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He YF, Hu XD, Liu JQ, Li HM, Lu SF. Bariatric surgery and diabetes: Current challenges and perspectives. World J Diabetes 2024; 15:1692-1703. [PMID: 39192861 PMCID: PMC11346089 DOI: 10.4239/wjd.v15.i8.1692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/13/2024] [Accepted: 07/09/2024] [Indexed: 07/25/2024] Open
Abstract
Diabetes mellitus (DM) and obesity have become public issues of global concern. Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach; however, there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM. In this review, we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM. I believe that our insights will be of great help to clinicians in their daily practice.
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Affiliation(s)
- Yan-Fei He
- Health Management Center, The Sixth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Xiao-Dong Hu
- Department of Endocrinology, The Sixth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Jun-Qiang Liu
- Department of Thoracic Surgery, The Sixth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Hu-Ming Li
- Department of Respiratory Medicine, The Sixth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Shuang-Feng Lu
- Health Management Center, The Sixth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
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2
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Alshannaq H, Pollock RF, Joubert M, Ahmed W, Norman GJ, Lynch PM, Roze S. Cost-utility of real-time continuous glucose monitoring versus self-monitoring of blood glucose in people with insulin-treated Type II diabetes in France. J Comp Eff Res 2024; 13:e230174. [PMID: 38294332 PMCID: PMC10945438 DOI: 10.57264/cer-2023-0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
Aim: Clinical trials and real-world data for Type II diabetes both show that glycated hemoglobin (HbA1c) levels and hypoglycemia occurrence can be reduced by real-time continuous glucose monitoring (rt-CGM) versus self-monitoring of blood glucose (SMBG). The present cost-utility study investigated the long-term health economic outcomes associated with using rt-CGM versus SMBG in people with insulin-treated Type II diabetes in France. Materials & methods: Effectiveness data were obtained from a real-world study, which showed rt-CGM reduced HbA1c by 0.56% (6.1 mmol/mol) versus sustained SMBG. Analyses were conducted using the IQVIA Core Diabetes Model. A French payer perspective was adopted over a lifetime horizon for a cohort aged 64.5 years with baseline HbA1c of 8.3% (67 mmol/mol). A willingness-to-pay threshold of €147,093 was used, and future costs and outcomes were discounted at 4% annually. Results: The analysis projected quality-adjusted life expectancy was 8.50 quality-adjusted life years (QALYs) for rt-CGM versus 8.03 QALYs for SMBG (difference: 0.47 QALYs), while total mean lifetime costs were €93,978 for rt-CGM versus €82,834 for SMBG (difference: €11,144). This yielded an incremental cost-utility ratio (ICUR) of €23,772 per QALY gained for rt-CGM versus SMBG. Results were particularly sensitive to changes in the treatment effect (i.e., change in HbA1c), annual price and quality of life benefit associated with rt-CGM, SMBG frequency, baseline patient age and complication costs. Conclusion: The use of rt-CGM is likely to be cost-effective versus SMBG for people with insulin-treated Type II diabetes in France.
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Affiliation(s)
- Hamza Alshannaq
- Dexcom, San Diego, CA, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Michael Joubert
- Diabetes Care Unit, Caen University Hospital, UNICAEN, Caen, France
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3
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Zhang P, Bao Y, Chen M, Zhang H, Zhu D, Ji L, Li X, Ji J, Zhao F, Fisher EB, Zhao Y, Duolikun N, Wang D, Jia W. Changes of health-related quality of life after initiating basal insulin treatment among people with type 2 diabetes. Medicine (Baltimore) 2023; 102:e34718. [PMID: 37653806 PMCID: PMC10470713 DOI: 10.1097/md.0000000000034718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
To assess the association between insulin regimens and health-related quality of life (HRQoL) after the introduction of basal insulin (BI) among people with type 2 diabetes in real-world clinical settings. 16,339 registered people with diabetes who had inadequate glycaemic control by oral agents initiated BI (either single BI or Basal-bolus) and completed a 6-month follow-up from 209 hospitals were included in the analyses. At the end of the follow-up, the switches of insulin regimens, change of HRQoL (EQ-5D-3L) and their associations were assessed. Initial insulin regimens of single BI and of basal-bolus (BI included Glargine, Detemir, and Neutral Protamine Hagedorn) accounted for 75.6% and 24.4%, respectively. At 6 months, regimens used were BI alone (65.2%), basal-bolus (10.4%), and premixed (6.4%), whereas 17.9% stopped all insulin therapy. The visual analogue scale score increased by 5.46 (P < .001), and the index value increased slightly by 0.02 (P < .001). Univariate analysis showed that people with diabetes taking basal-bolus regimen had the greatest improvement on HRQoL in all dimensions, especially in the reduction of the percentage of Pain/Discomfort (by 10.03%) and Anxiety/Depression (by 11.21%). In multivariable analysis, single BI or premixed insulin at 6 months was associated with more improvement of visual analogue scale score compared with stopping all insulin. Improved HRQoL was observed after initiating BI in people with type 2 diabetes . If the same achievement on HbA1c control can be guaranteed, single BI is preferred to other regimens from the viewpoint of HRQoL. Basal-bolus has the most significant potential to increase HRQoL, however, the people with diabetes characteristics differ from those initiating BI alone. Further longitudinal cohort study with a longer study period might be necessary to evaluate the certain effect.
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Affiliation(s)
- Puhong Zhang
- The George Institute for Global Health, Beijing, China
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW
| | - Yuqian Bao
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Minyuan Chen
- The George Institute for Global Health, Beijing, China
| | - Heng Zhang
- The George Institute for Global Health, Beijing, China
| | - Dongshan Zhu
- The George Institute for Global Health, Beijing, China
| | - Linong Ji
- The George Institute for Global Health, Beijing, China
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, China
| | - Xian Li
- The George Institute for Global Health, Beijing, China
| | - Jiachao Ji
- The George Institute for Global Health, Beijing, China
| | - Fang Zhao
- The George Institute for Global Health, Beijing, China
| | - Edwin B. Fisher
- Peers for Progress and Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Yang Zhao
- The George Institute for Global Health, Beijing, China
- WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases, Melbourne, VIC
| | | | - Du Wang
- The George Institute for Global Health, Beijing, China
| | - Weiping Jia
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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4
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Xie LF, Roy-Fleming A, Haag S, Costa DD, Brazeau AS. Development of the Support self-guided, web application for adults living with type 1 diabetes in Canada by a multi-disciplinary team using a people-oriented approach based on the Behaviour Change Wheel. Digit Health 2023; 9:20552076231152760. [PMID: 36762025 PMCID: PMC9903036 DOI: 10.1177/20552076231152760] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 01/04/2023] [Indexed: 01/26/2023] Open
Abstract
Background Diabetes self-management education and support (DSME/S) are central in type 1 diabetes (T1D) where individuals are responsible for 95% of care. In-person DSME/S programs have been proven clinically effective (e.g. optimizing glycemic management, improving diabetes-related behaviors) but are limited by a lack of accessibility and long-term follow-up. Self-guided digital tools such as web applications (web apps) can be an alternative for delivering DSME/S. Objective This article describes the development of Support, a behavioral theory-based, self-guided, web application for adults living with T1D in the province of Quebec, Canada. Methods A multi-disciplinary team developed Support. Patient partners first proposed its focus, learning topics, and expressed barriers to using digital tools for DSME/S. These barriers were analyzed based on the Behaviour Change Wheel. A group of healthcare professionals (HCPs) drafted the evidence-based learning content which was reviewed by external HCPs and by patient partners. Results Support is a bilingual (English and French) web app accessible at any time via the Internet. It has four learning paths focusing on hypoglycemia and based on the user's method of diabetes treatment. Learning modules are divided into six categories with a maximum of three learning levels. It contains features such as a discussion forum, videos, and quizzes to ensure interactivity, provide social support, and maintain the motivation and long-term engagement of users. Conclusions To the best of the authors' knowledge, Support is the first self-guided evidence-based web app for adults living with T1D. It is currently under study to evaluate its feasibility and clinical impacts.
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Affiliation(s)
- Li Feng Xie
- School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Canada
| | - Amélie Roy-Fleming
- School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Canada
| | - Sarah Haag
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
| | - Deborah Da Costa
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada,Department of Medicine, McGill University, Sainte-Anne-de-Bellevue, Canada
| | - Anne-Sophie Brazeau
- School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Canada,Montreal Diabetes Research Center, Montreal, Quebec, Canada,Anne-Sophie Brazeau, School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Canada.
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5
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Weiner M, Adeoye P, Boeh MJ, Bodke K, Broughton J, Butler AR, Dafferner ML, Dirlam LA, Ferguson D, Keegan AL, Keith NR, Lee JL, McCorkle CB, Pino DG, Shan M, Srinivas P, Tang Q, Teal E, Tu W, Savoy A, Callahan CM, Clark DO. Continuous Glucose Monitoring and Other Wearable Devices to Assess Hypoglycemia among Older Adult Outpatients with Diabetes Mellitus. Appl Clin Inform 2023; 14:37-44. [PMID: 36351548 PMCID: PMC9848893 DOI: 10.1055/a-1975-4136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Hypoglycemia (HG) causes symptoms that can be fatal, and confers risk of dementia. Wearable devices can improve measurement and feedback to patients and clinicians about HG events and risk. OBJECTIVES The aim of the study is to determine whether vulnerable older adults could use wearables, and explore HG frequency over 2 weeks. METHODS First, 10 participants with diabetes mellitus piloted a continuous glucometer, physical activity monitor, electronic medication bottles, and smartphones facilitating prompts about medications, behaviors, and symptoms. They reviewed graphs of glucose values, and were asked about the monitoring experience. Next, a larger sample (N = 70) wore glucometers and activity monitors, and used the smartphone and bottles, for 2 weeks. Participants provided feedback about the devices. Descriptive statistics summarized demographics, baseline experiences, behaviors, and HG. RESULTS In the initial pilot, 10 patients aged 50 to 85 participated. Problems addressed included failure of the glucometer adhesive. Patients sought understanding of graphs, often requiring some assistance with interpretation. Among 70 patients in subsequent testing, 67% were African-American, 59% were women. Nearly one-fourth (23%) indicated that they never check their blood sugars. Previous HG was reported by 67%. In 2 weeks of monitoring, 73% had HG (glucose ≤70 mg/dL), and 42% had serious, clinically significant HG (glucose under 54 mg/dL). Eight patients with HG also had HG by home-based blood glucometry. Nearly a third of daytime prompts were unanswered. In 24% of participants, continuous glucometers became detached. CONCLUSION Continuous glucometry occurred for 2 weeks in an older vulnerable population, but devices posed wearability challenges. Most patients experienced HG, often serious in magnitude. This suggests important opportunities to improve wearability and decrease HG frequency among this population.
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Affiliation(s)
- Michael Weiner
- Department of Medicine, Indiana University, Indianapolis, Indiana,Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13–416, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana,Address for correspondence Michael Weiner, MD, MPH Regenstrief Institute, Inc.1101 West 10th Street, Indianapolis, IN 46202United States
| | - Philip Adeoye
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | | | - Kunal Bodke
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | | | - Anietra R. Butler
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | | | - Lindsay A. Dirlam
- Lifestyle Health and Wellness, Eskenazi Health, Indianapolis, Indiana
| | - Denisha Ferguson
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Amanda L. Keegan
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - NiCole R. Keith
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana,Department of Kinesiology, Indiana University, Indianapolis, Indiana
| | - Joy L. Lee
- Department of Medicine, Indiana University, Indianapolis, Indiana,Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Corrina B. McCorkle
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Daniel G. Pino
- Department of Medicine, Indiana University, Indianapolis, Indiana,Lifestyle Health and Wellness, Eskenazi Health, Indianapolis, Indiana
| | - Mu Shan
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana
| | - Preethi Srinivas
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Qing Tang
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana
| | - Evgenia Teal
- Data Services, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Wanzhu Tu
- Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana,Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana
| | - April Savoy
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana,Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13–416, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana,Computer and Information Technology, Purdue School of Engineering and Technology, Indiana University-Purdue University Indianapolis, Indiana
| | - Christopher M. Callahan
- Department of Medicine, Indiana University, Indianapolis, Indiana,Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana,Senior Care, Eskenazi Health, Indianapolis, Indiana
| | - Daniel O. Clark
- Department of Medicine, Indiana University, Indianapolis, Indiana,Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
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6
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Kant R, Antony MA, Geurkink D, Gilreath N, Chandra L, Zipprer E, Munir KM, Chandra R, Parker VG, Verma V. Real-time continuous glucose monitoring improves glycemic control and reduces hypoglycemia: Real-world data. Prim Care Diabetes 2022; 16:786-790. [PMID: 36117090 DOI: 10.1016/j.pcd.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 08/31/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
AIM To study the effect of real time continuous glucose monitor (RT-CGM) use on glycemic parameters in patients with diabetes mellitus (DM) in real world practice. METHODS We retrospectively studied 91 adult subjects with DM who had been using Dexcom™ RT-CGM. Two consecutive hemoglobin A1c (HbA1c), both prior to and after at least 3 months of RT-CGM initiation, were collected. A total of 31 subjects completed a 5-14 day user blinded CGM using a Freestyle Libre™ prior to RT-CGM initiation. The first two week period following at least 3 months use of RT-CGM was analyzed for CGM metrics. RESULTS A total of 51.6 % of subjects had T1DM, 34.1 % used continuous subcutaneous insulin infusion (CSII), and 62.6 % had DM for > 10 years. Both HbA1c obtained following RT-CGM initiation decreased significantly compared to baseline (8.11 + 1.47% vs 7.69 + 1.25 %; P = 0.002 & 8.16 + 1.51 % vs 7.62 + 1.06 %; P = 0.001). Subjects with baseline HbA1c > 7.0 % showed even more robust reduction in both HbA1c after RT-CGM initiation (8.74 + 1.24 % vs 7.99 + 1.22 %; P = 0.000 & 8.74 + 1.32 % vs 7.85 + 1.07 %; P = 0.001). On comparison of CGM metrics, there was a significant reduction in time spent in hypoglycemia (sugars < 70 mg/dl) including severe hypoglycemia (sugars < 54 mg/dl) after initiation of the RT-CGM (9.16 + 8.68 % vs 1.29 + 2.21 %; P = <0.001 & 4.58 + 5.43 % vs 0.28 + 0.58 %; P = <0.001). CoV of glucose was also decreased significantly (39.61 + 9.36 % vs 31.06 + 6.74 %; P = <0.001) with RT- CGM use. CONCLUSION RT-CGM use for at least 3 months in patients with DM results in meaningful HbA1c reductions with stable glycemic control without increasing the risk of hypoglycemia.
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Affiliation(s)
- Ravi Kant
- Division of Endocrinology, Diabetes and Nutrition, Medical University of South Carolina, AnMed Campus, Anderson, SC 29621, United States
| | - Mc Anto Antony
- Division of Endocrinology, Diabetes and Nutrition, Medical University of South Carolina, AnMed Campus, Anderson, SC 29621, United States
| | - David Geurkink
- Department of Medicine, Medical University of South Carolina, AnMed Campus, Anderson, SC 29621, United States
| | - Nathan Gilreath
- Department of Medicine, Medical University of South Carolina, AnMed Campus, Anderson, SC 29621, United States
| | - Lakshya Chandra
- Department of Medicine, Bon Secours Saint Francis Health System, Greenville, SC 29601, United States
| | - Elizabeth Zipprer
- Department of Surgery, MercyOne Des Moines, Des Moines, Iowa, IA 50314, Unites States
| | - Kashif M Munir
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Rashmi Chandra
- Department of Medicine, Medical University of South Carolina, AnMed Campus, Anderson, SC 29621, United States
| | - Veronica G Parker
- Biostatistician, School of Nursing, Clemson University, Clemson, SC 29634, United States
| | - Vipin Verma
- Department of Medicine, Medical University of South Carolina, AnMed Campus, Anderson, SC 29621, United States.
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7
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Pease AJ, Zoungas S, Callander E, Jones TW, Johnson SR, Holmes-Walker DJ, Bloom DE, Davis EA, Zomer E. Nationally Subsidized Continuous Glucose Monitoring: A Cost-effectiveness Analysis. Diabetes Care 2022; 45:2611-2619. [PMID: 36162008 DOI: 10.2337/dc22-0951] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/22/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Continuous Glucose Monitoring (CGM) Initiative recently introduced universal subsidized CGM funding for people with type 1 diabetes under 21 years of age in Australia. We thus aimed to evaluate the cost-effectiveness of this CGM Initiative based on national implementation data and project the economic impact of extending the subsidy to all age-groups. RESEARCH DESIGN AND METHODS We used a patient-level Markov model to simulate disease progression for young people with type 1 diabetes and compared government-subsidized access to CGM with the previous user-funded system. Three years of real-world clinical input data were sourced from analysis of the Australasian Diabetes Data Network and National Diabetes Services Scheme registries. Costs were considered from the Australian health care system's perspective. An annual discount rate of 5% was applied to future costs and outcomes. Uncertainty was evaluated with probabilistic and deterministic sensitivity analyses. RESULTS Government-subsidized CGM funding for young people with type 1 diabetes compared with a completely user-funded model resulted in an incremental cost-effectiveness ratio (ICER) of AUD 39,518 per quality-adjusted life-year (QALY) gained. Most simulations (85%) were below the commonly accepted willingness-to-pay threshold of AUD 50,000 per QALY gained in Australia. Sensitivity analyses indicated that base-case results were robust, though strongly impacted by the cost of CGM devices. Extending the CGM Initiative throughout adulthood resulted in an ICER of AUD 34,890 per QALY gained. CONCLUSIONS Providing subsidized access to CGM for people with type 1 diabetes was found to be cost-effective compared with a completely user-funded model in Australia.
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Affiliation(s)
- Anthony J Pease
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia.,Alfred Health, Melbourne, Victoria, Australia
| | - Emily Callander
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Timothy W Jones
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Stephanie R Johnson
- Department of Endocrinology and Diabetes, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - D Jane Holmes-Walker
- Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - David E Bloom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Elizabeth A Davis
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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8
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Pease A, Callander E, Zomer E, Abraham MB, Davis EA, Jones TW, Liew D, Zoungas S. The Cost of Control: Cost-effectiveness Analysis of Hybrid Closed-Loop Therapy in Youth. Diabetes Care 2022; 45:1971-1980. [PMID: 35775453 DOI: 10.2337/dc21-2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/18/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hybrid closed-loop (HCL) therapy is an efficacious management strategy for young people with type 1 diabetes. However, high costs prevent equitable access. We thus sought to evaluate the cost-effectiveness of HCL therapy compared with current care among young people with type 1 diabetes in Australia. RESEARCH DESIGN AND METHODS A patient-level Markov model was constructed to simulate disease progression for young people with type 1 diabetes using HCL therapy versus current care, with follow-up from 12 until 25 years of age. Downstream health and economic consequences were compared via decision analysis. Treatment effects and proportions using different technologies to define "current care" were based primarily on data from an Australian pediatric randomized controlled trial. Transition probabilities and utilities for health states were sourced from published studies. Costs were considered from the Australian health care system's perspective. An annual discount rate of 5% was applied to future costs and outcomes. Uncertainty was evaluated with probabilistic and deterministic sensitivity analyses. RESULTS Use of HCL therapy resulted in an incremental cost-effectiveness ratio of Australian dollars (AUD) $32,789 per quality-adjusted life year (QALY) gained. The majority of simulations (93.3%) were below the commonly accepted willingness-to-pay threshold of AUD $50,000 per QALY gained in Australia. Sensitivity analyses indicated that the base-case results were robust. CONCLUSIONS In this first cost-effectiveness analysis of HCL technologies for the management of young people with type 1 diabetes, HCL therapy was found to be cost-effective compared with current care in Australia.
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Affiliation(s)
- Anthony Pease
- School Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia
| | - Emily Callander
- School Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ella Zomer
- School Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mary B Abraham
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics, within the Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth A Davis
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics, within the Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Timothy W Jones
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia.,Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatrics, within the Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Danny Liew
- School Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Alfred Health, Melbourne, Victoria, Australia
| | - Sophia Zoungas
- School Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia.,Alfred Health, Melbourne, Victoria, Australia
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9
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Søholm U, Broadley M, Zaremba N, Divilly P, Nefs G, Mahmoudi Z, de Galan B, Pedersen-Bjergaard U, Brennan A, Pollard DJ, McCrimmon RJ, A Amiel S, Hendrieckx C, Speight J, Choudhary P, Pouwer F. Investigating the day-to-day impact of hypoglycaemia in adults with type 1 or type 2 diabetes: design and validation protocol of the Hypo-METRICS application. BMJ Open 2022; 12:e051651. [PMID: 35105572 PMCID: PMC8808414 DOI: 10.1136/bmjopen-2021-051651] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Hypoglycaemia is a frequent adverse event and major barrier for achieving optimal blood glucose levels in people with type 1 or type 2 diabetes using insulin. The Hypo-RESOLVE (Hypoglycaemia-Redefining SOLutions for better liVEs) consortium aims to further our understanding of the day-to-day impact of hypoglycaemia. The Hypo-METRICS (Hypoglycaemia-MEasurement, ThResholds and ImpaCtS) application (app) is a novel app for smartphones. This app is developed as part of the Hypo-RESOLVE project, using ecological momentary assessment methods that will minimise recall bias and allow for robust investigation of the day-to-day impact of hypoglycaemia. In this paper, the development and planned psychometric analyses of the app are described. METHODS AND ANALYSIS The three phases of development of the Hypo-METRICS app are: (1) establish a working group-comprising diabetologists, psychologists and people with diabetes-to define the problem and identify relevant areas of daily functioning; (2) develop app items, with user-testing, and implement into the app platform; and (3) plan a large-scale, multicountry study including interviews with users and psychometric validation. The app includes 7 modules (29 unique items) assessing: self-report of hypoglycaemic episodes (during the day and night, respectively), sleep quality, well-being/cognitive function, social interactions, fear of hypoglycaemia/hyperglycaemia and work/productivity. The app is designed for use within three fixed time intervals per day (morning, afternoon and evening). The first version was released mid-2020 for use (in conjunction with continuous glucose monitoring and activity tracking) in the Hypo-METRICS study; an international observational longitudinal study. As part of this study, semistructured user-experience interviews and psychometric analyses will be conducted. ETHICS AND DISSEMINATION Use of the novel Hypo-METRICS app in a multicountry clinical study has received ethical approval in each of the five countries involved (Oxford B Research Ethics Committee, CMO Region Arnhem-Nijmegen, Ethikkommission der Medizinischen Universität Graz, Videnskabsetisk Komite for Region Hovedstaden and the Comite Die Protection Des Personnes SUD Mediterranne IV). The results from the study will be published in peer review journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT04304963.
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Affiliation(s)
- Uffe Søholm
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Natalie Zaremba
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Patrick Divilly
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Giesje Nefs
- Department of Medical Psychology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Noord-Brabant, The Netherlands
- Diabeter, National treatment and research center for children, adolescents and adults with type 1 diabetes, Rotterdam, Netherlands
| | - Zeinab Mahmoudi
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Digital Therapeutics, Novo Nordisk A/S, Søborg, Denmark
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Division of Endocrinology and Metabolic Disease, Maastricht, Limburg, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology & Nephrology, Endocrine Section, Nordsjællands Hospital, Hillerød, Hillerød, Denmark
- Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| | - Alan Brennan
- School of Health & Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel John Pollard
- School of Health & Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Stephanie A Amiel
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Christel Hendrieckx
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Pratik Choudhary
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Diabetes Research Centre, University of Leicester, UK LE5 4PW, Leicester, UK
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Steno Diabetes Center Odense (SDCO), Odense, Denmark
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Chantzaras A, Yfantopoulos J. Evaluating the Incidence and Risk Factors Associated With Mild and Severe Hypoglycemia in Insulin-Treated Type 2 Diabetes. Value Health Reg Issues 2022; 30:9-17. [PMID: 35033801 DOI: 10.1016/j.vhri.2021.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/10/2021] [Accepted: 10/14/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study to assess the incidence rates and risk factors of hypoglycemia in a wide real-life sample of patients with insulin-treated type 2 diabetes mellitus. METHODS In a prospective epidemiological study, data from 817 subjects were collected from medical records and via interviews. Over a 3-month period, hypoglycemic episodes were recorded via self-measurement of glucose levels at least twice daily. Cox proportional and negative binomial multivariable models were applied to estimate adjusted and unadjusted hazard ratios and incidence rate ratios of hypoglycemic events. RESULTS Of the 817 patients, 52.9% experienced hypoglycemia, 38.1% had only nonsevere episodes, and 14.8% had at least 1 severe episode. Total events per patient-year were estimated at 13.3 (±24.8), with 11.8 (±21.6) and 1.4 (±4.7) being nonsevere and severe, respectively. History of hypoglycemia and severe hypoglycemia were consistent risk factors of hypoglycemia. Intensification of therapy was associated with higher incidence rates, whereas the effect on the hazard rates was more moderate. Longer duration of insulin therapy and the presence of congestive heart failure were associated with a higher risk of developing and frequency of hypoglycemia. Hypoglycemia awareness was found to independently affect only mild hypoglycemia. CONCLUSIONS Hypoglycemia is a common complication in patients with insulin-treated type 2 diabetes mellitus. The risk factors of developing hypoglycemia are to some extent different from those of the frequency of hypoglycemic episodes. Particular attention is required for patients with recurrent hypoglycemic events and on intensive antidiabetic therapy.
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Affiliation(s)
- Athanasios Chantzaras
- School of Economics and Political Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - John Yfantopoulos
- School of Economics and Political Sciences, National and Kapodistrian University of Athens, Athens, Greece.
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Yale JF, Osumili B, Mitchell BD, Hunt B, Sohi G, Jeddi M, Mojdami D, Valentine WJ. Evaluation of the cost and medical resource use outcomes associated with nasal glucagon versus injectable glucagon for treatment of severe hypoglycemia in people with diabetes in Canada: a modeling analysis. J Med Econ 2022; 25:238-248. [PMID: 35094622 DOI: 10.1080/13696998.2022.2035131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Treatments for severe hypoglycemia aim to restore blood glucose through successful administration of rescue therapy, and choosing the most effective and cost-effective option will improve outcomes for patients and may reduce costs for healthcare payers. The present analysis aimed to compare costs and use of medical services with nasal glucagon and injectable glucagon in people with type 1 and 2 diabetes in Canada when used to treat severe hypoglycemic events when impaired consciousness precludes treatment with oral carbohydrates using an economic model, based on differences in the frequency of successful administration of the two interventions. METHODS A decision tree model was prepared in Microsoft Excel to project outcomes with nasal glucagon and injectable glucagon. The model structure reflected real-world decision-making and treatment outcomes, based on Canada-specific sources. The model captured the use of glucagon, emergency medical services (EMS), emergency room, inpatient stay, and follow-up care. Costs were accounted for in 2019 Canadian dollars (CAD). RESULTS Nasal glucagon was associated with reduced use of all medical services compared with injectable glucagon. EMS call outs were projected to be reduced by 45%, emergency room treatments by 52%, and inpatient stays by 13%. Use of nasal glucagon was associated with reduced direct, indirect, and combined costs of CAD 1,249, CAD 460, and CAD 1,709 per severe hypoglycemic event, respectively, due to avoided EMS call outs and hospital costs, resulting from a higher proportion of successful administrations. CONCLUSIONS When a patient with type 1 or type 2 diabetes is being treated for a severe hypoglycemic event when impaired consciousness precludes treatment with oral carbohydrate, use of nasal glucagon was projected to be dominant versus injectable glucagon in Canada reducing costs and use of medical services.
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Affiliation(s)
- Jean-François Yale
- Department of Medicine, McGill University Health Center, McGill University, Montréal, Canada
| | | | | | - Barnaby Hunt
- Ossian Health Economics and Communications, Basel, Switzerland
| | | | - Mark Jeddi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Chevalier N, Penfornis A, Riveline JP, Chartier F, Mitchell B, Osumili B, Spaepen E, Snoek F, Peyrot M, Benabbad I. Conversations and Reactions Around Severe Hypoglycemia (CRASH) global survey of people with type-1 diabetes or insulin-treated type-2 diabetes and caregivers: findings from the French cohort. ANNALES D'ENDOCRINOLOGIE 2021; 83:16-26. [PMID: 34871601 DOI: 10.1016/j.ando.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022]
Abstract
AIM The objective of the CRASH (Conversations and Reactions Around Severe Hypoglycemia) survey was to further our understanding of the characteristics, experience, behavior and conversations with healthcare professionals (HCPs) of persons with diabetes (PWD) receiving insulin, and of their caregivers (CGs), concerning hypoglycemia requiring external assistance (severe hypoglycemic events [SHEs]). METHODS CRASH was an online cross-sectional survey conducted across eight countries. The PWDs with self-reported type 1 (T1D) or insulin-treated type 2 (T2D) diabetes were aged ≥18 years and had experienced one or more SHEs in past the 3 years; CGs were non-medical professionals aged ≥18 years, caring for a PWD meeting all the above criteria except for PWD age (≥4 rather than ≥18 years). The present report is a descriptive analysis of data from France. RESULTS Among PWDs who had ever discussed SHEs with an HCP, 38.9% of T1D PWDs and 50.0% of T2D PWDs reported that SHEs were discussed at every consultation; 26.3% and 8.8% respectively had not discussed the most recent SHE with an HCP. 35.7% of T1D PWDs and 53.8% of T2D PWDs reported that glucagon was not available to them at the time of their most recent SHE. Only 16.9% of T1D PWDs and 6.5% of T2D PWDs who had discussed their most recent SHE with an HCP reported that the HCP recommended obtaining a glucagon kit or asked them to confirm that they already had one. High proportions of PWDs and CGs reported that the most recent SHE had made them feel unprepared, scared and helpless and had affected mood, emotional state and activities. CONCLUSION CRASH survey data from France identify a need for greater discussion about SHEs between HCPs and PWDs and their CGs, and reveal gaps in the diabetes education of PWDs and CGs.
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Affiliation(s)
- Nicolas Chevalier
- Université Côte d'Azur, Centre Hospitalier Universitaire, INSERM, C3M, Nice, France
| | - Alfred Penfornis
- Service d'endocrinologie, diabétologie et maladies métaboliques, Centre Hospitalier Sud Francilien, Corbeil-Essonnes Cedex, Université Paris-Saclay, France
| | - Jean-Pierre Riveline
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Paris, France; Unité INSERM U1138 Immunity and Metabolism in Diabetes, ImMeDiab Team, Centre de Recherches des Cordeliers, Paris, France; Université de Paris, Paris, France
| | | | | | | | | | - Frank Snoek
- Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Mark Peyrot
- Loyola University Maryland, Baltimore, MD, USA
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Ampudia-Blasco FJ, Artime E, Díaz S, Rubio M, Reviriego J, Mitchell B, Osumili B, Peyrot M, Pokrzywinski R, Spaepen E, Snoek F. Conversations and Reactions Around Severe Hypoglycaemia (CRASH): Spanish results of a global survey of people with type 1 diabetes or insulin-treated type 2 diabetes and caregivers. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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14
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Conversations and Reactions Around Severe Hypoglycaemia (CRASH): Spanish results of a global survey of people with type 1 diabetes or insulin-treated type 2 diabetes and caregivers. ENDOCRINOLOGIA, DIABETES Y NUTRICION 2021; 68:557-566. [PMID: 34872639 DOI: 10.1016/j.endien.2021.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/14/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Information on experience/management of severe hypoglycaemic events (SHEs) among people with insulin-treated diabetes (PWD) and caregivers (CGs) providing care to PWD was sought. MATERIALS AND METHODS An online cross-sectional survey was conducted in eight countries. INCLUSION CRITERIA PWD (aged≥18 years; self-reported type 1 [T1D] or insulin-treated type 2 [T2D] diabetes; experienced ≥1 SHE [hypoglycaemia requiring external assistance] in past 3 years); CGs (layperson aged ≥18 years; caring for PWD meeting all criteria above except age [≥4 years]). This descriptive analysis provides data from Spain. SHE-associated data relate to the most recent SHE. RESULTS Across all groups (T1D PWD, n=106; T2D PWD, n=88, T1D CG, n=87; T2D CG, n=96), 76-89% reported that the SHE occurred at home; most common cause was eating less than planned (38-53%). Most usual action during the SHE was to intake carbohydrates (67-84%); glucagon use was low (9-36%). Discussion of the SHE with their healthcare provider (HCP) was reported by 70-75% of PWD. During the SHE, 35-69% of PWD/CGs reported feeling scared, unprepared and/or helpless. CONCLUSIONS Most SHEs occurred outside the healthcare setting; treatment therefore depends greatly on CGs. SHEs have a negative emotional impact on PWD/CGs, underscoring the need for HCPs to discuss SHEs with PWD/CGs, and to provide tools and strategies to prevent and effectively manage SHEs.
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Botan V, Law GR, Laparidou D, Rowan E, Smith MD, Ridyard C, Brewster A, Spaight R, Spurr K, Mountain P, Dunmore S, James J, Roberts L, Khunti K, Siriwardena AN. The effects of a leaflet-based intervention, 'Hypos can strike twice', on recurrent hypoglycaemic attendances by ambulance services: A non-randomised stepped wedge study. Diabet Med 2021; 38:e14612. [PMID: 34053095 DOI: 10.1111/dme.14612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/24/2021] [Indexed: 12/18/2022]
Abstract
AIMS We aimed to investigate the effect of an intervention in which ambulance personnel provided advice supported by a booklet-'Hypos can strike twice'-issued following a hypoglycaemic event to prevent future ambulance attendances. METHODS We used a non-randomised stepped wedge-controlled design. The intervention was introduced at different times (steps) in different areas (clusters) of operation within East Midlands Ambulance Service NHS Trust (EMAS). During the first step (T0), no clusters were exposed to the intervention, and during the last step (T3), all clusters were exposed. Data were analysed using a general linear mixed model (GLMM) and an interrupted-time series analysis (ITSA). RESULTS The study included 4825 patients (mean age 65.42 years, SD 19.42; 2,166 females) experiencing hypoglycaemic events attended by EMAS. GLMM indicated a reduction in the number of unsuccessful attendances (i.e., attendance followed by a repeat attendance) in the final step of the intervention when compared to the first (odds ratio OR: 0.50, 95%CI: 0.33-0.76, p = 0.001). ITSA indicated a significant decrease in repeat ambulance attendances for hypoglycaemia-relative to the pre-intervention trend (p = 0.008). Furthermore, the hypoglycaemia care bundle was delivered in 66% of attendances during the intervention period, demonstrating a significant level of practice change (p < 0.001). CONCLUSION The 'Hypos can strike twice' intervention had a positive effect on reducing numbers of repeat attendances for hypoglycaemia and in achieving the care bundle. The study supports the use of information booklets by ambulance clinicians to prevent future attendances for recurrent hypoglycaemic events.
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Affiliation(s)
- Vanessa Botan
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Graham R Law
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Despina Laparidou
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Elise Rowan
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Murray D Smith
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - Colin Ridyard
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
| | | | - Robert Spaight
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust (EMAS), Nottingham, UK
| | | | | | - Sally Dunmore
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust (EMAS), Nottingham, UK
| | - June James
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Leon Roberts
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust (EMAS), Nottingham, UK
| | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Aloysius N Siriwardena
- Community and Health Research Unit and Lincoln Clinical Trials Unit, School of Health and Social Care, University of Lincoln, Lincoln, UK
- Clinical Audit and Research Unit, East Midlands Ambulance Service NHS Trust (EMAS), Nottingham, UK
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Wellens MJ, Vollenbrock CE, Dekker P, Boesten LSM, Geelhoed-Duijvestijn PH, de Vries-Velraeds MMC, Nefs G, Wolffenbuttel BHR, Aanstoot HJ, van Dijk PR. Residual C-peptide secretion and hypoglycemia awareness in people with type 1 diabetes. BMJ Open Diabetes Res Care 2021; 9:9/1/e002288. [PMID: 34526306 PMCID: PMC8444236 DOI: 10.1136/bmjdrc-2021-002288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/27/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION This study aimed to assess the association between fasting serum C-peptide levels and the presence of impaired awareness of hypoglycemia (IAH) in people with type 1 diabetes. RESEARCH DESIGN AND METHODS We performed a cross-sectional study among 509 individuals with type 1 diabetes (diabetes duration 5-65 years). Extensive clinical data and fasting serum C-peptide concentrations were collected and related to the presence or absence of IAH, which was evaluated using the validated Dutch version of the Clarke questionnaire. A multivariable logistic regression model was constructed to investigate the association of C-peptide and other clinical variables with IAH. RESULTS In 129 (25%) individuals, residual C-peptide secretion was detected, while 75 (15%) individuals reported IAH. The median (IQR) C-peptide concentration among all participants was 0.0 (0.0-3.9) pmol/L. The prevalence of severe hypoglycemia was lower in people with demonstrable C-peptide versus those with absent C-peptide (30% vs 41%, p=0.025). Individuals with IAH were older, had longer diabetes duration, more frequently had macrovascular and microvascular complications, and more often used antihypertensive drugs, antiplatelet agents and cholesterol-lowering medication. There was a strong association between IAH and having a severe hypoglycemia in the preceding year. In multivariable regression analysis, residual C-peptide, either continuously or dichotomous, was associated with lower prevalence of IAH (p=0.040-0.042), while age at diabetes onset (p=0.001), presence of microvascular complications (p=0.003) and body mass index (BMI) (p=0.003) were also independently associated with the presence of IAH. CONCLUSIONS Higher BMI, the presence of microvascular complications and higher age at diabetes onset were independent risk factors for IAH in people with type 1 diabetes, while residual C-peptide secretion was associated with lower risk of this complication.
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Affiliation(s)
- Martine J Wellens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Charlotte E Vollenbrock
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Pim Dekker
- Diabeter, Center for Paediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands
| | - Lianne S M Boesten
- Department of Clinical Chemistry, IJsselland Hospital, Capelle aan den IJssel, Netherlands
| | | | | | - Giesje Nefs
- Diabeter, Center for Paediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Henk-Jan Aanstoot
- Diabeter, Center for Paediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands
| | - Peter R van Dijk
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Thirumalai M, Zengul AG, Evans E. Challenges and Lessons Learned From a Telehealth Community Paramedicine Program for the Prevention of Hypoglycemia: Pre-Post Pilot Feasibility Study. JMIR Diabetes 2021; 6:e26941. [PMID: 34342593 PMCID: PMC8371490 DOI: 10.2196/26941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/26/2021] [Accepted: 06/17/2021] [Indexed: 12/03/2022] Open
Abstract
Background Prevention through Intervention is a community paramedicine program developed by Birmingham Fire and Rescue Services in Alabama. This program aims to reduce dependency on emergency medical services (EMS) for nonemergency-related events through education and to lower the frequency of emergency calls in underserved populations. A telehealth intervention with an emphasis on hypoglycemia was implemented to (1) tailor the intervention to meet the educational needs of participants and (2) facilitate follow-ups. A pre-post pilot feasibility evaluation of the telehealth intervention was conducted. Objective This paper describes the results of the feasibility evaluation, implementation challenges, and the lessons learned about the deployment of a hypoglycemia prevention program in an underserved area and its evaluation. Methods This single-arm pretest-posttest intervention included (1) an initial in-person visit (week 1), (2) 3 weekly telecoaching calls (weeks 2-4), (3) 1 biweekly call (week 6), and (4) a final in-person visit (week 8) for collecting posttest data from individuals who called EMS due to hypoglycemic events. In-person visits included educational sessions conducted by EMS personnel. Participants’ education included tailored content related to hypoglycemia. Weekly telecoaching calls focused on hypoglycemia symptom monitoring and education reinforcement via a telehealth dashboard. The primary measures focused on feasibility measures, and exploratory measures focused on the fear of hypoglycemia, self-efficacy, and a knowledge of diabetes. Results A total of 40 participants participated in the intervention. However, the study was marred with high attrition. The various factors behind the low retention rate were discussed. There was a decreasing trend in all three subdomains of the fear of hypoglycemia from pretest to posttest. There was also a significant increase in participants’ self-efficacy in hypoglycemia self-management (P=.03). Conclusions This study shows preliminary and promising results for a community-based intervention specifically for hypoglycemia. However, the socioeconomic setting in which the intervention was delivered may have resulted in high dropout rates and low attendance during the intervention, which are considerations for future telehealth studies. Trial Registration ClinicalTrials.gov NCT03665870; https://clinicaltrials.gov/ct2/show/NCT03665870
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Affiliation(s)
- Mohanraj Thirumalai
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ayse G Zengul
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Eric Evans
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
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Sjöholm K, Jacobson P, Taube M, Svensson PA, Andersson Assarsson JC, Carlsson LMS, Peltonen M. Long-term incidence of hypoglycaemia-related events after bariatric surgery or usual care in the Swedish Obese Subjects study: A register-based analysis. Diabetes Obes Metab 2021; 23:1917-1925. [PMID: 33961331 DOI: 10.1111/dom.14420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 12/24/2022]
Abstract
AIMS To examine the incidence of hypoglycaemia-related events over a period of up to 31 years in patients treated with bariatric surgery in the prospective, controlled Swedish Obese Subjects (SOS) study. MATERIALS AND METHODS The SOS study (n = 4047) is a prospective controlled intervention study. The present analysis included 1989 patients treated with bariatric surgery and 2027 control patients with obesity who received usual care. Diagnosed hypoglycaemia and events commonly attributed to hypoglycaemia (confusion, syncope, epilepsy and seizures), requiring hospital or specialist outpatient treatment, were identified by searching the National Patient Register. Analyses were stratified by baseline glycaemic status. Hazard ratios were adjusted for inclusion year, age, sex, smoking, glycated haemoglobin (HbA1c) level and body mass index at baseline. At the time of analysis (December 31, 2018), the median follow-up was 22 years. RESULTS Compared with usual care, bariatric surgery was associated with increased incidence of hypoglycaemia-related events in patients without baseline diabetes (168 and 219 events, respectively; log-rank P = .011), with a more pronounced risk during the first years of follow-up (test of time-treatment interaction P = .010). Multivariate analyses in patients without baseline diabetes indicated that male sex (P < .001), older age (P = .001) and higher HbA1c levels (P = .006) were associated with hypoglycaemia-related events. No association was found between risk of hypoglycaemia-related events and bariatric surgery in patients with baseline diabetes. CONCLUSIONS Bariatric surgery is associated with an increased incidence of hypoglycaemia-related events in patients without baseline diabetes, especially during the first years after treatment.
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Affiliation(s)
- Kajsa Sjöholm
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Peter Jacobson
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Magdalena Taube
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Per-Arne Svensson
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Institute of Health and Care Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Lena M S Carlsson
- Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Markku Peltonen
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet (Solna), Stockholm, Sweden
- Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki, Finland
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19
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Xie X, Guo J, Bremner KE, Wang M, Shah BR, Volodin A. Review and estimation of disutility for joint health states of severe and nonsevere hypoglycemic events in diabetes. J Comp Eff Res 2021; 10:961-974. [PMID: 34287017 DOI: 10.2217/cer-2021-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aim: Many economic evaluations used linear or log-transformed additive methods to estimate the disutility of hypoglycemic events in diabetes, both nonsevere (NSHEs) and severe (SHEs). Methods: We conducted a literature search for studies of disutility for hypoglycemia. We used additive, minimum and multiplicative methods, and the adjusted decrement estimator to estimate the disutilities of joint health states with both NSHEs and SHEs in six scenarios. Results: Twenty-four studies reported disutilities for hypoglycemia in diabetes. Based on construct validity, the adjusted decrement estimator method likely provides less biased estimates, predicting that when SHEs occur, the additional impact from NSHEs is marginal. Conclusion: Our proposed new method provides a different perspective on the estimation of quality-adjusted life-years in economic evaluations of hypoglycemic treatments.
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Affiliation(s)
- Xuanqian Xie
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Jennifer Guo
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Karen E Bremner
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Myra Wang
- Health Technology Assessment Program, Ontario Health, Toronto, ON M5S 1N5, Canada
| | - Baiju R Shah
- Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada.,Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Andrei Volodin
- Department of Mathematics & Statistics, University of Regina, Regina, SK S4S 0A2, Canada
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20
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Mathieu C. Minimising hypoglycaemia in the real world: the challenge of insulin. Diabetologia 2021; 64:978-984. [PMID: 33452892 DOI: 10.1007/s00125-020-05354-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/04/2020] [Indexed: 02/07/2023]
Abstract
Insulin therapy has been a life saver for people with type 1 diabetes and has been an essential tool in the therapy of people with type 2 diabetes, but the risk for hypoglycaemia has been a major hurdle to achieving good glycaemic control for most. Insulin analogues, the availability of novel technologies for the administration of insulin, like insulin pumps, and, in particular, tools to measure glucose levels, evolving from capillary measurements to continuous glucose monitoring, have revolutionised the way in which people living with diabetes use insulin. Novel insulin concepts, like once-weekly or oral insulin administration, will have to demonstrate safety on the side of hypoglycaemia before they will be able to move into the clinic.
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Affiliation(s)
- Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium.
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21
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Beck RW, Bergenstal RM. Beyond A1C-Standardization of Continuous Glucose Monitoring Reporting: Why It Is Needed and How It Continues to Evolve. Diabetes Spectr 2021; 34:102-108. [PMID: 34149250 PMCID: PMC8178725 DOI: 10.2337/ds20-0090] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Continuous glucose monitoring (CGM) systems are becoming part of standard care for type 1 diabetes, and their use is increasing for type 2 diabetes. Consensus has been reached on standardized metrics for reporting CGM data, with time in range of 70-180 mg/dL and time below 54 mg/dL recognized as the key metrics of focus for diabetes management. The ambulatory glucose profile report has emerged as the standard for visualization of CGM data and will continue to evolve to incorporate other elements such as insulin, food, and exercise data to support glycemic management.
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22
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Wang Y, Zeng Z, Ding J, Yuan R, Wang R, Zhang Y, Bai L, Yu H, Tang J. Fear of hypoglycaemia among patients with type 2 diabetes mellitus: a cross-sectional study. Sci Rep 2021; 11:7971. [PMID: 33846441 PMCID: PMC8042064 DOI: 10.1038/s41598-021-86954-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/19/2021] [Indexed: 11/17/2022] Open
Abstract
To investigate the fear of hypoglycaemia in patients with type 2 diabetes mellitus (T2DM), to identify factors related to this fear, and thus to provide evidence for clinical assessment. A total of 385 patients with T2DM who were admitted to the departments of endocrinology in five tertiary grade-A hospitals in Chongqing, China were included in this study. A questionnaire for general information and a Chinese version of Hypoglycemia Fear Survey (HFS) were used to collect the data. The average total score on the HFS was 71.67 ± 17.06 (HFS-W was 38.15 ± 10.57; HFS-B was 33.52 ± 9.54).The three items with the highest average score for HFS-W were not recognising low blood glucose (BG), not having food available, experiencing a hypoglycaemic episode alone, and for HFS-B were eating large amount of snacks, measuring BG six or more times per day, and keeping BG > 150 mmol/L. Regressions showed that number of hospitalisations for T2DM, receiving health education on diabetes, age and hypoglycaemia history because of T2DM were associated with fear of hypoglycaemia (all p < 0.05). Fear of hypoglycaemia in hospitalised patients with T2DM was strongly associated with diabetes health education, hospitalisation for diabetes, age, and hypoglycaemia history. Medical professionals should attach importance to the specific psychological interventions, health education on diabetes and the early prevention of hypoglycaemia or diabetic complications for patients with T2DM to reduce the fear of hypoglycaemia and improve their health status.
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Affiliation(s)
- Yanhao Wang
- Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi'an Jiaotong University, 98 XiWu Road, Xi'an, 710004, Shaanxi, China.,Department of Orthodontics, Xi'an Jiaotong University School of Stomatology, 98# Xiwu Road, Xi'an, 710000, Shaanxi, China.,College of Stomatology, Chongqing Medical University, Chongqing, China
| | - Zihuan Zeng
- School of Nursing, Chongqing Medical University, 1#, Medical College Road, Chongqing, 400016, China
| | - Jie Ding
- School of Foreign Languages, Chongqing Medical University, Chongqing, China
| | - Ruizhu Yuan
- School of Nursing, Chongqing Medical University, 1#, Medical College Road, Chongqing, 400016, China
| | - Ruiding Wang
- School of Nursing, Chongqing Medical University, 1#, Medical College Road, Chongqing, 400016, China
| | - You Zhang
- School of Foreign Languages, Chongqing Medical University, Chongqing, China
| | - Liyao Bai
- School of Nursing, Chongqing Medical University, 1#, Medical College Road, Chongqing, 400016, China
| | - Huan Yu
- School of Nursing, Chongqing Medical University, 1#, Medical College Road, Chongqing, 400016, China
| | - Jiao Tang
- School of Nursing, Chongqing Medical University, 1#, Medical College Road, Chongqing, 400016, China.
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23
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Ma J, Zhao Y, Fan H, Liu J. The efficacy of dapagliflozin for type 1 diabetes: a meta-analysis of randomized controlled studies. Afr Health Sci 2021; 21:1-7. [PMID: 34394274 PMCID: PMC8356594 DOI: 10.4314/ahs.v21i1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction The efficacy of dapagliflozin for type 1 diabetes remains controversial. We conduct a systematic review and meta-analysis to explore the treatment efficacy of dapagliflozin versus placebo in patients with type 1 diabetes. Methods We have searched PubMed, EMbase, Web of science, EBSCO and Cochrane library databases through May 2019 for randomized controlled trials (RCTs) assessing the effect of dapagliflozin versus placebo for type 1 diabetes. This meta-analysis is performed using the random-effect model. Results Six RCTs are included in the meta-analysis. Overall, compared with control group for type 1 diabetes, dapagliflozin treatment shows favorable impact on glycated hemoglobin HbA1c (standard mean difference SMD=-3.93; 95% confidence interval CI =-4.44 to -3.48; P<0.00001), HbA1c reduction of ≥0.5% (risk ratio RR=1.98; 95% CI=1.65 to 2.39; P<0.00001), and fasting plasma glucose FPG (SMD=-0.93; 95% CI=-1.77 to -0.10; P=0.03). There is no statistical difference of hypoglycemia (RR=1.09; 95% CI=0.66 to 1.79; P=0.75) or adverse events (RR=1.07; 95% CI=0.96 to 1.20; P=0.20) between two groups, but the incidence of ketone-related events is higher than those in control group (RR=0.28; 95% CI=3.96 to 11.52; P=0.01). Conclusions Dapagliflozin treatment benefits to reduce HbA1c and FPG for type 1 diabetes.
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Affiliation(s)
- Jian Ma
- Department of endocrinology, Fenghua people's hospital, Ningbo, Zhejiang, China, 300061
| | - Yanhong Zhao
- Department of endocrinology, Fenghua people's hospital, Ningbo, Zhejiang, China, 300061
| | - Huihui Fan
- Department of endocrinology, Fenghua people's hospital, Ningbo, Zhejiang, China, 300061
| | - Jia Liu
- Obstetrics and Gynecology Department, Yuyao second people's hospital, NingBo, Zhejiang, China, 300061
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Ghandi K, Pieri B, Dornhorst A, Hussain S. A Comparison of Validated Methods Used to Assess Impaired Awareness of Hypoglycaemia in Type 1 Diabetes: An Observational Study. Diabetes Ther 2021; 12:441-451. [PMID: 33219468 PMCID: PMC7843675 DOI: 10.1007/s13300-020-00965-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/30/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Clarke, Gold and Pedersen are validated methods to assess awareness of hypoglycaemia. Identifying impaired awareness of hypoglycaemia (IAH) is critical for supporting people with structured education and diabetes technologies, to reduce harm of hypoglycaemia. This study compares the Clarke score, Gold score and Pedersen methods and their correlations with features of hypoglycaemia unawareness and patient characteristics, to evaluate the accuracy of the methods in identifying IAH. METHODS This retrospective, observational questionnaire-based study collected routine clinical data from 100 people with type 1 diabetes. The questionnaire included the three validated scoring methods, frequency of severe and nocturnal hypoglycaemia, knowledge and worry of hypoglycaemia and hypoglycaemia symptom scores using the Edinburgh Hypoglycaemia Scale. Data were analysed for IAH prevalence and the associations with features of IAH. The concordance of Clarke, Gold and Pedersen methods was evaluated using Spearman's correlation coefficient. RESULTS The prevalence of IAH in this cohort identified by Clarke, Gold and Pedersen methods was 18%, 19% and 61% respectively. The mean autonomic symptom score in people with IAH was significantly reduced using the Clarke method (P = 0.0002) but not on Gold (P = 0.12) and Pedersen methods (P = 0.79). For people with IAH assessed using the Clarke method, scores for night-time worry regarding hypoglycaemia (P = 0.04) and self-reported frequency of nocturnal hypoglycaemia (P = 0.001) were increased. Spearman's correlation coefficients between Pedersen and Clarke and Pedersen and Gold were Rs = 0.555 (P < 0.001) and Rs = 0.645 (P < 0.001) respectively. A moderate association was observed between Clarke and Gold Rs = 0.5669 (P < 0.001). CONCLUSION Whilst Clarke and Gold methods determined a similar prevalence of IAH, people identified with IAH assessed by the Clarke method had a significant association with the features and characteristics of IAH, including reduced autonomic symptoms. This study suggests that performing more than one score is important for a reliable risk assessment of IAH.
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Affiliation(s)
- Kshitiz Ghandi
- Department of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Beatrice Pieri
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK
| | - Anne Dornhorst
- Department of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Sufyan Hussain
- Department of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK.
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK.
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK.
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25
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Jendle J, Ericsson Å, Ekman B, Sjöberg S, Gundgaard J, da Rocha Fernandes J, Mårdby AC, Hunt B, Malkin SJP, Thunander M. Real-world cost-effectiveness of insulin degludec in type 1 and type 2 diabetes mellitus from a Swedish 1-year and long-term perspective. J Med Econ 2020; 23:1311-1320. [PMID: 32746676 DOI: 10.1080/13696998.2020.1805454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The ReFLeCT study demonstrated that switching to insulin degludec from other basal insulins was associated with reductions in glycated hemoglobin and hypoglycemic events in type 1 (T1D) and type 2 diabetes (T2D), and reductions in insulin doses in T1D. The aim of the present analysis was to assess the short- and long-term cost-effectiveness of switching to insulin degludec in Sweden. METHODS Short-term outcomes were evaluated over 1 year in a Microsoft Excel model, while long-term outcomes were projected over patient lifetimes using the IQVIA CORE Diabetes Model. Cohort characteristics and treatment effects were sourced from the ReFLeCT study. Costs (in 2018 Swedish krona [SEK]) encompassed direct medical expenditure and indirect costs from loss of workplace productivity. In the long-term analyses, patients were assumed to receive insulin degludec or continue prior insulin therapy (primarily insulin glargine U100) for 5 years, before all patients intensified to once-daily degludec and mealtime aspart. RESULTS Switching to insulin degludec was associated with improved quality-adjusted life expectancy of 0.04 and 0.02 quality-adjusted life years (QALYs) over 1 year, and 0.16 and 0.08 QALYs over patient lifetimes, in T1D and T2D. Combined costs in T1D and T2D were estimated to be SEK 1,249 lower and SEK 1,181 higher over the short-term, and SEK 157,258 and SEK 2,114 lower over the long-term. Benefits were due to lower insulin doses in T1D, reduced rates of hypoglycemia, and lower incidences of diabetes-related complications. Insulin degludec was associated with an incremental cost-effectiveness ratio of SEK 64,298 per QALY gained for T2D over 1 year and considered dominant for T1D and T2D in all other comparisons. CONCLUSIONS Insulin degludec was projected to be cost-effective or dominant versus other basal insulins for the treatment of T1D and T2D in Sweden.
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Affiliation(s)
- Johan Jendle
- Institute of Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Bertil Ekman
- Department of Endocrinology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Stefan Sjöberg
- Department of Medicine, Karolinska Huddinge University Hospital, Stockholm, Sweden
| | | | | | | | - Barnaby Hunt
- Ossian Health Economics and Communications, Basel, Switzerland
| | | | - Maria Thunander
- Department of Clinical Sciences, Endocrinology and Diabetes, Lund University, Lund, Sweden
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Abstract
In spite of developments with novel insulin preparations, novel modes of insulin delivery with insulin infusion pumps, and the facility of continuous glucose monitoring, only 20% of patients with type 1 diabetes are under adequate control. The need for innovation is clear, and, therefore, the use of adjunct therapies with other pharmacological agents currently in use for type 2 diabetes, has been tried. Currently, pramlintide is the only agent licensed for use in this condition in addition to insulin. Global trials have been conducted with liraglutide, a glucagon-like peptide 1 receptor agonist (GLP-1RA), dapagliflozin, a sodium glucose cotransporter 2 (SGLT2) inhibitor, and sotagliflozin, an inhibitor of both SGLT1 and SGLT2 transporters. While dapagliflozin and sotagliflozin have now been licensed for clinical use in this condition in Europe and Japan, they have hitherto not been licensed in the United States due to a small increase in the risk of diabetic ketoacidosis. However, these agents reduce glycosylated hemoglobin (HbA1c) by 0.4%, reduce glycemic oscillations, and do not increase the risk of hypoglycemia. Liraglutide, on the other hand, induced a smaller reduction in HbA1c and thus was not considered for a license. However, further trials are currently being conducted with a combination of semaglutide, the most potent GLP-1RA, and dapagliflozin to determine whether this approach would yield better outcomes.
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Affiliation(s)
- Itivrita Goyal
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo, Williamsville, New York
| | - Alamgir Sattar
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo, Williamsville, New York
| | - Megan Johnson
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo, Williamsville, New York
| | - Paresh Dandona
- Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo, Williamsville, New York
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Beyond the Sick Role: The Many Roles of Adults With Type 1 and Type 2 Diabetes in the Management of Hypoglycemia-The InHypo-DM Study, Canada. Can J Diabetes 2020; 44:657-662. [PMID: 32565069 DOI: 10.1016/j.jcjd.2020.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/24/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Hypoglycemia is a common adverse event for people with type 1 and type 2 diabetes mellitus. In this article, we explore the specific roles that individuals assume to prevent or treat hypoglycemia. METHODS A descriptive qualitative study from the UnderstandINg the impact of HYPOglycemia on Diabetes Management Study (InHypo-DM) research program. A purposive sample of people with type 1 and type 2 diabetes were recruited for semistructured interviews. There were 16 participants (women and men), who were, on average, 53 years old. Average time since diagnosis was 15 (type 1) and 21 (type 2) years; all patients had at least 1 hypoglycemic event in the past year. Individual and team analysis of interviews were conducted to identify overarching themes. RESULTS Participants articulated 4 roles in preventing or treating hypoglycemia. The first role was being a manager by assuming ownership and accountability for their own glycemic control. The second role, being a technician, used both subjective and objective information and employed specific strategies to respond to hypoglycemic events. The third role, educator, extended beyond self-management to increase others' awareness of hypoglycemia. The fourth role, advocate, involved championing one's own needs during a hypoglycemic event. These 4 roles were, in turn, influenced by the contexts of work, social settings, exercise and travel. CONCLUSIONS These findings demonstrate that strategies that individuals use to avoid or reduce the severity of a hypoglycemic event extend beyond merely making impromptu decisions during events. Instead, these 4 roles of manager, technician, educator and advocate, embedded in specific contexts, enhanced their mastery in managing hypoglycemia in daily life.
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Abstract
Type 1 diabetes (T1D) is a chronic illness that requires intensive lifelong management of blood glucose concentrations by means of external insulin administration. There have been substantial developments in the ways of measuring glucose levels, which is crucial to T1D self-management. Recently, continuous glucose monitoring (CGM) has allowed people with T1D to keep track of their blood glucose levels in near real-time. These devices have alarms that warn users about potentially dangerous blood glucose trends, which can often be shared with ther people. CGM is consistently associated with improved glycemic control and reduced hypoglycemia and is currently recommended by doctors. However, due to the costs of CGM, only those who qualify for hospital provision or those who can personally afford it are able to use it, which excludes many people. In this paper, I argue that unequal access to CGM results in: (1) unjust health inequalities, (2) relational injustice, (3) injustice with regard to agency and autonomy, and (4) epistemic injustice. These considerations provide prima facie moral reasons why all people with T1D should have access to CGM technology. I discuss the specific case of CGM policy in the Netherlands, which currently only provides coverage for a small group of people with T1D, and argue that, especially with additional considerations of cost-effectiveness, the Dutch government ought to include CGM in basic health care insurance for all people with T1D.
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Abstract
Type 1 diabetes (T1D) is a chronic illness that requires intensive lifelong management of blood glucose concentrations by means of external insulin administration. There have been substantial developments in the ways of measuring glucose levels, which is crucial to T1D self-management. Recently, continuous glucose monitoring (CGM) has allowed people with T1D to keep track of their blood glucose levels in near real-time. These devices have alarms that warn users about potentially dangerous blood glucose trends, which can often be shared with ther people. CGM is consistently associated with improved glycemic control and reduced hypoglycemia and is currently recommended by doctors. However, due to the costs of CGM, only those who qualify for hospital provision or those who can personally afford it are able to use it, which excludes many people. In this paper, I argue that unequal access to CGM results in: (1) unjust health inequalities, (2) relational injustice, (3) injustice with regard to agency and autonomy, and (4) epistemic injustice. These considerations provide prima facie moral reasons why all people with T1D should have access to CGM technology. I discuss the specific case of CGM policy in the Netherlands, which currently only provides coverage for a small group of people with T1D, and argue that, especially with additional considerations of cost-effectiveness, the Dutch government ought to include CGM in basic health care insurance for all people with T1D.
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Andreano A, Bosio M, Russo AG. Emergency attendance for acute hyper- and hypoglycaemia in the adult diabetic population of the metropolitan area of Milan: quantifying the phenomenon and studying its predictors. BMC Endocr Disord 2020; 20:72. [PMID: 32429960 PMCID: PMC7238653 DOI: 10.1186/s12902-020-0546-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/06/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND We quantified, among diabetic adults, the frequency, costs, and factors associated with visits to the emergency department (EDs) and subsequent hospitalizations for acute hypoglycaemic and hyperglycaemic events. METHODS We included adults with diabetes residing in the Milan Agency for Health Protection between 2015 and 2017. From healthcare databases, we identified demographic variables, comorbidities, type of treatment, insulin treatment duration, previous ED attendances for acute glycaemic events, and two indicators of glycaemic monitoring. Using a validated ICD-9-CM coding algorithm, we identified all ED attendances for acute glycaemic events from the ED database and calculated their incidence. We computed the direct costs from health databases and presented them as average annual mean costs for those having had at least an ED attendance. The analysis of the association between the number of ED attendances and potential determinants was performed using zero-inflated negative binomial regression models. These two-part models concomitantly estimate two sets of parameters: the odds-ratios (ORs) of having no attendances and the incidence rate ratios (IRRs) of attendance. RESULTS The cohort included 168,285 subjects, 70% of subjects were older than 64 years, 56% were males, and 26% were treated with insulin. The incidence of acute glycaemic events for those attending the ED was 7.0 per 1000 patient-years, followed by hospitalization 26.0% of the time. The total annual direct cost for ED attendances due to acute glycaemic events was 174,000 €. Type of antidiabetic treatment had the strongest association with ED attendances for hypoglycaemia. Patients assuming insulin only had a lower probability of having no attendances (OR compared to those who assumed non-insulin antidiabetic drugs =0.01, 95% CI = 0.00-0.02). These patients also had the highest rate of hyperglycaemic episodes (IRR = 7.7, 95% CI = 5.1-11.7 for insulin only vs. non-insulin antidiabetic drugs). Subjects having had a previous episode of the same type leading to an ED visit had a higher rate of subsequent attendances (IRR for hypoglycaemia = 5.3, 95% CI = 3.9-7.3 and IRR for hyperglycaemia = 3.7, 95% CI = 1.3-10.2). CONCLUSION Insulin treatment and having had a prior acute glycaemic event leading to an ED visit were major predictors of ED attendance for hyper and hypoglycaemia in a population of adults with diabetes.
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Affiliation(s)
- Anita Andreano
- Epidemiology Unit, Agency for Health Protection (ATS) of Milan, C.so Italia, 19, 20122 Milano, Milan, (MI) Italy
| | - Marco Bosio
- General Directorate, Agency for Health Protection (ATS) of Milan, Milan, Italy
| | - Antonio Giampiero Russo
- Epidemiology Unit, Agency for Health Protection (ATS) of Milan, C.so Italia, 19, 20122 Milano, Milan, (MI) Italy
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Prevalence of severe hypoglycemia in a cohort of patients with type 1 diabetes. ACTA ACUST UNITED AC 2020; 68:47-52. [PMID: 32349942 DOI: 10.1016/j.endinu.2020.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/06/2020] [Accepted: 01/09/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Hypoglycemia is the major limiting factor in the glycemic management of type 1 diabetes. Severe hypoglycemia puts patients at risk of injury and death. Recurrent hypoglycemia leads to impaired awareness of hypoglycemia and this increases the risk of severe hypoglycemia. Recent studies have reported rates for severe hypoglycemia of 35% in type 1 diabetic patients. OBJECTIVES To assess the prevalence of severe hypoglycemia in type 1 diabetes mellitus patients and to evaluate the relationship between this and impaired awareness of hypoglycemia according to the Clarke test. PATIENTS AND METHODS The following data were collected from a cohort of type 1 diabetic patients: age, gender, duration of type 1 diabetes, treatment (multiple daily insulin injection or continuous subcutaneous insulin infusion), glycemia self-control, HbA1c, episodes of severe hypoglycemia and impaired awareness of hypoglycemia. RESULTS Of the participants, 39.8% had had at least one episode of severe hypoglycemia (in the previous 6 months), 11.4% with loss of consciousness (in the previous 12 months). According to the Clark test, 40.9% had impaired awareness of hypoglycemia. Older age and longer duration of diabetes were associated with a higher prevalence of severe hypoglycemia with unconsciousness; older age and a lower level of HbA1c were associated with impaired awareness of hypoglycemia. CONCLUSIONS Our study allows us to confirm the high rate of severe hypoglycemia and impaired awareness of hypoglycemia in patients with type 1 diabetes.
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Weiner M, Cummins J, Raji A, Ofner S, Iglay K, Teal E, Li X, Engel SS, Knapp K, Rajpathak S, Baker J, Chatterjee AK, Radican L. A randomized study on the usefulness of an electronic outpatient hypoglycemia risk calculator for clinicians of patients with diabetes in a safety-net institution. Curr Med Res Opin 2020; 36:583-593. [PMID: 31951747 DOI: 10.1080/03007995.2020.1717451] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Hypoglycemia (HG) occurs in up to 60% of patients with diabetes mellitus (DM) each year. We assessed a HG alert tool in an electronic health record system, and determined its effect on clinical practice and outcomes.Methods: The tool applied a statistical model, yielding patient-specific information about HG risk. We randomized outpatient primary-care providers (PCPs) to see or not see the alerts. Patients were assigned to study group according to the first PCP seen during four months. We assessed prescriptions, testing, and HG. Variables were compared by multinomial, logistic, or linear model. ClinicalTrials.gov ID: NCT04177147 (registered on 22 November 2019).Results: Patients (N = 3350) visited 123 intervention PCPs; 3395 patients visited 220 control PCPs. Intervention PCPs were shown 18,645 alerts (mean of 152 per PCP). Patients' mean age was 55 years, with 61% female, 49% black, and 49% Medicaid recipients. Mean baseline A1c and body mass index were similar between groups. During follow-up, the number of A1c and glucose tests, and number of new, refilled, changed, or discontinued insulin prescriptions, were highest for patients with highest risk. Per 100 patients on average, the intervention group had fewer sulfonylurea refills (6 vs. 8; p < .05) and outpatient encounters (470 vs. 502; p < .05), though the change in encounters was not significant. Frequency of HG events was unchanged.Conclusions: Informing PCPs about risk of HG led to fewer sulfonylurea refills and visits. Longer-term studies are needed to assess potential for long-term benefits.
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Affiliation(s)
- Michael Weiner
- Regenstrief Institute, Inc, Indianapolis, IN, USA
- Indiana University Center for Health Services and Outcomes Research, Indianapolis, IN, USA
- Center for Health Information and Communication, U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | | | | | - Susan Ofner
- Department of Biostatistics, Indiana University, Indianapolis, IN, USA
| | | | - Evgenia Teal
- Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Xiaochun Li
- Department of Biostatistics, Indiana University, Indianapolis, IN, USA
| | | | | | | | - Jarod Baker
- Regenstrief Institute, Inc, Indianapolis, IN, USA
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Mayoral K, Rajmil L, Murillo M, Garin O, Pont A, Alonso J, Bel J, Perez J, Corripio R, Carreras G, Herrero J, Mengibar JM, Rodriguez-Arjona D, Ravens-Sieberer U, Raat H, Serra-Sutton V, Ferrer M. Measurement Properties of the Online EuroQol-5D-Youth Instrument in Children and Adolescents With Type 1 Diabetes Mellitus: Questionnaire Study. J Med Internet Res 2019; 21:e14947. [PMID: 31714252 PMCID: PMC6880238 DOI: 10.2196/14947] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 11/23/2022] Open
Abstract
Background The lack of continuity between health-related quality of life (HRQoL) instruments designed for children and adults hinders change analysis with a life course approach. To resolve this gap, EuroQol (EQ) developed the EQ-5D-Youth (EQ-5D-Y), derived from the EQ-5D for adults. Few studies have assessed the metric properties of EQ-5D-Y in children with specific chronic conditions, and none have done so for children with type I diabetes mellitus (T1DM). Objective This study aimed to evaluate the acceptability, validity, reliability, and responsiveness of the EQ-5D-Y in children and adolescents with T1DM, when administered online. Methods Participants with T1DM were consecutively recruited from July to December 2014, from a list of potential candidates aged 8-19 years, who attended outpatient pediatric endocrinology units. Before every quarterly routine visit, participants received an email/telephone reminder to complete the online version of two generic HRQoL questionnaires: EQ-5D-Y and KIDSCREEN-27. The EQ-5D-Y measures five dimensions, from which an equally weighted summary score was constructed (range: 0-100). Completion rate and distribution statistics were calculated. Construct validity was evaluated through known group comparisons based on general health, acute diabetic decompensations, mental health, family function, and a multitrait, multimethod matrix between EQ-5D-Y and KIDSCREEN by using Spearman correlations. Construct validity hypotheses were stated a priori. Reliability was assessed with the intraclass correlation coefficient and responsiveness by testing changes over time and calculating the effect size. Reliability and responsiveness were tested among the stable and improved subsamples defined by a KIDSCREEN-10 index change of <4.5 points or ≥4.5 points, respectively, from the first to the fourth visit. Results Of the 136 participants, 119 (87.5%) responded to the EQ-5D-Y at the last visit. The dimensions that showed higher percentages of participants with problems were “having pain/discomfort” (34.6%) and “worried/sad/unhappy” (28.7%). The mean (SD) of the EQ-5D-Y summary score was 8.5 (10.9), with ceiling and floor effects of 50.7% and 0%, respectively. Statistically significant HRQoL differences between groups defined by their general health (excellent/very good and good/regular/bad) and mental health (Strengths and Difficulties Questionnaire score ≤15 and >16, respectively) were found in three EQ-5D-Y dimensions (“doing usual activities,” “having pain/discomfort,” and “feeling worried/sad/unhappy”), summary score (effect size for general health and mental health groups=0.7 and 1.5, respectively), and KIDSCREEN-10 index (effect size for general health and mental health groups=0.6 and 0.9, respectively). Significant differences in the EQ-5D-Y dimensions were also found according to acute diabetic decompensations in “looking after myself” (P=.005) and according to family function in “having pain/discomfort” (P=.03). Results of the multitrait, multimethod matrix confirmed three of the four relationships hypothesized as substantial (0.21, 0.58, 0.50, and 0.46). The EQ-5D-Y summary score presented an intraclass correlation coefficient of 0.83. Statistically significant change between visits was observed in the improved subsample, with an effect size of 0.7 (P<.001). Conclusions These results support the use of the EQ-5D-Y administered online as an acceptable, valid, reliable, and responsive instrument for evaluating HRQoL in children and adolescents with T1DM.
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Affiliation(s)
- Karina Mayoral
- Health Services Research Group, Hospital del Mar Medical Research Institute, Barcelona, Spain.,Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
| | - Luis Rajmil
- Agency for Health Quality & Assessment of Catalonia, Barcelona, Spain
| | - Marta Murillo
- Pediatric Service, Department of Pediatric Endocrinology, University Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Olatz Garin
- Health Services Research Group, Hospital del Mar Medical Research Institute, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain.,Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Angels Pont
- Health Services Research Group, Hospital del Mar Medical Research Institute, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
| | - Jordi Alonso
- Health Services Research Group, Hospital del Mar Medical Research Institute, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain.,Experimental and Health Sciences, Pompeu Fabra University, Barcelona, Spain
| | - Joan Bel
- Pediatric Service, Department of Pediatric Endocrinology, University Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Jacobo Perez
- Department of Pediatric Endocrine, Hospital of Sabadell, Corporació Sanitària Parc Taulí, Sabadell, Spain.,University Institute Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Raquel Corripio
- Department of Pediatric Endocrine, Hospital of Sabadell, Corporació Sanitària Parc Taulí, Sabadell, Spain.,University Institute Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Gemma Carreras
- Pediatric Endocrinology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Herrero
- Corporació de Salut del Maresme i la Selva, Hospital de Calella, Calella, Spain
| | - Jose-Maria Mengibar
- Corporació de Salut del Maresme i la Selva, Hospital de Blanes, Blanes, Spain
| | | | - Ulrike Ravens-Sieberer
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Center Hamburg - Eppendorf, Hamburg, Germany
| | - Hein Raat
- Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Vicky Serra-Sutton
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain.,Agency for Health Quality & Assessment of Catalonia, Barcelona, Spain
| | - Montse Ferrer
- Health Services Research Group, Hospital del Mar Medical Research Institute, Barcelona, Spain.,Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
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Li X, Yu S, Zhang Z, Radican L, Cummins J, Engel SS, Iglay K, Duke J, Baker J, Brodovicz KG, Naik RG, Leventhal J, Chatterjee AK, Rajpathak S, Weiner M. Predictive modeling of hypoglycemia for clinical decision support in evaluating outpatients with diabetes mellitus. Curr Med Res Opin 2019; 35:1885-1891. [PMID: 31234649 DOI: 10.1080/03007995.2019.1636016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective: Hypoglycemia occurs in 20-60% of patients with diabetes mellitus. Identifying at-risk patients can facilitate interventions to lower risk. We sought to develop a hypoglycemia prediction model. Methods: In this retrospective cohort study, urban adults prescribed a diabetes drug between 2004 and 2013 were identified. Demographic and clinical data were extracted from an electronic medical record (EMR). Laboratory tests, diagnostic codes and natural language processing (NLP) identified hypoglycemia. We compared multiple logistic regression, classification and regression trees (CART), and random forest. Models were evaluated on an independent test set or through cross-validation. Results: The 38,780 patients had mean age 57 years; 56% were female, 40% African-American and 39% uninsured. Hypoglycemia occurred in 8128 (539 identified only by NLP). In logistic regression, factors positively associated with hypoglycemia included infection, non-long-acting insulin, dementia and recent hypoglycemia. Negatively associated factors included long-acting insulin plus sulfonylurea, and age 75 or older. The models' area under curve was similar (logistic regression, 89%; CART, 88%; random forest, 90%, with ten-fold cross-validation). Conclusions: NLP improved identification of hypoglycemia. Non-long-acting insulin was an important risk factor. Decreased risk with age may reflect treatment or diminished awareness of hypoglycemia. More complex models did not improve prediction.
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Affiliation(s)
- Xiaochun Li
- Indiana University , Indianapolis , IN , USA
| | | | - Zuoyi Zhang
- Regenstrief Institute Inc. , Indianapolis , IN , USA
| | | | | | | | | | - Jon Duke
- Indiana University , Indianapolis , IN , USA
- Regenstrief Institute Inc. , Indianapolis , IN , USA
| | - Jarod Baker
- Regenstrief Institute Inc. , Indianapolis , IN , USA
| | | | | | | | | | | | - Michael Weiner
- Indiana University , Indianapolis , IN , USA
- Regenstrief Institute Inc. , Indianapolis , IN , USA
- Department of Veterans Affairs, Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA
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Proulx É, Auclair A, Piché ME, Harvey J, Pettigrew M, Biertho L, Marceau S, Poirier P. Safety of Blood Glucose Response Following Exercise Training After Bariatric Surgery. Obes Surg 2019; 28:3976-3983. [PMID: 30097897 DOI: 10.1007/s11695-018-3449-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Safety of exercise training in relationship with the risk of hypoglycemia post-bariatric surgery is unknown. OBJECTIVE To evaluate the safety and magnitude of changes in blood glucose levels during exercise training following bariatric surgery. MATERIAL AND METHODS Twenty-nine severely obese patients undergoing either sleeve gastrectomy (SG) (n = 16) or biliopancreatic diversion with duodenal switch (BPD-DS) (n = 13) were prospectively enrolled. Three months after surgery, patients participated in a 12-week supervised exercise training program, (35-min aerobic training with a 25-min resistance exercises) three times a week. Capillary blood glucose (CBG) levels were measured immediately before and after each exercise session. RESULTS Seven patients (24%) had type 2 diabetes before surgery (mean duration: 10 years); four patients still have type 2 diabetes 3 months post-bariatric surgery. A total of 577 exercise training sessions with CBG monitoring were recorded. Only seven sessions (1.2%) were associated with an episode of asymptomatic hypoglycemia (CBG ≤ 3.9 mmol/L). Patients with type 2 diabetes at baseline showed a larger decrease in CBG with pre-exercise CBG being between 6.1 and 8.0 mmol/L (- 1.6 ± 1.2 vs. - 1.1 ± 0.9 mmol/L, p = 0.02). BPD-DS patients with CBG ≥ 6.1 mmol/L showed higher reduction in CBG following exercise vs. SG patients (- 1.7 ± 1.0 vs. - 1.1 ± 1.1 mmol/L; p < 0.001 and - 4.3 ± 1.0 vs. - 2.2 ± 1.4 mmol/L, p < 0.001, respectively). CONCLUSION Three months after bariatric surgery, exercise training program in patients without and with type 2 diabetes is safe, and is associated with a desirable glycemic profile, with few episodes of asymptomatic hypoglycemia.
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Affiliation(s)
| | - Audrey Auclair
- Laval University, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, QC, G1V 4G5, Canada
| | - Marie-Eve Piché
- Laval University, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, QC, G1V 4G5, Canada
| | - Jany Harvey
- Laval University, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, QC, G1V 4G5, Canada
| | - Myriam Pettigrew
- Laval University, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, QC, G1V 4G5, Canada
| | - Laurent Biertho
- Laval University, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, QC, G1V 4G5, Canada
| | - Simon Marceau
- Laval University, Québec, Canada
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, QC, G1V 4G5, Canada
| | - Paul Poirier
- Laval University, Québec, Canada.
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, QC, G1V 4G5, Canada.
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Nilsson M, Jensen N, Gejl M, Bergmann ML, Storgaard H, Zander M, Miskowiak K, Rungby J. Experimental non-severe hypoglycaemia substantially impairs cognitive function in type 2 diabetes: a randomised crossover trial. Diabetologia 2019; 62:1948-1958. [PMID: 31367958 DOI: 10.1007/s00125-019-4964-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/21/2019] [Indexed: 12/27/2022]
Abstract
AIMS/HYPOTHESIS Previous studies have demonstrated a relationship between cognitive impairment and hypoglycaemia (<3 mmol/l). This study hypothesised that non-severe insulin-induced hypoglycaemia reduces cognitive function in individuals with type 2 diabetes. METHODS In this randomised crossover study, 25 participants with type 2 diabetes attended two experimental visits with hyperinsulinaemic glucose clamping: one hypoglycaemic clamp (plasma glucose 3.0 ± 0.2 mmol/l) and one euglycaemic clamp (plasma glucose 6.0 ± 0.2 mmol/l). Participants were eligible if their diabetes was treated with diet or glucose-lowering medications (except sulfonylureas or insulin), age was 35-70 years, BMI was 23-35 kg/m2 and HbA1c was below 75 mmol/mol (9%). Cognitive function was assessed with a neurocognitive test battery measuring verbal memory, executive function, sustained attention and psychomotor speed. From the examined cognitive domains, a global cognition score was constructed estimating global cognition. A measurement for psychomotor speed was selected as the primary outcome. Participants and people assessing the outcomes were blinded to group assignment. RESULTS Cognitive performance was impaired during hypoglycaemia with a mean score in the primary outcome test, Symbol Digit Modalities Test measuring psychomotor speed, of 48.7 ± 9.8 (hypoglycaemia) vs 56.6 ± 12.0 (euglycaemia); i.e. a change of -7.9 points (95% CI -10.9, -4.9; p < 0.0001). In addition, hypoglycaemia reduced global cognitive score by -0.7 (95% CI -0.9, -0.6; p < 0.0001). A stable glucose plateau was achieved during both experimental visits. For the hypoglycaemic clamp, mean plasma glucose concentration (± SD) during neurocognitive testing was 3.1 (± 0.3) mmol/l. Age, sex, fasting C-peptide, counter-regulatory hormones and the severity of hypoglycaemic symptoms did not influence cognitive function. CONCLUSIONS/INTERPRETATION Acute non-severe hypoglycaemia (mean plasma glucose 3.1 mmol/l) has a substantial negative impact on cognitive function in individuals with type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT03014011. FUNDING The study was supported in part by a research grant from the Investigator Initiated Studies Program of Merck Sharp & Dohme Corp (MSD-MA-NORD-007-01). The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. Funding was also received from Skibsreder Per Henriksen, R. og hustrus Foundation, The Danish Alzheimer Foundation and Savværksejer Jeppe Juhl og hustrus Foundation.
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Affiliation(s)
- Malin Nilsson
- Department of Endocrinology, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark.
| | - Nicole Jensen
- Department of Endocrinology, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - Michael Gejl
- Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne L Bergmann
- Department of Biochemistry and Immunology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Heidi Storgaard
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, Gentofte Hospital, Hellerup, Denmark
| | - Mette Zander
- Department of Endocrinology, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
| | - Kamilla Miskowiak
- Department of Psychology and Mental Health Services, University of Copenhagen, Copenhagen, Denmark
- Psychiatric Centre Copenhagen, Rigshospitalet, Denmark
| | - Jørgen Rungby
- Department of Endocrinology, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400, Copenhagen, NV, Denmark
- Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark
- Copenhagen Center for Translational Research, Bispebjerg University Hospital, Copenhagen, Denmark
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Survey on hypoglycemia among insulin-treated patients with diabetes: The Colombian International Operations Hypoglycemia Assessment Tool population. BIOMEDICA 2019; 39:576-586. [PMID: 31584770 PMCID: PMC7357359 DOI: 10.7705/biomedica.4365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Indexed: 12/30/2022]
Abstract
Introduction: The non-interventional International Operations Hypoglycemia Assessment Tool (IO-HAT) study assessed the incidence of hypoglycemia in patients with insulin-treated diabetes across nine countries, including a cohort of patients in Colombia. Materials and methods: Hypoglycemia incidence among patients with insulin-treated diabetes was assessed across 26 sites in Colombia. Hypoglycaemic events (any, nocturnal or severe) were reported in self-assessment questionnaires (SAQ) and patient diaries based on capillary blood glucose measurement or symptoms. Retrospective events (severe events 6 months before baseline and any event 4 weeks before baseline) were recorded in SAQ, Part 1, and prospective events (4 weeks from baseline) were recorded in SAQ, Part 2, and patient diaries. Differences in hypoglycemia incidence reported in the retrospective and prospective periods were assessed using two-sided tests. Results: Of the 664 patients assessed, 213 had type 1 diabetes (T1D) and 451 had type 2 diabetes (T2D). Nearly all patients experienced at least one hypoglycaemic event in the prospective period (97.1% T1D; 93.3% T2D). Rates of hypoglycemia (events per person- year, PPY) were higher prospectively than retrospectively for any hypoglycemia (T1 D: 121.6 vs. 83.2, p<0.001; T2D: 28.1 vs. 24.6, p=0.127) and severe hypoglycemia (T 1D: 15.3 vs. 9.2, p=0.605; T 2 D: 9.5 vs. 3.5 p=0.040). Conclusion: These results, the first from a patient-reported dataset on hypoglycemia in insulin-treated patients with diabetes in Colombia, show that patients reported higher rates of any hypoglycemia during the prospective period.
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Hendrieckx C, Ivory N, Singh H, Frier BM, Speight J. Impact of severe hypoglycaemia on psychological outcomes in adults with Type 2 diabetes: a systematic review. Diabet Med 2019; 36:1082-1091. [PMID: 31271669 DOI: 10.1111/dme.14067] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/02/2019] [Indexed: 12/25/2022]
Abstract
AIM Hypoglycaemia affects many people with Type 2 diabetes using insulin and other glucose-lowering therapies. This systematic review examined the impact of severe hypoglycaemia (episodes requiring external assistance) on psychological outcomes (e.g. emotional well-being, health status and quality of life) in adults with Type 2 diabetes. METHODS MEDLINE Complete, PsycINFO and CINAHL databases were searched for peer-reviewed empirical studies, published in English, reporting the occurrence and severity of hypoglycaemia and its relationship with patient-reported outcomes (PROs) in adults with Type 2 diabetes. Data were extracted from published reports and analysed. RESULTS Of 3756 potentially relevant abstracts, 29 studies met the inclusion criteria. Most reported cross-sectional data and sample sizes varied widely (N = 71 to 17 563). Although definitions of mild and severe hypoglycaemia were largely consistent between studies, additional non-standard categorizations (e.g. moderate, very severe) were apparent and recall periods varied. Overall, severe hypoglycaemia was associated with increased fear of hypoglycaemia and decreased emotional well-being, health status and diabetes-specific quality of life. Effect sizes show that the association with fear of hypoglycaemia was stronger than with general health status. CONCLUSIONS Notwithstanding the limitations of the empirical studies, these findings indicate that severe hypoglycaemia in adults with Type 2 diabetes (insulin- and non-insulin-treated) is associated with impaired psychological outcomes. Healthcare professionals should address the psychological impact of severe hypoglycaemia during clinical consultations, to support individuals to minimize exposure to, and the psychological consequences of, severe hypoglycaemia.
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Affiliation(s)
- C Hendrieckx
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - N Ivory
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - H Singh
- Mary & Dick Allen Diabetes Center, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - B M Frier
- The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - J Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
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Brown JB, Reichert SM, Valliere Y, Webster-Bogaert S, Ratzki-Leewing A, Ryan BL, Harris SB. Living With Hypoglycemia: An Exploration of Patients' Emotions: Qualitative Findings From the InHypo-DM Study, Canada. Diabetes Spectr 2019; 32:270-276. [PMID: 31462884 PMCID: PMC6695265 DOI: 10.2337/ds18-0074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hypoglycemia is one of the most common adverse events for people living with type 1 or type 2 diabetes. To gain a deeper understanding of patients' emotions regarding hypoglycemia, we conducted a descriptive qualitative study. Purposive sampling was used to recruit participants for a 30- to 45-minute semi-structured interview. The 16 participants included both women and men with either type 1 or type 2 diabetes, with a mean age of 53 years and mean time since diagnosis of 21 years. All participants had experienced more than one hypoglycemia event in the past year, ranging from nonsevere to severe. Data collection and analysis occurred in an iterative manner. Individual and team analyses of interviews were conducted to identify overarching themes and sub-themes. Thematic analysis revealed the unique interconnection among the emotions experienced by participants, including fear, anxiety, frustration, confidence, and hope. Time, experience, and reflection helped to build participants' confidence in their ability to manage a hypoglycemia event. Patients' emotions regarding hypoglycemia provide valuable insights into life with diabetes. Although hypoglycemia continues to evoke feelings of fear and anxiety, the role of hope may temper these emotions. Understanding the complex interplay of emotions concerning hypoglycemia can guide health care providers in improving clinical practice and promoting patient-centered interventions. Ultimately, health care providers can build patients' hypoglycemia-related confidence by using a strengths-based approach.
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Affiliation(s)
- Judith Belle Brown
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- School of Social Work, King’s University College, Western University, London, Ontario, Canada
| | - Sonja M. Reichert
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Yashoda Valliere
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Susan Webster-Bogaert
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Alexandria Ratzki-Leewing
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Bridget L. Ryan
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Stewart B. Harris
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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Ames A, Lago-Hernandez CA, Grunvald E. Hypoglycemia After Gastric Bypass Successfully Treated With Calcium Channel Blockers: Two Case Reports. J Endocr Soc 2019; 3:1417-1422. [PMID: 31286108 PMCID: PMC6608552 DOI: 10.1210/js.2019-00097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/22/2019] [Indexed: 12/14/2022] Open
Abstract
Postprandial hyperinsulinemic hypoglycemia is an uncommon yet well-established complication of Roux-en-Y gastric bypass (RYGB) that can result in serious morbidity and adversely affect quality of life. It is often unrecognized and may be difficult to diagnose. Management is challenging. As the number of bariatric procedures increases in parallel with the obesity epidemic, clinicians will be tasked to offer effective medical therapies for this complication. Two patients presented several years after RYGB with severe postprandial hypoglycemia. In one of the patients, we were able to document simultaneous postprandial hypoglycemia and hyperinsulinemia. Conventional treatment approaches, including medical nutrition therapy, acarbose, diazoxide, and octreotide, were either ineffective or limited by poor tolerance. Nifedipine and verapamil were used adjunctively with dietary modification, resulting in resolution of symptomatic hypoglycemic episodes. These agents are therapeutic options that can be used for some patients refractory to more traditional treatments. They should be tried before surgical procedures are considered for affected patients. These two cases demonstrate that calcium channel blockers may be efficacious and appropriate for select patients refractory to dietary interventions alone.
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Affiliation(s)
- Angharad Ames
- School of Medicine, University of California, San Diego, California.,Department of Psychiatry, University of California, Riverside, California
| | | | - Eduardo Grunvald
- School of Medicine, University of California, San Diego, California.,Bariatric and Metabolic Institute, Division of Minimally Invasive Surgery, Department of Surgery, University of California, San Diego, California.,Division of General Internal Medicine, Department of Medicine, University of California, San Diego, California
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Prevalence of Hypoglycemia, Treatment Satisfaction, Adherence and Their Associations with Glycemic Goals in Patients with Type 2 Diabetes Mellitus Treated with Sulfonylureas: Findings from the Real-Life Effectiveness and Care Patterns of Diabetes Management (RECAP-DM) in Romania. ROMANIAN JOURNAL OF DIABETES NUTRITION AND METABOLIC DISEASES 2019. [DOI: 10.2478/rjdnmd-2019-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background and aims: The aim of this study was to assess the prevalence and evaluate the impact on several treatment and quality of life parameters of hypoglycemia in type 2 diabetes mellitus patients treated with sulfonylureas (SU) in Romania. Secondary objective was to determine the proportion of patients attaining haemoglobin A1c (HbA1c) target of <7%.
Material and method: This was a multi-center, observational study using retrospective clinical chart and laboratory parameters review, and a cross-sectional survey in Romania. The sample in this study consisted of 385 patients. Socio-demographic and clinical variables were compared between patients with inadequate and adequate control.
Results: The mean age of all enrolled subjects was 65.37 (33-87) years. The average BMI was 30.44 kg/m2. Mean diabetes duration was 7.76 (6 months -32) years with the mean age of diabetes at diagnosis of 57.75 (31-85) years. HbA1c was recorded for 238 subjects with mean value of 7.12 (4.8-10.97) %.
Conclusions: The prevalence of hypoglycaemia in SU treated patients was 42.2%. Highest prevalence was in the 50-60 age category, at 49.2% and lowest among the eldest subjects (>70 years), at 38.6%. Prevalence of patients at the goal of HbA1c<7% was 50.8 %. Patients with adequate glycaemic control had more acceptable BMI than those with inadequate glycaemic control. In patients not achieving a goal of HbA1c < 7%, higher level of plasma glucose and total cholesterol was determined compared to those with adequate glycaemic control. There were no significant differences in the HDL-C, triglycerides or albumin:creatinine ratios in patients with both adequate and inadequate glycaemic control.
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Pedersen‐Bjergaard U, Alsifri S, Aronson R, Berković MC, Galstyan G, Gydesen H, Lekdorf JB, Ludvik B, Moberg E, Ramachandran A, Khunti K. Comparison of the HAT study, the largest global hypoglycaemia study to date, with similar large real-world studies. Diabetes Obes Metab 2019; 21:844-853. [PMID: 30456887 PMCID: PMC6590793 DOI: 10.1111/dom.13588] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 11/30/2022]
Abstract
AIMS Optimal diabetes care requires clear understanding of the incidence of hypoglycaemia in real-world clinical practice. Current data on hypoglycaemia are generally limited to those reported from randomised controlled clinical trials. The Hypoglycaemia Assessment Tool (HAT) study, a non-interventional real-world study of hypoglycaemia, assessed hypoglycaemia in 27 585 individuals across 24 countries. The present study compared the incidence of hypoglycaemia from the HAT study with other similarly designed, large, real-world studies. MATERIALS AND METHODS A literature search of PubMed (1995-2017) for population-based studies of insulin-treated patients with type 1 or type 2 diabetes (T1D, T2D), excluding clinical trials and reviews, identified comparable population-based studies reporting the incidence of hypoglycaemia. RESULTS The 24 comparative studies, including more than 24 000 participants with T1D and more than 160 000 participants with T2D, varied in design, size, inclusion criteria, definitions of hypoglycaemia and method of recording hypoglycaemia. Reported rates (events per patient-year [PPY]) of hypoglycaemia were higher in patients with T1D than in those with T2D (overall T1D, 21.8-73.3 and T2D, 1.3-37.7; mild/non-severe T1D, 29.0-126.7 and T2D, 1.3-41.5; severe T1D, 0.7-5.8 and T2D, 0.0-2.5; nocturnal T1D, 2.6-11.3 and T2D, 0.38-9.7) and were similar to the ranges found in the HAT study. CONCLUSIONS The HAT data on hypoglycaemia incidence were comparable with those from other real-world studies and indicate a high incidence of hypoglycaemia among insulin-treated patients. Differences in rates among studies are mostly explained by differences in patient populations and study methodology. The goal of reducing hypoglycaemia should be a target for continued educational and evidence-based pharmacological interventions.
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Affiliation(s)
| | | | - Ronnie Aronson
- Endocrinology and MetabolismLMC Diabetes and EndocrinologyTorontoOntarioCanada
| | | | | | | | | | - Bernhard Ludvik
- Division of Endocrinology and MetabolismRudolfstiftung Hospital and Karl‐Landsteiner InstituteViennaAustria
| | | | | | - Kamlesh Khunti
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
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Pratipanawatr T, Satirapoj B, Ongphiphadhanakul B, Suwanwalaikorn S, Nitiyanant W. Impact of Hypoglycemia on Health-Related Quality of Life among Type 2 Diabetes: A Cross-Sectional Study in Thailand. J Diabetes Res 2019; 2019:5903820. [PMID: 31772942 PMCID: PMC6854960 DOI: 10.1155/2019/5903820] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/27/2019] [Indexed: 01/06/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases. Patients are generally advised lifestyle changes with antihyperglycemic agents prescribed. The major drawback of prescribing antihyperglycemic agents is the risk of hypoglycemia which subsequently impacts on health-related quality of life (HRQoL). This study is aimed at examining association between previous history of hypoglycemia and HRQoL. The study was a multicenter cross-sectional study, conducted from February 2013 to March 2015 at 5 tertiary care hospitals in Thailand (Srinagarind, Phramongkutklao, Ramathibodi, King Chulalongkorn Memorial, and Siriraj hospitals). The study population were males or females diagnosed with type 2 DM according to ADA criteria, 30 years of age or older, who had been treated with sulfonylurea (SU) monotherapy or SU and metformin combination for at least 6 months. Prespecified medical factors were extracted from medical records 12 months prior to patients' enrolment. The experience of hypoglycemia questionnaire was used to collect and measure severity of hypoglycemia experienced during the previous 6 months. HRQoL was assessed using the 3-level version of EuroQol-5-dimension (EQ-5D-3L) and visual analogue scale (EQ-VAS) questionnaires. Of 659 eligible patients surveyed, 202 patients (30.65%) had experienced symptoms of hypoglycemia. HRQoL was significantly lower among patients reporting at least one of hypoglycemic symptoms, measured by EQ-VAS scores (mean ± SD; 73.66 ± 13.18, 73.56 ± 15.10, or 68.93 ± 14.76 vs. 77.01 ± 13.02, one-way ANOVA; p = 0.006) and EQ-5D-3L index scores (0.62 ± 0.47, 0.68 ± 0.38, or 0.58 ± 0.51 vs. 0.79 ± 0.31, one-way ANOVA; p < 0.001) for mild, moderate, or severe/very severe hypoglycemic patients compared with patients without hypoglycemic symptoms. After adjusting for confounding factors in a multiple linear regression model, patients with hypoglycemic symptoms either mild, moderate, or severe/very severe demonstrated significantly higher impairment for EQ-VAS and EQ-5D indexes than those who did not experience hypoglycemic symptoms. In conclusion, our study showed decreased HRQoL determined by EQ-5D and EQ-VAS in patients reporting symptoms of hypoglycemia compared with patients not reporting hypoglycemic symptoms, relative to severity of hypoglycemia.
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Affiliation(s)
- Thongchai Pratipanawatr
- Department of Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Bancha Satirapoj
- Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok 10400, Thailand
| | - Boonsong Ongphiphadhanakul
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Sompongse Suwanwalaikorn
- Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
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Beck RW, Bergenstal RM, Riddlesworth TD, Kollman C. The Association of Biochemical Hypoglycemia with the Subsequent Risk of a Severe Hypoglycemic Event: Analysis of the DCCT Data Set. Diabetes Technol Ther 2019; 21:1-5. [PMID: 30575408 PMCID: PMC6909677 DOI: 10.1089/dia.2018.0362] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the association of biochemical hypoglycemia with subsequent severe hypoglycemia (SH) events using the Diabetes Control and Complications Trial (DCCT) data set. RESEARCH DESIGN AND METHODS The frequency of biochemical hypoglycemia (percentage of values <70 and <54 mg/dL [3.9 and 3.0 mmol/L) was assessed using DCCT blood glucose concentrations measured at a central laboratory from seven finger-stick samples (7-point testing: pre- and 90-min postmeals and at bedtime) collected during 1 day every 3 months. SH events required a change in mental status necessitating the involvement of another individual to provide treatment. A Poisson model accounting for repeated measures from each participant was used to assess the association of biochemical hypoglycemia frequency, computed from the 7-point finger-stick data, with the development of SH events. RESULTS The risk of SH during a 3-month period was substantially higher (P < 0.001) when there was at least one hypoglycemic blood glucose value in the preceding 7-point profile, with similar results seen for both the 70 mg/dL (rate ratio = 3.0 [95% confidence interval: 2.6-3.3]) and 54 mg/dL (rate ratio = 2.7 [95% confidence interval: 2.4-3.1]) thresholds. CONCLUSIONS The occurrence of biochemical hypoglycemia <70 or <54 mg/dL is associated with an increased risk of SH. For this reason as well as the deleterious effects of hypoglycemia on glucose counter-regulation and hypoglycemia awareness, cognition, quality of life, and arrhythmias, it is important in diabetes management to avoid hypoglycemic glucose levels as much as possible.
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Affiliation(s)
- Roy W. Beck
- Jaeb Center for Health Research, Tampa, Florida
- Address correspondence to: Roy W. Beck, MD, PhD, Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647
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Melo KFS, Bahia LR, Pasinato B, Porfirio GJM, Martimbianco AL, Riera R, Calliari LEP, Minicucci WJ, Turatti LAA, Pedrosa HC, Schaan BD. Short-acting insulin analogues versus regular human insulin on postprandial glucose and hypoglycemia in type 1 diabetes mellitus: a systematic review and meta-analysis. Diabetol Metab Syndr 2019; 11:2. [PMID: 30622653 PMCID: PMC6317184 DOI: 10.1186/s13098-018-0397-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 12/24/2018] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Strict glucose control using multiple doses of insulin is the standard treatment for type 1 diabetes mellitus (T1DM), but increased risk of hypoglycemia is a frequent drawback. Regular insulin in multiple doses is important for achieving strict glycemic control for T1DM, but short-acting insulin analogues may be better in reducing hypoglycemia and postprandial glucose levels. OBJECTIVE We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose in patients with T1DM. METHODS Searches were run on the electronic databases MEDLINE, Cochrane-CENTRAL, EMBASE, ClinicalTrials.gov, LILACS, and DARE for RCTs published until August 2017. To be included in the study, the RCTs had to cover a minimum period of 4 weeks and had to assess the effects of short-acting insulin analogues vs regular human insulin on hypoglycemia and postprandial glucose levels in patients with T1DM. Two independent reviewers extracted the data and assessed the quality of the selected studies. The primary outcomes analyzed were hypoglycemia (total episodes, nocturnal hypoglycemia, and severe hypoglycemia) and postprandial glucose (at all times, after breakfast, after lunch, and after dinner). Glycated hemoglobin (HbA1c) levels and quality of life were considered secondary outcomes. The risk of bias of each RCT was assessed using the Cochrane Collaboration Risk of Bias table, while the quality of evidence for each outcome was assessed using the GRADEpro software. The pooled mean difference in the number of hypoglycemic episodes and postprandial glucose between short-acting insulin analogues vs. regular human insulin was calculated using the random-effects model. RESULTS Of the 2897 articles retrieved, 22 (6235 patients) were included. Short-acting insulin analogues were associated with a decrease in total hypoglycemic episodes (risk rate 0.93, 95% CI 0.87-0.99; 6235 patients; I2 = 81%), nocturnal hypoglycemia (risk rate 0.55, 95% CI 0.40-0.76, 1995 patients, I2 = 84%), and severe hypoglycemia (risk rate 0.68, 95% CI 0.60-0.77; 5945 patients, I2 = 0%); and with lower postprandial glucose levels (mean difference/MD - 19.44 mg/dL; 95% CI - 21.49 to - 17.39; 5031 patients, I2 = 69%) and lower HbA1c (MD - 0,13%; IC 95% - 0.16 to - 0.10; 5204 patients; I2 = 73%) levels. CONCLUSIONS Short-acting insulin analogues are superior to regular human insulin in T1DM patients for the following outcomes: total hypoglycemic episodes, nocturnal hypoglycemia, severe hypoglycemia, postprandial glucose, and HbA1c.
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Affiliation(s)
- Karla F. S. Melo
- Diabetes Division, Hospital de Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, Brazil
- Sociedade Brasileira de Diabetes, Rua Afonso Brás, Rua Afonso Brás, 579, cjs 72/74, Vila Nova Conceição, 04511-011 São Paulo, SP Brazil
- Quasar Telemedicina Ltda, São Paulo, Brazil
| | - Luciana R. Bahia
- Sociedade Brasileira de Diabetes, Rua Afonso Brás, Rua Afonso Brás, 579, cjs 72/74, Vila Nova Conceição, 04511-011 São Paulo, SP Brazil
- Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ Brazil
| | - Bruna Pasinato
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - Rachel Riera
- Cochrane Brazil, São Paulo, Brazil
- School of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis E. P. Calliari
- Pediatric Endocrine Unit, Pediatric Department, Santa Casa School of Medical Sciences, São Paulo, Brazil
| | - Walter J. Minicucci
- Sociedade Brasileira de Diabetes, Rua Afonso Brás, Rua Afonso Brás, 579, cjs 72/74, Vila Nova Conceição, 04511-011 São Paulo, SP Brazil
| | - Luiz A. A. Turatti
- Sociedade Brasileira de Diabetes, Rua Afonso Brás, Rua Afonso Brás, 579, cjs 72/74, Vila Nova Conceição, 04511-011 São Paulo, SP Brazil
| | - Hermelinda C. Pedrosa
- Sociedade Brasileira de Diabetes, Rua Afonso Brás, Rua Afonso Brás, 579, cjs 72/74, Vila Nova Conceição, 04511-011 São Paulo, SP Brazil
| | - Beatriz D. Schaan
- Department of Internal Medicine, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Alramadan MJ, Magliano DJ, Almigbal TH, Batais MA, Afroz A, Alramadhan HJ, Mahfoud WF, Alragas AM, Billah B. Glycaemic control for people with type 2 diabetes in Saudi Arabia - an urgent need for a review of management plan. BMC Endocr Disord 2018; 18:62. [PMID: 30200959 PMCID: PMC6131885 DOI: 10.1186/s12902-018-0292-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/29/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The aim of this study was to assess inadequate glycaemic control and its associated factors among people with type 2 diabetes in Saudi Arabia. METHODS A cross-sectional study design was used. Adults with type 2 diabetes attending diabetes centres in Riyadh, Hofuf and Jeddah cities were interviewed and their anthropometrics were measured. Their medical records were also reviewed to collect information related to recent lab tests, medications, and documented comorbidities. Multivariable logistic regression were used for data analysis. RESULTS A total of 1111 participants were recruited in the study. Mean age was 57.6 (±11.1) years, 65.2% of the participants were females, and mean HbA1c was 8.5 ± 1.9%. About three-fourths of participants had inadequate glycaemic control (≥ 7%). Multivariable analysis showed that age ≤ 60 years, longer duration of diabetes, living in a remote location, low household income, low intake of fruits and vegetable, low level of physical activity, lack of knowledge about haemoglobin A1c, high waist-hip ratio, low adherence to medication, and using injectable medications were independent risk factors for inadequate glycaemic control. CONCLUSIONS Inadequate glycaemic control is prevalent among people with type 2 diabetes in Saudi Arabia. In order to improve glycaemic control diabetes management plan should aim at controlling the modifiable risk factors which include low intake of fruits and vegetable, low level of physical activity, lack of knowledge about haemoglobin A1c, high waist-hip ratio, and low adherence to medications.
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Affiliation(s)
- Mohammed J. Alramadan
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dianna J. Magliano
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC Australia
| | | | | | - Afsana Afroz
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Mathieu C, Dandona P, Gillard P, Senior P, Hasslacher C, Araki E, Lind M, Bain SC, Jabbour S, Arya N, Hansen L, Thorén F, Langkilde AM, Luquez C, Manghi FP, Ulla MR, Moisello MA, Visco V, De Lapertoza SG, Solis SE, Farias J, Sposetti G, Gillard P, Abrams P, van Ypersele de Strihou M, Conway J, Pedersen S, Senior P, Liutkus JF, Yip CE, Punthakee Z, Bernier F, Lochnan H, Woo V, Elliott T, Palma J, Merino CS, Vargas AD, Wendisch U, Reichel A, Seufert J, Becker B, Alawi H, Birkenfeld AL, Hasslacher C, Luedemann J, Schaum T, Marck C, Sauter J, Aigner U, Onishi Y, Seino H, Sato Y, Nunoi K, Yamauchi A, Nakashima E, Ikeda H, Shiraiwa T, Yamasaki Y, Yokoyama H, Nakamura K, Noritake M, Miyauchi S, Hakoda T, Hirohata Y, Hasegawa A, Fukumoto Y, Nagashima H, Takihata M, Kamada T, Jinnouchi H, Ono Y, Watanabe T, Ohashi H, Takai M, Seguchi T, Yamazaki K, Maeda H, Iwasaki S, De Valk H, Kooy A, Landewe-Cleuren S, Madziarska K, Stankiewicz A, Wasilewska K, Rudofsky G, Malecki M, Pankowska E, Szyprowska E, Lukaszewicz M, Tokarska L, Bondar I, Karpova I, Ruyatkina L, Zalevskaya A, Sardinov R, Khalimov Y, Sjoberg F, Koskinen P, Curiac D, Lind M, Bach-Kliegel B, Schultes B, Issa BG, Kilvert A, Pereira O, Bain S, Mishra B, Bhatnagar D, Chuck L, Gorson D, Robertson D, Casaubon L, Chaykin L, Frias JP, Hsia S, Jenders R, Lerman S, Segel S, Weissman P, Chang A, Reed J, Madu IJ, Bressler P, Abbott L, Gangi S, Wheeler K, Cohen K, Biggs W, Jabbour S, Karounos D, Menon S, Miers W, Aleppo G, Lefebvre G, Sugimoto D, Ferraro R, Kelly R, Twahirwa M, Case C, Klonoff D, Denker P, Hollander P, Welch M, Leinung M, Kotek L, McGill J, Shlesinger Y, Huffman C, Aronoff S, Lorber D, Terrelonge A, Akhrass F, Bredefeld C, Hershon K, Lenhard J, Donovan D, Stonesifer L, Greenberg C, Ipp E, Bhargava A, Bao S. Efficacy and Safety of Dapagliflozin in Patients With Inadequately Controlled Type 1 Diabetes (the DEPICT-2 Study): 24-Week Results From a Randomized Controlled Trial. Diabetes Care 2018; 41:1938-1946. [PMID: 30026335 DOI: 10.2337/dc18-0623] [Citation(s) in RCA: 176] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/18/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This 24-week, double-blinded, phase 3 clinical trial (DEPICT-2; ClinicalTrials.gov, NCT02460978) evaluated efficacy and safety of dapagliflozin as adjunct therapy to adjustable insulin in patients with inadequately controlled type 1 diabetes (HbA1c 7.5-10.5%). RESEARCH DESIGN AND METHODS Patients were randomized 1:1:1 to dapagliflozin 5 mg (n = 271), dapagliflozin 10 mg (n = 270), or placebo (n = 272) plus insulin. Insulin dose was adjusted by investigators according to self-monitored glucose readings, local guidance, and individual circumstances. RESULTS Baseline characteristics were balanced between treatment groups. At week 24, dapagliflozin significantly decreased HbA1c (primary outcome; difference vs. placebo: dapagliflozin 5 mg -0.37% [95% CI -0.49, -0.26], dapagliflozin 10 mg -0.42% [-0.53, -0.30]), total daily insulin dose (-10.78% [-13.73, -7.72] and -11.08% [-14.04, -8.02], respectively), and body weight (-3.21% [-3.96, -2.45] and -3.74% [-4.49, -2.99], respectively) (P < 0.0001 for all). Mean interstitial glucose, amplitude of glucose excursion, and percent of readings within target glycemic range (>70 to ≤180 mg/dL) versus placebo were significantly improved. More patients receiving dapagliflozin achieved a reduction in HbA1c ≥0.5% without severe hypoglycemia compared with placebo. Adverse events were reported for 72.7%, 67.0%, and 63.2% of patients receiving dapagliflozin 5 mg, dapagliflozin 10 mg, and placebo, respectively. Hypoglycemia, including severe hypoglycemia, was balanced between groups. There were more adjudicated definite diabetic ketoacidosis (DKA) events with dapagliflozin: 2.6%, 2.2%, and 0% for dapagliflozin 5 mg, dapagliflozin 10 mg, and placebo, respectively. CONCLUSIONS Dapagliflozin as adjunct therapy to adjustable insulin in patients with type 1 diabetes was well tolerated and improved glycemic control with no increase in hypoglycemia versus placebo but with more DKA events.
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Affiliation(s)
- Chantal Mathieu
- Clinical and Experimental Endocrinology, University of Leuven, Leuven, Belgium
| | - Paresh Dandona
- Department of Medicine, State University of New York at Buffalo, Buffalo, NY
| | - Pieter Gillard
- Clinical and Experimental Endocrinology, University of Leuven, Leuven, Belgium
| | - Peter Senior
- Division of Endocrinology, University of Alberta, Edmonton, Canada
| | | | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Marcus Lind
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
| | - Stephen C. Bain
- Diabetes Research Unit, Swansea University, Swansea, Wales, U.K
| | - Serge Jabbour
- Division of Endocrinology, Diabetes and Metabolic Diseases, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
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Wan W, Skandari MR, Minc A, Nathan AG, Winn A, Zarei P, O'Grady M, Huang ES. Cost-effectiveness of Continuous Glucose Monitoring for Adults With Type 1 Diabetes Compared With Self-Monitoring of Blood Glucose: The DIAMOND Randomized Trial. Diabetes Care 2018; 41:1227-1234. [PMID: 29650803 PMCID: PMC5961392 DOI: 10.2337/dc17-1821] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 02/27/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study evaluated the societal cost-effectiveness of continuous glucose monitoring (CGM) in patients with type 1 diabetes (T1D) using multiple insulin injections. RESEARCH DESIGN AND METHODS In the Multiple Daily Injections and Continuous Glucose Monitoring in Diabetes (DIAMOND) trial, 158 patients with T1D and HbA1c ≥7.5% were randomized in a 2:1 ratio to CGM or control. Participants were surveyed at baseline and 6 months. Within-trial and lifetime cost-effectiveness analyses were conducted. A modified Sheffield T1D policy model was used to simulate T1D complications. The main outcome was cost per quality-adjusted life-year (QALY) gained. RESULTS Within the 6-month trial, the CGM group had similar QALYs to the control group (0.462 ± 0.05 vs. 0.455 ± 0.06 years, P = 0.61). The total 6-month costs were $11,032 (CGM) vs. $7,236 (control). The CGM group experienced reductions in HbA1c (0.60 ± 0.74% difference in difference [DiD]), P < 0.01), the daily rate of nonsevere hypoglycemia events (0.07 DiD, P = 0.013), and daily test strip use (0.55 ± 1.5 DiD, P = 0.04) compared with the control group. In the lifetime analysis, CGM was projected to reduce the risk of T1D complications and increase QALYs by 0.54. The incremental cost-effectiveness ratio (ICER) was $98,108 per QALY for the overall population. By extending sensor use from 7 to 10 days in a real-world scenario, the ICER was reduced to $33,459 per QALY. CONCLUSIONS For adults with T1D using multiple insulin injections and still experiencing suboptimal glycemic control, CGM is cost-effective at the willingness-to-pay threshold of $100,000 per QALY, with improved glucose control and reductions in nonsevere hypoglycemia.
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Affiliation(s)
- Wen Wan
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - M Reza Skandari
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Alexa Minc
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Aviva G Nathan
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin, Milwaukee, WI
| | - Parmida Zarei
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Michael O'Grady
- National Opinion Research Center, University of Chicago, Chicago, IL
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, IL
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Weatherall J, Polonsky WH, Lanar S, Knoble N, Håkan-Bloch J, Constam E, Philis-Tsimikas A, Marrel A. When insulin degludec enhances quality of life in patients with type 2 diabetes: a qualitative investigation. Health Qual Life Outcomes 2018; 16:87. [PMID: 29720273 PMCID: PMC5932896 DOI: 10.1186/s12955-018-0883-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 03/25/2018] [Indexed: 11/16/2022] Open
Abstract
Background Anecdotal reports suggest that insulin degludec (IDeg) may offer unique health-related quality of life (HRQoL) benefits. As the nature of these benefits remain unclear, this study utilized qualitative research methods to investigate and elucidate the experience of “feeling better” after initiating IDeg. Methods Twenty adults with type 2 diabetes (T2D) who reported “feeling better” on IDeg for > 3 months participated in 90-min interviews. One focus group and nine telephone interviews were conducted at two sites in the United States (US) and one focus group was conducted in Switzerland. Patients were ≥ 18 years of age, did not take mealtime insulin, and had switched to IDeg from another basal insulin. Discussions were audio-recorded, transcribed and translated (Swiss German). Utilizing grounded theory, transcripts were analyzed by sorting quotes into concepts using thematic analysis. Results Participants' mean age was 66 years and the average duration of T2D was 17.6 years. Mean duration of IDeg use was 1.45 years. Four major factors were identified as key contributors to patients’ sense of “feeling better”: 1) reduced sense of diabetes as burdensome and requiring excessive attention; 2) enhanced feelings of adaptability and freedom; 3) heightened sense of security, especially regarding concerns about hypoglycemia; and 4) greater sense of physical well-being (greater energy/less fatigue). Content saturation was achieved. Generally, patients from the US sites were more focused on medical results than Swiss patients, who were more likely to identify IDeg’s effect on overall HRQoL. A limitation of the study was that the population was primarily white, > 60 and otherwise healthy (no comorbid physical or mental condition). Conclusions A group of patients with T2D, who had switched to IDeg from another basal insulin, reported HRQoL benefits which were attributed to both diabetes-specific improvements (feeling less burdened by day-to-day diabetes demands) and non-specific gains (greater energy). The conclusions may have limited transferability due to the characteristics of the sample population and further research is needed.
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Affiliation(s)
| | - William H Polonsky
- Behavioral Diabetes Institute, San Diego, CA, USA.,University of California, San Diego, CA, USA
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Epidemiology and clinical management of type 2 diabetes mellitus and associated comorbidities in Spain (e-Management study). Med Clin (Barc) 2018; 147 Suppl 1:1-7. [PMID: 28760219 DOI: 10.1016/s0025-7753(17)30618-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Type 2 diabetes mellitus is currently the most frequent chronic metabolic disease. In spain, according to the di@bet.es study, its prevalence is 13.8% in the adult population (although it is undiagnosed in 6%). The main risk factor for type 2 diabetes mellitus is obesity. The severity of type 2 diabetes mellitus is determined not only by the presence of hyperglycaemia, but also by the coexistence of other risk factors such as hypertension or dyslipidaemia, which are often associated with the disease. Its impact on the presence of chronic diabetic complications varies. While hyperglycaemia mainly influences the presence of microvascular complications, hypertension, dyslipidaemia and smoking play a greater role in macrovascular atherosclerotic disease. One of the most powerful ways to study the epidemiology of the disease is through the use of large databases that analyse the situation in the routine clinical management of huge numbers of patients. Recently, the data provided by the e-Management Project, based on the SIDIAP database, have allowed updating of many data on the health care of diabetic persons in Catalonia. This not only allows determination of the epidemiology of the disease but is also a magnificent starting point for the design of future studies that will provide answers to more questions. However, the use of large databases is not free of certain problems, especially those concerning the reliability of registries. This article analyses some of the data obtained by the e-Management study and other spanish epidemiological studies of equal importance.
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