020; 11:2042018820911803. [PMID: 32489579 PMCID: PMC7238305 DOI: 10.1177/2042018820911803] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/30/2020] [Indexed: 01/11/2023] Open
Abstract
Hypoglycaemia remains an inevitable risk in insulin-treated type 1 diabetes and type 2 diabetes and has been associated with multiple adverse outcomes. Whether hypoglycaemia is a cause of fatal cardiac arrhythmias in diabetes, or merely a marker of vulnerability, is still unknown. Since a pivotal report in 1991, hypoglycaemia has been suspected to induce cardiac arrhythmias in patients with type 1 diabetes, the so-called 'dead-in-bed syndrome'. This suspicion has subsequently been supported by the coexistence of an increased mortality and a three-fold increase in severe hypoglycaemia in patients with type 2 diabetes receiving intensive glucose-lowering treatment in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Studies have investigated the association between hypoglycaemia-induced cardiac arrhythmias. In a rat-model, severe hypoglycaemia resulted in a specific pattern of cardiac arrhythmias including QT-prolongation, ventricular tachycardia, second- and third-degree AV block and ultimately cardiorespiratory arrest. In clinical studies of experimentally induced hypoglycaemia, QTc-prolongation, a risk factor of ventricular arrhythmias, is an almost consistent finding. The extent of QT-prolongation seems to be modified by several factors, including antecedent hypoglycaemia, diabetes duration and cardiac autonomic neuropathy. Observational studies indicate diurnal differences in the pattern of electrocardiographic alterations during hypoglycaemia with larger QTc-prolongations during daytime, whereas the risk of bradyarrhythmias may be increased during sleep. Daytime periods of hypoglycaemia are characterized by shorter duration, increased awareness and a larger increase in catecholamines. The counterregulatory response is reduced during nightly episodes of hypoglycaemia, resulting in prolonged periods of hypoglycaemia with multiple nadirs. An initial sympathetic activity at plasma glucose nadir is replaced by increased vagal activity, which results in bradycardia. Here, we provide an overview of the existing literature exploring potential mechanisms for hypoglycaemia-induced cardiac arrhythmias and studies linking hypoglycaemia to cardiac arrhythmias in patients with diabetes.
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Affiliation(s)
- Andreas Andersen
- Steno Diabetes Center Copenhagen, Gentofte
Hospital, Hellerup, Denmark
- Center for Clinical Metabolic Research, Herlev
and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Peter G. Jørgensen
- Department of Cardiology, Herlev and Gentofte
Hospital, University of Copenhagen, Hellerup, Denmark
| | - Filip K. Knop
- Center for Clinical Metabolic Research, Herlev
and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Steno Diabetes Center Copenhagen, Gentofte
Hospital, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of
Health and Medical Sciences, University of Copenhagen, Copenhagen,
Denmark
- Novo Nordisk Foundation Center for Basic
Metabolic Research, Faculty of Health and Medical Sciences, University of
Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Steno Diabetes Centre Copenhagen, Gentofte
Hospital, Kildegårdsvej 28, Hellerup, 2900, Denmark
- Center for Clinical Metabolic Research, Herlev
and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of
Health and Medical Sciences, University of Copenhagen, Copenhagen,
Denmark
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Khunti K, Giorgino F, Berard L, Mauricio D, Harris SB. The importance of the initial period of basal insulin titration in people with diabetes. Diabetes Obes Metab 2020; 22:722-733. [PMID: 31865632 PMCID: PMC7187252 DOI: 10.1111/dom.13946] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 12/13/2022]
Abstract
Achieving target glycaemic control is essential in people with diabetes to minimize the risk of long-term complications, and many people with type 2 diabetes will ultimately require basal insulin (BI) therapy to achieve their individualized glycaemic targets. Usually, the first 12 weeks following initiation of BI therapy represents the period when the greatest dose increases and glycaemic reductions occur. Effective glycaemic control combined with minimizing the risk of hypoglycaemia is important to enable the achievement of glycaemic control in the longer term. However, substantial therapeutic inertia exists in clinical practice, both in initiation and up-titration of BI, owing to patient-, physician- and healthcare system-related barriers, including fear of hypoglycaemia and the perception of a burdensome regimen. The more prolonged duration of action, reduced glycaemic variability and lower risk of hypoglycaemia seen with second-generation versus first-generation BI analogues may help alleviate patients' and physicians' concerns and facilitate titration. In turn, optimal BI titration and subsequent metabolic benefits may help improve therapy adherence and self-management. This review details the clinical implications of prompt titration of BI to achieve early glycaemic control, and the importance of minimizing hypoglycaemia risk within the initial titration period. Facilitation of patients' self-management of BI is also addressed.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research CentreUniversity of Leicester, Leicester General HospitalLeicesterUK
| | - Francesco Giorgino
- University of Bari Aldo Moro, Department of Emergency and Organ TransplantationSection of Internal Medicine, Endocrinology, Andrology and Metabolic DiseasesBariItaly
| | - Lori Berard
- Winnipeg Regional Health Authority, Health Sciences CentreWinnipegManitobaCanada
| | - Didac Mauricio
- Institut Investigació Biomèdica Sant PauBarcelonaSpain
- Department of Endocrinology and Nutrition, CIBER of Diabetes and Associated Metabolic DiseasesHospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Stewart B. Harris
- The Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
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Evaluating the Long-Term Cost-Effectiveness of Once-Weekly Semaglutide Versus Once-Daily Liraglutide for the Treatment of Type 2 Diabetes in the UK. Adv Ther 2020; 37:2427-2441. [PMID: 32306244 PMCID: PMC7467468 DOI: 10.1007/s12325-020-01337-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Indexed: 11/29/2022]
Abstract
Introduction Once-weekly semaglutide 1 mg is a novel glucagon-like peptide-1 receptor agonist (GLP-1 RA) for the treatment of type 2 diabetes that has demonstrated significantly greater reductions in glycated haemoglobin (HbA1c) and body weight than the GLP-1 RA once-daily liraglutide 1.2 mg in the SUSTAIN 10 trial. The present analysis aimed to evaluate the long-term cost-effectiveness of once-weekly semaglutide 1 mg versus once-daily liraglutide 1.2 mg from a UK healthcare payer perspective. Methods Long-term outcomes were projected using the IQVIA CORE Diabetes Model (version 9.0), with baseline characteristics and treatment effects sourced from SUSTAIN 10. Patients were assumed to initiate treatment with GLP-1 RAs and continue treatment until HbA1c exceeded 7.5%, at which point GLP-1 RAs were discontinued and basal insulin was initiated. Pharmacy costs and costs of complications were measured in 2018 pounds sterling (GBP), with future costs and outcomes discounted at 3.5% per annum. Utilities were taken from published sources. Results In the base-case analysis, once-weekly semaglutide 1 mg was associated with an increase in discounted life expectancy of 0.21 years and discounted quality-adjusted life expectancy of 0.30 quality-adjusted life-years, compared with once-daily liraglutide 1.2 mg. Clinical benefits were achieved at reduced costs, with lifetime cost savings of GBP 140 per patient with semaglutide versus liraglutide, owing to a reduction in diabetes-related complications, in particular cardiovascular disease (mean cost saving of GBP 279 per patient). Therefore, once-weekly semaglutide 1 mg was dominant compared with once-daily liraglutide 1.2 mg. The results of the sensitivity analyses were similar, demonstrating the robustness of the base-case analysis. Conclusions Once-weekly semaglutide 1 mg is a cost-effective treatment option versus once-daily liraglutide 1.2 mg, based on the SUSTAIN 10 trial, from a UK healthcare payer perspective. Electronic Supplementary Material The online version of this article (10.1007/s12325-020-01337-7) contains supplementary material, which is available to authorized users.
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13
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Flatt AJS, Bennett D, Counter C, Brown AL, White SA, Shaw JAM. β-Cell and renal transplantation options for diabetes. Diabet Med 2020; 37:580-592. [PMID: 31705689 DOI: 10.1111/dme.14177] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 12/16/2022]
Abstract
Despite major advances in structured education, insulin delivery and glucose monitoring, diabetes self-management remains an unremitting challenge. Insulin therapy is inextricably linked to risk of dangerous hypoglycaemia and sustained hyperglycaemia remains a leading cause of renal failure. This review sets out to demystify transplantation for diabetes multidisciplinary teams, facilitating consideration and incorporation within holistic overall person-centred management. Deceased and living donor kidney, whole pancreas and isolated islet transplant procedures, indications and potential benefits are described, in addition to outcomes within the integrated UK transplant programme.
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Affiliation(s)
- A J S Flatt
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - D Bennett
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - C Counter
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - A L Brown
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - S A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - J A M Shaw
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
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14
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Cabré C, Colungo C, Vinagre I, Jansà M, Conget I. Frequency and awareness of hypoglycemia in patients with Type 2 Diabetes treated with two or more insulin injections in primary care outpatient clinics. Prim Care Diabetes 2020; 14:168-172. [PMID: 31474469 DOI: 10.1016/j.pcd.2019.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/16/2019] [Accepted: 08/02/2019] [Indexed: 12/26/2022]
Abstract
AIMS To assess the frequency of hypoglycemia events, patient characteristics and the prevalence of impaired awareness of hypoglycemia (IAH) in patients with Type 2 Diabetes (T2D) using two or more insulin injections in primary care. METHODS Cross-sectional study performed at 9 Primary Care Centers including review of electronic medical records and an on-site visit to patients using >2 insulin injections with suboptimal control. Episodes of severe hypoglycemia (SH) in the last 12months were recorded. Non-severe hypoglycemia (NSH) was considered as self-monitoring blood glucose <70mg/dl. IAH was evaluated and HbA1c was obtained. RESULTS 157 subjects were included (age 68.4+10.7years, 82 women, T2D duration 18.3+8.7years). 57% used multiple daily injections. Total insulin was 66.9+43.4 units/day. The mean HbA1c was 9.2±1.4% (77±12mmol/mol) and only 13.4% had HbA1c <8% (64mmol/mol). The frequency of NSH was 0.74±1.37 episodes/week. Only one patient had a SH the last 12months. Around 10-12% of patients had IAH. In comparison with normal awareness, those with IAH had a longer duration of T2D (25.3±11.6 vs. 16.1±8.2 years, respectively, p<0.01). In the multiple linear regression analysis, only the IAH score and the total insulin dose independently determined the NSH number. CONCLUSIONS NSH/SH in patients with T2D treated with two or more insulin injections in primary care settings seems to be relatively common. Although hypoglycemia awareness is predominantly preserved, the presence of IAH should not be ignored as it increases the risk of hypoglycemia and constitutes an additional barrier to recognize and address this burden in T2D.
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Affiliation(s)
- Carla Cabré
- Diabetes Unit, Endocrinology and Nutrition Dpt. Hospital Clínic, Barcelona, Spain
| | - Cristina Colungo
- Diabetes Unit, Endocrinology and Nutrition Dpt. Hospital Clínic, Barcelona, Spain; Research in Primary Care, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Comte Borrell Primary Health-Care Center, Consorci d'Atenció Primària de Salut de' Eixample (CAPSBE), Barcelona, Spain
| | - Irene Vinagre
- Diabetes Unit, Endocrinology and Nutrition Dpt. Hospital Clínic, Barcelona, Spain
| | - Margarita Jansà
- Diabetes Unit, Endocrinology and Nutrition Dpt. Hospital Clínic, Barcelona, Spain
| | - Ignacio Conget
- Diabetes Unit, Endocrinology and Nutrition Dpt. Hospital Clínic, Barcelona, Spain; IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Spain; CIBERDEM (CIBER in Diabetes and Associated Metabolic Disorders), Spain.
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15
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Farrell CM, McNeilly AD, Fournier P, Jones T, Hapca SM, West D, McCrimmon RJ. A randomised controlled study of high intensity exercise as a dishabituating stimulus to improve hypoglycaemia awareness in people with type 1 diabetes: a proof-of-concept study. Diabetologia 2020; 63:853-863. [PMID: 31942669 PMCID: PMC7054230 DOI: 10.1007/s00125-019-05076-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/25/2019] [Indexed: 01/08/2023]
Abstract
AIMS/HYPOTHESIS Approximately 25% of people with type 1 diabetes have suppressed counterregulatory hormonal and symptomatic responses to insulin-induced hypoglycaemia, which renders them at increased risk of severe, disabling hypoglycaemia. This is called impaired awareness of hypoglycaemia (IAH), the cause of which is unknown. We recently proposed that IAH develops through habituation, a form of adaptive memory to preceding hypoglycaemia. Consistent with this hypothesis, we demonstrated restoration of defective counterregulatory hormonal responses to hypoglycaemia (referred to as dishabituation) in a rodent model of IAH following introduction of a novel stress stimulus (high intensity training [HIT]). In this proof-of-concept study we sought to further test this hypothesis by examining whether a single episode of HIT would amplify counterregulatory responses to subsequent hypoglycaemia in people with type 1 diabetes who had IAH (assessed by Gold score ≥4, modified Clarke score ≥4 or Dose Adjustment For Normal Eating (DAFNE) hypoglycaemia awareness rating 2 or 3). The primary outcome was the difference in adrenaline response to hypoglycaemia following both a single episode of HIT and rest. METHODS In this randomised, crossover study 12 participants aged between 18 and 55 years with type 1 diabetes for ≥5 years and an HbA1c <75 mmol/mol (9%) were recruited. Individuals were randomised using computer generated block randomisation to start with one episode of HIT (4 × 30 s cycle sprints [2 min recovery] at 150% of maximum wattage achieved during [Formula: see text] assessment) or rest (control). The following day they underwent a 90 min hyperinsulinaemic-hypoglycaemic clamp study at 2.5 mmol/l with measurement of hormonal counterregulatory response, symptom scores and cognitive testing (four-choice reaction time and digit symbol substitution test). Each intervention and subsequent clamp study was separated by at least 2 weeks. The participants and investigators were not blinded to the intervention or measurements during the study. The investigators were blinded to the primary outcome and blood analysis results. RESULTS All participants (six male and six female, age 19-54 years, median [IQR] duration of type 1 diabetes 24.5 [17.3-29.0] years, mean [SEM] HbA1c 56 [3.67] mmol/mol; 7.3% [0.34%]) completed the study (both interventions and two clamps). In comparison with the rest study, a single episode of HIT led to a 29% increase in the adrenaline (epinephrine) response (mean [SEM]) (2286.5 [343.1] vs 2953.8 [384.9] pmol/l); a significant increase in total symptom scores (Edinburgh Hypoglycaemia Symptom Scale: 24.25 [2.960 vs 27.5 [3.9]; p<0.05), and a significant prolongation of four-choice reaction time (591.8 [22.5] vs 659.9 [39.86] ms; p<0.01] during equivalent hypoglycaemia induced the following day. CONCLUSIONS/INTERPRETATION These findings are consistent with the hypothesis that IAH develops in people with type 1 diabetes as a habituated response and that introduction of a novel stressor can restore, at least partially, the adapted counterregulatory hormonal, symptomatic and cognitive responses to hypoglycaemia. TRIAL REGISTRATION ISRCTN15236211.
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Affiliation(s)
- Catriona M Farrell
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, DD19SY, UK
| | - Alison D McNeilly
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, DD19SY, UK
| | - Paul Fournier
- Faculty of Science, School of Human Science, The University of Western Australia, Perth, Australia
| | - Timothy Jones
- Faculty of Health and Medical Sciences, Paediatrics, The University of Western Australia, Perth, Australia
| | - Simona M Hapca
- Computing Science and Mathematics, Faculty of Natural Sciences, University of Stirling, Stirling, UK
| | - Daniel West
- Institute of Cellular Medicine, Faculty of Medical Science, Newcastle University, Newcastle, UK
| | - Rory J McCrimmon
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, DD19SY, UK.
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16
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Uzoigwe C, Hamersky CM, Arbit DI, Weng W, Radin MS. Assessing Prevalence of Hypoglycemia in a Medical Transcription Database. Diabetes Metab Syndr Obes 2020; 13:2209-2216. [PMID: 32612376 PMCID: PMC7322136 DOI: 10.2147/dmso.s235298] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 05/29/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The prevalence of hypoglycemia in patients with diabetes mellitus is likely underreported, particularly with regard to non-severe episodes, and representative estimates require more detailed data than claims or typical electronic health record (EHR) databases provide. This study examines the prevalence of hypoglycemia as identified in a medical transcription database. PATIENTS AND METHODS The Amplity Insights database contains medical content dictated by providers detailing patient encounters with health care professionals (HCPs) from across the United States. Natural language processing (NLP) was used to identify episodes of hypoglycemia using both symptom-based and non-symptom-based definitions of hypoglycemic events. This study examined records of 41,688 patients with type 1 diabetes mellitus and 317,399 patients with type 2 diabetes mellitus between January 1, 2016, and April 30, 2018. RESULTS Using a non-symptom-based definition, the prevalence of hypoglycemia was 18% among patients with T1DM and 8% among patients with T2DM. These estimates show the prevalence of hypoglycemia to be 2- to 9-fold higher than the 1% to 4% prevalence estimates suggested by claims database analyses. CONCLUSION In this exploration of a medical transcription database, the prevalence of hypoglycemia was considerably higher than what has been reported via retrospective analyses from claims and EHR databases. This analysis suggests that data sources other than claims and EHR may provide a more in-depth look into discrepancies between the mention of hypoglycemia events during a health care visit and documentation of hypoglycemia in patient records.
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Affiliation(s)
- Chioma Uzoigwe
- Novo Nordisk Inc., Plainsboro, NJ, USA
- Correspondence: Chioma Uzoigwe Novo Nordisk Inc., 800 Scudders Mill Road, Plainsboro, NJ08536, USATel +1 609 786 4317 Email
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17
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Abstract
In health hypoglycaemia is rare and occurs only in circumstances like extreme sports. Hypoglycaemia in type 1 Diabetes (T1D) and advanced type 2 Diabetes (T2D) are the result of interplay between absolute or relative insulin access and defective glucose counterregulation. The basic mechanism is, failure of decreasing insulin and failure of the compensatory increasing counterregulatory hormones at the background of falling blood glucose. Any person with Diabetes on anti-diabetic medication who behaves oddly in any way whatsoever is hypoglycaemic until proven otherwise. Hypoglycaemia can be a terrifying experience for a patient with Diabetes. By definition, hypoglycaemic symptoms are subjective and vary from person to person and even episode to episode in same person. Fear of iatrogenic hypoglycaemia is a major barrier in achieving optimum glycaemic control and quality of life which limits the reduction of diabetic complications. Diabetes patients with comorbidities especially with chronic renal failure, hepatic dysfunction, major limb amputation, terminal illness, cognitive dysfunction etc. are more vulnerable to hypoglycaemia. In most cases, prompt glucose intake reverts hypoglycaemia. Exogenous insulin in T1D and insulin treated advanced T2D have no control by pancreatic regulation. Moreover, failure of increase of glucagon and attenuated secretion in epinephrine causes the defective glucose counterregulation. In this comprehensive review, I will try to touch all related topics for better understanding of hypoglycaemia.
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18
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Langer J, Wolden ML, Shimoda S, Sato M, Araki E. Short-Term Cost-Effectiveness of Switching to Insulin Degludec in Japanese Patients with Type 2 Diabetes Receiving Basal-Bolus Therapy. Diabetes Ther 2019; 10:1347-1356. [PMID: 31168694 PMCID: PMC6612353 DOI: 10.1007/s13300-019-0635-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION With one of the fastest aging populations in the world, demographic changes in Japan are a major public health concern due to the substantial burden that aging-associated diseases, such as type 2 diabetes (T2D), place on public healthcare systems. The aim of this analysis was to evaluate the short-term cost-effectiveness of switching Japanese patients with T2D receiving basal-bolus insulin therapy from their previous basal insulin to insulin degludec (degludec) under conditions of routine clinical practice. METHODS A previously published, open-source model developed in Microsoft Excel was used to evaluate the cost-effectiveness of switching basal-bolus insulin therapy from patients' previous basal insulin to degludec versus continuing the previous basal insulin therapeutic regimen in terms of costs (2018 Japanese Yen [JPY]) and quality-adjusted life years (QALYs), from a Japanese public healthcare payer perspective. The model captured hypoglycemia rates and insulin dosing over a 1-year time horizon, and was informed by Japanese real-world evidence from the T2D cohort (N = 135) of the Kumamoto Insulin Degludec Observational study. RESULTS Treatment with degludec was associated with improved effectiveness (+ 0.0354 QALYs), driven by lower daytime non-severe hypoglycemia rates with degludec, at slightly higher annual treatment costs (JPY 9510) versus continuing the previous basal insulin. Switching basal insulin to degludec was found to be a cost-effective intervention with an incremental cost-effectiveness ratio (JPY 268,811 per QALY gained) substantially below the willingness-to-pay threshold of 5 million JPY per QALY used in the Japanese Health Technology Assessment framework. Sensitivity analyses confirmed the robustness of this finding and indicated that the daytime non-severe hypoglycemia benefit with degludec was a key driver of outcomes in the base case. CONCLUSION Based on Japanese real-world evidence, our analysis suggests that switching Japanese patients with T2D receiving a basal-bolus regimen from their previous basal insulin to degludec would be highly cost-effective. These data may help decision-makers in Japan allocate healthcare resources efficiently. TRIAL REGISTRATION The KIDUNA study is registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR): UMIN000021569. FUNDING Novo Nordisk Pharma Ltd. Japan.
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Affiliation(s)
| | | | | | - Miki Sato
- Kumamoto University, Kumamoto, Japan
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19
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Dunkley AJ, Fitzpatrick C, Gray LJ, Waheed G, Heller SR, Frier BM, Davies MJ, Khunti K. Incidence and severity of hypoglycaemia in type 2 diabetes by treatment regimen: A UK multisite 12-month prospective observational study. Diabetes Obes Metab 2019; 21:1585-1595. [PMID: 30843327 DOI: 10.1111/dom.13690] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/28/2019] [Accepted: 03/05/2019] [Indexed: 12/28/2022]
Abstract
AIMS To determine the incidence and severity of self-reported hypoglycaemia in a primary care population with type 2 diabetes. The study also aimed to compare incidence by treatment regimen. MATERIALS AND METHODS A prospective observational study in 17 centres throughout the UK was conducted. Recruitment was based on treatment regimen (metformin alone, sulphonylurea-, insulin- or incretin-based therapy). Participants were asked to keep a blood glucose diary and self-report hypoglycaemia episodes [non-severe (self-treated) and severe (requiring external help)] over a 12-month period. RESULTS Three hundred and twenty-five participants were enrolled, of whom 274 (84%) returned ≥1 monthly diaries. Overall, 39% reported experiencing hypoglycaemia; 32% recorded ≥1 symptomatic, 36% ≥1 non-severe, and 7% ≥1 severe episodes. By treatment, incidence (events per person/year) for any hypoglycaemia type was 4.39 for insulin, 2.34 for sulphonylurea, 0.76 for metformin, and 0.56 for incretin-based therapy. Compared with metformin, risk of non-severe hypoglycaemia was ~3 times higher for participants on sulphonylureas and > 5 times higher for those on insulin [incidence rate ratio (IRR) 3.02 (1.76-5.18), P < 0.001, and IRR 5.96 (3.48-10.2), P < 0.001, respectively]. For severe episodes, the incidence for sulphonylurea (0.09) was similar to metformin (0.07) and incretin-based therapy (0.07); for insulin the risk remained almost 5 times higher than metformin [incidence 0.32; IRR 4.55 (1.28-16.20), P = 0.019]. CONCLUSIONS Hypoglycaemia represents a substantial burden for people with type 2 diabetes. Sulphonylureas and insulin are both associated with a risk of reported non-severe hypoglycaemia, but only insulin with severe episodes. This suggests the importance of the continued use of sulphonylureas in appropriate patients with type 2 diabetes.
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Affiliation(s)
- Alison J Dunkley
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | - Laura J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Ghazala Waheed
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Simon R Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Brian M Frier
- BHF Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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20
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Heller SR, DeVries JH, Wysham C, Hansen CT, Hansen MV, Frier BM. Lower rates of hypoglycaemia in older individuals with type 2 diabetes using insulin degludec versus insulin glargine U100: Results from SWITCH 2. Diabetes Obes Metab 2019; 21:1634-1641. [PMID: 30891886 PMCID: PMC6618254 DOI: 10.1111/dom.13708] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/06/2019] [Accepted: 03/16/2019] [Indexed: 01/09/2023]
Abstract
AIM This study aimed to investigate the safety of insulin degludec (degludec) in relation to age and risk of hypoglycaemia post hoc in individuals with type 2 diabetes (T2D) (SWITCH 2 trial). METHODS In this crossover study, individuals with T2D who were at risk of hypoglycaemia were randomized to double-blind treatment with degludec or insulin glargine 100 units/mL (glargine U100) ± oral antidiabetic drugs. After 32 weeks, patients crossed over to the other treatment. Primary endpoint was number of overall severe (positively adjudicated) or glucose-confirmed (plasma glucose <56 mg/dL; 3.1 mmol/L) symptomatic hypoglycaemia events during the two 16-week maintenance periods. RESULTS For individuals ≤65 (n = 450) and >65 (n = 270) years, baseline median (range) duration of diabetes was 12 (1-40) vs 15 (1-54) years, mean HbA1c was 7.7% vs 7.4% and mean estimated glomerular filtration rate was 87.0 vs 63.7 mL/min/1.73 m2 , respectively. No significant differences in HbA1c reduction were seen in individuals ≤65 or >65 years. During both maintenance periods, treatment with degludec lowered rates of hypoglycaemia (overall/nocturnal symptomatic) vs those with glargine U100 in individuals ≤65 (31% vs 43%) and >65 (30% vs 41%) years. With degludec and glargine U100, respectively, six vs nine severe hypoglycaemic events occurred in individuals ≤65 years and four vs eight events occurred in those >65 years. Adverse event rates were 3.2 and 3.3 events/patient-year for individuals ≤65 years and were 3.5 and 4.1 events/patient-year for individuals >65 years with degludec and glargine U100, respectively. CONCLUSION Treatment with degludec was safe and effective, with a frequency of hypoglycaemia lower than that with glargine U100 in both younger and older individuals (>65 years) with T2D.
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Affiliation(s)
- Simon R. Heller
- Academic Unit of Diabetes, Endocrinology and MetabolismUniversity of SheffieldSheffieldUK
| | - J. Hans DeVries
- Academic Medical CenterUniversity of AmsterdamAmsterdamthe Netherlands
| | - Carol Wysham
- School of MedicineUniversity of Washington/Multicare Rockwood ClinicSpokaneWashington
| | | | | | - Brian M. Frier
- The Queen's Medical Research CentreUniversity of EdinburghEdinburghUK
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21
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Tentolouris N, Knudsen ST, Lapolla A, Wolden ML, Haldrup S, Schultes B. Switching "Real-World" Diabetes Patients to Degludec from Other Basal Insulins Provides Different Clinical Benefits According to Their Baseline Glycemic Control. Adv Ther 2019; 36:1201-1210. [PMID: 30879256 PMCID: PMC6824376 DOI: 10.1007/s12325-019-00916-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The stable, ultra-long duration of action of insulin degludec (degludec) minimizes fluctuations in glucose-lowering activity over the daily (24-h) dosing period, and comparative studies with other basal insulins suggest that these properties translate into a lower risk of hypoglycemia at equivalent levels of glycemic control. Results from the real-world European multicenter, retrospective chart review study of 2550 patients with type 1 and type 2 diabetes (T1D and T2D) in routine clinical care EU-TREAT (NCT02662114) showed that patients benefited from improved glycemic control and significantly reduced rates of hypoglycemia following a switch to degludec. METHODS In this post hoc analysis, EU-TREAT patients were stratified into good (≤ 7.5% HbA1c), intermediate (> 7.5 to ≤ 8.5% HbA1c), and poor (> 8.5% HbA1c) glycemic control at baseline to investigate the possibility of differential benefits, either improved control or reduced risk of hypoglycemia, whichever the need. Changes in HbA1c, overall hypoglycemia, and total insulin dose from baseline to 6 and 12 months follow-up were assessed for each group. RESULTS For both T1D and T2D patients, those in good initial control experienced significant reductions in rates of hypoglycemia and total insulin dose following the switch, without compromising control. Those in poor initial control achieved significant improvements in HbA1c with no change in rates of hypoglycemia or total insulin dose. CONCLUSION This analysis expands the findings of EU-TREAT by showing differential changes in the clinical endpoints depending on particular need. It introduces the possibility that the differential benefits of degludec could address two of the renowned clinical challenges faced when treating diabetes: improving glycemic control for optimal management of T1D and titrating insulin dose in T2D, both without fear of increased hypoglycemia. TRIAL REGISTRATION ClinicalTrials.gov, NCT02662114. FUNDING Novo Nordisk A/S.
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Affiliation(s)
| | | | | | | | | | - Bernd Schultes
- eSwiss Medical and Surgical Center, St Gallen, Switzerland
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22
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Pedersen‐Bjergaard U, Alsifri S, Aronson R, Berković MC, Galstyan G, Gydesen H, Lekdorf JB, Ludvik B, Moberg E, Ramachandran A, Khunti K. Comparison of the HAT study, the largest global hypoglycaemia study to date, with similar large real-world studies. Diabetes Obes Metab 2019; 21:844-853. [PMID: 30456887 PMCID: PMC6590793 DOI: 10.1111/dom.13588] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 11/30/2022]
Abstract
AIMS Optimal diabetes care requires clear understanding of the incidence of hypoglycaemia in real-world clinical practice. Current data on hypoglycaemia are generally limited to those reported from randomised controlled clinical trials. The Hypoglycaemia Assessment Tool (HAT) study, a non-interventional real-world study of hypoglycaemia, assessed hypoglycaemia in 27 585 individuals across 24 countries. The present study compared the incidence of hypoglycaemia from the HAT study with other similarly designed, large, real-world studies. MATERIALS AND METHODS A literature search of PubMed (1995-2017) for population-based studies of insulin-treated patients with type 1 or type 2 diabetes (T1D, T2D), excluding clinical trials and reviews, identified comparable population-based studies reporting the incidence of hypoglycaemia. RESULTS The 24 comparative studies, including more than 24 000 participants with T1D and more than 160 000 participants with T2D, varied in design, size, inclusion criteria, definitions of hypoglycaemia and method of recording hypoglycaemia. Reported rates (events per patient-year [PPY]) of hypoglycaemia were higher in patients with T1D than in those with T2D (overall T1D, 21.8-73.3 and T2D, 1.3-37.7; mild/non-severe T1D, 29.0-126.7 and T2D, 1.3-41.5; severe T1D, 0.7-5.8 and T2D, 0.0-2.5; nocturnal T1D, 2.6-11.3 and T2D, 0.38-9.7) and were similar to the ranges found in the HAT study. CONCLUSIONS The HAT data on hypoglycaemia incidence were comparable with those from other real-world studies and indicate a high incidence of hypoglycaemia among insulin-treated patients. Differences in rates among studies are mostly explained by differences in patient populations and study methodology. The goal of reducing hypoglycaemia should be a target for continued educational and evidence-based pharmacological interventions.
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Affiliation(s)
| | | | - Ronnie Aronson
- Endocrinology and MetabolismLMC Diabetes and EndocrinologyTorontoOntarioCanada
| | | | | | | | | | - Bernhard Ludvik
- Division of Endocrinology and MetabolismRudolfstiftung Hospital and Karl‐Landsteiner InstituteViennaAustria
| | | | | | - Kamlesh Khunti
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
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23
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Tiruneh GG, Abebe N, Dessie G. Self-reported hypoglycemia in adult diabetic patients in East Gojjam, Northwest Ethiopia: institution based cross-sectional study. BMC Endocr Disord 2019; 19:17. [PMID: 30700277 PMCID: PMC6354379 DOI: 10.1186/s12902-019-0341-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 01/14/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hypoglycemia presents a barrier to optimum diabetes management and it is related to a negative impact on health-related quality of life, healthcare resource use, and work productivity. Despite the fact that the magnitude of hypoglycemia and factors associated with hypoglycemia in diabetic population were demonstrated in clinical trial settings; there is no adequate evidence concerning to the problem in real-world settings, in particular in the study area. The aim of the study was to assess the magnitude of hypoglycemia and factors associated with hypoglycemia among adult diabetic patients attending chronic follow up clinic at Debre Markos referral hospital, East Gojjam Zone, Northwest Ethiopia, 2017. METHODS An institution-based cross-sectional study was conducted among 394 sampled diabetic patients who were selected through systematic random sampling technique at Debre Markos referral hospital. Data were collected using structured interviewer-administered questionnaire. The collected data were entered and cleared using epi-data version 3.1 and analyzed by SPSS version 20. We used bivariate and multivariate logistic regression models to identify variables for multivariate analysis and to identify associated factors for hypoglycemia, respectively. RESULT The study revealed that 279(70.8%) of diabetic patients had experienced hypoglycemic event since the diagnosis of diabetes. Patients with type 1 diabetes were more likely to have hypoglycemia as compared with type 2 diabetic patients. The factors found to be significantly associated with hypoglycemia included type 2 diabetes (AOR 0.34, 95%CI: 0.14, 0.82), duration of diabetes from 10 to 14 years (AOR 6.34, 95%CI: 2.12, 18.96) and insulin therapy (AOR 4.93, 95%CI: 2.05, 11.86). Diabetic patients who are government employees (AOR = 0.29, 95%CI: 0.11, 0.78) were less likely to have hypoglycemia when compared to farmers. CONCLUSION The magnitude of hypoglycemia was found to be high and significantly associated with occupation, type of diabetes mellitus, type of medication and duration of diabetes mellitus since diagnosis. Therefore, attention is needed from health-related governmental organizations and health care providers to decrease the burden of hypoglycemia and to address the major contributing factors.
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Affiliation(s)
- Gashayeneh Genetu Tiruneh
- Department of Internal Medicine, School of Medicine, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Nurilign Abebe
- Department of Public health, College of Health Sciences, Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Getenet Dessie
- Department of Nursing, College of Medicine and Health Sciences, Bahir Dar University, P.O. Box 79, Bahir Dar, Ethiopia
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Riddle M, Bolli G, Avogaro A, Gimenez Álvarez M, Merino-Trigo A, Boëlle-Le Corfec E, Home P. Assessment of hypoglycaemia during basal insulin therapy: Temporal distribution and risk of events using a predefined or an expanded definition of nocturnal events. DIABETES & METABOLISM 2018; 44:333-340. [DOI: 10.1016/j.diabet.2017.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 12/03/2017] [Indexed: 10/18/2022]
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Perceptions of insulin use in type 2 diabetes in primary care: a thematic synthesis. BMC FAMILY PRACTICE 2018; 19:70. [PMID: 29788908 PMCID: PMC5964885 DOI: 10.1186/s12875-018-0753-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/01/2018] [Indexed: 01/29/2023]
Abstract
Background Increasing numbers of patients with type 2 diabetes mellitus are progressing to insulin therapy, and despite its potency many such individuals still have suboptimal glycaemic control. Insulin initiation and intensification is now often conducted by Practice Nurses and General Practitioners in many parts of the UK. Therefore, gaining insight into perspectives of patients and primary care clinicians is important in determining self-management and engagement with insulin. A thematic synthesis of studies was conducted exploring the views and experiences of people with type 2 diabetes and of healthcare professionals on insulin use and management in the context of primary care. Methods Protocol based systematic searches of electronic databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Web of Science) were performed on 1 October 2014 and updated on 31 March 2015, to identify studies that identified the views and experiences of adults with type 2 diabetes or primary care clinicians on the use of insulin in the management of type 2 diabetes. Studies meeting the review inclusion criteria were critically appraised using the CASP qualitative research checklist or Barley’s checklist for survey designs. A thematic synthesis was then conducted of the collected studies. Results Thirty-four studies were selected. Of these, 12 used qualitative interviews (nine with patients and three with healthcare professionals) and 22 were survey based (14 with patients, three with healthcare professionals, and five with both). Twelve key themes were identified and formed three domains, patient perceptions, healthcare professional perceptions, and health professional-patient relationships. The patient-centred themes were: insulin-related beliefs, social influences, psychological factors, hypoglycaemia, and therapy barriers. The clinician-related themes were: insulin skills of general practitioners, healthcare integration, healthcare professional-perceived barriers, hypoglycaemia, and explanations for adherence. Healthcare professional-patient relationship themes were drawn from the perspectives of patients and from clinicians. Conclusions This review reveals multiple barriers to optimal insulin use in primary care at both the patient and healthcare professional levels. These barriers indicate the need for multimodal interventions to: improve the knowledge and competencies of primary care professionals in insulin use; provide more effective patient education and self-management support; and introduce integrated insulin support systems. Electronic supplementary material The online version of this article (10.1186/s12875-018-0753-2) contains supplementary material, which is available to authorized users.
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Corley BT, Carroll RW, Hall RM, Weatherall M, Parry-Strong A, Krebs JD. Intermittent fasting in Type 2 diabetes mellitus and the risk of hypoglycaemia: a randomized controlled trial. Diabet Med 2018; 35:588-594. [PMID: 29405359 DOI: 10.1111/dme.13595] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 01/01/2023]
Abstract
AIMS To establish whether the risk of hypoglycaemia is greater with 2 consecutive days of very-low-calorie diet compared with 2 non-consecutive days of very-low-calorie diet in people with Type 2 diabetes. METHODS This was a non-blinded randomized parallel group interventional trial of intermittent fasting in adults. The participants had a BMI of 30-45 kg/m2 , Type 2 diabetes treated with metformin and/or hypoglycaemic medications and an HbA1c concentration of 50-86 mmol/mol (6.7-10%). The participants followed a 2092-2510-kJ diet on 2 days per week for 12 weeks. A total of 41 participants were randomized 1:1 to consecutive (n=19) or non-consecutive (n=22) day fasts, of whom 37 (n=18 and n=19, respectively) were included in the final analysis. The primary outcome was difference in the rate of hypoglycaemia between the two study arms. Secondary outcomes included change in diet, quality of life, weight, lipid, glucose and HbA1c levels, and liver function. RESULTS The mean hypoglycaemia rate was 1.4 events over 12 weeks. Fasting increased the rate of hypoglycaemia despite medication reduction (RR 2.05, 95% CI 1.17 to 3.52). There was no difference between fasting on consecutive days and fasting on non-consecutive days (RR 1.54, 95% CI 0.35 to 6.11). Improvements in weight, HbA1c , fasting glucose and quality of life were experienced by participants in both arms. CONCLUSIONS In individuals with Type 2 diabetes on hypoglycaemic medications, fasting of any type increased the rate of hypoglycaemia. With education and medication reduction, fewer than expected hypoglycaemic events occurred. Although it was not possible to determine whether fasting on consecutive days increased the risk of hypoglycaemia, an acceptable rate was observed in both arms.
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Affiliation(s)
- B T Corley
- Centre for Endocrine Diabetes and Obesity Research, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - R W Carroll
- Centre for Endocrine Diabetes and Obesity Research, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - R M Hall
- Centre for Endocrine Diabetes and Obesity Research, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - M Weatherall
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - A Parry-Strong
- Centre for Endocrine Diabetes and Obesity Research, Wellington Hospital, Wellington, New Zealand
| | - J D Krebs
- Centre for Endocrine Diabetes and Obesity Research, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
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Agesen RM, Kristensen PL, Beck-Nielsen H, Nørgaard K, Perrild H, Jensen T, Parving HH, Thorsteinsson B, Tarnow L, Pedersen-Bjergaard U. Effect of Insulin Analogs on Frequency of Non-Severe Hypoglycemia in Patients with Type 1 Diabetes Prone to Severe Hypoglycemia: Much Higher Rates Detected by Continuous Glucose Monitoring than by Self-Monitoring of Blood Glucose-The HypoAna Trial. Diabetes Technol Ther 2018; 20:247-256. [PMID: 29565719 DOI: 10.1089/dia.2017.0372] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hypoglycemia is an increasingly important endpoint in clinical diabetes trials. The assessment of hypoglycemia should therefore be as complete as possible. Blinded continuous glucose monitoring (CGM) provides an improved opportunity to capture asymptomatic and nocturnal events. Here we report results from the HypoAna trial comparing all-analog-insulin therapy (aspart/detemir) with all-human-insulin therapy (neutral protamine Hagedorn/regular) on non-severe hypoglycemia (symptomatic and asymptomatic hypoglycemia) as assessed by blinded CGM and compared with data obtained by self-monitoring of blood glucose (SMBG) in patients with type 1 diabetes and recurrent severe hypoglycemia. METHODS Fifty-three patients completed a substudy of 4 × 3 days of blinded CGM. CGM traces were reviewed for hypoglycemic events lasting 15 min or longer. RESULTS At the threshold ≤3.9 mmol/L, the per-protocol analysis demonstrated a 40% rate reduction (95% confidence interval [CI] 20%-60%; P = 0.002) in nocturnal non-severe hypoglycemia during analog treatment, mainly due to a 40% rate reduction (95% CI 0%-70%; P = 0.03) of nocturnal asymptomatic hypoglycemia. Similar nonsignificant trends were seen at the glucose threshold ≤3.0 mmol/L. Overall CGM-detected that nocturnal asymptomatic hypoglycemia ≤3.9 mmol/L was ∼17 times more frequent than SMBG-detected episodes (52 vs. 3 events/patient-year). This translates into a time needed to treat one patient with insulin analogs to prevent one episode that is 34 times shorter using CGM data than SMBG data (1.4 vs. 47 weeks). CONCLUSIONS Capturing hypoglycemic events by the conventional method of SMBG in patients with impaired awareness reveals only a limited number of events. Blinded CGM can provide more complete data, particularly in terms of asymptomatic and nocturnal events.
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Affiliation(s)
- Rikke Mette Agesen
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | - Peter Lommer Kristensen
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 3 Clinical Research Unit, Steno Diabetes Center , Gentofte, Denmark
| | - Henning Beck-Nielsen
- 4 Department of Endocrinology M, Odense University Hospital , Odense, Denmark
- 5 Faculty of Health Sciences, University of Southern Denmark , Odense, Denmark
| | - Kirsten Nørgaard
- 6 Department of Endocrinology, Hvidovre Hospital , Hvidovre, Denmark
| | - Hans Perrild
- 7 Department of Internal Medicine, Bispebjerg Hospital , Copenhagen, Denmark
| | - Tonny Jensen
- 8 Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet) , Copenhagen, Denmark
| | - Hans-Henrik Parving
- 8 Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet) , Copenhagen, Denmark
- 9 Health, University of Aarhus , Aarhus, Denmark
| | - Birger Thorsteinsson
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
| | - Lise Tarnow
- 3 Clinical Research Unit, Steno Diabetes Center , Gentofte, Denmark
- 9 Health, University of Aarhus , Aarhus, Denmark
- 10 Department of Clinical Research, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
| | - Ulrik Pedersen-Bjergaard
- 1 Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital-Hillerød , Hillerød, Denmark
- 2 Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen, Denmark
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Pollock RF, Chubb B, Valentine WJ, Heller S. Evaluating the cost-effectiveness of insulin detemir versus neutral protamine Hagedorn insulin in patients with type 1 or type 2 diabetes in the UK using a short-term modeling approach. Diabetes Metab Syndr Obes 2018; 11:217-226. [PMID: 29844693 PMCID: PMC5962301 DOI: 10.2147/dmso.s156739] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND To estimate the short-term cost-effectiveness of insulin detemir (IDet) versus neutral protamine Hagedorn (NPH) insulin based on the incidence of non-severe hypoglycemia and changes in body weight in subjects with type 1 diabetes (T1D) or type 2 diabetes (T2D) in the UK. METHODS A model was developed to evaluate cost-effectiveness based on non-severe hypoglycemia, body mass index, and pharmacy costs over 1 year. Published rates of non-severe hypoglycemia were employed in the T1D and T2D analyses, while reduced weight gain with IDet was modeled in the T2D analysis only. Effectiveness was calculated in terms of quality-adjusted life expectancy using published utility scores. Pharmacy costs were captured using published prices and defined daily doses. Costs were expressed in 2016 pounds sterling (GBP). Sensitivity analyses were performed (including probabilistic sensitivity analysis). RESULTS In T1D, IDet was associated with fewer non-severe hypoglycemic events than NPH insulin (126.7 versus 150.8 events per person-year), leading to an improvement of 0.099 quality-adjusted life years (QALYs). Costs with IDet were GBP 60 higher, yielding an incremental cost-effectiveness ratio (ICER) of GBP 610 per QALY gained. In T2D, mean non-severe hypoglycemic event rates and body weight were lower with IDet than NPH insulin, leading to a total incremental utility of 0.120, accompanied by an annual cost increase of GBP 171, yielding an ICER of GBP 1,422 per QALY gained for IDet versus NPH insulin. CONCLUSION Short-term health economic evaluation showed IDet to be a cost-effective alternative to NPH insulin in the UK due to lower rates of non-severe hypoglycemia (T1D and T2D) and reduced weight gain (T2D only).
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Affiliation(s)
- Richard F Pollock
- Health Economics and Outcomes Research, Ossian Health Economics and Communications GmbH, Basel, Switzerland
- Correspondence: Richard F Pollock, Ossian Health Economics and Communications GmbH, Bäumleingasse 20, 4051 Basel, Switzerland, Tel +41 61 271 6214, Email
| | | | - William J Valentine
- Health Economics and Outcomes Research, Ossian Health Economics and Communications GmbH, Basel, Switzerland
| | - Simon Heller
- Department of Oncology & Metabolism, The University of Sheffield, Sheffield, UK
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Emral R, Pathan F, Cortés CAY, El-Hefnawy MH, Goh SY, Gómez AM, Murphy A, Abusnana S, Rudijanto A, Jain A, Ma Z, Mirasol R. Self-reported hypoglycemia in insulin-treated patients with diabetes: Results from an international survey on 7289 patients from nine countries. Diabetes Res Clin Pract 2017; 134:17-28. [PMID: 28951336 DOI: 10.1016/j.diabres.2017.07.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 07/05/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
Abstract
AIMS Hypoglycemia constitutes a significant barrier to achieving glycemic control with insulin in both type 1 and type 2 diabetes. Historically, it has been difficult to accurately verify the rates of hypoglycemia within a clinical setting and there is a need for high-quality, real-world data to ascertain the true rates of hypoglycemia in clinical practice. The global Hypoglycemia Assessment Tool (HAT) study was designed to assess the global incidence of hypoglycemia in patients with insulin-treated diabetes, and the results have indicated that the overall incidence of hypoglycemia is high, with large variations between geographical regions. METHODS The International Operations HAT (IO HAT) study retrospectively and prospectively assessed the incidence of hypoglycemia in patients with insulin-treated diabetes in Bangladesh, Colombia, Egypt, Indonesia, Philippines, Singapore, South Africa, Turkey, and United Arab Emirates. RESULTS During the prospective period, hypoglycemic events were reported by 97.4% of patients with type 1 diabetes and 95.3% of those with type 2 diabetes, with an estimated rate of 6.86 events per patient per month (PPPM) for patients with type 1 diabetes and 2.37 events PPPM for patients with type 2 diabetes. CONCLUSIONS These results represent the first patient-reported dataset on hypoglycemia in the participating countries and confirm that hypoglycemia is under-reported and more widespread than previously believed. Although the incidence of hypoglycemia was variable among patients on different treatment regimens, there were substantial impacts on both productivity and healthcare utilization following an episode of hypoglycemia. This trial is registered at clinicaltrials.gov: NCT02306681.
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Affiliation(s)
- Rifat Emral
- Ankara University, Faculty of Medicine, Department of Endocrinology and Metabolic Diseases, Ankara, Turkey.
| | | | - Carlos Augusto Yepes Cortés
- Department of Internal Medicine and Endocrinology, Hospital Universitario Clínica San Rafael, Bogotá, Colombia.
| | | | | | - Ana Maria Gómez
- Department of Internal Medicine and Endocrinology, Medical Faculty of Javeriana University, Head of Endocrinology Unit, San Ignacio Hospital, Bogotá, Colombia.
| | - Angela Murphy
- Sunward Park Centre for Diabetes Excellence, Boksburg, South Africa.
| | - Salah Abusnana
- Rashid Center for Diabetes and Research, Al Jurf Ajman, Ajman, United Arab Emirates.
| | - Achmad Rudijanto
- Department of Internal Medicine, Medical Faculty of Brawijaya University, Kota Malang, Jawa Timur 65145, Indonesia.
| | - Anand Jain
- Novo Nordisk Region International Operations AG, Zurich, Switzerland.
| | - Zhulin Ma
- Novo Nordisk Region International Operations AG, Zurich, Switzerland.
| | - Roberto Mirasol
- Section of Endocrinology, Diabetes and Metabolism, St. Luke's Medical Center, Quezon City, Philippines.
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Graveling AJ, Frier BM. The risks of nocturnal hypoglycaemia in insulin-treated diabetes. Diabetes Res Clin Pract 2017; 133:30-39. [PMID: 28888993 DOI: 10.1016/j.diabres.2017.08.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 12/29/2022]
Abstract
Over half of all episodes of severe hypoglycaemia (requiring external help) occur during sleep, but nocturnal hypoglycaemia is often asymptomatic and unrecognised. The precise incidence of nocturnal hypoglycaemia is difficult to determine with no agreed definition, but continuous glucose monitoring has shown that it occurs frequently in people taking insulin. Attenuation of the counter-regulatory responses to hypoglycaemia during sleep may explain why some episodes are undetected and more prolonged, and modifies cardiovascular responses. The morbidity and mortality associated with nocturnal hypoglycaemia is probably much greater than realised, causing seizures, coma and cardiovascular events and affecting quality of life, mood and work performance the following day. It may induce impaired awareness of hypoglycaemia. Cardiac arrhythmias that occur during nocturnal hypoglycaemia include bradycardia and ectopics that may provoke dangerous arrhythmias. Treatment strategies are discussed that may help to minimise the frequency of nocturnal hypoglycaemia.
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Affiliation(s)
- Alex J Graveling
- JJR Macleod Centre for Diabetes & Endocrinology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZP, UK.
| | - Brian M Frier
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK.
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Abstract
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.
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Affiliation(s)
- Ulrik Pedersen-Bjergaard
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital, Dyrehavevej 29, 3400, Hillerød, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Birger Thorsteinsson
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital, Dyrehavevej 29, 3400, Hillerød, Denmark.
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Karter AJ, Warton EM, Lipska KJ, Ralston JD, Moffet HH, Jackson GG, Huang ES, Miller DR. Development and Validation of a Tool to Identify Patients With Type 2 Diabetes at High Risk of Hypoglycemia-Related Emergency Department or Hospital Use. JAMA Intern Med 2017; 177:1461-1470. [PMID: 28828479 PMCID: PMC5624849 DOI: 10.1001/jamainternmed.2017.3844] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable. OBJECTIVE To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D. DESIGN, SETTING, AND PARTICIPANTS Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D. EXPOSURES Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records. MAIN OUTCOMES AND MEASURES Hypoglycemia-related ED or hospital use during 12 months of follow-up. RESULTS The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (>5%), intermediate (1%-5%), or low (<1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79). CONCLUSIONS AND RELEVANCE This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.
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Affiliation(s)
- Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of General Internal Medicine, University of California, San Francisco.,Department of Epidemiology, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Elbert S Huang
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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Brož J, Frier BM. Regarding Insulin Initiation in Type 2 Diabetes Mellitus and the Risk for Hypoglycemia. Can J Diabetes 2017; 42:221. [PMID: 28803821 DOI: 10.1016/j.jcjd.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Jan Brož
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Brian M Frier
- British Heart Foundation Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
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Pouwer F. Fatigue in type 1 diabetes: an understudied problem. Lancet Diabetes Endocrinol 2017; 5:409-410. [PMID: 28462868 DOI: 10.1016/s2213-8587(17)30137-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 03/27/2017] [Accepted: 03/29/2017] [Indexed: 11/21/2022]
Affiliation(s)
- Frans Pouwer
- Department of Psychology, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
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Evans M, Chubb B, Gundgaard J. Cost-effectiveness of Insulin Degludec Versus Insulin Glargine in Adults with Type 1 and Type 2 Diabetes Mellitus. Diabetes Ther 2017; 8:275-291. [PMID: 28210866 PMCID: PMC5380498 DOI: 10.1007/s13300-017-0236-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION To estimate the cost-effectiveness of insulin degludec (IDeg) versus insulin glargine U100 (IGlar U100) and new-to-market basal insulin analogues in patients with diabetes in order to aid decision-making in a complex basal insulin market. METHODS A simple, short-term model was used to evaluate the costs and effects of treatment with IDeg versus IGlar U100 over a 12-month period in patients with type 1 (T1DM) and type 2 diabetes (T2DM) from the perspective of the UK National Health Service. New-to-market basal insulin analogues were evaluated in scenario analyses. RESULTS IDeg is dominant (more effective and less costly) versus IGlar U100 in patients with T1DM and patients with T2DM on a basal-only therapy regimen (T2DMBOT), and is cost-effective versus IGlar U100 in patients with T2DM on a basal-bolus regimen (T2DMB/B). In T1DM, lower costs are primarily driven by lower insulin costs, as a result of a lower daily dose of IDeg. In T2DMBOT, lower overall costs with IDeg are driven by lower costs of severe hypoglycaemic events due to the significant reduction in number of events with IDeg versus IGlar U100. Improvements in clinical outcomes in all three patient groups are a result of the reduced incidence of hypoglycaemic events. Sensitivity analyses demonstrate that the results are robust. Scenario analyses versus two new-to-market basal insulin analogues indicate that in patients with T1DM and T2DMBOT, IDeg is likely to be highly cost-effective versus IGlar biosimilar Abasaglar® and dominant versus IGlar U300 (Toujeo®). In T2DMB/B, IDeg is likely to be cost-effective versus both comparators, with incremental cost-effectiveness ratios (ICERs) below the accepted threshold. CONCLUSION IDeg is a cost-effective alternative to IGlar U100 for patients with diabetes in the UK, and it also likely to be cost-effective versus two new-to-market basal insulin analogues.
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Affiliation(s)
- Marc Evans
- University Hospital Llandough, Cardiff, UK.
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Furler J, O'Neal D, Speight J, Manski-Nankervis JA, Gorelik A, Holmes-Truscott E, Ginnivan L, Young D, Best J, Patterson E, Liew D, Segal L, May C, Blackberry I. Supporting insulin initiation in type 2 diabetes in primary care: results of the Stepping Up pragmatic cluster randomised controlled clinical trial. BMJ 2017; 356:j783. [PMID: 28274941 PMCID: PMC6287657 DOI: 10.1136/bmj.j783] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective To compare the effectiveness of a novel model of care ("Stepping Up") with usual primary care in normalising insulin initiation for type 2 diabetes, leading to improved glycated haemoglobin (HbA1c) levels.Design Cluster randomised controlled trial.Setting Primary care practices in Victoria, Australia, with a practice nurse and at least one consenting eligible patient (HbA1c ≥7.5% with maximal oral treatment).Participants 266 patients with type 2 diabetes and 74 practices (mean cluster size 4 (range 1-8) patients), followed up for 12 months.Intervention The Stepping Up model of care intervention involved theory based change in practice systems and reorientation of the roles of health professionals in the primary care diabetes team. The core components were an enhanced role for the practice nurse in leading insulin initiation and mentoring by a registered nurse with diabetes educator credentials.Main outcome measures The primary endpoint was change in HbA1c. Secondary endpoints included the proportion of participants who transitioned to insulin, proportion who achieved target HbA1c, and a change in depressive symptoms (patient health questionnaire, PHQ-9), diabetes specific distress (problem areas in diabetes scale, PAID), and generic health status (assessment of quality of life instrument, AQoL-8D).Results HbA1c improved in both arms, with a clinically significant between arm difference (mean difference -0.6%, 95% confidence interval -0.9% to -0.3%), favouring the intervention. At 12 months, in intervention practices, 105/151 (70%) of participants had started insulin, compared with 25/115 (22%) in control practices (odds ratio 8.3, 95% confidence interval 4.5 to 15.4, P<0.001). Target HbA1c (≤7% (53 mmol/mol)) was achieved by 54 (36%) intervention participants and 22 (19%) control participants (odds ratio 2.2, 1.2 to 4.3, P=0.02). Depressive symptoms did not worsen at 12 months (PHQ-9: -1.1 (3.5) v -0.1 (2.9), P=0.05). A statistically significant difference was found between arms in the mean change in mental health (AQoL mental component summary: 0.04 (SD 0.16) v -0.002 (0.13), mean difference 0.04 (95% confidence interval 0.002 to 0.08), P=0.04), favouring the intervention, but no significant difference in physical health (AQoL physical component summary: 0.03 (0.15) v 0.02 (0.13)) nor diabetes specific distress (5.6 (15.5) v -2.4 (15.4)). No severe hypoglycaemia events were reported.Conclusions The Stepping Up model of care was associated with increased insulin initiation rates in primary care, and improvements in glycated haemoglobin without worsening emotional wellbeing.Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12612001028897.
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Affiliation(s)
- John Furler
- Department of General Practice, University of Melbourne, Carlton, Melbourne, VIC, 3053, Australia
| | - David O'Neal
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | - Jane Speight
- School of Psychology, Deakin University, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Victoria, Australia
- AHP Research, United Kingdom
| | - Jo-Anne Manski-Nankervis
- Department of General Practice, University of Melbourne, Carlton, Melbourne, VIC, 3053, Australia
| | - Alexandra Gorelik
- Melbourne EpiCentre, the University of Melbourne, Melbourne, Australia
| | - Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Victoria, Australia
| | - Louise Ginnivan
- School of Psychology, Deakin University, Victoria, Australia
| | - Doris Young
- Department of General Practice, University of Melbourne, Carlton, Melbourne, VIC, 3053, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - James Best
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | | | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Leonie Segal
- Health Economics and Social Policy Group, Division of Health Sciences, University of South Australia, Adelaide, Australia
| | - Carl May
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Irene Blackberry
- John Richards Initiative, Australian Institute for Primary Care and Ageing, College of Science, Health and Engineering, La Trobe University, Melbourne, Australia
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37
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Zhu H, Colgan J, Reddy M, Choe EK. Sharing Patient-Generated Data in Clinical Practices: An Interview Study. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2017; 2016:1303-1312. [PMID: 28269928 PMCID: PMC5333267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Patients are tracking and generating an increasingly large volume of personal health data outside the clinic due to an explosion of wearable sensing and mobile health (mHealth) apps. The potential usefulness of these data is enormous as they can provide good measures of everyday behavior and lifestyle. However, how we can fully leverage patient-generated data (PGD) and integrate them in clinical practice is less clear. In this interview study, we aim to understand how patients and clinicians currently share patient-generated data in clinical care practice. From the study, we identified technical, social, and organizational challenges in sharing and fully leveraging patient-generated data in clinical practices. Our findings can provide researchers potential avenues for enablers and barriers in sharing patient-generated data in clinical settings.
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Affiliation(s)
- Haining Zhu
- Pennsylvania State University, University Park, PA
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38
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Frier BM, Jensen MM, Chubb BD. Hypoglycaemia in adults with insulin-treated diabetes in the UK: self-reported frequency and effects. Diabet Med 2016; 33:1125-32. [PMID: 26248501 PMCID: PMC5054881 DOI: 10.1111/dme.12878] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 01/26/2023]
Abstract
AIM Few real-life studies of non-severe (self-treated) hypoglycaemic events are available. This survey quantified the self-reported frequency of non-severe hypoglycaemia and its effects in adults with insulin-treated diabetes in the UK. METHODS Adults aged > 15 years with Type 1 diabetes or insulin-treated Type 2 diabetes completed ≤ 4 weekly questionnaires (7-day recall). Respondents with Type 2 diabetes were grouped by insulin regimen: basal-only, basal-bolus and 'other'. RESULTS Overall, 1038 respondents (466 with Type 1 diabetes, 572 with Type 2 diabetes) completed 3528 questionnaires. Mean numbers of non-severe events per week were 2.4 (Type 1 diabetes; median = 2) and 0.8 (Type 2 diabetes; median = 0); 23% and 26% of non-severe events occurred at night, respectively. Fatigue and reduced alertness were the commonest issues following events (78% and 51% of respondents, respectively). The effects of nocturnal events persisted longer than those of daytime events: Type 1 diabetes = 10.6 vs. 4.9 h (P = 0.0002); Type 2 diabetes = 15.3 vs. 5.1 h (P < 0.0001). In the week following an event, respondents' blood glucose measurements increased by 4.3 (Type 1 diabetes; 12% increment) and 4.2 (Type 2 diabetes; 21% increment) tests/week. In employed respondents, 20% of events caused work-time loss, more so following nocturnal (vs. daytime) hypoglycaemia: Type 1 diabetes = 2.7 vs. 1.1 h (P = 0.0184); Type 2 diabetes = 2.5 vs. 1.6 h (P = 0.1340). Most respondents rarely/never informed healthcare professionals about events (Type 1 diabetes = 82%, Type 2 diabetes = 69%). CONCLUSIONS Non-severe hypoglycaemia is common in adults with insulin-treated diabetes in the UK, with consequent health-related/economic effects. Communication about non-severe hypoglycaemia is limited and the burden of hypoglycaemia may be underestimated.
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Affiliation(s)
- B M Frier
- The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - M M Jensen
- Novo Nordisk Scandinavia AB, Copenhagen, Denmark
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