Impact of improved glycaemic control on rates of hypoglycaemia in insulin dependent diabetes mellitus

Insulin settings and their association with time in range in patients with type 1 diabetes users of predictive low glucose suspend (PLGS) augmented insulin pumps in Santiago, Chile

AIMS

Sensor augmented insulin pumps have become a powerful tool for managing type 1 diabetes (T1D). This study aimed to analyze the insulin pump configuration in users of predictive insulin suspension technology (PLGS).

METHODS

T1D patients on insulin pumps with PLGS (Medtronic 640G®) were enrolled. Data was obtained from medical records and pump data was downloaded for 30 days. Basal insulin, bolus calculator parameters, and PLGS operation parameters were analyzed and compared with Time in Range, Time Below Range, and Time Above Range.

RESULTS

112 patients were included, with average TIR of 73,96 % and HbA1c 7,0 % and 25 months of follow-up. Basal insulin remained similar to initial doses, with an increase of 27 % for the Dawn phenomenon. The Carbohydrate ratio was slightly more aggressive. Insulin sensitivity was 17 % less stringent than initially programmed. No differences were observed in Time in Rage according to the number of basal, ratio, and sensitivity segments. Time of insulin suspension correlated directly with Time Bellow Range.

CONCLUSIONS

Patients with good metabolic control have basal insulin programming similar to their initiation doses with less aggressive sensitivity factors. Excessive suspension time determined by PLGS could be an expression of excess insulin and increased hypoglycemia risk.

A practical approach to continuous glucose monitoring (rtCGM) and FreeStyle Libre systems (isCGM) in children and young people with Type 1 diabetes

Real-time continuous glucose monitoring (rtCGM) and FreeStyle Libre glucose monitoring systems (isCGM) are new evolving technologies used in the management of Type 1 diabetes. They offer potential to improve diabetes control and reduce hypoglycaemia. rtCGM can be linked to insulin pump providing hybrid closed loop therapy. Families of children and young people are keen to have the benefit from these technologies. These are relatively expensive so it is important that health care professionals, families of children and young people (CYP) with diabetes are adequately trained in the use of these devices. Health care professionals need to be able to make patient selection based on individual needs and preferences to achieve maximum benefit. Association of Children's Diabetes Clinicians (ACDC) developed a comprehensive guideline in 2017 to help identify which patients may be most likely to benefit and how these technologies may be practically implemented. Since then new technologies have been introduced and the use of GCM has expanded in routine clinical practice. This article, aims to provide a practical approach and help identify which patients may be most likely to benefit and how the technology may be implemented in order to maximise the clinical benefits.

Lower versus standard sucrose dose for treating hypoglycemia in patients with type 1 diabetes mellitus in therapy with predictive low glucose suspend (PLGS) augmented insulin pumps: A randomized crossover trial in Santiago, Chile

BACKGROUND AND AIMS

Recommended hypoglycemia treatment in adults with T1D consists of 15 g of rapid absorption carbohydrates. We aimed to evaluate the response to fewer carbohydrates for treating hypoglycemia in patients with T1D on insulin pumps with predictive suspension technology (PLGS).

METHODS

T1D patients on insulin pumps with PLGS were randomized to receive 10 or 15 g of sucrose per hypoglycemia for two weeks (S10 and S15 groups, respectively) when capillary blood glucose (BG) was <70 mg/dL, with crossover after two weeks. Evolution of capillary BG, active insulin, and suspension time were assessed.

RESULTS

59 hypoglycemic episodes were analyzed, 33 in S10 and 26 in S15. Baseline BG in S10 was 54.3 ± 7.7 mg/dL versus 56.9 ± 8.8 in S15 (p = 0,239). Active insulin, present in 85% of the episodes, and PLGS suspension time were similar between groups. BG at 15 min was 77 mg/dL in S10 and 95 mg/dL in S15 (p = 0.0007). In S10, 21% of the episodes required to repeat the treatment after 15 min compared with none on S15, with a RR of 0,79 (95% CI 0.66, 0.940, p = 0,014) for successfully treating the episode. Sensor glucose was significantly different from BG at the moment of the hypoglycemia and control 15 min after treatment. No severe hypoglycemia and no rebound hyperglycemia occurred in neither group.

CONCLUSIONS

A hypoglycemia treatment protocol with a lower dose of sucrose might be insufficient despite PLGS technology. Our data suggest that standard doses of sucrose should still be recommended.

Incidence and prevalence of hypoglycaemia in type 1 and type 2 diabetes individuals: A systematic review and meta-analysis

BACKGROUND

Previous meta-analysis investigating the incidence and prevalence of hypoglycaemia in both types of diabetes is limited. The purpose of this review is to conduct a systematic review and meta-analysis of the existing literature which investigates the incidence and prevalence of hypoglycaemia in individuals with diabetes.

METHODS

PubMed, Embase and Cochrane library databases were searched up to October 2018. Observational studies including individuals with diabetes of all ages and reporting incidence and/or prevalence of hypoglycaemia were included. Two reviewers independently screened articles, extracted data and assessed the quality of included studies. Meta-analysis was performed using a random effects model with 95% confidence interval (CI) to estimate the pooled incidence and prevalence of hypoglycaemia in individuals with diabetes.

RESULTS

Our search strategy generated 35,007 articles, of which 72 studies matched the inclusion criteria and were included in the meta-analysis. The prevalence of hypoglycaemia ranged from 0.074% to 73.0%, comprising a total of 2,462,810 individuals with diabetes. The incidence rate of hypoglycaemia ranged from 0.072 to 42,890 episodes per 1,000 person-years: stratified by type of diabetes, it ranged from 14.5 to 42,890 episodes per 1,000 person-years and from 0.072 to 16,360 episodes per 1,000-person years in type 1 and type 2 diabetes, respectively.

CONCLUSION

Hypoglycaemia is very common among individuals with diabetes. Further studies are needed to investigate hypoglycaemia-associated risk factors.

Weight-based carbohydrate treatment of hypoglycaemia in people with Type 1 diabetes using insulin pump therapy: a randomized crossover clinical trial

AIM

To test whether weight-based treatment is more effective than usual care in people with Type 1 diabetes receiving continuous subcutaneous insulin infusion therapy with regard to both hypoglycaemia and avoiding excessive rebound hyperglycaemia.

METHODS

Children and adults on continuous subcutaneous insulin infusion were enrolled into a study with a crossover design. Each episode of hypoglycaemia (defined as capillary glucose <4.0 mmol/l) was randomly assigned one of two treatment protocols using glucose tablets: either 0.3 g/kg body weight or usual treatment with 15 g (adults) or 10 g (children) for capillary glucose levels 3-3.9 mmol/l or twice these doses for capillary glucose levels <3 mmol/l. All participants received each treatment in random order for up to 10 hypoglycaemic episodes. Glucose levels were re-tested 10 min after treatment, with a repeat dose if still <4 mmol/l.

RESULTS

Of the 37 participants enrolled, 35 (aged 6-68 years) completed the study. Twenty-four participants completed all treatment episodes, while 10 participants had <10 hypoglycaemic episodes and two withdrew without data. The mean glucose difference between weight-based and usual treatment after 10 min was 0.33 mmol/l (95% CI 0.005 to 0.66; P=0.047) in adults and 0.45 (95% CI 0.18 to 0.72; P=0.001) in children. The odds ratios for resolution of hypoglycaemia at 10 min with a single treatment using weight-based compared with usual treatment were 3.12 (95% CI 1.38 to 7.02; P=0.0070) in adults and 2.61 (95% CI 1.19 to 5.74; P=0.017) in children.

CONCLUSIONS

Weight-based treatment using 0.3 g/kg glucose was more effective for symptomatic hypoglycaemia in children and adults with Type 1 diabetes who were using continuous subcutaneous insulin infusion than treatment based on current international recommendations.

Challenges of Diabetes Management in Toddlers

Toddlers with type 1 diabetes have distinctive combination of challenges to their families and healthcare providers. A major factor is the difficulty in achieving metabolic control without risking hypoglycemia. The rising incidence of type 1 diabetes in toddlers increases the magnitude of the problem and creates a greater need for providing specialized service to cater for this age group's unique need. Type 1 has a specific disease nature in younger children and its clinical presentation mimics common childhood diseases. Symptoms and signs in the newly presented toddler with diabetes might be unspecific causing diagnosis to be missed or delayed. With the low cognitive ability and immature communication, toddlers might not be able to express their ill-feeling resulting from hypoglycemia or hyperglycemia. Hypoglycemia fear is common, which aggravates stress and reduces adherence to strict metabolic control. Nocturnal hypoglycemia is more common in toddlers and can be undiagnosed unless continuous glucose monitoring is used. Insulin administration and adjustment can be challenging due to pain, fear, refusal, and frequent intercurrent illness. Glucose monitoring is crucial. However, it can be distressing to the child and difficult to adhere to due to commitment or financial reasons. Insulin pump therapy is proven to be an effective and a safe method of treatment for toddlers, but it requires intensive training, resources, and long-term support. Provision of multidisciplinary team with special expertise in managing toddlers with diabetes is essential. Providing more physiological insulin regimes and customized technology is required to improve treatment compliance and diabetes control.

Continuous Subcutaneous Insulin Infusion in Children: A Pilot Study Validating a Protocol to Avoid Hypoglycemia at Initiation

BACKGROUND

The occurrence of hypoglycemia and hyperglycemia during the first days after transition to continuous subcutaneous insulin infusion (CSII) in patients with type 1 diabetes has not been systematically studied in children. The aim of this prospective study was to demonstrate that the protocol applied in our diabetes clinic is safe at CSII initiation in children.

METHODS

We assessed 22 pediatric patients with type 1 diabetes, using continuous glucose monitoring (CGM) before and after CSII initiation (±3 days).

RESULTS

After CSII initiation, there was no difference in the rates of hypoglycemic events expressed as relative rates (RRs) per person-reading (RR = 0.85, p = 0.52, 95% CI 0.52-1.39), as well as in the number of prolonged hypoglycemic events (>1 h) per day (RR = 1.12, p = 0.56, 95% CI 0.75-1.68). We observed only a trend toward prolonged episodes of hyperglycemia after pump initiation (RR = 1.52, p = 0.06, 95% CI 0.97-2.35).

CONCLUSION

Our study is the first to assess, through CGM and in a prospective way, the impact of a CSII initiation protocol on glycemic values. Our protocol provides a safe model to avoid hypoglycemia at CSII initiation in children.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov, identifier NCT01840358.

Prospective assessment of hypoglycemia symptoms in children and adults with type 1 diabetes

PURPOSE

To compare the characteristics of symptoms of hypoglycemia in children and in adults with type 1 diabetes.

METHODS

Adults with diabetes and parents of children with diabetes who were participants were asked to call a phone system to report episodes of hypoglycemia (presence of symptoms and a blood glucose <4.0 mmol/L). For each episode, blood glucose reading and a scoring of 28 symptoms on a 7-point scale (1 = not present, 7 = very intense) were collected.

RESULTS

Sixty six children (49.2% males, mean age = 12.1±2.4 years, mean age at diagnosis = 7.5±2.9 years) and 53 adults (41.2% males, mean age 38.7±14.5 years, mean age at diagnosis = 17.5±12.9 years) with type 1 diabetes participated. The most common symptoms in adults were hunger, sweating, trembling and weakness. The most common symptoms in children were weakness, trembling and hunger. The 2 most discriminating variables between children and adults were sleepiness and tiredness, which were more common in children (p<0.01). In a comparative factor analysis, 3 factors emerged: factor 1, autonomic and neuroglycopenic; factor 2, behavioural; and factor 3, general malaise. Factors 2 and 3 were significantly more common or intense in children than in adults; MANOVA: F(1, 113) = 6.72, p<0.05 and F(1, 113) = 4.64, p<0.05, respectively.

CONCLUSIONS

Symptoms relating to behaviour and general malaise are more common in children than in adults with type 1 diabetes. The results of this study may assist providers in educating caregivers of children and patients with diabetes how to better recognize episodes of hypoglycemia.

Weight-based hypoglycaemia treatment protocol for adults with Type 1 diabetes: a randomized crossover clinical trial

AIM

To determine whether a weight-based hypoglycaemia treatment using 0.3 g/kg (or 0.2 g/kg) glucose effectively treats adults with Type 1 diabetes mellitus compared with an internationally recommended 15-g treatment.

METHODS

Patients with frequent hypoglycaemia were recruited from hospital-based diabetes clinics. The treatment for each hypoglycaemic episode, defined as capillary glucose <4.0 mmol/l, was randomly assigned to one of three protocols: 0.2 g/kg, 0.3 g/kg, or 15 g, using Dextro(TM) glucose tablets (Dextro Energy, Krefeld, Germany). Each participant received each treatment in random order for up to 15 hypoglycaemic episodes. Capillary glucose was re-tested 10 min after treatment, with a repeat dose if still < 4 mmol/l.

RESULTS

The study recruited 34 participants aged 22-71 years, whose mean (sd) BMI was 25.2 (3.1) kg/m(2) and HbA1c 63 (10.4) mmol/mol [7.9 (0.9)%]. Two people withdrew because they did not like the taste of the Dextro tablets and one was excluded because they used their own glucose preparation. Unadjusted for clustering within participants, the mean (sd) capillary glucose after 10 min was 4.67 (1.25) mmol/l for 0.3 g/kg (141 episodes), 4.29 (0.94) mmol/l for 0.2 g/kg (132 episodes), and 4.37(0.99) mmol/l for 15 g (136 episodes). Capillary glucose, adjusted for clusters and baseline, was higher after 10 min for 0.3 g/kg glucose compared with 15 g glucose; a difference of 0.26 (95% CI 0.04-0.48) mmol/l (P = 0.02), but not for 0.2 g/kg; -0.07 (95% CI -0.29-0.16) mmol/l (P = 0.56). Capillary glucose for only three hypoglycaemic episodes rose above 8 mmol/l.

CONCLUSIONS

A weight-based protocol of 0.3 g/kg glucose appears more effective for treating symptomatic hypoglycaemia in adults with Type 1 diabetes than either the most common current recommendation of 15 g glucose or a 0.2 g/kg glucose dose.

Prevalence and predictors of severe hypoglycemia in Danish children and adolescents with diabetes

OBJECTIVE

To investigate the prevalence of severe hypoglycemia in Danish children and adolescents with type 1 diabetes and to pinpoint predictors of this acute complication in children on modern treatment modalities.

RESEARCH DESIGN AND METHODS

The study is based on data from DanDiabKids, a national diabetes register for children and adolescents. The register contains data on patients with type 1 diabetes with an ascertainment rate of 99%. Data from 3320 patients aged 0-18 yr was included in the study period from 1998 to 2009 and analyzed using a negative binomial model.

RESULTS

One thousand nine hundred and ninety-nine episodes of severe hypoglycemia in 867 patients were registered conferring an overall incidence of severe hypoglycemia of 15.1 [95% confident interval (CI): 13.8; 16.4] per 100 patient years. This remained unchanged during the study period. Duration of diabetes, age and treatment in centers managing less than 100 patients significantly increased the risk of severe hypoglycemia (p < 0.001). Patients on insulin pump therapy had a 42% reduced risk of severe hypoglycemia compared with pen treated patients (p = 0.01). Patients treated with five or more daily insulin injections had a 31% (95% CI: 17; 49) reduced risk of severe hypoglycemia compared to patients on fewer daily injections (p = 0.015).

CONCLUSIONS

Despite improvements in metabolic control over a decade the prevalence of severe hypoglycemic events remained unchanged. More intensive treatments such as insulin pump therapy and multiple daily injections on a national level seems to be a protective factor for developing severe hypoglycemia up to 2009.

Clinical usefulness of the measurement of serum fructosamine in childhood diabetes mellitus

PURPOSE

Glycosylated hemoglobin (HbA1c) is often used as an indicator of glucose control. It usually reflects the average glucose levels over two to three months, and is correlated with the development of long-term diabetic complications. However, it can vary in cases of hemoglobinopathy or an altered red blood cell lifespan. The serum fructosamine levels reflect the mean glucose levels over two to three weeks. This study was designed to determine the clinical usefulness of the combined measurement of serum fructosamine and HbA1c in the management of childhood diabetes mellitus and the correlation between them.

METHODS

Clinical data on 74 Korean children and adolescents with diabetes mellitus who were under management at the Department of Pediatrics of Dankook University Hospital were evaluated. Their fructosamine and HbA1c levels were reviewed based on clinical information, and analyzed using IBM SPSS Statistics ver. 21.

RESULTS

Their HbA1c levels showed a strong correlation with their fructosamine levels (r=0.868, P<0.001). The fructosamine level was useful for the prompt evaluation of the recent therapeutic efficacy after the change in therapeutic modality. It was also profitable in determining the initial therapeutics and for the estimation of the onset of the disease, such as fulminant diabetes.

CONCLUSION

The measurement of both fructosamine and HbA1c was useful in managing childhood diabetes mellitus, especially when there was discrepancy between the clinical information and the HbA1c level.

Melatonin Reduces Hypoglycemia-Induced Neuronal Death in Rats

Melatonin, N-aceyl-5-methoxytryptamine, is the main secretory product of the pineal gland and has neuroprotective effects on several brain injuries, including ischemic stroke. In the present study, we hypothesized that exogenous melatonin may decrease hypoglycemia-induced neuronal death through the prevention of superoxide generation. To test our hypothesis, hypoglycemia was induced by injecting human insulin (10 U/kg, i.p.) in rats. Melatonin injection was started immediately after hypoglycemia (10 mg/kg, i.p.). The first melatonin injection was performed at the end of a 30-min isoelectric EEG period. The second and third injections were administered at 1 and 3 h after the first injection. Reactive oxygen species generation, as detected by dihydroethidium staining, was significantly reduced by melatonin treatment. Neuronal injury was reduced by the treatment of melatonin in the hippocampal CA1 and dentate granule cells. Microglia activation was robust in the hippocampus after hypoglycemia, which was almost completely prevented by melatonin treatment. Hypoglycemia-induced cognitive impairment was also significantly prevented by melatonin treatment. The present study suggests that melatonin has therapeutic potential to prevent hypoglycemia-induced brain injury.

7(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG), May 8-10, 2014, Helsinki, Finland

International experts in the fields of diabetes, diabetes technology, endocrinology, mobile health, sport science, and regulatory issues gathered for the 7(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG). The aim of this meeting was to facilitate new collaborations and research projects to improve the lives of people with diabetes. The 2014 meeting comprised a comprehensive scientific program, parallel interactive workshops, and two keynote lectures.

Hemoglobin A1c Levels and risk of severe hypoglycemia in children and young adults with type 1 diabetes from Germany and Austria: a trend analysis in a cohort of 37,539 patients between 1995 and 2012

BACKGROUND

Severe hypoglycemia is a major complication of insulin treatment in patients with type 1 diabetes, limiting full realization of glycemic control. It has been shown in the past that low levels of hemoglobin A1c (HbA1c), a marker of average plasma glucose, predict a high risk of severe hypoglycemia, but it is uncertain whether this association still exists. Based on advances in diabetes technology and pharmacotherapy, we hypothesized that the inverse association between severe hypoglycemia and HbA1c has decreased in recent years.

METHODS AND FINDINGS

We analyzed data of 37,539 patients with type 1 diabetes (mean age ± standard deviation 14.4 ± 3.8 y, range 1-20 y) from the DPV (Diabetes Patienten Verlaufsdokumentation) Initiative diabetes cohort prospectively documented between January 1, 1995, and December 31, 2012. The DPV cohort covers an estimated proportion of >80% of all pediatric diabetes patients in Germany and Austria. Associations of severe hypoglycemia, hypoglycemic coma, and HbA1c levels were assessed by multivariable regression analysis. From 1995 to 2012, the relative risk (RR) for severe hypoglycemia and coma per 1% HbA1c decrease declined from 1.28 (95% CI 1.19-1.37) to 1.05 (1.00-1.09) and from 1.39 (1.23-1.56) to 1.01 (0.93-1.10), respectively, corresponding to a risk reduction of 1.2% (95% CI 0.6-1.7, p<0.001) and 1.9% (0.8-2.9, p<0.001) each year, respectively. Risk reduction of severe hypoglycemia and coma was strongest in patients with HbA1c levels of 6.0%-6.9% (RR 0.96 and 0.90 each year) and 7.0%-7.9% (RR 0.96 and 0.89 each year). From 1995 to 2012, glucose monitoring frequency and the use of insulin analogs and insulin pumps increased (p<0.001). Our study was not designed to investigate the effects of different treatment modalities on hypoglycemia risk. Limitations are that associations between diabetes education and physical activity and severe hypoglycemia were not addressed in this study.

CONCLUSIONS

The previously strong association of low HbA1c with severe hypoglycemia and coma in young individuals with type 1 diabetes has substantially decreased in the last decade, allowing achievement of near-normal glycemic control in these patients. Please see later in the article for the Editors' Summary.

Prospective assessment of hypoglycemia symptoms in children and adults with type 1 diabetes

PURPOSE

To compare the characteristics of symptoms of hypoglycemia in children and in adults with type 1 diabetes.

METHODS

Adults with diabetes and parents of children with diabetes who were participants were asked to call a phone system to report episodes of hypoglycemia (presence of symptoms and a blood glucose <4.0 mmol/L). For each episode, blood glucose reading and a scoring of 28 symptoms on a 7-point scale (1 = not present, 7 = very intense) were collected.

RESULTS

Sixty six children (49.2% males, mean age = 12.1±2.4 years, mean age at diagnosis = 7.5±2.9 years) and 53 adults (41.2% males, mean age 38.7±14.5 years, mean age at diagnosis = 17.5±12.9 years) with type 1 diabetes participated. The most common symptoms in adults were hunger, sweating, trembling and weakness. The most common symptoms in children were weakness, trembling and hunger. The 2 most discriminating variables between children and adults were sleepiness and tiredness, which were more common in children (p<0.01). In a comparative factor analysis, 3 factors emerged: factor 1, autonomic and neuroglycopenic; factor 2, behavioural; and factor 3, general malaise. Factors 2 and 3 were significantly more common or intense in children than in adults; MANOVA: F(1, 113) = 6.72, p<0.05 and F(1, 113) = 4.64, p<0.05, respectively.

CONCLUSIONS

Symptoms relating to behaviour and general malaise are more common in children than in adults with type 1 diabetes. The results of this study may assist providers in educating caregivers of children and patients with diabetes how to better recognize episodes of hypoglycemia.

Prevalence of impaired awareness of hypoglycemia and identification of predictive symptoms in children and adolescents with type 1 diabetes

BACKGROUND

In children with type 1 diabetes mellitus (T1DM) the prevalence of impaired awareness of hypoglycemia (IAH) is uncertain. This study aimed to ascertain this with greater precision. Secondary aims were to assess symptoms of hypoglycemia and which of these best predict awareness of hypoglycemia in children.

METHODS

Questionnaires were completed by 98 children with T1DM (mean age 10.6 yr) and their parent(s); hospital admission data for the previous year were collected. Awareness of hypoglycemia was assessed using two questionnaire-based methods that have been validated in adults. For 4 wk, participants performed routine blood glucose measurements and completed questionnaires after each episode of hypoglycemia. Principal components analysis determined how symptoms correlate; multinomial logistic regression models identified which symptom aggregate best predicted awareness status.

RESULTS

The 'Gold' questionnaire classified a greater proportion of the participants as having IAH than the 'Clarke' questionnaire (68.4 vs. 22.4%). Using the 'Clarke' method, but not the 'Gold' method, children with IAH were younger and more likely to require external assistance or hospital admission. Most aged ≥9 yr (98.6%) were able to self-assess awareness status accurately. Puberty and increasing age, augmented symptom scores; duration of diabetes and glycemic control had no effect. In contrast to adults, behavioral symptoms were the best predictors of awareness status.

CONCLUSIONS

IAH affects a substantial minority of children and impending hypoglycemia may be heralded by behavioral symptoms. The 'Clarke' method was more effective at identifying those at increased risk and could be used as a screening tool.

Closing the loop overnight at home setting: psychosocial impact for adolescents with type 1 diabetes and their parents

OBJECTIVE

To explore the experiences of adolescents with type 1 diabetes mellitus (T1DM) and their parents taking part in an overnight closed loop study at home, using qualitative and quantitative research methods.

RESEARCH DESIGN AND METHODS

Adolescents aged 12-18 years on insulin pump therapy were recruited to a pilot closed loop study in the home setting. Following training on the use of a study insulin pump and continuous glucose monitoring (CGM), participants were randomized to receive either real-time CGM combined with overnight closed loop or real-time CGM alone followed by the alternative treatment for an additional 21 days with a 2-3-week washout period in between study arms. Semistructured interviews were performed to explore participants' perceptions of the impact of the closed loop technology. At study entry and again at the end of each 21-day crossover arm of the trial, participants completed the Diabetes Technology Questionnaire (DTQ) and Hypoglycemia Fear Survey (HFS; also completed by parents).

RESULTS

15 adolescents and 13 parents were interviewed. Key positive themes included reassurance/peace of mind, confidence, 'time off' from diabetes demands, safety, and improved diabetes control. Key negative themes included difficulties with calibration, alarms, and size of the devices. DTQ results reflected these findings. HFS scores were mixed.

CONCLUSIONS

Closed loop insulin delivery represents cutting-edge technology in the treatment of T1DM. Results indicate that the psychological and physical benefits of the closed loop system outweighed the practical challenges reported. Further research from longitudinal studies is required to determine the long-term psychosocial benefit of the closed loop technology.

Hypoglycemia induced by insulin as a triggering factor of cognitive deficit in diabetic children

This paper provides an overview of insulin-induced hypoglycemia as a triggering factor of cognitive deficit in children with type 1 diabetes mellitus. For this purpose, databases from 1961 to 2013 were used with the objective of detecting the primary publications that address the impact of hypoglycemia on cognitive performance of diabetic children. The results obtained from experimental animals were excluded. The majority of studies demonstrated that the cognitive deficit in diabetic children involves multiple factors including duration, intensity, severity, and frequency of hypoglycemia episodes. Additionally, age at the onset of type 1 diabetes also influences the cognitive performance, considering that early inception of the disease is a predisposing factor for severe hypoglycemia. Furthermore, the results suggest that there is a strong correlation between brain damage caused by hypoglycemia and cognitive deterioration. Therefore, a more cautious follow-up and education are needed to impede and treat hypoglycemia in children with diabetes mellitus.

Striatal dopamine receptors modulate the expression of insulin receptor, IGF-1 and GLUT-3 in diabetic rats: effect of pyridoxine treatment

The incidence of type 2 diabetes mellitus is rising at alarming proportions. Central nervous system plays an important part in orchestrating glucose metabolism, with accumulating evidence linking dysregulated central nervous system circuits to the failure of normal glucoregulatory mechanisms. Pyridoxine is a water soluble vitamin and it has important role in brain function. This study aims to evaluate the role of pyridoxine in striatal glucose regulation through dopaminergic receptor expressions in streptozotocin induced diabetic rats. Radio receptor binding assays for dopamine D(1), D(2) receptors were done using [(3)H] 7-chloro-3-methyl-1-phenyl-1,2,4,5-tetrahydro-3-benzazepin-8-ol and [(3)H] 5-chloro-2-methoxy-4-methylamino-N-[-2-methyl-1-(phenylmethyl)pyrrolidin-3-yl]benzamide. Gene expressions were done using fluorescently labeled Taqman probes of dopamine D(1), D(2) receptor, Insulin receptor, Insulin like growth factor-1(IGF-1) and Glucose transporter-3 (GLUT-3). Bmax of dopamine D(1) receptor is decreased and B(max) of dopamine D(2) was increased in diabetic rats compared to control. Gene expression of dopamine D(1) receptor was down regulated and dopamine D(2) receptor was up regulated in diabetic rats. Our results showed decreased gene expression of Insulin receptor, IGF-1 and increased gene expression of GLUT-3 in diabetic rats compared to control. Pyridoxine treatment restored diabetes induced alterations in dopamine D(1), D(2) receptors, Insulin receptor, IGF-1, GLUT-3 gene expressions in striatum compared to diabetic rats. Insulin treatment reversed dopamine D(1), D(2) receptor, GLUT-3 mRNA expression, D(2) receptor binding parameters in the striatum compared to diabetic group. Our results suggest the potential role of pyridoxine supplementation in ameliorating diabetes mediated dysfunctions in striatal dopaminergic receptor expressions and insulin signaling. Thus pyridoxine has therapeutic significance in diabetes management.

Severe hypoglycaemia in drug-treated diabetic patients needs attention: a population-based study

OBJECTIVE

To study one-year incidence and risk factors of severe hypoglycaemias (SH) in adult drug-treated diabetic patients living in two Finnish communities.

DESIGN

The episodes of SH and their risk factors were identified from local ambulance registers, from the databases of local health care units, and from patient questionnaires.

SETTING

The target population consisted of all drug-treated diabetic patients from the two middle-sized communities in southern Finland, altogether 1776 patients. The study was retrospective.

SUBJECTS

A total of 1469 patients (82.7% of the target population) gave informed consent for the use of their medical records and 1325 patients (74.6% of the target population) returned the detailed 36-item questionnaire.

RESULTS

Of type 1 and type 2 insulin-treated diabetic patients, 14.6% and 1.0%, respectively, needed ambulance or emergency room care (incidence of 30.5 and 3.0 per 100 patient years). However, 31.0% of type 1 and 12.3% of type 2 diabetic patients reported at least one episode of SH (incidence of 72.0 and 27.0 per 100 patient years). Of all insulin-treated patients, 53 (7.8%) reported three or more episodes of SH. Significant independent risk factors for SH were depression, daily exercise, and nephropathy but not glycaemic control.

CONCLUSION

The incidence of SH was high in both types of insulin-treated diabetic patients. However, the recurrent episodes of SH were clustered in a small minority of insulin-treated patients with diabetes. The risk of SH should be considered when assessing the treatment target for an individual diabetic patient.

Effective treatment of hypoglycemia in children with type 1 diabetes: a randomized controlled clinical trial

OBJECTIVE

To determine the most effective of four oral treatments for hypoglycemia in children with type 1 diabetes using a weight-based protocol during diabetes camp.

METHODS

During diabetes camp treatment of hypoglycemia was randomized to one of the four treatments, randomly assigned for each episode using a sealed envelope: glucose tablets, jellybeans, orange juice, and sugar mints (Mentos dragees®). An equivalent carbohydrate dose was calculated for each patient for each treatment (0.3 g carbohydrate/kg) and provided to camp leaders. Glucose was measured at 0, 2, 5, 10, and 15 min and symptoms recorded.

RESULTS

A total of 191 episodes of hypoglycemia were recorded in 39 children (1-12 episodes per child), with 2 episodes excluded because of protocol violations. Fifty-two episodes were treated with glucose tablets, 45 with jellybeans, 44 with juice, and 48 with sugar mints. Change in glucose at 10 (p = 0.034) and 15 min (p = 0.005) and glucose at 15 min (p = 0.026) were significantly different between treatment groups - jellybeans produced the lowest and slowest response. Glucose tablets did not differ significantly from juice or Mentos dragees. There was a trend for repeat treatment to be required more often with a single treatment 'dose' of jellybeans (p = 0.058). Symptoms occurred in 112 episodes, with a median time to symptom resolution of 12 min (interquartile range (IQR) 8-15 min).

CONCLUSIONS

Jellybeans are less effective treatment for hypoglycemia than the other three treatments. Glucose tablets, Mentos dragees® and orange juice are of similar efficacy. Treatment with 0.3 g/kg of carbohydrate (excluding jellybeans) effectively resolved hypoglycemia in most children, with 15 min often required to normalize blood glucose.

Variables associated with severe hypoglycemia in children and adolescents with type 1 diabetes: a population-based study

OBJECTIVE

Hypoglycemia remains a central problem in the management of type 1 diabetes mellitus (T1DM) and limits the achievement of good or normal glycemic control. The Diabetes Control and Complication Trial showed that intensive treatment of T1DM increased the risk of severe hypoglycemia (SH) when compared to conventional therapy. The aim of our study was to determine the incidence of SH and associated variables in a population of children and adolescents with T1DM.

RESEARCH DESIGN AND METHODS

We performed a 7.5-yr prospective study enrolling 195 patients aged 13.9 ± 6.6 yr. The study was carried out by referring to the T1DM population-based register in the Abruzzo region of Italy. The incidence of SH, defined as blood glucose levels <50 mg/dL (<2.77 mmol/L) associated with altered states of consciousness (including confusional state, seizures, and coma) was recorded. Glycated hemoglobin (HbA1c) percentage, insulin dose, insulin regimen, time since diagnosis, and age at onset were also recorded.

RESULTS

One hundred and thirty-three severe hypoglycemic events occurred during the study period; the overall incidence was 9.4 episodes per 100 patient-years. Significant predictors of hypoglycemia were diabetes duration >10 yr (p = 0.01), basal/bolus insulin ratio (ratio of daily basal insulin units to daily bolus insulin units) >0.8 (p = 0.01). No relationship was found between hypoglycemic episodes and HbA1c levels, daily insulin requirements, or insulin regimen.

CONCLUSIONS

In these patients, a relatively low incidence of SH was recorded, without pronounced association with lower HbA1c or multiple daily injection insulin therapy. SH seems to be mainly related to management of diabetes. We believe that the main path to SH prevention is through patient and family education in the management of T1DM.

Curcumin modulates dopaminergic receptor, CREB and phospholipase C gene expression in the cerebral cortex and cerebellum of streptozotocin induced diabetic rats

Curcumin, an active principle component in rhizome of Curcuma longa, has proved its merit for diabetes through its anti-oxidative and anti-inflammatory properties. This study aims at evaluating the effect of curcumin in modulating the altered dopaminergic receptors, CREB and phospholipase C in the cerebral cortex and cerebellum of STZ induced diabetic rats. Radioreceptor binding assays and gene expression was done in the cerebral cortex and cerebellum of male Wistar rats using specific ligands and probes. Total dopaminergic receptor binding parameter, B_max showed an increase in cerebral cortex and decrease in the cerebellum of diabetic rats. Gene expression studies using real time PCR showed an increased expression of dopamine D1 and D2 receptor in the cerebral cortex of diabetic rats. In cerebellum dopamine D1 receptor was down regulated and D2 receptor showed an up regulation. Transcription factor CREB and phospholipase C showed a significant down regulation in cerebral cortex and cerebellum of diabetic rats. We report that curcumin supplementation reduces diabetes induced alteration of dopamine D1, D2 receptors, transcription factor CREB and phospholipase C to near control. Our results indicate that curcumin has a potential to regulate diabetes induced malfunctions of dopaminergic signalling, CREB and Phospholipase C expression in cerebral cortex and cerebellum and thereby improving the cognitive and emotional functions associated with these regions. Furthermore, in line with these studies an interaction between curcumin and dopaminergic receptors, CREB and phospholipase C is suggested, which attenuates the cortical and cerebellar dysfunction in diabetes. These results suggest that curcumin holds promise as an agent to prevent or treat CNS complications in diabetes.

The effectiveness of glucose, sucrose, and fructose in treating hypoglycemia in children with type 1 diabetes

OBJECTIVE

There is a lack of evidence regarding the most effective treatment option for managing naturally occurring hypoglycemia in children with type 1 diabetes. The objectives of this study were (i) to determine if sucrose and fructose are equally effective as glucose in the treatment of spontaneous hypoglycemia in children with type 1 diabetes; and (ii) to determine prestudy and poststudy hypoglycemia treatment preferences.

METHODS

Thirty-three subjects [aged 5.4-15.5 yr and average duration of type 1 diabetes of 3.1 yr (SD = 2.3)] participated in a randomized, crossover design. The main outcome was the effectiveness of treatment as defined by a blood glucose meter reading that was > or = 4.0 mmol/L 15 min after treatment. Each subject treated five hypoglycemic events with each treatment type: glucose (BD Glucose Tablets), sucrose (Skittles), and fructose (Fruit to Go).

RESULTS

There was a significant difference between the effectiveness of the three treatments [Wilk's Lambda F(2,28) = 8.64, p = 0.001]. No significant difference between treatment with glucose and treatment with sucrose was noted, but the treatment effectiveness for fructose was significantly lower than sucrose [F (1,29) = 16.09, p < 0.001] and glucose [F (1,29) = 15.64, p < 0.001]. The preferred treatment choices before the study were as follows: 36% glucose, 18% sucrose, and 33% fructose sources. Poststudy, 52% of children preferred the same treatment, which was effective (glucose or sucrose), followed by 35% who changed their preference to an effective treatment.

CONCLUSION

Skittles are as effective in treating hypoglycemia as more expensive BD Glucose Tablets in children with type 1 diabetes.

Gcg-XTEN: an improved glucagon capable of preventing hypoglycemia without increasing baseline blood glucose

OBJECTIVE

While the majority of current diabetes treatments focus on reducing blood glucose levels, hypoglycemia represents a significant risk associated with insulin treatment. Glucagon plays a major regulatory role in controlling hypoglycemia in vivo, but its short half-life and hyperglycemic effects prevent its therapeutic use for non-acute applications. The goal of this study was to identify a modified form of glucagon suitable for prophylactic treatment of hypoglycemia without increasing baseline blood glucose levels.

METHODOLOGY/PRINCIPAL FINDINGS

Through application of the XTEN technology, we report the construction of a glucagon fusion protein with an extended exposure profile (Gcg-XTEN). The in vivo half-life of the construct was tuned to support nightly dosing through design and testing in cynomolgus monkeys. Efficacy of the construct was assessed in beagle dogs using an insulin challenge to induce hypoglycemia. Dose ranging of Gcg-XTEN in fasted beagle dogs demonstrated that the compound was biologically active with a pharmacodynamic profile consistent with the designed half-life. Prophylactic administration of 0.6 nmol/kg Gcg-XTEN to dogs conferred resistance to a hypoglycemic challenge at 6 hours post-dose without affecting baseline blood glucose levels. Consistent with the designed pharmacokinetic profile, hypoglycemia resistance was not observed at 12 hours post-dose. Importantly, the solubility and stability of the glucagon peptide were also significantly improved by fusion to XTEN.

CONCLUSIONS/SIGNIFICANCE

The data show that Gcg-XTEN is effective in preventing hypoglycemia without the associated hyperglycemia expected for unmodified glucagon. While the plasma clearance of this Gcg-XTEN has been optimized for overnight dosing, specifically for the treatment of nocturnal hypoglycemia, constructs with significantly longer exposure profiles are feasible. Such constructs may have multiple applications such as allowing for more aggressive insulin treatment regimens, treating hypoglycemia due to insulin-secreting tumors, providing synergistic efficacy in combination therapies with long-acting GLP1 analogs, and as an appetite suppressant for treatment of obesity. The improved physical properties of the Gcg-XTEN molecule may also allow for novel delivery systems not currently possible with native glucagon.

Parental attitudes towards overnight closed-loop glucose control in children with type 1 diabetes

BACKGROUND

This study examined parental attitudes towards overnight closed-loop (CL) glucose control in children and young people with type 1 diabetes (T1D).

METHODS

Twelve families recruited by the INsulin PUmp Therapy group (INPUT), a U.K. patient/carer-led support group for people with T1D, attended a focus meeting on CL. The concept of CL was explained, and clinical results and plans regarding the Artificial Pancreas Project at Cambridge were presented. Participants completed a questionnaire to evaluate parental feelings about T1D management and attitudes towards overnight CL insulin delivery.

RESULTS

Nineteen parents (12 mothers and seven fathers) anonymously completed the questionnaire. Main concerns about diabetes were related to long-term complications (84%) and hypoglycemia (16%). Achieving good glucose control represented major challenge for carers (83%) with nighttime being the most difficult period to manage (56%), worrying most parents (71%) particularly because of fear of hypoglycemia (33%). The development of CL to manage diabetes was welcomed by all parents (100%) with 95% happy for their child to wear a continuous glucose monitor together with an insulin pump. All parents were ready to respond to additional alarms at night with 90% parents not worried about their child's overnight insulin delivery being controlled by a computer.

CONCLUSIONS

Selected parents of children with T1D who are already insulin pump users express implied trust in the technology for overnight CL insulin delivery. Nighttime blood glucose control is the biggest challenge and concern for parents, and the development of a commercially available overnight CL system may be an important goal.

A look inside the diabetic brain: Contributors to diabetes-induced brain aging

Central nervous system (CNS) complications resulting from diabetes is a problem that is gaining more acceptance and attention. Recent evidence suggests morphological, electrophysiological and cognitive changes, often observed in the hippocampus, in diabetic individuals. Many of the CNS changes observed in diabetic patients and animal models of diabetes are reminiscent of the changes seen in normal aging. The central commonalities between diabetes-induced and age-related CNS changes have led to the theory of advanced brain aging in diabetic patients. This review summarizes the findings of the literature as they relate to the relationship between diabetes and dementia and discusses some of the potential contributors to diabetes-induced CNS impairments.

Blocking of beta-2 adrenergic receptors hastens recovery from hypoglycemia-associated social withdrawal

OBJECTIVE

Hypoglycemia is associated with a variety of adverse behaviors including fatigue, confusion and social withdrawal. While these clinical symptoms are well characterized, the mechanism of their cause is not understood. Here we investigated how insulin-induced hypoglycemia causes social withdrawal.

RESEARCH DESIGN AND METHODS

Male 8-12-week-old C57BL/6J mice were injected intraperitoneally (IP) with or without and/or insulin, norepinephrine (NE) and epinephrine (Epi), terbutaline and butoxamine with subsequent measurement of blood glucose, social withdrawal and plasma catecholamines.

RESULTS

Insulin generated (0.75h post-injection) significant hypoglycemia with blood glucose nadirs of 64+/-4 and 48+/-5mg/dl for 0.8 and 1.2units/kg of insulin, respectively. Insulin (0.8 or 1.2units/kg) caused near total social withdrawal at 0.75h with full recovery not occurring until 4h (0.8units/kg) or 8h (1.2units/kg) post-insulin injection. Insulin also caused a marked elevation in plasma catecholamines. Basal 12h fasting NE and Epi were 287+/-38 and 350+/-47pg/ml, respectively. Insulin at 0.8units/kg increased plasma NE and Epi to 994+/-73 and 1842+/-473pg/ml, respectively. Administration of exogenous NE or Epi caused social withdrawal similar in magnitude to insulin. Importantly, administration of the beta-2 adrenergic receptor agonist terbutaline also caused social withdrawal while administration of the beta-2 adrenergic receptor antagonist butoxamine blocked NE-induced social withdrawal. Finally, butoxamine blocked insulin-induced social withdrawal.

CONCLUSIONS

These data demonstrate that hypoglycemia-associated social withdrawal is dependent on catecholamines via a beta-2 receptor-mediated pathway.

JDRF randomized clinical trial to assess the efficacy of real-time continuous glucose monitoring in the management of type 1 diabetes: research design and methods

BACKGROUND

While real-time (RT) continuous glucose monitoring (CGM) systems may revolutionize treatment of type 1 diabetes (T1D), there is insufficient evidence currently available to support widespread utilization of these devices. The Juvenile Diabetes Research Foundation (JDRF) CGM Study Group developed a randomized clinical trial to determine if RT-CGM can improve glycemic control and quality of life in children and adults with T1D. This paper presents the research design and methods that are being employed in this study.

METHODS

The JDRF CGM Study Group trial is a randomized, parallel group, efficacy and safety study. Subjects with T1DM who meet eligibility criteria are randomized to either standard self-monitoring of blood glucose (SMBG) alone or use of any of the three current RT-CGM systems as a supplement to SMBG. After the 6-month randomized period, the Control Group is offered use of RT-CGM, and both groups are studied for an additional 6 months. Subjects are divided into two cohorts: the Main Study Cohort includes subjects with baseline glycosylated hemoglobin (HbA1c) 7.0-10.0% inclusive, and the Exploratory Pilot Study Cohort includes subjects with HbA1c<7.0%. Difference in HbA1c is the primary outcome in the Main Study. Other outcomes include the percentage of sensor glucose values within the 70-180 mg/dL range, scores on questionnaires that assess the impact of RT-CGM on living with T1D, and the cost-effectiveness of RT-CGM.

RESULTS

Recruitment for the study was completed on December 15, 2007.

CONCLUSION

Results of this clinical trial should help establish whether or not current RT-CGM devices are beneficial to patients with T1D.

Hypoglycemic neuronal death is triggered by glucose reperfusion and activation of neuronal NADPH oxidase

Hypoglycemic coma and brain injury are potential complications of insulin therapy. Certain neurons in the hippocampus and cerebral cortex are uniquely vulnerable to hypoglycemic cell death, and oxidative stress is a key event in this cell death process. Here we show that hypoglycemia-induced oxidative stress and neuronal death are attributable primarily to the activation of neuronal NADPH oxidase during glucose reperfusion. Superoxide production and neuronal death were blocked by the NADPH oxidase inhibitor apocynin in both cell culture and in vivo models of insulin-induced hypoglycemia. Superoxide production and neuronal death were also blocked in studies using mice or cultured neurons deficient in the p47(phox) subunit of NADPH oxidase. Chelation of zinc with calcium disodium EDTA blocked both the assembly of the neuronal NADPH oxidase complex and superoxide production. Inhibition of the hexose monophosphate shunt, which utilizes glucose to regenerate NADPH, also prevented superoxide formation and neuronal death, suggesting a mechanism linking glucose reperfusion to superoxide formation. Moreover, the degree of superoxide production and neuronal death increased with increasing glucose concentrations during the reperfusion period. These results suggest that high blood glucose concentrations following hypoglycemic coma can initiate neuronal death by a mechanism involving extracellular zinc release and activation of neuronal NADPH oxidase.

A longitudinal observational study of insulin therapy and glycaemic control in Scottish children with Type 1 diabetes: DIABAUD 3

OBJECTIVE/BACKGROUND

Our objective was to investigate glycaemic control in children with Type 1 diabetes in Scotland and to analyse the effect of changing 'conventional' insulin regimen strategies on outcome. DIABAUD 2 (1997-1998) (D2) demonstrated that average glycaemic control in young people with Type 1 diabetes in Scotland was poor, with mean HbA(1c) of 9.0%. Over 90% were then treated with a twice-daily insulin regimen. The aim of DIABAUD 3 (2002-2004) (D3) was to determine if control had improved, and to examine changes in insulin regimen and effects on glycaemic control.

METHODS

In DIABAUD 3, data were collected prospectively on children aged < 15 years. in nine out of 15 centres throughout Scotland. HbA(1c) on 986 subjects was measured in a single Diabetes Control and Complications Trial-aligned laboratory. The results were compared with those from DIABAUD 2, for the same nine centres. Multiple regression comparison was performed to adjust for imbalance in relevant confounders (e.g. age, duration, height and weight, insulin dose and centre).

RESULTS

For D3, the age range was 1.1-14.9 years (62% aged 10-14 years), mean (+/- sd) HbA(1c) 9.2% +/- 1.5 (compared with D2, 9.0% +/- 1.5). Only 9.7% achieved the target of HbA(1c) < 7.5%. The number of subjects in D3 on twice-daily injections was 51% (compared with 94% in D2), 43% on three-times-daily injections (2% in D2) and 2.3% on four or more (1.9% in D2): HbA(1c) did not differ in these groups. In both the D2 and D3 cohorts, HbA(1c) rose with age. After adjustment for other variables in the combined datasets, insulin regimen was not a significant predictor of HbA(1c) (F = 0.19, d.f. = 3, 1774; P = 0.90).

CONCLUSION

The glycaemic control in young people in Scotland remains poor and above the national target. Over 4 years, moderate intensification of insulin therapy (i.e. from two to three injections each day, usually reflecting splitting of the evening dose) across the population failed to improve the average HbA(1c) and reduce the increase seen with age. A national programme away from 'conventional' to an 'intensive' regimen of insulin therapy is required.

Hypoglycemia: a complication of diabetes therapy in children

The experience of hypoglycemia is probably the most feared and hated consequence of life with type 1 diabetes among pediatric patients and their parents. Although transient detrimental effects are clearly disturbing and may have severe results, there is surprisingly little evidence of long-term CNS damage, even after multiple hypoglycemic episodes, except in rare instances. Despite the latter evidence, we advocate that every treatment regimen be designed to prevent hypoglycemia without inducing unacceptable hyperglycemia and increasing the risk of micro- and macrovascular complications.

Hypoglycemia, hypoglycemia unawareness and counterregulation in children and adolescents with type 1 diabetes mellitus

Three clinical phenomena have been defined in the last decade in patients with diabetes mellitus as a dangerous iatrogenic sequel of hypoglycemia. These are hypoglycemia unawareness, defective glucose counterregulation and a lowered hypoglycemic threshold for hypoglycemic symptoms. Former mild hypoglycemia episodes cause a decrease and a delay in the protective hormonal counterregulatory response and warning symptoms in subsequent episodes, and in the absence of these, risk of severe hypoglycemia increases considerably. It has been demonstrated that when protection is provided against hypoglycemia with strict monitoring programs designed to avoid even mild hypoglycemia episodes, blunted autonomic symptoms and counterregulatory hormonal responses are rectified. Therefore, the best course of action in the treatment of pediatric diabetes mellitus is frequent blood sugar measurements, flexible multiple dose insulin regimens facilitating insulin dose adjustments as required, and a diet. In order to implement this, it is essential to organize an intensive training program with the patient and family, and to provide psychological support and close coordination with the diabetes treatment team.

Past 10-year status of insulin therapy for preschool-age Japanese children with type 1 diabetes

The aim of this study was to evaluate the past 10-year status of insulin therapy for preschool-age children with type 1 diabetes in Japan. One-hundred and forty-two patients who had been diagnosed at less than 5 years of age within the past 10 years (1993-2002) at 36 hospitals were registered in this study on April 2003. The methods of daily insulin therapy and episodes of severe hypoglycemia during the preschool period were investigated. Eighty-six (60.6%) children were treated with a pen-type device and 56 (39.4%) were treated with a syringe-type device. The once-a-day insulin regimen was used for 2, a twice-a-day regimen for 104, a three-times-a-day for 28 and a four-times-a-day for 8. Episodes of severe hypoglycemia were recorded in nearly half of the subjects, and one-fourth of the subjects had repeated episodes. One hundred and eleven of their parents were questioned regarding the degree of psychosocial stress experienced during the care of their children. Most parents worried about the glycosylated hemoglobin value at each hospital visit. They were next very afraid of nocturnal severe hypoglycemia, independent of any actual experience. These results suggest that although insulin therapy can involve various methods, the important point is to simultaneously provide good glycemic control and prevent severe hypoglycemia, especially during this age.

Continuous glucose monitoring and the reality of metabolic control in preschool children with type 1 diabetes

OBJECTIVE

To determine using the MiniMed continuous glucose monitoring system (CGMS) 1) whether twice-daily insulin injection therapy achieves adequate control in preschool children with type 1 diabetes and 2) whether the CGMS is more informative than self-monitoring of blood glucose (SMBG) regarding glucose control and well tolerated by preschool children and their families.

RESEARCH DESIGN AND METHODS

Ten children <6 years of age with type 1 diabetes were monitored twice using the CGMS. The distribution of glucose values was analyzed, particularly the frequency, duration, and distribution of hypoglycemia. We analyzed the accuracy of the CGMS in detecting hypoglycemia as well as the clinical relevance of the difference between CGMS and SMBG values.

RESULTS

Although hypoglycemia was more frequent during the night (0.8 nighttime episodes . subject(-1) . 24 h(-1) vs. 0.3 daytime episodes . subject(-1) . 24 h(-1)), the difference did not reach statistical significance (P=0.07). However, nighttime episodes lasted longer than daytime episodes (1.2 vs. 0.2 h . subject(-1) . 24 h(-1), P=0.006). Hypoglycemia accounted for 7% and normoglycemia for 24%, while hyperglycemia occurred 64% of the time, with postprandial hyperglycemia being an almost universal feature (94 +/- 7% of all postmeal values). The CGMS correlated well with SMBG without significant clinical discrepancy. The CGMS sensitivity to detect hypoglycemia was 70% with a specificity of 99%; however, the CGMS detected twice as many total episodes as SMBG (82 vs. 40).

CONCLUSIONS

Twice-daily insulin injection rarely achieves control in preschool children with type 1 diabetes. The CGMS is well tolerated by patients and has the advantage of revealing daily glucose trends missed by SMBG.

The impact of a decade of changing treatment on rates of severe hypoglycemia in a population-based cohort of children with type 1 diabetes

OBJECTIVE

To determine the impact of changes to treatment on the incidence of severe hypoglycemia and its risk factors in a large population-based cohort of children with type 1 diabetes.

RESEARCH DESIGN AND METHODS

The cohort consisted of 1,335 children (age at entry 9.5 +/- 4.3 years [mean +/- SD], range 0-18), yielding 6,928 patient-years of data. The mean follow-up period was 4.7 +/- 3.1 years (range 0-10.7). Prospective assessment of severe hypoglycemia (an event leading to loss of consciousness or seizure) and associated clinical factors and outcomes was made between 1992 and 2002. Patients were reviewed every 3 months. Data were analyzed using the negative binomial regression model.

RESULTS

A total of 944 severe events were recorded. The incidence of severe hypoglycemia increased significantly by 29% per year for the first 5 years but appeared to plateau over the last 5 years. The overall average HbA1c significantly decreased (by 0.2% per year) over the whole follow-up period. An increased risk of severe hypoglycemia was associated with lower HbA1c, younger age, higher insulin dose, male sex, and lower parental socioeconomic status. Of insulin therapies, only pump treatment was associated with reduced rates of severe hypoglycemia.

CONCLUSIONS

Severe hypoglycemia remains a major problem for children and adolescents with type 1 diabetes. Recent approaches to therapy may be allowing a degree of improved control without the expected increased risk of severe hypoglycemia but further monitoring will be important.

Evaluating risk factors associated with severe hypoglycaemia in epidemiology studies-what method should we use?

AIMS

To determine the most appropriate regression models to use when assessing risk factors for severe hypoglycaemia and to investigate the impact of model misspecification and its clinical implications.

METHODS

A total of 1229 children with Type 1 diabetes (mean age 11.7 years sd 4.1), of which 605 (49.2%) were males, were studied. Prospective assessment of severe hypoglycaemia (an event leading to loss of consciousness or seizure) was made over the 9-year period, 1992-2001. Patients were seen every 3 months and episodes of hypoglycaemia along with clinical data were recorded. Over 70% of children never experienced a severe hypoglycaemic event. Data were analysed using the Poisson regression, negative binomial, zero-inflated Poisson (ZIP) and zero-inflated negative binomial (ZINB) models. The over-dispersion and likelihood ratio statistics were calculated and the analytical methods compared.

RESULTS

The Poisson regression model did not fit the data well. The negative binomial and the zero inflated Poisson and negative binomial models fitted the data better than Poisson.

CONCLUSIONS

The commonly used Poisson regression models to analyse hypoglycaemia epidemiology may lead to biased parameter estimates and incorrect determination of risk factors for hypoglycaemia. We recommend the use of the negative binomial or zero inflated models to examine any risk factors associated with severe hypoglycaemia. Careful consideration must be given to the interpretation of hypoglycaemia surveys and their analysis.