A nine country study of the burden of non-severe nocturnal hypoglycaemic events on diabetes management and daily function

Nocturnal Hypoglycemia in the Era of Continuous Glucose Monitoring

Nocturnal hypoglycemia is a common acute complication of people with diabetes on insulin therapy. In particular, the inability to control glucose levels during sleep, the impact of external factors such as exercise, or alcohol and the influence of hormones are the main causes. Nocturnal hypoglycemia has several negative somatic, psychological, and social effects for people with diabetes, which are summarized in this article. With the advent of continuous glucose monitoring (CGM), it has been shown that the number of nocturnal hypoglycemic events was significantly underestimated when traditional blood glucose monitoring was used. The CGM can reduce the number of nocturnal hypoglycemia episodes with the help of alarms, trend arrows, and evaluation routines. In combination with CGM with an insulin pump and an algorithm, automatic glucose adjustment (AID) systems have their particular strength in nocturnal glucose regulation and the prevention of nocturnal hypoglycemia. Nevertheless, the problem of nocturnal hypoglycemia has not yet been solved completely with the technologies currently available. The CGM systems that use predictive models to warn of hypoglycemia, improved AID systems that recognize hypoglycemia patterns even better, and the increasing integration of artificial intelligence methods are promising approaches in the future to significantly minimize the risk of a side effect of insulin therapy that is burdensome for people with diabetes.

Insulin therapy in type 2 diabetes: Insights into clinical efficacy, patient-reported outcomes, and adherence challenges

Insulin therapy plays a crucial role in the management of type 2 diabetes as the disease progresses. Over the past century, insulin formulations have undergone significant modifications and bioengineering, resulting in a diverse range of available insulin products. These products show distinct pharmacokinetic and pharmacodynamic profiles. Consequently, various insulin regimens have em-erged for the management of type 2 diabetes, including premixed formulations and combinations of basal and bolus insulins. The utilization of different insulin regimens yields disparate clinical outcomes, adverse events, and, notably, patient-reported outcomes (PROs). PROs provide valuable insights from the patient's perspective, serving as a valuable mine of information for enhancing healthcare and informing clinical decisions. Adherence to insulin therapy, a critical patient-reported outcome, significantly affects clinical outcomes and is influenced by multiple factors. This review provides insights into the clinical effectiveness of various insulin preparations, PROs, and factors impacting insulin therapy adherence, with the aim of enhancing healthcare practices and informing clinical decisions for individuals with type 2 diabetes.

Factors and economic burden of non-severe hypoglycemia among insulin-treated type 2 diabetes patients: a cross-sectional study

OBJECTIVE

This cross-sectional survey was performed to assess the prevalence, factors, and economic burden of non-severe hypoglycemia among insulin-treated type 2 diabetes (T2D) patients in northern Thailand.

METHODS

Between April 2021 and August 2022, 600 participants were evaluated via structured questionnaires containing sociodemographic and clinical characteristics, medications, and economic burden. Patients were divided into two groups (having and not having non-severe hypoglycemia). Variables with a p value <.05 in the univariate model were included in the multivariate model.

RESULTS

The percentage of non-severe hypoglycemia was 50.3% (302/600). Of all participants, the average age was 61.4 ± 26.0 years, 55.7% were female, 53.5% used premix insulin, and the average duration of diabetes was 16.1 ± 10.0 years. Multivariate logistic regression analysis indicated that age (OR = .96; p <.001), duration of diabetes (OR = 1.04; p <.001), BMI (OR = .95; p = .002), thiazolidinedione (OR = 1.56; p = .012) and insulin regimens were associated with having non-severe hypoglycemia. Compared to basal insulin, basal bolus (OR = 6.93; p = .001), basal plus (OR = 3.58; p <.001), and premix insulin (OR = 1.83; p =.003) were associated with hypoglycemia. Greater numbers of sick leave were found in the hypoglycemia group (14 vs 4 patients, p = .029).

CONCLUSIONS

These findings help to individuate those patients who are at higher risk of non-severe hypoglycemia in insulin-treated T2D patients. Compared to the non-hypoglycemia group, patients with hypoglycemia were younger, had longer diabetes duration, lower BMI, received thiazolidinedione and insulin regimens such as premix, basal plus, or basal bolus insulins, and more productivity loss.

Glycemic Outcomes During Early Use of the MiniMed™ 780G Advanced Hybrid Closed-Loop System with Guardian™ 4 Sensor

Background: Safety and significant improvement in overall glycated hemoglobin (A1C) and percentage of time spent in (TIR), below (TBR), and above (TAR) glucose range were demonstrated in the pivotal trial of adolescents and adults using the MiniMed™ advanced hybrid closed-loop (AHCL) system with the adjunctive, calibration-required Guardian™ Sensor 3. The present study evaluated early outcomes of continued access study (CAS) participants who transitioned from the pivotal trial investigational system to the approved MiniMed™ 780G system with the non-adjunctive, calibration-free Guardian™ 4 Sensor (MM780G+G4S). Study data were presented alongside those of real-world MM780G+G4S users from Europe, the Middle East, and Africa. Methods: The CAS participants (N = 109, aged 7-17 years and N = 67, aged >17 years) used the MM780G+G4S for 3 months and data of real-world MM780G+G4S system users (N = 10,204 aged ≤15 years and N = 26,099 aged >15 years) were uploaded from September 22, 2021 to December 02, 2022. At least 10 days of real-world continuous glucose monitoring (CGM) data were required for analyses. Glycemic metrics, delivered insulin and system use/interactions underwent descriptive analyses. Results: Time in AHCL and CGM use were >90% for all groups. AHCL exits averaged 0.1/day and there were few blood glucose measurements (BGMs) (0.8/day-1.0/day). Adults in both cohorts met most consensus recommendations for glycemic targets. Pediatric groups met recommendations for %TIR and %TBR, although not those for mean glucose variability and %TAR, possibly due to low use of recommended glucose target (100 mg/dL) and active insulin time (2 h) settings (28.4% in the CAS cohort and 9.4% in the real-world cohort). The CAS pediatric and adult A1C were 7.2% ± 0.7% and 6.8% ± 0.7%, respectively, and there were no serious adverse events. Conclusions: Early clinical use of the MM780G+G4S was safe and involved minimal BGMs and AHCL exits. Consistent with real-world pediatric and adult use, outcomes were associated with achievement of recommended glycemic targets. Clinical Trial Registration number: NCT03959423.

Real-time continuous glucose monitoring improves glycemic control and reduces hypoglycemia: Real-world data

AIM

To study the effect of real time continuous glucose monitor (RT-CGM) use on glycemic parameters in patients with diabetes mellitus (DM) in real world practice.

METHODS

We retrospectively studied 91 adult subjects with DM who had been using Dexcom™ RT-CGM. Two consecutive hemoglobin A1c (HbA1c), both prior to and after at least 3 months of RT-CGM initiation, were collected. A total of 31 subjects completed a 5-14 day user blinded CGM using a Freestyle Libre™ prior to RT-CGM initiation. The first two week period following at least 3 months use of RT-CGM was analyzed for CGM metrics.

RESULTS

A total of 51.6 % of subjects had T1DM, 34.1 % used continuous subcutaneous insulin infusion (CSII), and 62.6 % had DM for > 10 years. Both HbA1c obtained following RT-CGM initiation decreased significantly compared to baseline (8.11 + 1.47% vs 7.69 + 1.25 %; P = 0.002 & 8.16 + 1.51 % vs 7.62 + 1.06 %; P = 0.001). Subjects with baseline HbA1c > 7.0 % showed even more robust reduction in both HbA1c after RT-CGM initiation (8.74 + 1.24 % vs 7.99 + 1.22 %; P = 0.000 & 8.74 + 1.32 % vs 7.85 + 1.07 %; P = 0.001). On comparison of CGM metrics, there was a significant reduction in time spent in hypoglycemia (sugars < 70 mg/dl) including severe hypoglycemia (sugars < 54 mg/dl) after initiation of the RT-CGM (9.16 + 8.68 % vs 1.29 + 2.21 %; P = <0.001 & 4.58 + 5.43 % vs 0.28 + 0.58 %; P = <0.001). CoV of glucose was also decreased significantly (39.61 + 9.36 % vs 31.06 + 6.74 %; P = <0.001) with RT- CGM use.

CONCLUSION

RT-CGM use for at least 3 months in patients with DM results in meaningful HbA1c reductions with stable glycemic control without increasing the risk of hypoglycemia.

The 12-Item Hypoglycemia Impact Profile (HIP12): psychometric validation of a brief measure of the impact of hypoglycemia on quality of life among adults with type 1 or type 2 diabetes

INTRODUCTION

The aim of this study was to determine the psychometric properties of the 12-Item Hypoglycemia Impact Profile (HIP12), a brief measure of the impact of hypoglycemia on quality of life (QoL) among adults with type 1 (T1D) or type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

Adults with T1D (n=1071) or T2D (n=194) participating in the multicountry, online study, 'Your SAY: Hypoglycemia', completed the HIP12. Psychometric analyses were undertaken to determine acceptability, structural validity, internal consistency, convergent/divergent validity, and known-groups validity.

RESULTS

Most (98%) participants completed all items on the HIP12. The expected one-factor solution was supported for T1D, T2D, native English speaker, and non-native English speaker groups. Internal consistency was high across all groups (ω=0.91-0.93). Convergent and divergent validity were satisfactory. Known-groups validity was demonstrated for both diabetes types, by frequency of severe hypoglycemia (0 vs ≥1 episode in the past 12 months) and self-treated episodes (<2 vs 2-4 vs ≥5 per week). The measure also discriminated by awareness of hypoglycemia in those with T1D.

CONCLUSIONS

The HIP12 is an acceptable, internally consistent, and valid tool for assessing the impact of hypoglycemia on QoL among adults with T1D. The findings in the relatively small sample with T2D are encouraging and warrant replication in a larger sample.

Comparison of treatment with insulin degludec and glargine U100 in patients with type 1 diabetes prone to nocturnal severe hypoglycaemia: The HypoDeg randomized, controlled, open-label, crossover trial

AIM

To investigate whether the long-acting insulin analogue insulin degludec compared with insulin glargine U100 reduces the risk of nocturnal symptomatic hypoglycaemia in patients with type 1 diabetes (T1D).

METHODS

Adults with T1D and at least one episode of nocturnal severe hypoglycaemia during the last 2 years were included in a 2-year prospective, randomized, open, multicentre, crossover trial. A total of 149 patients were randomized 1:1 to basal-bolus therapy with insulin degludec and insulin aspart or insulin glargine U100 and insulin aspart. Each treatment period lasted 1 year and consisted of 3 months of run-in or crossover followed by 9 months of maintenance. The primary endpoint was the number of blindly adjudicated nocturnal symptomatic hypoglycaemic episodes. Secondary endpoints included the occurrence of severe hypoglycaemia. We analysed all endpoints by intention-to-treat.

RESULTS

Treatment with insulin degludec resulted in a 28% (95% CI: 9%-43%; P = .02) relative rate reduction (RRR) of nocturnal symptomatic hypoglycaemia at level 1 (≤3.9 mmol/L), a 37% (95% CI: 16%-53%; P = .002) RRR at level 2 (≤3.0 mmol/L), and a 35% (95% CI: 1%-58%; P = .04) RRR in all-day severe hypoglycaemia compared with insulin glargine U100.

CONCLUSIONS

Patients with T1D prone to nocturnal severe hypoglycaemia have lower rates of nocturnal symptomatic hypoglycaemia and all-day severe hypoglycaemia with insulin degludec compared with insulin glargine U100.

Nocturnal hypoglycemia in type 1 and type 2 diabetes: an update on prevalence, prevention, pathophysiology and patient awareness

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.

The participatory development of a national core set of person-centred diabetes outcome constructs for use in routine diabetes care across healthcare sectors

BACKGROUND

This study sought to utilise participatory research methods to identify the perspectives of people with diabetes regarding which diabetes outcomes were most important to them. These findings were then used to support an expert working group representing multiple health sectors and healthcare disciplines and people with diabetes to establish a core set of patient-important outcome constructs for use in routine diabetes care.

METHODS

26 people with diabetes and family members were recruited through purposive sampling to participate in interviews, focus groups, voting and plenary activities in order to be part of identifying outcome constructs. Content and qualitative analysis methods were used with literature reviews to inform a national multi-stakeholder consensus process for a core set of person-centred diabetes outcome constructs to be used in routine diabetes care across health care settings.

RESULTS

21 people with diabetes and 5 family members representing type 1 and 2 diabetes and a range of age groups, treatment regimens and disease burden identified the following patient-reported outcome constructs as an important supplement to clinical indicators for outcome assessment in routine diabetes care: self-rated health, psychological well-being, diabetes related emotional distress and quality of life, symptom distress, treatment burden, blood sugar regulation and hypoglycemia burden, confidence in self-management and confidence in access to person-centred care and support. Consensus was reached by a national multi-stakeholder expert group to adopt measures of these constructs as a national core diabetes outcome set for use in routine value-based diabetes care.

CONCLUSIONS

We found that patient-reported outcome (PRO) constructs and clinical indicators are needed in core diabetes outcome sets to evaluate outcomes of diabetes care which reflect key needs and priorities of people with diabetes. The incorporation of patient-reported outcome constructs should be considered complementary to clinical indicators in multi-stakeholder value-based health care strategies. We found participatory research methods were useful in facilitating the identification of a core prioritised set of diabetes outcome constructs for routine value-based diabetes care. The use of our method for involving patients may be useful for similar efforts in other disease areas aimed at defining suitable outcomes of person-centred value-based care. Future research should focus on developing acceptable and psychometrically valid measurement instruments to evaluate these outcome constructs as part of routine diabetes care.

Duration of type 2 diabetes does not appear to moderate hypoglycaemia rate with insulin degludec versus insulin glargine U100

In the DEVOTE and SWITCH 2 trials, insulin degludec 100 units/mL (degludec) was superior to insulin glargine 100 units/mL (glargine U100) with respect to the rates of severe (DEVOTE; across trial) and overall symptomatic (SWITCH 2; during the maintenance period of the trial) hypoglycaemia in individuals with type 2 diabetes. In this post hoc analysis, data from 7635 individuals from DEVOTE and 720 individuals from SWITCH 2 were analysed by subgroups of diabetes duration at baseline (<10, ≥10-<15, ≥15-<20 and ≥20 years) using prespecified models from both trials. There was a trend towards lower rates of hypoglycaemia with degludec versus glargine U100 across all diabetes duration subgroups in both trials, with the difference being statistically significant in some subgroups in DEVOTE and SWITCH 2. Overall, however, no significant interaction was observed between diabetes duration and treatment (DEVOTE interaction, P = .496; SWITCH 2 interaction, P = .144). Therefore, in this post hoc analysis of DEVOTE and SWITCH 2, diabetes duration did not appear to affect the reduction in rates of hypoglycaemia observed with degludec compared with glargine U100.

Preferences for Outcomes Among Adults with Type 1 Diabetes and Caregivers of Children with Type 1 Diabetes

PURPOSE

Hemoglobin A1c (HbA1c) is the accepted measure of effectiveness for type 1 diabetes therapies. We investigated preferences for measures of diabetes control in addition to HbA1c among adults with type 1 diabetes and caregivers of children with type 1 diabetes.

METHODS

Using discrete-choice experiment methodology, surveys for adults with type 1 diabetes and caregivers presented choices between hypothetical treatments described by six attributes with varying levels: HbA1c, time in optimal glucose range, weekly number and severity of hypoglycemic and hyperglycemic events, additional disease management time, and additional treatment cost. Choice data were analyzed using random-parameters logit.

RESULTS

A total of 300 adults with type 1 diabetes and 400 caregivers completed the survey. Adults and caregivers placed the most importance on reducing hypoglycemic and hyperglycemic events. For adults, avoiding 1-5 mild-to-moderate hypoglycemic events (glucose 54-69 mg/dL)/week was five times more important than being a half-point above target HbA1c. Avoiding 1-5 hyperglycemic events (glucose >180 mg/dL)/week was seven times more important than being a half-point above target HbA1c. Additional time in optimal glucose range was as important as a reduction greater than a half-point in HbA1c. Avoiding hyperglycemic and hypoglycemic events was more important than all other outcomes for caregivers of younger children. Caregivers of children >12 years placed relatively more weight on avoiding hypoglycemic events <54 mg/dL than those with younger children and preferred avoiding additional costs.

CONCLUSION

Adults with type 1 diabetes and caregivers prioritize controlling hypoglycemic and hyperglycemic events, including mild-to-moderate events. These preferences should be considered in drug development and regulatory decisions.

Family Members: The Forgotten Players in the Diabetes Care Team (The TALK-HYPO Study)

INTRODUCTION

The objective of this study was to establish the burden of hypoglycemia on family members of people with diabetes (PWDs) and to gain an understanding of how conversations about hypoglycemia can contribute to diabetes care.

METHODS

This was a multinational cross-sectional study of family members of people with type 1 or type 2 diabetes taking insulin and/or secretagogues for ≥ 12 months who voluntarily completed an online questionnaire.

RESULTS

Overall, 4300 family members of PWDs (type 1 [29%], type 2 [46%], unknown [25%]) were surveyed. Two in three family members (66%) reported thinking about the hypoglycemia of the PWD at least monthly, and 64% felt worried or anxious about the PWD's risk for hypoglycemia. There was general agreement among family members that more conversations about hypoglycemia would have a positive impact on the PWD's life (76%).

CONCLUSIONS

Hypoglycemia can present a burden on the lives of family members of PWDs. Conversations about hypoglycemia, facilitated by a healthcare professional, may reduce this burden and hypoglycemia risk.

FUNDING

Novo Nordisk A/S.

Estimating the Impact of Diabetes Mellitus on Worker Productivity Using Self-Report, Electronic Health Record and Human Resource Data

OBJECTIVE

We assessed the relationship between diabetes mellitus (DM) and measures of worker productivity, direct health care costs, and costs associated with lost productivity (LP) among health care industry workers across two integrated health care systems.

METHODS

We used data from the Value Based Benefit Design Health and Wellness Study Phase II (VBD), a prospective study of employees surveyed across health systems. Survey and health care utilization data were linked to estimate LP and health care utilization costs.

RESULTS

Mean marginal lost productive time per week was 0.56 hours higher for respondents with DM. Mean adjusted monthly total health care utilization costs were $467 higher for respondents with DM.

CONCLUSION

The impact of DM is reflected in higher rates of LP and higher indirect costs for employers related to LP and higher health care resource use.

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

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.

Incidence and severity of hypoglycaemia in type 2 diabetes by treatment regimen: A UK multisite 12-month prospective observational study

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.

Epidemiology, Quality of Life, and Costs Associated with Hypoglycemia in Patients with Diabetes in Spain: A Systematic Literature Review

OBJECTIVE

To assess the burden of hypoglycemia in patients with diabetes mellitus (DM) in Spain, including epidemiological data and information relating to healthcare resource utilization (HRU) and costs, and patients' quality of life (QoL).

METHODS

A systematic literature review (SLR) was conducted to identify studies that included original information on epidemiology, HRU and costs, and/or QoL associated with hypoglycemia in patients with DM in Spain, published in either Spanish or English, between January 2007 and April 2017.

RESULTS

Fifteen articles, involving 14 studies, were identified in the SLR and included in the analysis. The estimated rate of severe hypoglycemia (SH) events per patient per year ranged from 0.90 to 1.50 in patients with type 1 DM (T1DM) and from 0.30 to 0.63 in patients with type 2 DM (T2DM). The data on HRU differed extensively between studies, making it difficult to draw a conclusion. Total costs per SH event ranged from €409.97 in patients with T1DM to €713.10 in patients with DM. Work absence was reported in 11.80-18% of the working patients. Further, patients who experienced hypoglycemic events expressed a higher fear and had a poorer QoL than those who did not report these events.

CONCLUSION

Although the data included in the SLR were difficult to synthesize due to heterogeneity of the study designs and patient characteristics in the 14 studies, our search identified a high burden associated with hypoglycemic events in terms of HRU and costs, and patients' QoL. Further research is recommended to reach a consensus on hypoglycemia definition and study design to provide robust evidence on the burden of hypoglycemia and to accurately weigh the impact of this acute complication in Spain.

FUNDING

Eli Lilly and Company.

Perceptions of insulin use in type 2 diabetes in primary care: a thematic synthesis

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.

Direct and indirect health economic impact of hypoglycaemia in a global population of patients with insulin-treated diabetes

AIMS

The Hypoglycaemia Assessment Tool (HAT) study investigated the health economic impact of hypoglycaemic events in 24 countries, including countries without previously published data on hypoglycaemia.

METHODS

Self-assessment questionnaires and patient diaries (4-week prospective period) were completed by adults with type 1 (T1D) or type 2 diabetes (T2D) treated with insulin for more than 12 months (N = 27,585).

RESULTS

Direct economic impacts of hypoglycaemia during the 4-week prospective period, included increased blood glucose monitoring (reported by 69.7% [T1D] and 60.9% [T2D] of patients), hospitalisation (T1D 2.1%; T2D 3.4% of patients) and medical contact (clinic or telephone; T1D 3.8%; T2D 6.8% of patients). Regional variation in medical contact and hospitalisation was found, with the highest usage in Russia (T1D 17.1%; T2D 17.3%), and Latin America (T1D 5.2%; T2D 6.8%) respectively. Indirect economic impacts following hypoglycaemia included loss of productivity due to absence from work or study; 3.9% (T1D) and 6.2% (T2D) of patients. Regional differences in work productivity were noted among patients with T2D, with a low prevalence in Northern Europe and Canada (0.9%) and high in Southeast Asia (14.6%).

CONCLUSIONS

This study shows that hypoglycaemia has a significant but variable impact on the economics of diabetes healthcare globally.

The impact of non-severe hypoglycemia on quality of life in patients with type 2 diabetes

AIMS

To determine the impact of frequency of non-severe hypoglycemic events (NSHE) and the perceived burden of NSHE on quality of life (QOL) over time.

METHODS

T2D adults (n = 424) were re-contacted two years after initial QOL assessment. Responding subjects (n = 290) reported the frequency and burden of NSHE over time and completed six generic and diabetes-specific QOL measures.

RESULTS

Most subjects (86%) reported ≥ one NSHE over time. Higher frequency of NSHE was significantly associated with decrements in QOL. Greater perceived burden of NSHE was significantly linked to decreases in QOL over time for all six QOL measures. Interaction terms indicated that participants with a higher frequency of NSHE and higher perceived burden reported the greatest decrease in QOL; participants who experienced frequent NSHE but did not perceive these events as burdensome evidenced little worsening in QOL over time.

CONCLUSIONS

NSHE have a negative impact on QOL over time in T2D adults. However, it is not just the occurrence of NSHE that affects QOL; it is the individual's felt burden of these events that is critical. The greatest reductions in QOL are seen among those subjects reporting a higher frequency of NSHE and indicating that such events are burdensome.

Effects of Hypoglycemia on Circulating Stem and Progenitor Cells in Diabetic Patients

CONTEXT

Iatrogenic hypoglycemia is the most common acute diabetic complication, and it significantly increases morbidity. In people with diabetes, reduction in the levels of circulating stem and progenitor cells predicts adverse outcomes.

OBJECTIVE

To evaluate whether hypoglycemia in diabetes affects circulating stem cells and endothelial progenitor cells (EPCs).

DESIGN

We performed an experimental hypoglycemia study (Study 1) and a case-control study (Study 2).

SETTING

Tertiary referral inpatient clinic.

PATIENTS AND OTHER PARTICIPANTS

Type 1 diabetic patients (Study 1, n = 19); diabetic patients hospitalized for severe iatrogenic hypoglycemia, matched inpatient and outpatient controls (Study 2, n = 22/group).

INTERVENTIONS

Type 1 diabetic patients underwent two in-hospital sessions of glucose monitoring during a breakfast meal with or without induction of hypoglycemia in random order. In Study 2, patients hospitalized for hypoglycemia and matched controls were compared.

MAIN OUTCOME MEASURE

Circulating stem cells and EPCs were measured by flow cytometry based on the expression of CD34 and kinase insert domain receptor (KDR).

RESULTS

In Study 1, the physiologic decline of CD34+KDR+ EPCs from 8 am to 2 pm was abolished by insulin-induced hypoglycemia in type 1 diabetic patients. In Study 2, diabetic patients hospitalized for severe iatrogenic hypoglycemia had significantly lower levels of CD34+ stem cells and CD34+KDR+ EPCs compared with diabetic inpatients or outpatient controls.

CONCLUSIONS

In diabetic patients, a single mild hypoglycemic episode can compromise the physiologic EPC fluctuation, whereas severe hypoglycemia is associated with a marked reduction in stem cells and EPCs. These data provide a possible link between hypoglycemia and adverse outcomes of diabetes.

Severity of hypoglycaemia and health-related quality of life, work productivity and healthcare costs in patients with type 2 diabetes in Europe

Aims

Hypoglycaemia in patients with type 2 diabetes mellitus (T2DM) is associated with poor health outcomes, such as reduced health‐related quality of life (HRQoL). This study aimed to assess the impact of hypoglycaemic events by severity on HRQoL, work productivity and healthcare costs in patients with T2DM.

Materials and Methods

European patients with T2DM selected from the National Health and Wellness Survey who were currently receiving pharmacologic therapy were stratified into 3 groups based on the reported history and severity of hypoglycaemic events (no event, nonsevere, severe) experienced in the previous 3 months. Patients’ work productivity, HRQoL, healthcare resource use (HCRU) and associated costs were assessed as self‐reported outcomes.

Results

Of 1269 patients included in the study, 652 (51.4%) patients had not experienced an event, while 533 (42.0%) and 84 (6.6%) patients had experienced nonsevere and severe hypoglycaemic events, respectively, in the previous 3 months. An increase in hypoglycaemia severity was associated with a decrease in HRQoL, and an increase in HCRU and healthcare costs.

Conclusions

The impact of hypoglycaemia varies by severity and has a negative impact on HRQoL and overall HCRU and costs.

Nonsevere Hypoglycemia Episode Clinical and Economic Outcomes: A Comparison between Sulfonylurea and Sodium-Glucose Cotransporter 2 Inhibitor as Add-On to Metformin from a Canadian Perspective

BACKGROUND

Nonsevere hypoglycemia episodes (NSHEs) are associated with clinically adverse outcomes, lower health-related quality of life, increased burden of disease, and reduced work productivity.

OBJECTIVE

To estimate prevalence of NSHEs and associated economic outcomes attributable to sulfonylurea (SU) versus sodium-glucose cotransporter 2 inhibitor (SGLT2i) initiation after metformin over one year for Canadian patients with type 2 diabetes (T2DM).

METHODS

Risk difference for NSHEs was calculated for SU and SGLT2i from RCT data. Estimation of NSHEs attributable to SU utilization in Canada was calculated from published data. Both direct and indirect costs associated with NSHEs were obtained from previous published studies in literature.

RESULTS

The number of patients with T2DM and exposure to SU in Canada in 2016 was estimated to be 1,246,438. The average underreported NSHEs in clinical settings were estimated at 67.7%. Risk difference for NSHEs for SU versus SGLT2i was estimated at 26.7%. Estimation of excess NSHEs attributable to SU utilization versus SGLT2i in Canada was estimated at 130,434 events per year (sensitivity analysis: minimum 80,680 and maximum 624,465). Total indirect costs including loss-of-work productivity and out-of-pocket costs secondary to excess NSHEs due to SU utilization versus SGLT2i after metformin were estimated at CDN$8.6M (M = millions) for 2016 (sensitivity analysis: minimum CDN$5.3M and maximum CDN$81.2M).

CONCLUSION

NSHE, which is a forgotten variable in economic evaluations for healthcare reimbursement models, occurs frequently in real-world clinical settings but is infrequently reported. NSHEs can lead to a significant loss-of-work productivity and out-of-pocket costs.

The risks of nocturnal hypoglycaemia in insulin-treated diabetes

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.

Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease

This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease. The authors provide an update for ophthalmologists and allied healthcare professionals on key aspects of diabetes management, supported by a review of the pertinent literature, and recommend practice principles for optimal patient management in treating visual impairment due to diabetic eye disease. In people with diabetes, early optimal glycaemic control reduces the long-term risk of both microvascular and macrovascular complications. The authors propose more can and should be done to maximise metabolic control, promote appropriate behavioural modifications and encourage timely treatment intensification when indicated to ameliorate diabetes-related complications. All people with diabetes should be screened for sight-threatening diabetic retinopathy promptly and regularly. It is shown that attitudes towards treatment adherence in diabetic macular oedema appear to mirror patients' views and health behaviours towards the management of their own diabetes. Awareness of diabetic macular oedema remains low among people with diabetes, who need access to education early in their disease about how to manage their diabetes to delay progression and possibly avoid eye-related complications. Ophthalmologists and allied healthcare professionals play a vital role in multidisciplinary diabetes management and establishment of dedicated diabetic macular oedema clinics is proposed. A broader understanding of the role of the diabetes specialist nurse may strengthen the case for comprehensive integrated care in ophthalmic practice. The recommendations are based on round table presentations and discussions held in London, UK, September 2016.

Impact of hypoglycaemia on patient-reported outcomes from a global, 24-country study of 27,585 people with type 1 and insulin-treated type 2 diabetes

AIMS

Data on the impact of hypoglycaemia on patients' daily lives and diabetes self-management, particularly in developing countries, are lacking. The aim of this study was to assess fear of, and responses to, hypoglycaemia experienced by patients globally.

MATERIALS AND METHODS

This non-interventional, multicentre, 4-week prospective study using self-assessment questionnaires and patient diaries consisted of 27,585 patients, ≥18years, with type 1 diabetes (n=8022) or type 2 diabetes (n=19,563) treated with insulin for >12months, at 2004 sites in 24 countries worldwide.

RESULTS

Increased blood glucose monitoring (69.7%) and seeking medical assistance (62.0%) were the most common responses in the 4weeks following hypoglycaemic events for patients with type 1 diabetes and type 2 diabetes, respectively. Approximately 44% of patients with type 1 diabetes or type 2 diabetes increased calorie intake in response to a hypoglycaemic episode. Following hypoglycaemia, 3.9% (type 1 diabetes) and 6.2% (type 2 diabetes) of patients took leave from work or study. Regional differences in fear of, and responses to, hypoglycaemia were evident - in particular, a lower level of hypoglycaemic fear and utilisation of healthcare resources in Northern Europe and Canada.

CONCLUSIONS

Hypoglycaemia has a major impact on patients and their behaviour. These global data for the first time reveal regional variations in response to hypoglycaemia and highlight the importance of patient education and management strategies.

Short- and long-term health consequences of sleep disruption

Sleep plays a vital role in brain function and systemic physiology across many body systems. Problems with sleep are widely prevalent and include deficits in quantity and quality of sleep; sleep problems that impact the continuity of sleep are collectively referred to as sleep disruptions. Numerous factors contribute to sleep disruption, ranging from lifestyle and environmental factors to sleep disorders and other medical conditions. Sleep disruptions have substantial adverse short- and long-term health consequences. A literature search was conducted to provide a nonsystematic review of these health consequences (this review was designed to be nonsystematic to better focus on the topics of interest due to the myriad parameters affected by sleep). Sleep disruption is associated with increased activity of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis, metabolic effects, changes in circadian rhythms, and proinflammatory responses. In otherwise healthy adults, short-term consequences of sleep disruption include increased stress responsivity, somatic pain, reduced quality of life, emotional distress and mood disorders, and cognitive, memory, and performance deficits. For adolescents, psychosocial health, school performance, and risk-taking behaviors are impacted by sleep disruption. Behavioral problems and cognitive functioning are associated with sleep disruption in children. Long-term consequences of sleep disruption in otherwise healthy individuals include hypertension, dyslipidemia, cardiovascular disease, weight-related issues, metabolic syndrome, type 2 diabetes mellitus, and colorectal cancer. All-cause mortality is also increased in men with sleep disturbances. For those with underlying medical conditions, sleep disruption may diminish the health-related quality of life of children and adolescents and may worsen the severity of common gastrointestinal disorders. As a result of the potential consequences of sleep disruption, health care professionals should be cognizant of how managing underlying medical conditions may help to optimize sleep continuity and consider prescribing interventions that minimize sleep disruption.

Comparing effects of insulin analogues and human insulin on nocturnal glycaemia in hypoglycaemia-prone people with Type 1 diabetes

AIMS

To assess the difference between analogue and human insulin with regard to nocturnal glucose profiles and risk of hypoglycaemia in people with recurrent severe hypoglycaemia.

METHODS

A total of 72 people [46 men, mean ± sd age 54 ± 12 years, mean ± sd HbA_1c 65 ± 12 mmol/mol (8.1 ± 1.1%), mean ± sd duration of diabetes 30 ± 14 years], who participated in a 2-year randomized, crossover trial of basal-bolus therapy with insulin detemir/insulin aspart or human NPH insulin/human regular insulin (the HypoAna trial) were studied for 2 nights during each treatment. Venous blood was drawn hourly during sleep. Primary endpoints were nocturnal glucose profiles and occurrence of hypoglycaemia (blood glucose ≤ 3.9 mmol/l).

RESULTS

During insulin analogue treatment, the mean nocturnal plasma glucose level was significantly higher than during treatment with human insulin (10.6 vs 8.1 mmol/l). The fasting plasma glucose level was similar between the treatments. Nocturnal hypoglycaemia was registered during 41/101 nights (41%) in the human insulin arm and 19/117 nights (16%) in the insulin analogue arm, corresponding to a hazard ratio of 0.26 (95% CI 0.14 to 0.45; P < 0.0001) with insulin analogue.

CONCLUSIONS

Treatment with insulin analogue reduces the occurrence of nocturnal hypoglycaemia assessed by nocturnal glucose profiles in people with Type 1 diabetes prone to severe hypoglycaemia. Nocturnal glucose profiles provide a more comprehensive assessment of clinical benefit of insulin regimens as compared to conventional recording of hypoglycaemia.

Diabetes management and daily functioning burden of non-severe hypoglycemia in Japanese people treated with insulin

AIMS/INTRODUCTION

The present study investigated the impact of non-severe hypoglycemic events (NSHE) on patients' diabetes management, daily functioning and well-being.

MATERIALS AND METHODS

A survey assessing the impact of NSHEs was completed by insulin-treated Japanese people with diabetes, aged ≥20 years with self-reported diabetes, who had experienced at least one NSHE in the past 3 months. Survey questions captured reasons for and the length of the event, and impacts on diabetes management, daily functioning, sleep and well-being.

RESULTS

A total of 3,145 people with type 1 diabetes mellitus and type 2 diabetes mellitus were screened, of which 411 respondents were eligible. Increased glucose monitoring was reported by 57 and 54% of respondents after daytime and night-time NSHE, respectively. The average number of additional glucose monitoring tests was 2.4 and 3.0 for daytime and night-time NSHE. Among all respondents, 19% (daytime) and 16% (night-time) changed their insulin dose after an NSHE. After a daytime NSHE, 25% of respondents reported a negative impact on their daily activities or work. After a night-time NSHE, 34 and 23% of respondents reported a negative impact on sleep and next day emotional state, respectively.

CONCLUSIONS

NSHEs have a negative impact on the diabetes management, daily functioning, sleep and well-being of Japanese patients.

Safety and efficacy of insulin degludec/insulin aspart with bolus mealtime insulin aspart compared with standard basal-bolus treatment in people with Type 1 diabetes: 1-year results from a randomized clinical trial (BOOST® T1)

AIMS

To evaluate the long-term safety and efficacy of a simplified basal-bolus regimen of once-daily insulin degludec/insulin aspart (IDegAsp) with additional IAsp vs. a standard basal-bolus insulin regimen of insulin detemir (IDet) with IAsp in adults with Type 1 diabetes.

METHODS

This was an open-label trial comprising a 26-week core phase followed by a 26-week extension phase. Participants were randomized to IDegAsp once daily at the main meal and IAsp at remaining meals (IDegAsp+IAsp), or IDet (once or twice daily) and IAsp at all meals (IDet+IAsp). Insulins were titrated to target plasma glucose of < 5 mmol/l (< 90 mg/dl) at pre-breakfast (IDegAsp and IDet) and at pre-meal (IAsp).

RESULTS

After 52 weeks, the overall confirmed hypoglycaemia rate was 31.8 episodes/patient-years of exposure (PYE) with IDegAsp+Asp and 36.7 episodes/PYE with IDet+IAsp, and the rate of nocturnal confirmed hypoglycaemia was significantly lower with IDegAsp+Asp than with IDet+IAsp (3.1 vs. 5.4 episodes/PYE, respectively; P < 0.05). Adverse event rates were comparable between groups. Mean HbA_1c decreased from baseline by 0.7% (IDegAsp+IAsp) and 0.6% (IDet+IAsp), achieving 60 or 61 mmol/mol (7.6% or 7.7%, respectively), at Week 52. The mean total daily insulin dose was lower with IDegAsp+IAsp than with IDet+IAsp (ratio: 0.87; 95% CI 0.79-0.95; P = 0.0026).

CONCLUSIONS

Once-daily treatment with IDegAsp and IAsp as bolus insulin for remaining meals was associated with significantly lower risk of nocturnal confirmed hypoglycaemia, improved glycaemic control and showed non-inferiority compared with IDet+IAsp, the standard of care in Type 1 diabetes.

History of mild hypoglycaemia does not affect the prevalence of diabetes-related distress in people with diabetes

AIMS

The occurrence of hypoglycaemia is assumed to be associated with increased diabetes-related distress. We investigated the association of mild hypoglycaemia (MH) with diabetes-related distress in a large outpatient cohort with diabetes type 1 (DM1) and type 2 (DM2).

METHODS

In a cross-sectional study, we recorded MH and simultaneously assessed diabetes-related distress with the PAID questionnaire in 783 people with diabetes [female 43.8 %, age 63.7 years, duration of diabetes 17.3 years, HbA1c 7.0 % (53 mmol/mol)] in an university outpatient department for metabolic diseases over a period of three months. Participants with and without MH were compared.

RESULTS

People with DM1 (n = 191) had 1.09 MH per week. Diabetes-related distress was not different comparing people with DM1 with (n = 125) and without (n = 66) MH (PAID score 18.4 ± 16.2 vs. 16.6 ± 15.0, p = 0.449). The frequency of MH per week in people with DM2 on oral antidiabetic therapy (n = 182) and with insulin therapy (n = 410) is low (0.03 vs. 0.1 episodes). People with DM2 on insulin therapy with (n = 72) and without (n = 338) MH have a comparable PAID score (17.9 ± 13.3 vs. 16.8 ± 14.9, p = 0.552). 14.4 % of those with DM1 as well as 12.5 % of those with DM2 on insulin feel hypoglycaemic events to be a "somewhat serious problem" or "serious problem".

CONCLUSIONS

In an outpatient setting, MH is not associated with increased diabetes-related distress or burden in people with DM1 or DM2.

Coming of age: the artificial pancreas for type 1 diabetes

The artificial pancreas (closed-loop system) addresses the unmet clinical need for improved glucose control whilst reducing the burden of diabetes self-care in type 1 diabetes. Glucose-responsive insulin delivery above and below a preset insulin amount informed by sensor glucose readings differentiates closed-loop systems from conventional, threshold-suspend and predictive-suspend insulin pump therapy. Insulin requirements in type 1 diabetes can vary between one-third-threefold on a daily basis. Closed-loop systems accommodate these variations and mitigate the risk of hypoglycaemia associated with tight glucose control. In this review we focus on the progress being made in the development and evaluation of closed-loop systems in outpatient settings. Randomised transitional studies have shown feasibility and efficacy of closed-loop systems under supervision or remote monitoring. Closed-loop application during free-living, unsupervised conditions by children, adolescents and adults compared with sensor-augmented pumps have shown improved glucose outcomes, reduced hypoglycaemia and positive user acceptance. Innovative approaches to enhance closed-loop performance are discussed and we also present the outlook and strategies used to ease clinical adoption of closed-loop systems.

Hypoglycaemia in adults with insulin-treated diabetes in the UK: self-reported frequency and effects

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.

Self-Treated Hypoglycemia in Type 2 Diabetes Mellitus: Results from the Second Wave of an International Cross-Sectional Survey

INTRODUCTION

The aim of this study was to assess the total frequency of self-treated hypoglycemia in type 2 diabetes mellitus patients using regimens including basal insulin analogs, and to describe the psychological impact and behavioral response to these events from the perspective of patients and prescribers (i.e., hospital specialists and primary care physicians).

METHODS

The global attitude of patients and physicians 2 (GAPP2) survey was an online multinational, cross-sectional survey of patients with type 2 diabetes mellitus treated with basal insulin analogs, with or without bolus insulin. Prescribers directly involved in the care of these patients were also surveyed. Here, we report the results of the second wave of the GAPP2 survey, in which the primary variable of interest was self-treated hypoglycemia.

RESULTS

A total of 855 patients and 1003 prescribers, from 7 countries, completed the survey. Overall, 28% of patients had experienced self-treated hypoglycemia during the previous 30 days, with two-thirds of events occurring during the day and one-third of events occurring nocturnally. Prescribers reported discussing events with 55% of patients over this period. Patients worried about self-treated hypoglycemia in a range of situations, and prescribers under-estimated this worry. Many patients who had experienced self-treated hypoglycemia in the last 30 days reported missing (19%), mistiming (7%), or reducing (7%) their basal insulin dose as a result.

CONCLUSION

Self-treated hypoglycemia was relatively common in patients using basal insulin analogs, with or without bolus insulin. Whilst the frequency of hypoglycemia was greater during the daytime than at night, patients worried more about nocturnal events and this level of worry was under-estimated by physicians. Additional advice and support may be needed for both patients and prescribers, to reduce the frequency and impact of self-treated hypoglycemia.

FUNDING

Novo Nordisk.

Hypoglycemia, diabetes therapies and driving categories in type 2 diabetes

OBJECTIVE

To assess the experiences of hypoglycemia in drivers with type 2 diabetes according to types of diabetes treatment; to determine experiences in different driving groups; and to ascertain whether UK-based Driving and Vehicle Licensing Agency (DVLA) guidance concerning hypoglycemia and driving is understood. Research, design, and methods: An online questionnaire was sent to UK drivers with type 2 diabetes between June and September 2014. Study limitations included selection bias inherent in online surveys, and lack of validation of the definition of hypoglycemic symptoms by an expert patient group.

RESULTS

The survey was completed by 1569 (457 social, 590 commuters, and 522 business/work) drivers. Vocational drivers were more likely to be treated with an insulin secretagogue (sulfonylureas and glinides) (52%) than diet alone (18%), a non-insulin secretagogue (26%) or insulin (16%). Symptoms of hypoglycemia (both mild and severe) were reported by 62% of the total cohort in the past year. Risk was greatest in those with poor diabetes self-management behavior and those receiving an insulin secretagogue. Among the 1112 respondents commuting or driving for a living, 16.8% had poor, 49.6% average, and 33.6% good diabetes self-management. Poor self-management was more frequent among vocational drivers and those receiving insulin secretagogues. Following a hypoglycemic episode, only 24% of insulin-secretagogue-treated drivers and 39% of insulin-treated drivers would discontinue driving for the DVLA-recommended 45 minutes. Insulin-treated drivers were best informed about diabetes and driving. Healthcare providers were the preferred source of information on driving and diabetes for 78% of drivers.

CONCLUSION

Hypoglycemia risk is highest among drivers with poor diabetes self-management, those commuting or driving for a living and those taking insulin secretagogues. There is an educational need for all drivers concerning driving and hypoglycemia.

Contributions of Comorbid Diabetes to Sleep Characteristics, Daytime Symptoms, and Physical Function Among Patients With Stable Heart Failure

BACKGROUND

Diabetes mellitus (DM) and heart failure (HF) are often comorbid. Sleep disturbances, poor physical functioning, and high levels of daytime symptoms are prevalent and contribute to poor quality of life in both populations. However, little is known about the independent and additive effects of comorbid DM on sleep, physical function, and daytime symptoms among patients with HF.

OBJECTIVE

The aim of this study was to investigate the extent to which comorbid DM confers independent and additive effects on sleep disturbance, physical functioning, and symptoms among patients with stable HF.

METHODS

This secondary analysis was conducted on a sample of 173 stable class II to IV HF patients. Self-report and polysomnography were used to measure sleep quality, objective sleep characteristics, and sleep-disordered breathing. Physical function measures included wrist actigraphy, the 6-minute walk test (6MWT), and the Medical Outcomes Study 36-item Short Form physical component summary score. Fatigue, sleepiness, and depression were also measured. Univariate analyses and hierarchical regression models were computed.

RESULTS

The sample included 173 (n = 119/68% HF and n = 54/32% HF plus DM) patients (mean [SD] age, 60.4 [16.1] years). In analyses adjusted for age, gender, body mass index, and New York Heart Association classification, the HF patients with DM had longer sleep latency and spent a greater percentage of time awake after sleep onset than the HF patients who did not have DM (all P < 0.05). There were no statistically significant differences in Respiratory Disturbance Index or self-reported sleep quality. Sleep duration was low in both groups. The patients with DM had shorter 6MWT distance, lower ratio of daytime to nighttime activity, as well as lower general health and self-reported physical function. Hierarchical regression models revealed that age and DM were the only significant correlates of the sleep variables, whereas age, gender, New York Heart Association class, and DM were all associated with 6MWT distance.

CONCLUSIONS

Comorbid DM contributes independent and additive effects on sleep disturbances and poor physical functioning in patients with stable HF.

A meta-analysis of rate ratios for nocturnal confirmed hypoglycaemia with insulin degludec vs. insulin glargine using different definitions for hypoglycaemia

AIMS

A prospective meta-analysis of phase 3 trials showed lower rates of nocturnal hypoglycaemia with insulin degludec vs. insulin glargine. We investigated the consistency of the results across different definitions of hypoglycaemia.

METHODS

This post-hoc, patient-level meta-analysis included six randomized, controlled, 26- or 52-week phase 3a trials in insulin-naïve participants with Type 2 diabetes mellitus (Type 2 diabetesinsulin naïve ), participants with Type 2 diabetes mellitus using basal-bolus therapy (Type 2 diabetesBB ) and those with Type 1 diabetes mellitus. We used three definitions of hypoglycaemia and different timescales for the nocturnal period. Rates were analysed for the entire core trial period, the 'maintenance period' only, and the extension trial set population. Analyses utilized a negative binomial regression model.

RESULTS

In Type 2 diabetesinsulin naïve participants, risk of nocturnal hypoglycaemia was significantly lower with insulin degludec vs. insulin glargine for all hypoglycaemia definitions and trial periods. Risk was also lower for the timescale 21.59-05.59, but not 00.01-07.59. For Type 2 diabetesBB , nocturnal hypoglycaemia rates were lower with insulin degludec vs. insulin glargine across all definitions, timescales and trial periods, with one exception. For individuals with Type 1 diabetes mellitus, nocturnal hypoglycaemia risk was significantly lower with insulin degludec during the maintenance period for the original definition (plasma glucose < 3.1 mmol/l, timescale 00.01-05.59) and in the extension trial set population for all hypoglycaemia definitions except for the nocturnal timescale 00.01-07.59.

CONCLUSIONS

Compared with insulin glargine, insulin degludec is associated with lower rates of nocturnal hypoglycaemia in people with Type 2 diabetes mellitus, and similar or lower rates in Type 1 diabetes mellitus, across different definitions.

Safety and efficacy of insulin glargine 300 u/mL compared with other basal insulin therapies in patients with type 2 diabetes mellitus: a network meta-analysis

OBJECTIVE

To compare the efficacy and safety of a concentrated formulation of insulin glargine (Gla-300) with other basal insulin therapies in patients with type 2 diabetes mellitus (T2DM).

DESIGN

This was a network meta-analysis (NMA) of randomised clinical trials of basal insulin therapy in T2DM identified via a systematic literature review of Cochrane library databases, MEDLINE and MEDLINE In-Process, EMBASE and PsycINFO.

OUTCOME MEASURES

Changes in HbA1c (%) and body weight, and rates of nocturnal and documented symptomatic hypoglycaemia were assessed.

RESULTS

41 studies were included; 25 studies comprised the main analysis population: patients on basal insulin-supported oral therapy (BOT). Change in glycated haemoglobin (HbA1c) was comparable between Gla-300 and detemir (difference: -0.08; 95% credible interval (CrI): -0.40 to 0.24), neutral protamine Hagedorn (NPH; 0.01; -0.28 to 0.32), degludec (-0.12; -0.42 to 0.20) and premixed insulin (0.26; -0.04 to 0.58). Change in body weight was comparable between Gla-300 and detemir (0.69; -0.31 to 1.71), NPH (-0.76; -1.75 to 0.21) and degludec (-0.63; -1.63 to 0.35), but significantly lower compared with premixed insulin (-1.83; -2.85 to -0.75). Gla-300 was associated with a significantly lower nocturnal hypoglycaemia rate versus NPH (risk ratio: 0.18; 95% CrI: 0.05 to 0.55) and premixed insulin (0.36; 0.14 to 0.94); no significant differences were noted in Gla-300 versus detemir (0.52; 0.19 to 1.36) and degludec (0.66; 0.28 to 1.50). Differences in documented symptomatic hypoglycaemia rates of Gla-300 versus detemir (0.63; 0.19 to 2.00), NPH (0.66; 0.27 to 1.49) and degludec (0.55; 0.23 to 1.34) were not significant. Extensive sensitivity analyses supported the robustness of these findings.

CONCLUSIONS

NMA comparisons are useful in the absence of direct randomised controlled data. This NMA suggests that Gla-300 is also associated with a significantly lower risk of nocturnal hypoglycaemia compared with NPH and premixed insulin, with glycaemic control comparable to available basal insulin comparators.

Concepts and clinical use of ultra-long basal insulin

Diabetes mellitus (DM) is a public health issue, affecting around 382 million people worldwide. In order to achieve glycemic goals, insulin therapy is the frontline therapy for type 1 DM patients; for patients with type 2 DM, use of insulin therapy is an option as initial or add-on therapy for those not achieving glycemic control. Despite insulin therapy developments seen in the last decades, several barriers remain for insulin initiation and optimal maintenance in clinical practice. Fear of hypoglycemia, weight gain, pain associated with blood testing and injection-related pain are the most cited reasons for not starting insulin therapy. However, new generation of basal insulin formulations, with longer length of action, have shown the capability of providing adequate glycemic control with lower risk of hypoglycemia.

Insulin glargine 300 U/mL in the management of diabetes: clinical utility and patient perspectives

There is ongoing interest in optimizing basal insulin treatment by developing insulins with a flat pharmacological profile, a long duration of action (typically beyond 24 hours) and minimum day-to-day variation. Glargine-300 is a modified form of the long-acting insulin analog glargine in that it has been concentrated at 300 units/mL rather than the conventional 100 units/mL. Glargine-300 has a longer duration of action and a flatter pharmacological profile than original glargine-100. This property allows for more flexibility around the timing of administration, when injected once per day. Open-label studies in patients with diabetes have shown that treatment with glargine-300 achieves comparable glycemic control compared to treatment with glargine-100, albeit with consistently higher insulin requirements. These studies also showed that treatment with glargine-300 was associated with lower risks of nocturnal hypoglycemia in patients with type 2 diabetes, particularly those already on insulin, whereas data are mixed in insulin-naïve patients with type 2 diabetes or in patients with type 1 diabetes. Treatment with glargine-300 did not appear to affect the risk of overall hypoglycemia, whereas studies lacked sufficient power to investigate the effect on the risk of severe hypoglycemia. Future studies need to establish the role of glargine-300 in the treatment of diabetes alongside the other new long-acting insulin analog, insulin degludec, which was recently introduced to the market.

Cost-Effectiveness Analysis of Insulin Detemir Compared to Neutral Protamine Hagedorn (NPH) in Patients with Type 1 and Type 2 Diabetes Mellitus in Spain

INTRODUCTION

An Excel® (Microsoft Corporation) model was adapted to estimate the short-term (1-year) cost effectiveness of insulin detemir (IDet) versus neutral protamine Hagedorn (NPH) insulin in patients initiating insulin treatment with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) in Spain.

METHODS

Clinical benefits included the non-severe hypoglycemia rate for T1DM and T2DM, and weight change for T2DM. Three scenarios were included with different hypoglycemia rates estimated on the basis of clinical trials and observational studies. Costs, estimated from perspective of the Spanish Public Healthcare System (Euros 2014), included insulin treatment and non-severe hypoglycemia management costs. Non-severe hypoglycemia, defined as a self-managed event, implied the use of extra glucose testing strips and a general practitioner visit during the week following the event for 25% of patients. An average disutility value was associated to non-severe hypoglycemia events and, for T2DM, to one body mass index unit gain to calculate quality-adjusted life years (QALYs).

RESULTS

For the three scenarios a range of 0.025-0.076 QALYs for T1DM and 0.014-0.051 QALYs for T2DM were gained for IDet versus NPH due to non-severe hypoglycemia and weight gain avoidance, in return of an incremental cost of €145-192 for T1DM and €128-206 for T2DM. This resulted in the IDet versus NPH incremental cost-effectiveness ratio (ICER) ranging between €1910/QALY and €7682/QALY for T1DM and €2522/QALY and €15,009/QALY for T2DM.

CONCLUSION

IDet was a cost-effective alternative to NPH insulin in the first year of treatment of patients with T1DM and patients with T2DM in Spain, with ICERs under the threshold value commonly accepted in Spain (€30,000/QALY).

FUNDING

Novo Nordisk.

Recognizing and minimizing hypoglycemia: The need for individualized care

Hypoglycemia is a condition known to disrupt many everyday activities and is associated with increased risks of hospitalization, falls, motor vehicle accidents and mortality. Many patients with diabetes have an increased risk of hypoglycemia due to interventions targeting glycemic control. In these patients, hypoglycemia and fear of hypoglycemia may further reduce adherence to glucose-lowering regimens, contributing to the further aggravation of diabetes-related complications. Avoiding hypoglycemia should be one of the principal goals of any treatment strategies employing agents that can induce hypoglycemia in order to prevent the occurrence of associated symptoms and consequences. The education of patients and their families is an important feature of individualized management strategies in order to prevent, mitigate and treat hypoglycemic episodes. Patients with diabetes need to be made aware of how to recognize the signs of hypoglycemia and of the simple, highly effective steps that they can take to self-manage hypoglycemic episodes. Clinicians should be familiar with the risk factors for hypoglycemia, especially the profiles of the different classes of glucose-lowering medications such as the sulfonylureas and insulin. This article aims to review the risk factors for hypoglycemia and its implications for patients and healthcare systems, and provide practical advice for minimizing the risk of hypoglycemia and its consequences.

High incidence of hypoglycemia in stable insulin-treated type 2 diabetes mellitus: continuous glucose monitoring vs. self-monitored blood glucose. Observational prospective study

OBJECTIVES

Hypoglycemia is a limiting factor in the achievement of strict glycemic control. The primary objective of this 9-week study was to determine the frequency of hypoglycemia in patients with stable insulin-treated type 2 diabetes mellitus by comparing self-monitored blood glucose (SMBG) measurement with continuous glucose monitoring (CGM).

METHODS

This was an observational prospective study. Included in the study were 63 stable, insulin-treated patients with type 2 diabetes. They were instructed to record 2 daily capillary blood glucose readings, pre- and/or postprandial, in a sequential way during 8 consecutive weeks. A CGM system was worn during an additional week. We evaluated the frequency of hypoglycemia using the 8-week SMBG profile and the 1 CGM week.

RESULTS

SMBG revealed that 50% of the patients had experienced hypoglycemia. CGM found hypoglycemia in 59% of patients. Significantly higher percentages of hyperglycemic and hypoglycemic episodes were detected by CGM than by capillary blood glucose measurements (61.1% vs. 50.8%; p=0.047) and (3.8% vs. 1.7%; p=0.016); 33% of patients experienced nocturnal hypoglycemia, and 19% of patients who had no data concerning hypoglycemia recorded in the capillary blood glucose diary had experienced hypoglycemia as measured by CGM, and the hypoglycemia occurred mainly during the nocturnal period.

CONCLUSIONS

In stable well-controlled, insulin-treated patients with type 2 diabetes, CGM showed higher numbers of hypoglycemic events than did SMBG, especially at night. CGM is a useful tool that provides clinically valuable information about glucose control in these patients.

Assessing the impact of non-severe hypoglycemic events and treatment in adults: development of the Treatment-Related Impact Measure-Non-severe Hypoglycemic Events (TRIM-HYPO)

PURPOSE

Non-severe hypoglycemic events (NSHEs) are commonly experienced by diabetes patients, particularly among insulin users, and can have serious impacts on daily functioning, emotional well-being, sleep, work productivity, and treatment adherence. Currently, no PRO measures are available to assess the impacts of non-severe hypoglycemia. To address this gap, the Treatment-Related Impact Measure-Non-severe Hypoglycemic Events (TRIM-HYPO) was developed. This paper describes the TRIM-HYPO development and validation.

METHODS

The creation of the TRIM-HYPO followed FDA's guideline for PRO development. Concept elicitation data were gathered from literature review, clinical expert interviews, and focus groups of patients with Type 1 or 2 diabetes in four countries. Based on the qualitative analysis, draft items were generated and cognitively debriefed. Psychometric validation included factor analysis, item response theory analysis, and assessment of psychometric characteristics for the TRIM-HYPO.

RESULTS

Eight clinical experts and 167 patients participated in concept elicitation. The validation study included 407 patients. Thirteen of the 46 items from the preliminary measure were dropped due to ceiling/floor effects and high correlations between conceptually similar items. Factor analysis confirmed five domains in the TRIM-HYPO: daily function, emotional well-being, diabetes management, sleep disruption, and work productivity. All scores were internally consistent (0.86-0.95) and reproducible with a test-retest range of 0.75-0.98. All but one a priori hypothesized associations for validity were confirmed.

CONCLUSIONS

Study findings demonstrate that the final, 33-item TRIM-HYPO is reliable and valid and may be useful for assessing impacts related to NSHEs in research and clinical practice.

Demographic Disparities Among Medicare Beneficiaries with Type 2 Diabetes Mellitus in 2011: Diabetes Prevalence, Comorbidities, and Hypoglycemia Events

This study describes demographic characteristics, comorbidities, and hypoglycemia events in patients with type 2 diabetes mellitus (T2DM) identified using 2011 Medicare 5% Standard Analytical Files. Among 1,913,477 Medicare beneficiaries, 367,602 (19.2%) had T2DM. T2DM prevalence increased with age and was higher in blacks (26.4%) and Hispanics (25.5%) than in whites (18.0%); and in Medicare/Medicaid dual-eligible versus non-dual-eligible patients (28.0% vs 17.2%, respectively). Compared with whites, diagnosed hypertension and diabetic retinopathy were more common in blacks and Hispanics, and lipid metabolism disorders and atrial fibrillation were less common. Hypoglycemia requiring health care services was more common in blacks (4.7%) and Hispanics (3.6%) compared with whites (2.9%). T2DM, related comorbidities, and hypoglycemia are burdensome to the Medicare population. Differences in these endpoints were observed based on race/ethnicity, age, and dual-eligible status, highlighting the importance of demographic factors when determining T2DM management strategies.

Insulin degludec early clinical experience: does the promise from the clinical trials translate into clinical practice--a case-based evaluation

BACKGROUND

Clinical experience of patients is an additional source of information that can inform prescribing decisions for new therapies in practice. In diabetes, for example, patients with recurrent hypoglycemia may be excluded from trials conducted for regulatory purposes. Using insulin degludec (IDeg), a new basal insulin with an ultra-long duration of action as an example, an interim analysis is presented describing whether the decision to prescribe IDeg to patients experiencing treatment-limiting problems on their existing insulin regimes represented good clinical and economic value.

METHODS

Records from the first 51 consecutive patients with diabetes (35 type 1 [T1D] and 16 type 2 [T2D]) switching to insulin degludec from either insulin glargine (IGlar) or insulin detemir (IDet), mostly due to problems with hypoglycemia (39/51, 76.5%), were reviewed at up to 37 weeks. Patients indicated frequency of hypoglycemia and completed a disease-specific questionnaire reporting six measures of confidence and treatment satisfaction. For the largest group of exposed patents, the T1D module of the IMS Core Diabetes Model (CDM) was used to evaluate the cost-effectiveness of the treatment decision.

FINDINGS

HbA1c decreased by 0.5 ± 0.3% points and 0.7 ± 0.3% points for T1D and T2D, respectively. Hypoglycemic events decreased by >90%. Combined mean scores were ≥ 3.7 (1 = much worse, 3 = no change, 5 = much improved) for all six satisfaction and confidence items. In T1D, the treatment decision was highly cost-effective in the CDM lifetime analysis. Even when excluding benefits beyond hypoglycemia reduction, predicted cost per quality-adjusted life-year for IDeg vs IGlar/IDet was £10,754.

INTERPRETATION

These data illustrate the complementary nature of clinical trial and practice data when evaluating the value of therapeutic innovations in diabetes care. There were reductions in patient-reported hypoglycemia, reduced HbA1c, and improved treatment satisfaction in relation to the decision to prescribe IDeg. Initial health economic evaluation suggested that the decision to prescribe IDeg in this phenotypic group of T1D patients represented good value for money.

Cost-effectiveness of insulin degludec compared with insulin glargine in a basal-bolus regimen in patients with type 1 diabetes mellitus in the UK

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of insulin degludec (IDeg) vs insulin glargine (IGlar) as part of a basal-bolus treatment regimen in adults with T1DM, using a short-term economic model.

METHODS

Data from two phase III clinical studies were used to populate a simple and transparent short-term model. The costs and effects of treatment with IDeg vs IGlar were calculated over a 12-month period. The analysis was conducted from the perspective of the UK National Health Service. Sensitivity analyses were conducted to assess the degree of uncertainty surrounding the results. The main outcome measure, the incremental cost-effectiveness ratio (ICER), was the cost per quality-adjusted life-year (QALY).

RESULTS

IDeg is a cost-effective treatment option vs IGlar in patients with T1DM on a basal-bolus regimen. The base case ICER was estimated at £16,895/QALY, which is below commonly accepted thresholds for cost-effectiveness in the UK. Sensitivity analyses demonstrated that the ICER was stable to variations in the majority of input parameters. The parameters that exerted the most influence on the ICER were hypoglycemia event rates, daily insulin dose, and disutility associated with non-severe nocturnal hypoglycemic events. However, even under extreme assumptions in the majority of analyses the ICERs remained below the commonly accepted threshold of £20,000-£30,000 per QALY gained.

CONCLUSIONS

This short-term modeling approach accommodates the treat-to-target trial design required by regulatory bodies, and focuses on the impact of important aspects of insulin therapy such as hypoglycemia and dosing. For patients with T1DM who are treated with a basal-bolus insulin regimen, IDeg is a cost-effective treatment option compared with IGlar. IDeg may be particularly cost-effective for sub-groups of patients, such as those suffering from recurrent nocturnal hypoglycemia and those with impaired awareness of hypoglycemia.

Association between post-dinner dietary intakes and nocturnal hypoglycemic risk in adult patients with type 1 diabetes

AIMS

To describe (i) current bedtime nutritional practices and (ii) the association between post-dinner dietary intake and the occurrence of non-severe nocturnal hypoglycemia (NH) in real-life conditions among adult patients with type 1 diabetes using insulin analogs.

METHODS

One hundred adults (median [interquartile range]: age 46.4 [36.0-55.8] years, HbA1c 7.9 [7.3-8.6] % (63 [56-70] mmol/mol)) using multiple daily injections (n=67) or insulin pump (n=33) wore a blinded continuous glucose monitoring system and completed a food diary for 72-h.

RESULTS

NH occurred on 28% of 282 nights analyzed. (i) Patients reported post-dinner dietary intakes on 63% of the evenings. They injected rapid-acting insulin boluses on 64 occasions (23% of 282 evenings). These insulin boluses were mostly injected with (n=37) dietary intakes. (ii) Post-dinner dietary intake was not associated with NH occurrence in univariate analyses. In multivariate analyses, the injection of rapid-acting insulin modulated the association between post-dinner dietary intake and NH: with insulin, post-dinner carbohydrate intake was positively associated with NH (odds ratio (OR): 1.16 [95% confidence interval, CI: 1.04-1.29] per 5g increase, p=0.008); without insulin, post-dinner protein intake was inversely associated with NH occurrence (OR [95% CI]: 0.88 [0.78-1.00] per 2g increase, p=0.048).

CONCLUSIONS

NH remains frequent in adults with type 1 diabetes. There is a complex relationship between post-dinner dietary intake and NH occurrence, including the significant role of nutrient content and rapid-acting insulin injection that requires further investigation.

The psychosocial and financial impact of non-severe hypoglycemic events on people with diabetes: two international surveys

OBJECTIVES

To understand the impact of nocturnal and daytime non-severe hypoglycemic events on healthcare systems, work productivity and quality of life in people with type 1 or type 2 diabetes.

METHODS

People with diabetes who experienced a non-severe hypoglycemic event in the 4 weeks prior to the survey were eligible to participate in a nocturnal and/or daytime hypoglycemia survey. Surveys were conducted in Argentina, Australia, Brazil, Israel, Mexico and South Africa.

RESULTS

In total, 300 respondents were included in nocturnal/daytime hypoglycemia surveys (50/participating country/survey). All respondents with type 1 diabetes and 68%/62% (nocturnal/daytime) with type 2 diabetes were on insulin treatment. After an event, 25%/30% (nocturnal/daytime) of respondents decreased their insulin dose and 39%/36% (nocturnal/daytime) contacted a healthcare professional. In the week after an event, respondents performed an average of 5.6/6.4 (nocturnal/daytime) additional blood glucose tests. Almost half of the respondents (44%) reported that the event had a high impact on the quality of their sleep. Among nocturnal survey respondents working for pay, 29% went to work late, 16% left work early and 12% reported missing one or more full work days due to the surveyed event. In addition, 50%/39% (nocturnal/daytime) indicated that the event had a high impact on their fear of future hypoglycemia.

CONCLUSIONS

The findings suggest that nocturnal and daytime non-severe hypoglycemic events have a large financial and psychosocial impact. Diabetes management that minimizes hypoglycemia while maintaining good glycemic control may positively impact upon the psychological wellbeing of people with diabetes, as well as reducing healthcare costs and increasing work productivity.

Self-reported frequency and impact of hypoglycemic events in Spain

INTRODUCTION

Hypoglycemia is a common side effect of insulin therapy and has negative implications for quality of life and healthcare resources. The authors investigated the self-reported frequency of non-severe and severe hypoglycemic events (NSHEs and SHEs), hypoglycemia awareness, patient-physician communication, health-related effects and economic impact on people with insulin-treated diabetes (Type-1 and Type-2) in Spain.

METHODS

People with Type-1 (T1DM) or insulin-treated Type-2 (T2DM) diabetes older than 15 years of age completed up to 4 questionnaires at weekly intervals. NSHE was an event which respondents could manage without assistance. SHE needed help from a third party to manage.

RESULTS

In total, 630 respondents completed questionnaires covering 2,235 weeks. Mean self-reported NSHEs per respondent-week were 1.7 (T1DM) and 0.4-0.8 (T2DM). Impaired hypoglycemia awareness or unawareness was reported by 55% of T1DM and 39% of T2DM respondents. Overall, 31% of T1DM and 20% of T2DM respondents rarely/never informed their physician about NSHEs. Respondents reported feeling tired/fatigued after 67% of NSHE and less alert after 45% of NSHE. Over the week following an NSHE, blood glucose measurement test-strip use increased by 5.3 (mean). In employed respondents (43%), 18% of NSHEs were reported to lead to lost work time (mean 1.5 h per event). After an SHE, 49% of respondents required emergency visits and/or hospital admission.

CONCLUSION

NSHE are a common occurrence with T1DM and insulin-treated T2DM in Spain and are associated with a cost burden and negative impact on well-being. Patient-physician communication is higher in Spain than Europe overall; however, many patients expressed reluctance to discuss their hypoglycemia.

Fear of hypoglycaemia in patients with type 1 diabetes

Independently of causes and risk factors of hypoglycaemia, its manifestations are always unfavourable and evoke fear and other negative emotions that lead to negative consequences connected with quality of diabetes control. The fear of hypoglycaemia creates an internal conflict by diminishing patients? motivation to adhere to intensive treatment regimes. In addition to the severity of hypoglycaemia and its negative consequences, quality of life is one of the main criteria for evaluating the physical, psychological and social components of patient's life as a whole. Fear of hypoglycaemia is one of the most important factors; it either directly or indirectly affects quality of life and influences all aspects of the patient's life. Fear of hypoglycaemia is also a source of anxiety for the patient's relatives, causing damage to their familial and social relations. The negative consequences of hypoglycaemia can affect the relationship between spouses, as well as between parents and children with type 1 diabetes. The qualitative and quantitative data demonstrate that non-severe nocturnal hypoglycaemia causes more anxiety and fear in patients than daytime hypoglycaemia does. To quantify the fear of hypoglycaemia in adults with type 1 diabetes, the hypoglycaemia fear scale (HFS) was developed and still is the most commonly used instrument. To assess the fear of hypoglycaemia in children and their parents, the HFS scale was adapted to be used in the paediatric population: HFS for parents (PHFS) and HFS for children (CHFS). From a clinical point of view, these scales for measuring the level of fear of hypoglycaemia may be useful for monitoring adult patients and families who may need additional support, training or assistance in dealing with issues related to hypoglycaemia. The methods for regulating the fear of hypoglycaemia range from behavioural to pharmaceutical and surgical ones, and include a broad range of activities. Nevertheless, the problem remains quite relevant today and an integral approach for solving this problem, both by the physician and by the patient, should be used. Proper assessment of the patient's level of anxiety, impact of the fear of hypoglycaemia on his or her social life, awareness of the possible psychological consequences of this problem may positively affect both the behaviour and mood of the patient, and the opportunity to achieve better glycaemic control.