Frequency and Predictors of Self-Reported Hypoglycemia in Insulin-Treated Diabetes

Development and validation of a prediction model for self-reported hypoglycemia risk in patients with type 2 diabetes: A longitudinal cohort study

AIMS/INTRODUCTION

To develop and validate a simple prediction model for hypoglycemia risk in patients with type 2 diabetes.

MATERIALS AND METHODS

We prospectively analyzed the data of 1,303 subjects in a third-class hospital in Tianjin and followed up their hypoglycemia events at 3 and 6 months. The hypoglycemia risk prediction models for 3 and 6 months were developed and the model performance was evaluated.

RESULTS

A total of 340 (28.4%) patients experienced hypoglycemia within 3 months and 462 (37.2%) within 6 months during the follow-up period. Age, central obesity, intensive insulin therapy, frequency of hypoglycemia in the past year, and hypoglycemia prevention education entered both model3month and model6month. The area under the receiver operating characteristic curve of model3month and model6month were 0.711 and 0.723, respectively. The Youden index was 0.315 and 0.361, while the sensitivities were 0.615 and 0.714, and the specificities were 0.717 and 0.631. The calibration curves showed that the models were similar to reality. The decision curves implied that the clinical net benefit of the model was clear.

CONCLUSIONS

The study developed 3 and 6 month hypoglycemia risk prediction models for patients with type 2 diabetes. The discrimination and calibration of the two prediction models were good, and might help to improve clinical decision-making and guide patients to more reasonable self-care and hypoglycemia prevention at home.

Fear of hypoglycemia and illness perception in type II diabetes patients

BACKGROUND

Hypoglycemia, a prevalent acute complication among individuals with type 2 diabetes (T2D), manifests with varied symptoms. Those with diabetes who have previously encountered hypoglycemic episodes commonly develop a Fear of Hyperglycemia (FOH). Illness perception (IP) significantly affects self-care behaviors and health outcomes in individuals diagnosed with T2D.

OBJECTIVE

This study examined the correlation between IP and FOH among T2D patients and predictors of FOH.

METHODS

The present study employed a descriptive-analytical design. The target population for this investigation comprised patients diagnosed T2D who sought medical care at the clinic and endocrinology departments of a hospital affiliated with Alborz University of Medical Sciences. The data collection period spanned from August 2019 to March 2021. A total of 300 individuals were included in the sample. Questionnaires were administered to measure both IP and FOH. Statistical analysis was conducted to examine the association between IP and FOH, as well as to identify the predictors of FOH.

RESULTS

The results of the study indicated a statistically significant relationship between FOH and the mean score of IP among patients with diabetes (p = 0.001, r = 0.393), suggesting a moderate positive correlation between these variables. Additionally, the duration of illness, IP, and level of education were identified as variables that predicted FOH (p < 0.05).

CONCLUSION

The numerous factors that influence FOH in individuals diagnosed with T2D highlight the necessity for strategic planning and training initiatives aimed at enhancing IP and reducing FOH within this specific population. Healthcare providers should prioritize interventions that not only address patients' concerns but also contribute to the improvement of their overall well-being. By implementing such interventions, healthcare providers can optimize diabetes management strategies and ultimately enhance patient outcomes.

Effectiveness and User Perception of an In-Vehicle Voice Warning for Hypoglycemia: Development and Feasibility Trial

BACKGROUND

Hypoglycemia is a frequent and acute complication in type 1 diabetes mellitus (T1DM) and is associated with a higher risk of car mishaps. Currently, hypoglycemia can be detected and signaled through flash glucose monitoring or continuous glucose monitoring devices, which require manual and visual interaction, thereby removing the focus of attention from the driving task. Hypoglycemia causes a decrease in attention, thereby challenging the safety of using such devices behind the wheel. Here, we present an investigation of a hands-free technology-a voice warning that can potentially be delivered via an in-vehicle voice assistant.

OBJECTIVE

This study aims to investigate the feasibility of an in-vehicle voice warning for hypoglycemia, evaluating both its effectiveness and user perception.

METHODS

We designed a voice warning and evaluated it in 3 studies. In all studies, participants received a voice warning while driving. Study 0 (n=10) assessed the feasibility of using a voice warning with healthy participants driving in a simulator. Study 1 (n=18) assessed the voice warning in participants with T1DM. Study 2 (n=20) assessed the voice warning in participants with T1DM undergoing hypoglycemia while driving in a real car. We measured participants' self-reported perception of the voice warning (with a user experience scale in study 0 and with acceptance, alliance, and trust scales in studies 1 and 2) and compliance behavior (whether they stopped the car and reaction time). In addition, we assessed technology affinity and collected the participants' verbal feedback.

RESULTS

Technology affinity was similar across studies and approximately 70% of the maximal value. Perception measure of the voice warning was approximately 62% to 78% in the simulated driving and 34% to 56% in real-world driving. Perception correlated with technology affinity on specific constructs (eg, Affinity for Technology Interaction score and intention to use, optimism and performance expectancy, behavioral intention, Session Alliance Inventory score, innovativeness and hedonic motivation, and negative correlations between discomfort and behavioral intention and discomfort and competence trust; all P<.05). Compliance was 100% in all studies, whereas reaction time was higher in study 1 (mean 23, SD 5.2 seconds) than in study 0 (mean 12.6, SD 5.7 seconds) and study 2 (mean 14.6, SD 4.3 seconds). Finally, verbal feedback showed that the participants preferred the voice warning to be less verbose and interactive.

CONCLUSIONS

This is the first study to investigate the feasibility of an in-vehicle voice warning for hypoglycemia. Drivers find such an implementation useful and effective in a simulated environment, but improvements are needed in the real-world driving context. This study is a kickoff for the use of in-vehicle voice assistants for digital health interventions.

Risk of non-hypoglycemic agents for hypoglycemia-related hospitalization in patients with type 2 diabetes: a large-scale medical receipt database analysis

INTRODUCTION

Hypoglycemia is listed as an adverse effect in the package inserts of not only hypoglycemic agents but also many other drugs. We aimed to clarify real-world factors related to an increased risk of hypoglycemia-related hospitalization (HRH) in Japanese patients with type 2 diabetes (T2D) on non-hypoglycemic agents that have been associated with hypoglycemia.

RESEARCH DESIGN AND METHODS

This cross-sectional study was performed using data from the Medical Data Vision administrative claims database. We identified patients with T2D who were enrolled in the database between April 2014 and October 2019. Logistic regression analyses were performed to identify clinical factors associated with HRH due to non-hypoglycemic agents.

RESULTS

Among 703 745 patients with T2D, 10 376 patients (1.47%) experienced HRH. The use of 332 non-hypoglycemic agents was associated with hypoglycemia. Multivariate analysis was performed to calculate OR for HRH. Seventy-five drugs had an OR greater than 1, and the values were significant. The OR was the highest for diazoxide (OR 15.5, 95% CI 4.87 to 49.3). The OR was higher than 2.0 for methylphenidate (OR 5.15, 95% CI 1.53 to 17.3), disulfiram (OR 4.21, 95% CI 2.05 to 8.62) and hydrocortisone (OR 2.89, 95% CI 1.11 to 7.51).

CONCLUSION

This large retrospective analysis revealed that the risk of HRH from some non-hypoglycemic agents in patients with T2D may be increased. The results of this study are expected to support treatment planning by physicians and healthcare professionals involved in diabetes care.

A perspective on treating type 1 diabetes mellitus before insulin is needed

Type 1 diabetes mellitus (T1DM) is a progressive autoimmune disease that starts long before a clinical diagnosis is made. The American Diabetes Association recognizes three stages: stage 1 (normoglycaemic and positive for autoantibodies to β-cell antigens); stage 2 (asymptomatic with dysglycaemia); and stage 3, which is defined by glucose levels consistent with the definition of diabetes mellitus. This Perspective focuses on the management of the proportion of individuals with early stage 3 T1DM who do not immediately require insulin; a stage we propose should be termed stage 3a. To date, this period of non-insulin-dependent T1DM has been largely unrecognized. Importantly, it represents a window of opportunity for intervention, as remaining at this stage might delay the need for insulin by months or years. Extending the insulin-free period and/or avoiding unnecessary insulin therapy are important goals, as there is no risk of hypoglycaemia during this period and the adherence burden on patients of glycaemic monitoring and daily adjustments for diet and exercise is substantially reduced. Recognizing the pressing need for guidance on adequate management of children and adults with stage 3a T1DM, we present our perspective on the subject, which needs to be tested in formal and adequately powered clinical trials.

Glucagon-like peptide-1 agonists combined with sodium-glucose cotransporter-2 inhibitors reduce weight in type 1 diabetes

OBJECTIVE

This study evaluated whether adding sodium-glucose cotransporter-2 inhibitors (SGLT2i) and/or glucagon-like peptide-1 receptor agonists (GLP1-RA) to insulin reduced weight and glycemia in people with type 1 diabetes.

METHODS

This retrospective analysis of electronic health records evaluated 296 people with type 1 diabetes over 12 months after medications were first prescribed. Four groups were defined: control n = 80, SGLT2i n = 94, GLP1-RA n = 82, and combination of drugs (Combo) n = 40. We measured changes at 1 year in weight and glycated hemoglobin (HbA1c).

RESULTS

The control group did not have changes in weight or glycemic control. The mean (SD) percentage weight loss after 12 months was 4.4% (6.0%), 8.2%  (8.5%), and 9.0% (8.4%) in the SGLT2i, GLP1-RA, and Combo groups, respectively (p < 0.001). The Combo group lost the most weight (p < 0.001). The HbA1c reduction was 0.4%  (0.7%), 0.3% (0.7%), and 0.6% (0.8%) in the SGLT2i, GLP1-RA, and Combo groups, respectively (p < 0.001). The Combo group had the biggest improvements in glycemic control and total and low-density lipoprotein cholesterol compared with baseline (all p < 0.01). Severe adverse events were similar between all the groups, with no increased risk of diabetic ketoacidosis.

CONCLUSIONS

The SGLT2i and GLP1-RA agents on their own improved body weight and glycemia, but combining the medications resulted in more weight loss. Treatment intensification appears to result in benefits with no difference in severe adverse events.

Hypoglycemia prevention practice and associated factors among diabetes mellitus patients in Ethiopia: Systematic review and meta-analyssis

BACKGROUND

Hypoglycemia is an urgent, life-threatening condition that requires prompt recognition and treatment for diabetes mellitus patients to prevent organ and brain damage. Hypoglycemia is one of the most important complications of diabetes mellitus patients around the globe. Hypoglycemia may increase vascular events and even death, in addition to other possible detrimental effects. In spite of the absence of other risk factors, patients receiving intensive insulin therapy are more likely to experience hypoglycemia. To reduce the risk of hypoglycemia and calculate the combined prevalence of hypoglycemia prevention practices among diabetes mellitus patients, recognition of hypoglycemia is critical.

OBJECTIVE

The main aim of this review was to evaluate the available data on Ethiopian diabetes mellitus patients' practices for preventing hypoglycemia and related factors.

METHODS AND MATERIALS

This review was searched using PubMed, the Cochrane Library, Google, Google Scholar, and the Web of Sciences. Microsoft Excel was used to extract the data. All statistical analyses were done using STATA Version 14 software with a random-effects model. The funnel plot and heterogeneity of the studies were checked. Subgroup analysis was done with the study area and authors' names.

RESULTS

In this systematic review, 12 studies totaling 3,639 participants were included. The estimated overall practice for preventing hypoglycemia among diabetic patients in Ethiopia were 48.33% (95% CI (28.21%, 68.46%, I2 = 99.7%, p ≤ 0.001). According to the subgroup analysis based on region, the highest estimated prevalence of the prevention practice of hypoglycemia among diabetes patients in Addis Ababa was 90%, followed by SNNRP at 76.18% and in the Amhara region at 68.31% respectively. The least prevalent was observed in the Oromia region 6.10%. In this meta-analysis, diagnoses with type II diabetes (AOR = 2.53, 95%CI: 1.05, 4.04), duration (AOR = 5.49, 95%CI:3.27,7.70), taking insulin for a long time(AOR = 4.31,95%CI:2.60,6.02), having good prevention knowledge (AOR = 2.89, 95%CI: 1.15,4.23), and occupation (AOR = 4.17, 95%CI: 2.20, 6.15) were significantly associated with hypoglycemia prevention practice.

CONCLUSIONS

This systematic review revealed that diabetic patients in Ethiopia had poor hypoglycemia prevention practices. Being an employee, taking insulin for a long time, having a good prevention practice, and having a type of diabetes mellitus were strongly correlated with practicing hypoglycemia prevention. This review implied the subsequent need for educational interventions for an individualized patient.

Switching to iGlarLixi versus continuation of a daily or weekly glucagon-like peptide-1 receptor agonist (GLP-1 RA) in insufficiently controlled type 2 diabetes: A LixiLan-G trial subgroup analysis by HbA1c and GLP-1 RA use at screening

AIM

In people with type 2 diabetes (T2D) requiring intensification beyond glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and oral antihyperglycaemic drugs (OADs), switching to iGlarLixi was shown to be efficacious and well-tolerated in the LixiLan-G trial. This exploratory analysis of LixiLan-G assessed the efficacy and safety of switching to iGlarLixi versus continuing GLP-1 RA therapy, stratified by screening HbA1c level (≥7.0 to ≤7.5 %; >7.5 to ≤8.0 %; >8.0 to ≤9.0 % [≥53 to ≤58 mmol/mol; >58 to ≤64 mmol/mol; >64 to ≤75 mmol/mol]) and previous GLP-1 RA regimen at screening (once/twice daily or once weekly).

MATERIALS AND METHODS

Endpoints for all subgroups included: change in HbA1c, achievement of HbA1c <7 % and hypoglycaemia events. Adverse events and changes in fasting plasma glucose (FPG), 2-hour postprandial plasma glucose (PPG), 2-hour PPG excursion and weight were analysed according to previous GLP-1 RA regimen.

RESULTS

Switching to iGlarLixi in all subgroups resulted in significantly greater reductions in HbA1c and proportions of participants reaching HbA1c <7 % (including with no documented hypoglycaemia) at Week 26 compared with continued GLP-1 RA treatment. Switching to iGlarLixi also led to significantly greater reductions in FPG, 2-hour PPG, and 2-hour PPG excursion, irrespective of previous GLP-1 RA regimen. Rates of hypoglycaemia were low, but slightly higher in those who switched to iGlarLixi for all subgroups. Modest weight gain was seen with iGlarLixi, irrespective of previous GLP-1 RA regimen.

CONCLUSIONS

Switching to iGlarLixi improved glycaemic control, regardless of screening HbA1c or previous GLP-1 RA type, offering a simple, efficacious and well-tolerated treatment intensification option for people with T2D inadequately controlled by GLP-1 RAs and OADs.

Dietary intake and hospitalisation due to diabetic ketoacidosis and hypoglycaemia in individuals with type 1 diabetes

We investigated the association between diet and risk of hospitalisation for diabetic ketoacidosis (DKA) or hypoglycaemia in type 1 diabetes. Food records were used to assess dietary intake. Data on DKA and hypoglycaemia hospitalisations, within two years of dietary assessments, were obtained from registries. Analyses were conducted with and without macronutrient substitution. Data were available from 1391 participants, 28 (2.0%) and 55 (4.0%) of whom were hospitalised due to DKA or hypoglycaemia, respectively. In the adjusted model, self-reported alcohol intake was associated with increased (per 10 g: B = 1.463, 95% CI = 1.114-1.922, p = 0.006; per E%: B = 1.113, 95% CI = 1.027-1.206, p = 0.009), and fibre intake with reduced (per g/MJ: B = 0.934, 95% CI = 0.878-0.995, p = 0.034) risk of DKA hospitalisation. Substituting carbohydrates for fats was associated with increased risk for hypoglycaemia hospitalisation (B = 1.361, 95% CI = 1.031-1.795, p = 0.029), while substituting alcohol for carbohydrates (B = 1.644, 95% CI = 1.006-2.685, p = 0.047) or proteins (B = 2.278, 95% CI = 1.038-4.999, p = 0.040) increased the risk for DKA hospitalisation. In conclusion, refraining from alcohol intake is a preventable risk factor for DKA, while higher fibre intake seems rather protective. Increasing carbohydrate intake while decreasing that of fats, is associated with higher hypoglycaemia risk. Whether this is a cause or effect of hypoglycaemia remains to be established.

Association between reduced kidney function and incident hypoglycaemia in people with diabetes: The Stockholm Creatinine Measurements (SCREAM) project

AIM

To evaluate possible associations between estimated glomerular filtration rate (eGFR) and hypoglycaemia in adults with diabetes.

METHODS

We conducted an observational study in adults with diabetes from the Stockholm Creatinine Measurement (SCREAM) project, a Swedish healthcare utilization cohort during 2007 to 2011. We evaluated diagnoses and outpatient glucose tests for incidence rate ratios (IRRs) of hypoglycaemia (overall and by severity) in outpatient care by eGFR strata using zero-inflated negative binomial regression. We identified clinical predictors through ordinal logistic regression and assessed 7-day and 30-day mortality from hypoglycaemia in relation to eGFR with Cox proportional hazard models.

RESULTS

We identified 29 434 people with diabetes (13% with type 1 diabetes). Their mean age was 66 years, 43% were women and the median eGFR was 80 mL/min/1.73 m² . During 2 years of follow-up, 1812 patients (6.2%) had hypoglycaemia registered at least once. The risk of hypoglycaemia increased linearly with lower eGFR, with an IRR of 1.2 (95% confidence interval [CI] 1.0-1.4) for eGFR 60-89 mL/min/1.73 m² and 5.8 (95% CI 3.8-9.0) for eGFR <15 mL/min/1.73 m² compared to eGFR 90 to 104 mL/min/1.73 m² . This trend was observed for both mild and severe hypoglycaemia. Both 7-day and 30-day post-hypoglycaemia mortality increased with lower eGFR, peaking in those with eGFR <15 mL/min/1.73 m² (hazard ratio 21.2, 95% CI 5.1-87.9) as compared to those with eGFR 90 to 104 mL/min/1.73 m² . Lower eGFR categories, type 1 diabetes, previous hypoglycaemia, liver disease, presence of diabetic complications and use of insulin and sulphonylureas increased the odds of hypoglycaemia.

CONCLUSION

In this large, observational study, low eGFR was strongly associated with the occurrence, severity and fatality of hypoglycaemia in people with diabetes.

Development and Validation of a Hypoglycemia Risk Model for Intensive Insulin Therapy in Patients with Type 2 Diabetes

AIMS

To develop a simple hypoglycemic prediction model to evaluate the risk of hypoglycemia during hospitalization in patients with type 2 diabetes treated with intensive insulin therapy.

METHODS

We performed a cross-sectional chart review study utilizing the electronic database of the Third Affiliated Hospital of Sun Yat-sen University, and included 257 patients with type 2 diabetes undergoing intensive insulin therapy in the Department of Endocrinology and Metabolism. Logistic regression analysis was used to derive the clinical prediction rule with hypoglycemia (blood glucose ≤ 3.9 mmol/L) as the main result, and internal verification was performed.

RESULTS

In the derivation cohort, the incidence of hypoglycemia was 51%. The final model selected included three variables: fasting insulin, fasting blood glucose, and total treatment time. The area under the curve (AUC) of this model was 0.666 (95% CI: 0.594-0.738, P < 0.001).

CONCLUSIONS

The model's hypoglycemia prediction and the actual occurrence are in good agreement. The variable data was easy to obtain and the evaluation method was simple, which could provide a reference for the prevention and treatment of hypoglycemia and screen patients with a high risk of hypoglycemia.

Double diabetes: A distinct high-risk group?

The term double diabetes (DD) has been used to refer to individuals with type 1 diabetes (T1D) who are overweight, have a family history of type 2 diabetes and/or clinical features of insulin resistance. Several pieces of evidence indicate that individuals who display features of DD are at higher risk of developing future diabetes complications, independently of average glucose control, measured as glycated haemoglobin (HbA1c) concentration. Given the increased prevalence of individuals with features of DD, pragmatic criteria are urgently required to identify and stratify this group, which will help with subsequent implementation of more effective personalized interventions. In this review, we discuss the potential criteria for the clinical identification of individuals with DD, highlighting the strengths and weaknesses of each definition. We also cover potential mechanisms of DD and how these contribute to increased risk of diabetes complications. Special emphasis is placed on the role of estimated glucose disposal rate (eGDR) in the diagnosis of DD, which can be easily incorporated into clinical practice and is predictive of adverse clinical outcome. In addition to the identification of individuals with DD, eGDR has potential utility in monitoring response to different interventions. T1D is a more heterogeneous condition than initially envisaged, and those with features of DD represent a subgroup at higher risk of complications. Pragmatic criteria for the diagnosis of individuals with DD will help with risk stratification, allowing a more personalized and targeted management strategy to improve outcome and quality of life in this population.

Occurrence of severe hypoglycaemic events among US youth and young adults with type 1 or type 2 diabetes

OBJECTIVE

Although severe hypoglycaemia (SH) can lead to adverse health outcomes, little is known about its occurrence and re-occurrence among youth with type 1 or type 2 diabetes.

METHODS

This study included 2740 participants aged <20 years at diabetes diagnosis and 5-14 years diabetes duration from the SEARCH for Diabetes in Youth Cohort Study. Participants reported SH events in the past 6 months. Differences in SH events by demographic and clinical factors were tested using logistic regression models.

RESULTS

Severe hypoglycaemia in the past 6 months was more common among youth with type 1 (7.0%, 168 of 2399) than with type 2 diabetes (2.6%, nine of 341) (P < 0.002). The median number of SH events per youth who had at least one SH event in the past 6 months was 1 for both type 1 type 2 diabetes. For youth with type 1 diabetes, those who reported SH events were older, were more likely to have obesity or to be physically active, and had lower HbA1c. After adjustments, one unit increase in HbA1c was associated with 16% lower likelihood (OR 0.84, 95% CI 0.75, 0.94) and being physically active was associated with an 87% higher likelihood (OR 1.87, 95% CI 1.23, 2.86) of reporting a SH event. There were too few SH events among youth with type 2 diabetes to analyse further.

CONCLUSIONS

In youth with diabetes, SH was common even within a short 6-month window. Better understanding the causes of SH may help prevent them from occurring.

The association between hypoglycemia and hospital use, food insufficiency, and unstable housing conditions: a cross-sectional study among patients with type 2 diabetes in Sudan

Objectives

Hypoglycemia is associated with mortality and healthcare utilization. We aimed to assess hypoglycemia risk and Hospital use among Sudanese patients with type 2 diabetes.

Results

One hundred and fifty-nine patients with type 2 diabetes attending a diabetes center in Omdurman, Sudan during the period from June to September 2018were approached. A structured questionnaire based on hypoglycemia risk and Hospital use, Fasting plasma glucose (FPG) and the glycated hemoglobin (HbA_1c) was used to interview the patients. Participants (age 58.13 ± 9.96 years), 4.4%, 14.5%, and 81.1% were at high, moderate, and low hypoglycemia respectively, 66% reported food insufficiency, while 15.1% had unstable housing conditions. No relationship was evident between the hypoglycemia risk, gender, unstable housing conditions, food insufficiency, fasting plasma glucose,HbA_1c, and the duration since the diagnosis of diabetes. A considerable number (18.9%) of Sudanese patients with diabetes were at moderate/high risk of hypoglycemia and Hospital use, including hypoglycemia risk and hospital use assessment in the holistic care of diabetes are recommended.

Hypoglycemia Among Patients with Type 2 Diabetes: Epidemiology, Risk Factors, and Prevention Strategies

PURPOSE OF REVIEW

Hypoglycemia is the most common and often treatment-limiting serious adverse effect of diabetes therapy. Despite being potentially preventable, hypoglycemia in type 2 diabetes incurs substantial personal and societal burden. We review the epidemiology of hypoglycemia in type 2 diabetes, discuss key risk factors, and introduce potential prevention strategies.

RECENT FINDINGS

Reported rates of hypoglycemia in type 2 diabetes vary widely as there is marked heterogeneity in how hypoglycemia is defined, measured, and reported. In randomized controlled trials, rates of severe hypoglycemia ranged from 0.7 to 12 per 100 person-years. In observational studies, hospitalizations or emergency department visits for hypoglycemia were experienced by 0.2 (patients treated without insulin or sulfonylurea) to 2.0 (insulin or sulfonylurea users) per 100 person-years. Patient-reported hypoglycemia is much more common. Over the course of 6 months, 1-4% non-insulin users reported need for medical attention for hypoglycemia; 1-17%, need for any assistance; and 46-58%, any hypoglycemia symptoms. Similarly, over a 12-month period, 4-17% of insulin-treated patients reported needing assistance and 37-64% experienced any hypoglycemic symptoms. Hypoglycemia is most common among older patients with multiple or advanced comorbidities, patients with long diabetes duration, or patients with a prior history of hypoglycemia. Insulin and sulfonylurea use, food insecurity, and fasting also increase hypoglycemia risk. Clinical decision support tools may help identify at-risk patients. Prospective trials of efforts to reduce hypoglycemia risk are needed, and there is emerging evidence supporting multidisciplinary interventions including treatment de-intensification, use of diabetes technologies, diabetes self-management, and social support. Hypoglycemia among patients with type 2 diabetes is common. Patient-centered multidisciplinary care may help proactively identify at-risk patients and address the multiplicity of factors contributing to hypoglycemia occurrence.

Challenges Imposed By Hypoglycemia in Adults With Type 1 Diabetes

Little is known regarding how hypoglycemia and associated fears influence day-to-day life among adults with type 1 diabetes (T1DM) who use contemporary diabetes management strategies. To address this gap, we performed an exploratory qualitative study with five focus groups of 30 people aged 20 to 57 years with T1DM. Sessions were audiotaped and transcribed, and then analyzed. Eight themes emerged: (a) hypoglycemic worry, (b) unpredictability and loss of control, (c) contending with life stress, (d) exercise benefits and challenges, (e) a changed relationship with food, (f) sleep fears, (g) a love/hate relationship with technology, and (h) coping strategies to make it better. Fear of hypoglycemia, diabetes management, and work demands confer a high degree of stress. Challenges surround food, exercise, and sleep. Technology is important but does not relieve fear of hypoglycemia. Developing strong coping skills and creating a safety net of support are necessary.

Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycaemia awareness or severe hypoglycaemia treated with multiple daily insulin injections (HypoDE): a multicentre, randomised controlled trial

BACKGROUND

The effectiveness of real-time continuous glucose monitoring (rtCGM) in avoidance of hypoglycaemia among high-risk individuals with type 1 diabetes treated with multiple daily insulin injections (MDI) is unknown. We aimed to ascertain whether the incidence and severity of hypoglycaemia can be reduced through use of rtCGM in these individuals.

METHODS

The HypoDE study was a 6-month, multicentre, open-label, parallel, randomised controlled trial done at 12 diabetes practices in Germany. Eligible participants had type 1 diabetes and a history of impaired hypoglycaemia awareness or severe hypoglycaemia during the previous year. All participants wore a masked rtCGM system for 28 days and were then randomly assigned to 26 weeks of unmasked rtCGM (Dexcom G5 Mobile system) or to the control group (continuing with self-monitoring of blood glucose). Block randomisation with 1:1 allocation was done centrally, with the study site as the stratifying variable. Masking of participants and study sites was not possible. Control participants wore a masked rtCGM system during the follow-up phase (weeks 22-26). The primary outcome was the baseline-adjusted number of hypoglycaemic events (defined as glucose ≤3·0 mmol/L for ≥20 min) during the follow-up phase. The full dataset analysis comprised participants who wore the rtCGM system during the baseline and follow-up phases. The intention-to-treat analysis comprised all randomised participants. This trial is registered with ClinicalTrials.gov, number NCT02671968.

FINDINGS

Between March 4, 2016, and Jan 12, 2017, 149 participants were randomly assigned (n=74 to the control group; n=75 to the rtCGM group) and 141 completed the follow-up phase (n=66 in the control group, n=75 in the rtCGM group). The mean number of hypoglycaemic events per 28 days among participants in the rtCGM group was reduced from 10·8 (SD 10·0) to 3·5 (4·7); reductions among control participants were negligible (from 14·4 [12·4] to 13·7 [11·6]). Incidence of hypoglycaemic events decreased by 72% for participants in the rtCGM group (incidence rate ratio 0·28 [95% CI 0·20-0·39], p<0·0001). 18 serious adverse events were reported: seven in the control group, ten in the rtCGM group, and one before randomisation. No event was considered to be related to the investigational device.

INTERPRETATION

Usage of rtCGM reduced the number of hypoglycaemic events in individuals with type 1 diabetes treated by MDI and with impaired hypoglycaemia awareness or severe hypoglycaemia.

FUNDING

Dexcom Inc.