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McCall AL, Lieb DC, Gianchandani R, MacMaster H, Maynard GA, Murad MH, Seaquist E, Wolfsdorf JI, Wright RF, Wiercioch W. Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2023; 108:529-562. [PMID: 36477488 DOI: 10.1210/clinem/dgac596] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality. OBJECTIVE To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia. METHODS A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. RESULTS The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia. CONCLUSION The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.
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Affiliation(s)
- Anthony L McCall
- University of Virginia Medical School, Department of Medicine, Division of Endocrinology and Metabolism, Charlottesville, VA 22901, USA
| | - David C Lieb
- Eastern Virginia Medical School, Division of Endocrine and Metabolic Disorders, Department of Medicine, Norfolk, VA 23510, USA
| | | | | | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55905, USA
| | - Elizabeth Seaquist
- Diabetes Center and the Division of Endocrinology & Metabolism, Minneapolis, MN 55455, USA
| | - Joseph I Wolfsdorf
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Wojtek Wiercioch
- McMaster University GRADE Centre and Michael G. DeGroote Cochrane Canada Centre Department of Health Research Methods, Evidence, and Impact, Hamilton, ON, L8S 4L8, Canada
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Torres Roldan VD, Urtecho M, Nayfeh T, Firwana M, Muthusamy K, Hasan B, Abd-Rabu R, Maraboto A, Qoubaitary A, Prokop L, Lieb DC, McCall AL, Wang Z, Murad MH. A Systematic Review Supporting the Endocrine Society Guidelines: Management of Diabetes and High Risk of Hypoglycemia. J Clin Endocrinol Metab 2023; 108:592-603. [PMID: 36477885 DOI: 10.1210/clinem/dgac601] [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: 10/08/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Interventions targeting hypoglycemia in people with diabetes are important for improving quality of life and reducing morbidity and mortality. OBJECTIVE To support development of the Endocrine Society Clinical Practice Guideline for management of individuals with diabetes at high risk for hypoglycemia. METHODS We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence. RESULTS We included 149 studies reporting on 43 344 patients. Continuous glucose monitoring (CGM) reduced episodes of severe hypoglycemia in patients with type 1 diabetes (T1D) and reduced the proportion of patients with hypoglycemia (blood glucose [BG] levels <54 mg/dL). There were no data on use of real-time CGM with algorithm-driven insulin pumps vs multiple daily injections with BG testing in people with T1D. CGM in outpatients with type 2 diabetes taking insulin and/or sulfonylureas reduced time spent with BG levels under 70 mg/dL. Initiation of CGM in hospitalized patients at high risk for hypoglycemia reduced episodes of hypoglycemia with BG levels lower than 54 mg/dL and time spent under 54 mg/dL. The proportion of patients with hypoglycemia with BG levels lower than 70 mg/dL and lower than 54 mg/dL detected by CGM was significantly higher than point-of-care BG testing. We found no data evaluating continuation of personal CGM in the hospital. Use of an inpatient computerized glycemic management program utilizing electronic health record data was associated with fewer patients with and episodes of hypoglycemia with BG levels lower than 70 mg/dL and fewer patients with severe hypoglycemia compared with standard care. Long-acting basal insulin analogs were associated with less hypoglycemia. Rapid-acting insulin analogs were associated with reduced severe hypoglycemia, though there were more patients with mild to moderate hypoglycemia. Structured diabetes education programs reduced episodes of severe hypoglycemia and time below 54 mg/dL in outpatients taking insulin. Glucagon formulations not requiring reconstitution were associated with longer times to recovery from hypoglycemia, although the proportion of patients who recovered completely from hypoglycemia was not different between the 2 groups. CONCLUSION This systematic review summarized the best available evidence about several interventions addressing hypoglycemia in people with diabetes. This evidence base will facilitate development of clinical practice guidelines by the Endocrine Society.
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Affiliation(s)
| | - Meritxell Urtecho
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Mohammed Firwana
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | | | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Rami Abd-Rabu
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Andrea Maraboto
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Amjad Qoubaitary
- College of Arts and Science, University of San Francisco, San Francisco, CA 94117, USA
| | - Larry Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN 55902, USA
| | - David C Lieb
- Division of Endocrine and Metabolic Disorders, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23501-1980, USA
| | - Anthony L McCall
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
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Lechleitner M, Kaser S, Hoppichler F, Roden M, Weitgasser R, Ludvik B, Fasching P, Winhofer Y, Kautzky-Willer A, Schernthaner G, Prager R, Wascher TC, Clodi M. [Diagnosis and insulin therapy of type 1 diabetes mellitus (Update 2023)]. Wien Klin Wochenschr 2023; 135:98-105. [PMID: 37101030 PMCID: PMC10133075 DOI: 10.1007/s00508-023-02182-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/28/2023]
Abstract
This guideline summarizes diagnosis of type 1 diabetes, including accompanying autoimmune disorders, insulin therapy regimens and glycemic target values.
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Affiliation(s)
- Monika Lechleitner
- Avomed - Arbeitskreis für Vorsorgemedizin zbd Gesundheitsförderung in Tirol, Innsbruck, Österreich
| | - Susanne Kaser
- Department für Innere Medizin 1, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Friedrich Hoppichler
- Abteilung für Innere Medizin, Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Österreich
| | - Michael Roden
- Klinik für Endokrinologie und Diabetologie, Medizinische Fakultät, Heinrich-Heine-Universität, Düsseldorf, Deutschland
- Institut für Klinische Diabetologie, Deutsches Diabetes-Zentrum (DDZ), Leibniz-Zentrum für Diabetesforschung, Düsseldorf, Deutschland
- Deutsches Zentrum für Diabetesforschung (DZD e. V.), München-Neuherberg, Deutschland
| | - Raimund Weitgasser
- Abteilung für Innere Medizin, Privatklinik Wehrle-Diakonissen, Salzburg, Österreich
- Universitätsklinik für Innere Medizin I, LKH Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Bernhard Ludvik
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Peter Fasching
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Wilhelminenspital der Stadt Wien, Wien, Österreich
| | - Yvonne Winhofer
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Alexandra Kautzky-Willer
- Gender Medicine Unit, Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Guntram Schernthaner
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Department für Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - Rudolf Prager
- 3. Medizinische Abteilung mit Stoffwechselerkrankungen und Nephrologie, Krankenhaus Hietzing, Wien, Österreich
- Karl Landsteiner Institut für Stoffwechselerkrankungen und Nephrologie, Wien, Österreich
| | - Thomas C Wascher
- 1. Medizinische Abteilung, Hanusch-Krankenhaus, Wien, Österreich
| | - Martin Clodi
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
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Athanasiadou KI, Paschou SA, Stamatopoulos T, Papakonstantinou E, Haidich AB, Goulis DG. Safety and efficacy of insulin detemir versus NPH in the treatment of diabetes during pregnancy: Systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2022; 190:110020. [PMID: 35878788 DOI: 10.1016/j.diabres.2022.110020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/03/2022]
Abstract
AIMS To compare the safety and efficacy of insulin detemir versus neutral protamine Hagedorn (NPH) in pregnant women with diabetes. METHODS MEDLINE, CENTRAL, Google Scholar databases, and ClinicalTrials.gov registry were searched from inception to December 2021 to identify randomized controlled trials (RCTs) concerning adult women with singleton pregnancies, gestational or pregestational diabetes, and the need for insulin therapy. A systematic review and a meta-analysis (weighted data, random-effects model) were performed. Continuous outcomes were expressed as mean difference (MD) with 95% confidence interval (CI) (inverse variance method); dichotomous outcomes were expressed as risk ratio (RR) with 95% CI (Mantel-Haenszel method). Heterogeneity was quantified using the I2 index. RESULTS Five RCTs involving 1450 participants met the inclusion criteria. Outcomes that showed significant results in favor of insulin detemir over NPH were maternal hypoglycemic events (RR 0.64, 95% CI 0.48-0.86, p = 0.003; I2 = 0%) and gestational age at delivery (MD 0.48, 95% CI 0.16-0.81, p = 0.003; I2 = 0%). CONCLUSIONS Insulin detemir was associated with less maternal hypoglycemic events and decreased risk for prematurity compared with NPH insulin. More research should be conducted to reach a safe conclusion about the optimal insulin regimen for women with diabetes in pregnancy.
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Affiliation(s)
- Kleoniki I Athanasiadou
- 2(nd) Department of Internal Medicine and Diabetes Centre, 417 Veteran's Fund Military Hospital NIMTS, Athens, Greece.
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | | | | | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece.
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Jensen MH, Hejlesen O, Vestergaard P. Epidemiology of hypoglycaemic episodes leading to hospitalisations in Denmark in 1998-2018. Diabetologia 2021; 64:2193-2203. [PMID: 34245315 DOI: 10.1007/s00125-021-05507-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/01/2021] [Indexed: 11/30/2022]
Abstract
AIMS/HYPOTHESIS We aimed to investigate the nationwide trends in incidence and associated risk factors, with focus on blood glucose-lowering medication, for the first hypoglycaemic episode leading to hospitalisation in Denmark among people with type 1 and 2 diabetes mellitus. METHODS A cohort study of all people with diabetes from 1977 to 2018 experiencing hypoglycaemic episodes leading to hospitalisation in 1998-2018 was established. Data were extracted from the Danish National Patient Registry. Trends in incidence rates were investigated with Poisson regression models and linear regressions, and risk factors were investigated with Cox proportional hazards models. RESULTS A total of 66,438 hypoglycaemic episodes leading to hospitalisation in 1998-2018 was investigated among 641,402 people with type 1 (mean ± SD age 37 ± 22 years) and type 2 diabetes (mean ± SD age 61 ± 17 years). Between 2003 and 2018, the incidence rate fell by 66% for type 1 diabetes (incidence rate ratio [IRR] 0.34 [95% CI 0.31, 0.36], p < 0.0001) and 61% for type 2 diabetes (IRR 0.39 [95% CI 0.36, 0.42], p < 0.0001). With respect to hypoglycaemic episodes, insulin glargine (HR 1.20 [95% CI 1.05, 1.36], p = 0.0059), insulin detemir (HR 1.18 [95% CI 1.04, 1.32], p = 0.0077) and insulin degludec (HR 1.04 [95% CI 0.81,1.33], p = 0.7706) seemed safer than human insulin (long-acting insulin HR 1.38 [95% CI 1.25, 1.52], p < 0.0001; combination insulins HR 1.84 [95% CI 1.65, 2.05], p < 0.0001) and, especially, sodium-glucose cotransporter 2 inhibitors (HR 0.43 [95% CI 0.33, 0.56], p < 0.0001), glucagon-like peptide 1 receptor agonists (HR 0.51 [95% CI 0.44, 0.58], p < 0.0001) and dipeptidyl peptidase 4 inhibitors (HR 0.44 [95% CI 0.38, 0.49], p < 0.0001) seemed safer than sulfonylureas (HR 2.27 [95% CI 2.18, 2.37], p < 0.0001). CONCLUSIONS/INTERPRETATION Incidence rates of hypoglycaemic episodes leading to hospitalisation are declining in Denmark, and the advent of new treatment alternatives may play a significant role in this decline. From a safety perspective, these findings are important and should be considered by clinicians when assessing treatment options for patients.
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Affiliation(s)
- Morten H Jensen
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark.
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
| | - Ole Hejlesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Peter Vestergaard
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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Pedersen-Bjergaard U, Fabricius TW, Thorsteinsson B. Synthetic long-acting insulin analogs for the management of type 1 diabetes: an update. Expert Opin Pharmacother 2021; 22:2251-2259. [PMID: 34467826 DOI: 10.1080/14656566.2021.1970136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Type 1 diabetes is characterized by insulin deficiency and requires near-physiological insulin replacement. In most patients, this is accomplished by basal bolus therapy consisting of a long-acting basal insulin administered once or twice daily and short-acting insulin with main meals. Several long-acting insulin analogs have been developed to optimize basal insulin therapy. AREAS COVERED This paper reviews the design of - and data from - randomized controlled trials (RCTs) to assess glucose lowering efficacy and safety of long-acting insulin analogs for the treatment of type 1 diabetes. EXPERT OPINION Due to the non-inferiority treat-to-target design of insulin, RCTs treatment differences primarily appear as differences in hypoglycemia risk. Data suggest that the first generation long-acting insulin analogs insulin glargine U100 and insulin detemir have a similar glucose lowering efficacy compared to NPH insulin but a lower risk of hypoglycemia, particularly during nighttime. The newer analogs insulin glargine U300 and insulin degludec provide non-inferior efficacy, although insulin glargine U300 is less potent unit-to-unit. Insulin degludec reduces hypoglycemia risk compared to insulin glargine U100. Future studies should explore the potential for further improvement of treatment results in type 1 diabetes by a structured approach to personalization of basal insulin therapy.
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Affiliation(s)
- Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Therese W Fabricius
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
| | - Birger Thorsteinsson
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Hemmingsen B, Metzendorf MI, Richter B. (Ultra-)long-acting insulin analogues for people with type 1 diabetes mellitus. Cochrane Database Syst Rev 2021; 3:CD013498. [PMID: 33662147 PMCID: PMC8094220 DOI: 10.1002/14651858.cd013498.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND People with type 1 diabetes mellitus (T1DM) need treatment with insulin for survival. Whether any particular type of (ultra-)long-acting insulin provides benefit especially regarding risk of diabetes complications and hypoglycaemia is unknown. OBJECTIVES To compare the effects of long-term treatment with (ultra-)long-acting insulin analogues to NPH insulin (neutral protamine Hagedorn) or another (ultra-)long-acting insulin analogue in people with type 1 diabetes mellitus. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We explored the US Food and Drug Administration (FDA) and European Medical Agency (EMA) web pages. We asked pharmaceutical companies, EMA and investigators for additional data and clinical study reports (CSRs). The date of the last search of all databases was 24 August 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) with a duration of 24 weeks or more comparing one (ultra-)long-acting insulin to NPH insulin or another (ultra-)long-acting insulin in people with T1DM. DATA COLLECTION AND ANALYSIS Two review authors assessed risk of bias using the new Cochrane 'Risk of bias' 2 (RoB 2) tool and extracted data. Our main outcomes were all-cause mortality, health-related quality of life (QoL), severe hypoglycaemia, non-fatal myocardial infarction/stroke (NFMI/NFS), severe nocturnal hypoglycaemia, serious adverse events (SAEs) and glycosylated haemoglobin A1c (HbA1c). We used a random-effects model to perform meta-analyses and calculated risk ratios (RRs) and odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) and 95% prediction intervals for effect estimates. We evaluated the certainty of the evidence applying the GRADE instrument. MAIN RESULTS We included 26 RCTs. Two studies were unpublished. We obtained CSRs, clinical study synopses or both as well as medical reviews from regulatory agencies on 23 studies which contributed to better analysis of risk of bias and improved data extraction. A total of 8784 participants were randomised: 2428 participants were allocated to NPH insulin, 2889 participants to insulin detemir, 2095 participants to insulin glargine and 1372 participants to insulin degludec. Eight studies contributing 21% of all participants comprised children. The duration of the intervention varied from 24 weeks to 104 weeks. Insulin degludec versus NPH insulin: we identified no studies comparing insulin degludec with NPH insulin. Insulin detemir versus NPH insulin (9 RCTs): five deaths reported in two studies including adults occurred in the insulin detemir group (Peto OR 4.97, 95% CI 0.79 to 31.38; 9 studies, 3334 participants; moderate-certainty evidence). Three studies with 870 participants reported QoL showing no true beneficial or harmful effect for either intervention (low-certainty evidence). There was a reduction in severe hypoglycaemia in favour of insulin detemir: 171/2019 participants (8.5%) in the insulin detemir group compared with 138/1200 participants (11.5%) in the NPH insulin group experienced severe hypoglycaemia (RR 0.69, 95% CI 0.52 to 0.92; 8 studies, 3219 participants; moderate-certainty evidence). The 95% prediction interval ranged between 0.34 and 1.39. Only 1/331 participants in the insulin detemir group compared with 0/164 participants in the NPH insulin group experienced a NFMI (1 study, 495 participants; low-certainty evidence). No study reported NFS. A total of 165/2094 participants (7.9%) in the insulin detemir group compared with 102/1238 participants (8.2%) in the NPH insulin group experienced SAEs (RR 0.95, 95% CI 0.75 to 1.21; 9 studies, 3332 participants; moderate-certainty evidence). Severe nocturnal hypoglycaemia was observed in 70/1823 participants (3.8%) in the insulin detemir group compared with 60/1102 participants (5.4%) in the NPH insulin group (RR 0.67, 95% CI 0.39 to 1.17; 7 studies, 2925 participants; moderate-certainty evidence). The MD in HbA1c comparing insulin detemir with NPH insulin was 0.01%, 95% CI -0.1 to 0.1; 8 studies, 3122 participants; moderate-certainty evidence. Insulin glargine versus NPH insulin (9 RCTs): one adult died in the NPH insulin group (Peto OR 0.14, 95% CI 0.00 to 6.98; 8 studies, 2175 participants; moderate-certainty evidence). Four studies with 1013 participants reported QoL showing no true beneficial effect or harmful effect for either intervention (low-certainty evidence). Severe hypoglycaemia was observed in 122/1191 participants (10.2%) in the insulin glargine group compared with 145/1159 participants (12.5%) in the NPH insulin group (RR 0.84, 95% CI 0.67 to 1.04; 9 studies, 2350 participants; moderate-certainty evidence). No participant experienced a NFMI and one participant in the NPH insulin group experienced a NFS in the single study reporting this outcome (585 participants; low-certainty evidence). A total of 109/1131 participants (9.6%) in the insulin glargine group compared with 110/1098 participants (10.0%) in the NPH insulin group experienced SAEs (RR 1.08, 95% CI 0.63 to 1.84; 8 studies, 2229 participants; moderate-certainty evidence). Severe nocturnal hypoglycaemia was observed in 69/938 participants (7.4%) in the insulin glargine group compared with 83/955 participants (8.7%) in the NPH insulin group (RR 0.83, 95% CI 0.62 to 1.12; 6 studies, 1893 participants; moderate-certainty evidence). The MD in HbA1c comparing insulin glargine with NPH insulin was 0.02%, 95% CI -0.1 to 0.1; 9 studies, 2285 participants; moderate-certainty evidence. Insulin detemir versus insulin glargine (2 RCTs),insulin degludec versus insulin detemir (2 RCTs), insulin degludec versus insulin glargine (4 RCTs): there was no evidence of a clinically relevant difference for all main outcomes comparing (ultra-)long-acting insulin analogues with each other. For all outcomes none of the comparisons indicated differences in tests of interaction for children versus adults. AUTHORS' CONCLUSIONS Comparing insulin detemir with NPH insulin for T1DM showed lower risk of severe hypoglycaemia in favour of insulin detemir (moderate-certainty evidence). However, the 95% prediction interval indicated inconsistency in this finding. Both insulin detemir and insulin glargine compared with NPH insulin did not show benefits or harms for severe nocturnal hypoglycaemia. For all other main outcomes with overall low risk of bias and comparing insulin analogues with each other, there was no true beneficial or harmful effect for any intervention. Data on patient-important outcomes such as QoL, macrovascular and microvascular diabetic complications were sparse or missing. No clinically relevant differences were found between children and adults.
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Affiliation(s)
- Bianca Hemmingsen
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Bernd Richter
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Litchman ML, Oser TK, Wawrzynski SE, Walker HR, Oser S. The Underground Exchange of Diabetes Medications and Supplies: Donating, Trading, and Borrowing, Oh My! J Diabetes Sci Technol 2020; 14:1000-1009. [PMID: 31801370 PMCID: PMC7645126 DOI: 10.1177/1932296819888215] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The cost of diabetes medications and supplies is rising, resulting in access challenges. This study assessed the prevalence of and factors predicting underground exchange activities-donating, trading, borrowing, and purchasing diabetes medications and supplies. RESEARCH DESIGN AND METHODS A convenience sample of people affected by diabetes was recruited online to complete a survey. Mixed method analysis was undertaken, including logistic regression to examine the relationship between self-reported difficulty purchasing diabetes medications and supplies and engagement in underground exchange activity. Thematic qualitative analysis was used to examine open-text responses. RESULTS Participants (N = 159) self-reported engagement in underground exchange activities, including donating (56.6%), donation receiving (34.6%), trading (23.9%), purchasing (15.1%), and borrowing (22%). Such activity took place among a variety of individuals, including friends, family, coworkers, online acquaintances and strangers. Diabetes-specific financial stress predicted engagement in trading diabetes mediations or supplies (OR 6.3, 95% CI 2.2-18.5) and receiving donated medications or supplies (OR 2.8, 95% CI 1.1-7.2). One overarching theme, unmet needs, and three subthemes emerged: (1) factors influencing underground exchange activity, (2) perceived benefits of underground exchange activity, and (3) perceived consequences of underground exchange activity. CONCLUSION Over half of the participants in this study engaged in underground exchange activities out of necessity. Providers must be aware about this underground exchange and inquire about safety and possible alternative resources. There is an urgent need to improve access to medications that are essential for life. Our study points to a failure in the US healthcare system since such underground exchanges may not be necessary if medications and supplies were accessible.
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Affiliation(s)
- Michelle L. Litchman
- University of Utah College of Nursing, Salt Lake City, UT, USA
- Michelle L. Litchman, PhD, FNP-BC, FAANP, University of Utah College of Nursing, 10 South 2000 East, Salt Lake City, UT 84112, USA.
| | - Tamara K. Oser
- University of Colorado Denver, School of Medicine, CO, USA
| | | | | | - Sean Oser
- University of Colorado Denver, School of Medicine, CO, USA
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Jensen MH, Hejlesen O, Vestergaard P. Association of insulin regimens with severe hypoglycaemia in patients with type 1 diabetes: A Danish case-control study. Br J Clin Pharmacol 2020; 86:1560-1566. [PMID: 32086824 DOI: 10.1111/bcp.14263] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/24/2019] [Accepted: 02/14/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS To evaluate the risk of severe hypoglycaemia for patients with Type 1 diabetes (T1D) when exposed to insulin regimens including human insulin only or insulin analogues. METHODS A total of 19 896 patients with T1D were extracted from the Danish National Patient Register. Of these, 6379 T1D patients experiencing 1 of more severe hypoglycaemic episodes (total of 17 242 episodes) were matched 1:1 with T1D patients without severe hypoglycaemia. A logistic regression model with last insulin regimen used as exposure was constructed to analyse the effect on severe hypoglycaemia. RESULTS People on a basal-bolus regimen with insulin analogues had a reduced risk of severe hypoglycaemia of 39% (odds ratio: 0.61, 95% confidence interval: 0.54-0.68) compared to patients on a basal-bolus human insulin only regimen. Furthermore, patients on a premixed regimen containing an insulin analogue had a 58% (odds ratio: 0.42, 95% confidence interval: 0.36-0.49) reduced risk of severe hypoglycaemia compared to patients on premixed human insulin only. CONCLUSION This study indicates that use of a basal-bolus insulin regimen with an insulin analogue is safer with respect to severe hypoglycaemia in patients with T1D than the use of a basal-bolus human insulin only regimen.
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Affiliation(s)
- Morten Hasselstrøm Jensen
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Ole Hejlesen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Peter Vestergaard
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.,Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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10
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Agesen RM, Alibegovic AC, Andersen HU, Beck-Nielsen H, Gustenhoff P, Hansen TK, Hedetoft C, Jensen T, Juhl CB, Lerche SS, Nørgaard K, Parving HH, Tarnow L, Thorsteinsson B, Pedersen-Bjergaard U. The effect of insulin degludec on risk of symptomatic nocturnal hypoglycaemia in adults with type 1 diabetes and high risk of nocturnal severe hypoglycaemia (the HypoDeg trial): study rationale and design. BMC Endocr Disord 2019; 19:78. [PMID: 31337371 PMCID: PMC6652000 DOI: 10.1186/s12902-019-0408-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/15/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Hypoglycaemia, especially nocturnal, remains the main limiting factor of achieving good glycaemic control in type 1 diabetes. The effect of first generation long-acting insulin analogues in reducing nocturnal hypoglycaemia is well documented in patient with type 1 diabetes. The effect of the newer long-acting insulin degludec on risk of nocturnal hypoglycaemia remains undocumented in patients with type 1 diabetes and recurrent severe nocturnal hypoglycaemia. The HypoDeg trial is designed to investigate whether insulin degludec in comparison with insulin glargine U100 is superior in limiting the occurrence of nocturnal hypoglycaemia in patients with recurrent nocturnal severe hypoglycaemia. This paper reports the study design of the HypoDeg trial. METHODS/DESIGN A Danish investigator-initiated, prospective, randomised, open, blinded endpoint (PROBE), multicentre, two-year cross-over study investigating the effect of insulin degludec versus insulin glargine U100 on frequency of nocturnal hypoglycaemia in patients with type 1 diabetes and one or more episodes of nocturnal severe hypoglycaemia during the preceding two years as the major inclusion criteria. Patients are randomised (1:1) to basal therapy with insulin degludec or insulin glargine. Insulin aspart is used as bolus therapy in both treatment arms. DISCUSSION In contrast to most other insulin studies the HypoDeg trial includes only patients at high risk of hypoglycaemia. The HypoDeg trial will compare treatment with insulin degludec to insulin glargine U100 in terms of risk of nocturnal hypoglycaemic episodes in patients with type 1 diabetes with the greatest potential to benefit from near-physiological insulin replacement therapy. www.clinicaltrials.gov : NCT02192450.
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Affiliation(s)
- Rikke Mette Agesen
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Dyrehavevej 29, DK-3400 Hillerød, Denmark
| | | | | | - Henning Beck-Nielsen
- Department of Endocrinology M, Odense University Hospital, Søndre Boulevard 29, DK-5000 Odense C, Denmark
- Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 19, 3, DK-5000 Odense C, Denmark
| | - Peter Gustenhoff
- Department of Endocrinology, Aalborg University Hospital, Mølleparkvej 4, DK-9000, Aalborg, Denmark
| | - Troels Krarup Hansen
- Steno Diabetes Center Aarhus, Hedeager 3, DK-8200 Aarhus N, Denmark
- Health, University of Aarhus, Nordre Ringgade 1, DK-8000 Aarhus C, Denmark
| | - Christoffer Hedetoft
- Department of Internal Medicine, Køge Sygehus, Lykkebækvej 1, DK-4600 Køge, Denmark
| | - Tonny Jensen
- Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet), Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Claus Bogh Juhl
- Department of Medicine, Sydvestjysk Sygehus, Finsensgade 35, DK-6700 Esbjerg, Denmark
| | - Susanne Søgaard Lerche
- Department of Diabetes and Hormonal Diseases, Lillebælt Hospital Kolding, Sygehusvej 24, DK-6000 Kolding, Denmark
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, DK-2820 Gentofte, Denmark
- Department of Endocrinology, Hvidovre University Hospital, Kettegaards Alle 30, DK-2650 Hvidovre, Denmark
| | - Hans-Henrik Parving
- Health, University of Aarhus, Nordre Ringgade 1, DK-8000 Aarhus C, Denmark
- Department of Medical Endocrinology, Copenhagen University Hospital (Rigshospitalet), Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Lise Tarnow
- Health, University of Aarhus, Nordre Ringgade 1, DK-8000 Aarhus C, Denmark
- Department of Clinical Research, Nordsjællands Hospital, Hillerød, Dyrehavevej 29, DK-3400 Hillerød, Denmark
- Steno Diabetes Center Sjaelland, Akacievej 7, DK-4300 Holbaek, Denmark
| | - Birger Thorsteinsson
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Dyrehavevej 29, DK-3400 Hillerød, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Dyrehavevej 29, DK-3400 Hillerød, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, DK-2200 Copenhagen, Denmark
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11
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Lechleitner M, Kaser S, Hoppichler F, Roden M, Weitgasser R, Ludvik B, Fasching P, Winhofer-Stöckl Y, Kautzky-Willer A, Schernthaner G, Prager R, Wascher TC, Clodi M. [Diagnosis and insulin therapy of type 1 diabetes mellitus (Update 2019)]. Wien Klin Wochenschr 2019; 131:77-84. [PMID: 30980145 DOI: 10.1007/s00508-019-1493-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This guideline summarizes diagnosis of type 1 diabetes, including accompanying autoimmune disorders, insulin therapy regimens and glycemic target values.
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Affiliation(s)
- Monika Lechleitner
- Interne Abteilung, Landeskrankenhaus Hochzirl - Natters, Hochzirl, 6170, Zirl, Österreich.
| | - Susanne Kaser
- Department für Innere Medizin 1, Medizinische Universität Innsbruck, Innsbruck, Österreich
- Christian Doppler Labor für Insulinresistenz, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Friedrich Hoppichler
- Abteilung für Innere Medizin, Krankenhaus der Barmherzigen Brüder Salzburg, Salzburg, Österreich
| | - Michael Roden
- Klinik für Endokrinologie und Diabetologie, Medizinische Fakultät, Heinrich-Heine-Universität, Düsseldorf, Deutschland
- Institut für Klinische Diabetologie, Deutsches Diabetes-Zentrum (DDZ), Leibniz-Zentrum für Diabetesforschung, Düsseldorf, Deutschland
- Deutsches Zentrum für Diabetesforschung (DZD e. V.), München-Neuherberg, Deutschland
| | - Raimund Weitgasser
- Abteilung für Innere Medizin, Privatklinik Wehrle-Diakonissen, Salzburg, Österreich
- Universitätsklinik für Innere Medizin I, LKH Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Bernhard Ludvik
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - Peter Fasching
- 5. Medizinische Abteilung für Endokrinologie, Rheumatologie und Akutgeriatrie, Wilhelminenspital der Stadt Wien, Wien, Österreich
| | - Yvonne Winhofer-Stöckl
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Alexandra Kautzky-Willer
- Gender Medicine Unit, Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Guntram Schernthaner
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Department für Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - Rudolf Prager
- 3. Medizinische Abteilung mit Stoffwechselerkrankungen und Nephrologie, Krankenhaus Hietzing, Wien, Österreich
- Karl Landsteiner Institut für Stoffwechselerkrankungen und Nephrologie, Wien, Österreich
| | - Thomas C Wascher
- 1. Medizinische Abteilung, Hanusch-Krankenhaus, Wien, Österreich
| | - Martin Clodi
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
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12
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Evans M, Mehta R, Gundgaard J, Chubb B. Cost-Effectiveness of Insulin Degludec vs. Insulin Glargine U100 in Type 1 and Type 2 Diabetes Mellitus in a UK Setting. Diabetes Ther 2018; 9:1919-1930. [PMID: 30097995 PMCID: PMC6167291 DOI: 10.1007/s13300-018-0478-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Understanding which therapeutic innovations in diabetes represent the best value requires rigorous economic evaluation. Data from randomised controlled trials and observational studies indicate that insulin degludec has a hypoglycemia advantage versus insulin glargine 100 units/mL (glargine U100), the most widely prescribed basal insulin analogue in the UK. This analysis was done to more rigorously assess cost-effectiveness in a UK setting. METHODS Data from two double-blinded, randomised, two-period crossover trials in type 1 (SWITCH 1) and type 2 (SWITCH 2) diabetes mellitus were used to assess the cost-effectiveness of degludec vs. glargine U100 with an economic model. Cost-effectiveness was analysed over a 1-year time horizon based on the different rates of hypoglycaemia and actual doses of insulin used, rather than glycaemic control due to the treat-to-target trial design. RESULTS In type 1 diabetes mellitus, degludec was highly cost-effective compared with glargine U100, with an incremental cost-effectiveness ratio of £984 (increased costs of only £23/year and improvement in participant health of 0.0232 quality-adjusted life-years (QALYs)). In type 2 diabetes mellitus, it was estimated that quality of life was improved (0.0065 QALYs gain) with degludec compared with glargine U100 at an increased annual cost of £117 (incremental cost-effectiveness ratio, £17,939). One-way sensitivity analyses showed that the results were robust to changes in parameters in both type 1 and type 2 diabetes mellitus. CONCLUSIONS The rigorous design of the SWITCH trials, coupled with a representative patient population and a definition of hypoglycaemia that is relevant for real-world patients, makes the results of these trials highly generalisable. The within-trial analysis has the added value of being able to include doses and event rates directly from the trials. This short-term economic analysis estimated that IDeg would be cost-effective relative to IGlar U100 in both type 1 and type 2 diabetes mellitus in the UK. TRIAL REGISTRATION SWITCH 1 (NCT02034513); SWITCH 2 (NCT02030600). FUNDING Novo Nordisk, Søborg, Denmark.
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Affiliation(s)
- Marc Evans
- University Hospital Llandough, Penarth, Cardiff, UK.
| | - Roopa Mehta
- Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Médicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, Mexico
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13
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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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