Prevalence and Incidence of Hypoglycaemia in 532,542 People with Type 2 Diabetes on Oral Therapies and Insulin: A Systematic Review and Meta-Analysis of Population Based Studies

Economic Evaluation of Fasting Mimicking Diet vs Standard Care in Diabetic Patients on Dual or Triple Medications at Baseline in the United States: A Cost-Utility Analysis

OBJECTIVES

According to most guidelines, dietary interventions are essential in the management of diabetes. Fasting has emerged as potential therapeutic regimes for diabetes. The proof-of-concept study and the fasting in diabetes treatment trial are the first to explore the clinical impact of the Fasting Mimicking Diet (FMD) in patients with type 2 diabetes mellitus. Their results showed that FMD cycles improve glycemic management and can be integrated into usual care complementary to current guidelines. This economic evaluation aims to assess the 10-year quality-of-life effects, cost implications, and cost-effectiveness of adding a 3-year FMD program to diabetes standard care in diabetic population on dual or triple medications at baseline from the perspective of the US payer.

METHODS

We constructed a microsimulation model in TreeAge using a published US-specific diabetes model. The model was populated using FMD effectiveness outcomes and publicly available clinical and economic data associated with diabetes complications, use of diabetes medications, hypoglycemia incidence, direct medical costs in 2021 USD, quality of life, and mortality. All benefits were discounted by 3%.

RESULTS

This cost-utility analysis showed that the FMD program was associated with 11.4% less diabetes complications, 67.2% less overall diabetes medication use, and 45.0% less hypoglycemia events over the 10-year simulation period. The program generated an additional effectiveness benefit of 0.211 quality-adjusted life year and net monetary benefit of 41 613 USD per simulated patient. Thus, the FMD program is cost saving.

CONCLUSIONS

These results indicate that the FMD program is a beneficial first-line strategy in T2DM management.

Cost-utility analysis of a flash continuous glucose monitoring system in the management of people with type 2 diabetes mellitus on basal insulin therapy-An Italian healthcare system perspective

AIMS

To assess the cost-utility of the FreeStyle Libre flash continuous glucose monitoring (CGM) system from an Italian healthcare system perspective, when compared with self-monitoring of blood glucose (SMBG) in people living with type 2 diabetes mellitus (T2DM) receiving basal insulin.

MATERIALS AND METHODS

A patient-level microsimulation model was run using Microsoft Excel for 10 000 patients over a lifetime horizon, with 3.0% discounting for costs and utilities. Inputs were based on clinical trials and real-world evidence, with patient characteristics reflecting Italian population data. The effect of flash CGM was modelled as a persistent 0.8% reduction in glycated haemoglobin versus SMBG. Costs (€ 2023) and disutilities were applied to glucose monitoring, diabetes complications, severe hypoglycaemia, and diabetic ketoacidosis. The health outcome was measured as quality-adjusted life-years (QALYs).

RESULTS

Direct costs were €5338 higher with flash CGM than with SMBG. Flash CGM was associated with 0.51 more QALYs than SMBG, giving an incremental cost-effectiveness ratio (ICER) of €10 556/QALY. Scenario analysis ICERs ranged from €3825/QALY to €26 737/QALY. In probabilistic analysis, flash CGM was 100% likely to be cost effective at willingness-to-pay thresholds > €20 000/QALY.

CONCLUSIONS

From an Italian healthcare system perspective, flash CGM is cost effective compared with SMBG for people living with T2DM on basal insulin.

Continuous glucose monitoring for self-management of diabetes in people living with type 2 diabetes mellitus on basal insulin therapy: A microsimulation model and cost-effectiveness analysis from a US perspective with relevance to Medicaid

BACKGROUND

Reducing the risks of complications is a primary goal of diabetes management, with effective glycemic control a key factor. Glucose monitoring using continuous glucose monitoring (CGM) technology is an important part of diabetes self-management, helping patients reach and maintain targeted glucose and glycated hemoglobin (HbA1c) levels. Although clinical guidelines recommended CGM use, coverage by Medicaid is limited, likely because of cost concerns.

OBJECTIVE

To assess the cost-effectiveness of FreeStyle Libre CGM systems, compared with capillary-based self-monitoring of blood glucose (SMBG), in US individuals with type 2 diabetes mellitus using basal insulin.

METHODS

A patient-level microsimulation model was used to compare CGM with SMBG for a population of 10,000 patients. A 10-year horizon was used, with an annual discount rate of 3.0% for costs and utilities. Model population characteristics were based on US national epidemiology data. Patient outcomes were based on published clinical trials and real-world studies. Annual costs, reflective of 2023 values, included CGM and SMBG acquisition costs and the costs of treating diabetic ketoacidosis, severe hypoglycemia, and diabetes complications. The effect of CGM was modeled as a persistent 1.1% reduction in HbA1c relative to SMBG based on US real-world evidence. Disutilities were based on published clinical trials and other relevant literature. The primary outcome was cost per quality-adjusted life-year (QALY) gained. Sensitivity analyses were performed to test the validity of the model results when accounting for a plausible variation of inputs.

RESULTS

In the base case analysis, CGM was dominant to SMBG, providing more QALYs (6.18 vs 5.97) at a lower cost ($70,137 vs $71,809) over the 10-year time horizon. A $10,456 increase in glucose monitoring costs was offset by a $12,127 reduction in treatment costs. Cost savings reflected avoidance of acute diabetic events (savings owing to reductions in severe hypoglycemia and diabetic ketoacidosis were $271 and $2,159, respectively) and a reduced cumulative incidence of diabetes complications, particularly renal failure (saving $5,292), myocardial infarction (saving $1,996), and congestive heart failure (saving $1,061). Scenario analyses were consistent with the base case results, and the incremental cost-effectiveness ratio for CGM vs SMBG ranged from dominant to cost-effective. In probabilistic analysis, CGM was 100% likely to be cost-effective at a willingness-to-pay threshold of $50,000/QALY.

CONCLUSIONS

CGM is cost-effective compared with SMBG for US patients with type 2 diabetes mellitus receiving basal insulin therapy. This suggests that state Medicaid programs could benefit from broader coverage of CGM.

Prevalence and predictors of hypoglycemia in older outpatients with type 2 diabetes mellitus

BACKGROUND

The prevalence of type 2 diabetes (DM) has been increasing globally, particularly among older adults who are more susceptible to DM-related complications. Elderly individuals with diabetes are at higher risk of developing hypoglycemia compared with younger diabetes patients. Hypoglycemia in elderly patients can result in serious consequences such as cognitive changes, increased risk of falls, heart and other vascular problems, and even high mortality rate.

OBJECTIVE

To assess prevalence, and factors associated with hypoglycemia events among geriatric outpatients with type 2 diabetes mellitus.

METHODS

The study was conducted at King Abdullah University Hospital (KAUH) at the outpatient diabetes clinic from October 1st, 2022 to August 1st, 2023. Variables such as socio-demographics, medication history, and comorbidities were obtained using electronic medical records. The prevalence of hypoglycemia was determined through patient interviews during their clinic visit. Patients were prospectively monitored for hospital admissions, emergency department visits, and mortality using electronic medical records over a three-month follow-up period. Logistic regression models were conducted to identify factors associated with hypoglycemia and hospital admissions/ emergency visits. Ethical Approval (Reference # 53/151/2022) was obtained on 19/9/2022.

RESULTS

Electronic medical charts of 640 patients who have type 2 diabetes mellitus and age ≥ 60 years were evaluated. The mean age ± SD was 67.19 (± 5.69) years. Hypoglycemia incidents with different severity levels were prevalent in 21.7% (n = 139) of the patients. Insulin administration was significantly associated with more hypoglycemic events compared to other antidiabetic medication. Patients with liver diseases had a significantly higher risk of hypoglycemia, with odds 7.43 times higher than patients without liver diseases. Patients with dyslipidemia also had a higher risk of hypoglycemia (odd ratio = 1.87). Regression analysis revealed that hypoglycemia and educational level were significant predictors for hospital admission and emergency department (ER) visits. Hypoglycemia was a positive predictor, meaning it increased the odds of these outcomes, while having a college degree or higher was associated with reduced odds of hospital admission and ER visits.

CONCLUSION

Current study identified a considerable prevalence of hypoglycemia among older patients with type 2 diabetes, particularly, among those with concurrent liver diseases and dyslipidemia. Furthermore, hypoglycemia was associated with an increased rate of emergency department visits and hospital admissions by 2 folds in this population.

Out of Sight, Out of Mind: A Call to Action for the Treatment of Hypoglycemia

Hypoglycemia will inevitably occur. Being prepared and implementing a treatment plan should help to restore euglycemia and resolve hypoglycemia symptoms. The plan comprises fast-acting carbohydrates and, importantly, ready-to-use glucagon for self-administration when carbohydrates are not working or for third-party administration when the affected person is unwilling or unable to swallow (e.g., unconscious or in a coma).

Analysis of a lung cancer case with transient pseudo hypoglycemia after PEG-rhG-CSF treatment

Pegylated recombinant human granulocyte colony-stimulating factor (PEG-rhG-CSF) is an effective treatment for chemotherapy-induced neutropenia. However, it can also induce various adverse effects, including fever, bone pain, and other discomforts arising from the abnormal proliferation of blood cells. This study presents an analysis of a case involving a middle-aged patient with small cell lung cancer who exhibited transiently low blood glucose levels without experiencing any symptoms of hypoglycemia following PEG-rhG-CSF treatment. After thorough evaluation by clinicians and pharmacists, the condition was diagnosed as pseudohyperglycemia, a phenomenon distinct from true hyperglycemia. The article provides a pharmaceutical perspective on the contributing factors, mechanisms, and management strategies for pseudohypoglycemia, offering valuable insights for clinical practice.

Prevalence of Hypoglycemia and Its Determinants Among Diabetes Patients on Insulin Treatment at Tepi General Hospital, Southwest, Ethiopia

Background

Hypoglycemia occurs when the blood sugar levels are too low. In severe cases, hypoglycemia may give to seizures, coma, and sometimes death. The prevalence of hypoglycemia among patients with diabetes is likely underreported and undocumented.

Methods

An institutional-based cross-sectional study was conducted among 336 study participants at the Tepi General Hospital in Southwest Ethiopia. A binary logistic regression model was used to determine the association between the prevalence of hypoglycemia and the factors associated with it. After a bivariate analysis, variables with a p value of < 0.25 were selected as a candidate for multivariable analysis. An odds ratio with a 95% CI was considered to indicate a significant association.

Results

With 95% CI (52.48-62.25) the prevalence of hypoglycemia was determined as 57.44%. Nearly 11% of the patients encounter severe hypoglycemia. Female patients had three times higher odds of experiencing hypoglycemia (aOR=3, 95% CI: 2.10, 6.39). Those with no formal education had 1.5 times higher odds of experiencing hypoglycemia (aOR = 1.5, 95% CI: 1.08, 5.45). Patients with type 1 diabetes were 3.4 times more likely to experience hypoglycemia (aOR = 3.4, 95% CI: 1.87, 7.50). Those who had been diagnosed before 10 years (aOR = 1.3, 95% CI: 1.02, 3.21) were more likely to have hypoglycemia. Furthermore, patients who consumed alcohol were 3.0 times more likely to have a history of hypoglycemia (aOR = 3.0, 95% CI: 2.03, 6.43).

Conclusion

The magnitude of hypoglycemia among patients with diabetes is determined to be considerable with more than half of the participants encountered hypoglycemia. There is a strong relationship between the occurrence of hypoglycemia and sex, type of diabetes, time since diagnosis, alcohol status, and education status. Therefore, all concerned parties must pay close attention to lessen the prevalence of hypoglycemia and address the problems based on the primary contributing factors.

Validation of an international classification of disease, tenth revision, clinical modification (ICD-10-CM) algorithm in identifying severe hypoglycaemia events for real-world studies

AIM

The transition to the ICD-10-CM coding system has reduced the utility of hypoglycaemia algorithms based on ICD-9-CM diagnosis codes in real-world studies of antidiabetic drugs. We mapped a validated ICD-9-CM hypoglycaemia algorithm to ICD-10-CM codes to create an ICD-10-CM hypoglycaemia algorithm and assessed its performance in identifying severe hypoglycaemia.

MATERIALS AND METHODS

We assembled a cohort of Medicare patients with DM and linked electronic health record (EHR) data to the University of North Carolina Health System and identified candidate severe hypoglycaemia events from their Medicare claims using the ICD-10-CM hypoglycaemia algorithm. We confirmed severe hypoglycaemia by EHR review and computed a positive predictive value (PPV) of the algorithm to assess its performance. We refined the algorithm by removing poor performing codes (PPV ≤0.5) and computed a Cohen's κ statistic to evaluate the agreement of the EHR reviews.

RESULTS

The algorithm identified 642 candidate severe hypoglycaemia events, and we confirmed 455 as true severe hypoglycaemia events, PPV of 0.709 (95% confidence interval: 0.672, 0.744). When we refined the algorithm, the PPV increased to 0.893 (0.862, 0.918) and missed <2.42% (<11) true severe hypoglycaemia events. Agreement between reviewers was high, κ  = 0.93 (0.89, 0.97).

CONCLUSIONS

We translated an ICD-9-CM hypoglycaemia algorithm to an ICD-10-CM version and found its performance was modest. The performance of the algorithm improved by removing poor performing codes at the trade-off of missing very few severe hypoglycaemia events. The algorithm has the potential to be used to identify severe hypoglycaemia in real-world studies of antidiabetic drugs.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

More Frequent Use of Glucose Alarms Is Associated with Continuous Glucose Monitoring-Specific Diabetes Education: Findings from the Dia·Link Diabetes Panel

The associations of continuous glucose monitoring (CGM)-specific diabetes education with real-world utilization of glucose alerts and alarms were assessed in current CGM-users with type 1 or type 2 diabetes. A cross-sectional online survey was conducted in Germany assessing utilization (use and responses) of different alerts and alarms. Ordinal logistic regression analyses were conducted to analyze associations between utilization and participation in CGM-specific education. Data from 453 participants were analyzed (86.2% type 1 diabetes). Participants who received CGM-specific education were more likely to regularly use low-glucose alerts (odds ratio [OR] = 5.43, P < 0.001), low-glucose alarms (OR = 2.03, P = 0.027), and rate of change alerts (OR = 4.20, P = 0.009), and were more likely to immediately react to low-glucose alerts (OR = 5.23, P < 0.001) and rate of change alerts (OR = 3.75, P = 0.018). CGM-specific education has the potential to increase utilization of and response to alerts and alarms. This may help to implement more preventive elements regarding glucose management in everyday life.

Screening of Individuals with Type 2 Diabetes on Anti-Diabetic Agents for Probable Hypoglycaemia Using the Stanford Hypoglycemia Questionnaire (SHQ) in Outpatient Settings: A Cross-Sectional Study from Outpatient Diabetes Care Centres in North India

Introduction

The study was aimed at identifying the incidence of unreported probable hypoglycaemia in individuals with type 2 diabetes (T2DM) on anti-diabetic medications, using the screening Stanford Hypoglycemia Questionnaire (SHQ) in real-world situations.

Methods

It was a multicentre cross-sectional study on consecutive individuals attending 10 diabetes care centres in Lucknow, Uttar Pradesh, India. The inclusion criteria were as follows: known individuals with T2DM, literate, age greater than or equal to 18 years, on at least one anti-diabetic agent for more than a month and not engaged in regular self-monitoring of blood glucose (SMBG).

Results

This study was conducted from August 2017 to April 2018, involving 1198 participants. The mean age of the individuals enrolled was 53.45 years (±10.83), with males comprising 55.3% of the population. It was found that 63.6% of patients were on sulphonylurea (SU), 14.5% were on pioglitazone, 92.2% on metformin, 62.3% on Dipeptidyl peptidase (DPP4i) and 12.8% on Sodium-glucose cotransporter (SGLT2i). The mean SHQ score was 1.81 (±1.59). Probable hypoglycaemia was mild in 57.59%, moderate in 14.69% and severe in 1.41%. Those with diabetic neuropathy (P = <0.001), retinopathy (P = <0.001) and nephropathy (P = <0.001) had significantly higher SHQ scores. Insulin or SU use was associated with a significantly higher SHQ score. Concomitant statin use was associated with a lower incidence of mild, moderate and severe hypoglycaemia (P = 0.01). On multivariate analysis, we found that age, sex, systolic blood pressure (SBP), insulin use and fasting blood sugar were the most important factors associated with an increased risk of hypoglycaemia with an R2 cut-off of 0.7.

Conclusion

SHQ was discovered to be a simple and cost-effective screening tool for outpatient detection of hypoglycaemia in an Indian setting, and it can add value to management.

Reducing hypoglycemia from overtreatment of type 2 diabetes in older adults: The HypoPrevent study

BACKGROUND

Hypoglycemia from overtreatment is a serious but underrecognized complication among older adults with type 2 diabetes. However, diabetes treatment is seldom deintensified. We assessed the effectiveness of a Clinical Decision Support (CDS) tool and shared decision-making (SDM) in decreasing the number of patients at risk for hypoglycemia and reducing the impact of non-severe hypoglycemic events.

METHODS

HypoPrevent was a pre-post, single arm study at a five-site primary care practice. We identified at-risk patients (≥65 years-old, with type 2 diabetes, treated with insulin or sulfonylureas, and HbA1c  < 7.0%). During three clinic visits over 6 months, clinicians used the CDS tool and SDM to assess hypoglycemic risk, set individualized HbA1c goals, and adjust use of hypoglycemic agents. We assessed the number of patients setting individualized HbA1c goals or modifying medication use, changes in the population at risk for hypoglycemia, and changes in impact of non-severe hypoglycemic events using a validated patient-reported outcome tool (TRIM-HYPO).

RESULTS

We enrolled 94 patients (mean age-74; mean HbA1c (±SD)-6.36% ± 0.43), of whom 94% set an individualized HbA1c goal at either the baseline or first follow-up visit. Ninety patients completed the study. Insulin or sulfonylurea use was decreased or eliminated in 20%. An HbA1c level before and after goal setting was obtained in 53% (N = 50). Among these patients, the mean HbA1c increased 0.53% (p < 0.0001) and the number of patients at-risk decreased by 46% (p < 0.0001). Statistically significant reductions in the impact of hypoglycemia during daily activities occurred in both the total score and each functional domain of TRIM-HYPO.

CONCLUSIONS

In a population of older patients at risk for hypoglycemia, the use of a CDS tool and SDM reduced the population at risk and decreased the use of insulin and sulfonylureas. Using a patient-reported outcome tool, we demonstrated significant reductions in the impact of hypoglycemia on daily life.

Allo Beta Cell transplantation: specific features, unanswered questions, and immunological challenge

Type 1 diabetes (T1D) presents a persistent medical challenge, demanding innovative strategies for sustained glycemic control and enhanced patient well-being. Beta cells are specialized cells in the pancreas that produce insulin, a hormone that regulates blood sugar levels. When beta cells are damaged or destroyed, insulin production decreases, which leads to T1D. Allo Beta Cell Transplantation has emerged as a promising therapeutic avenue, with the goal of reinstating glucose regulation and insulin production in T1D patients. However, the path to success in this approach is fraught with complex immunological hurdles that demand rigorous exploration and resolution for enduring therapeutic efficacy. This exploration focuses on the distinct immunological characteristics inherent to Allo Beta Cell Transplantation. An understanding of these unique challenges is pivotal for the development of effective therapeutic interventions. The critical role of glucose regulation and insulin in immune activation is emphasized, with an emphasis on the intricate interplay between beta cells and immune cells. The transplantation site, particularly the liver, is examined in depth, highlighting its relevance in the context of complex immunological issues. Scrutiny extends to recipient and donor matching, including the utilization of multiple islet donors, while also considering the potential risk of autoimmune recurrence. Moreover, unanswered questions and persistent gaps in knowledge within the field are identified. These include the absence of robust evidence supporting immunosuppression treatments, the need for reliable methods to assess rejection and treatment protocols, the lack of validated biomarkers for monitoring beta cell loss, and the imperative need for improved beta cell imaging techniques. In addition, attention is drawn to emerging directions and transformative strategies in the field. This encompasses alternative immunosuppressive regimens and calcineurin-free immunoprotocols, as well as a reevaluation of induction therapy and recipient preconditioning methods. Innovative approaches targeting autoimmune recurrence, such as CAR Tregs and TCR Tregs, are explored, along with the potential of stem stealth cells, tissue engineering, and encapsulation to overcome the risk of graft rejection. In summary, this review provides a comprehensive overview of the inherent immunological obstacles associated with Allo Beta Cell Transplantation. It offers valuable insights into emerging strategies and directions that hold great promise for advancing the field and ultimately improving outcomes for individuals living with diabetes.

The Role of Real-World Evidence in Treatment Decision-Making, Regulatory Assessment, and Understanding the Perspectives of People with Type 2 Diabetes: Examples with Gliclazide MR

Real-world evidence (RWE) plays an important role in the management of type 2 diabetes (T2D). It provides data about the effectiveness and safety of an intervention from outside the randomised controlled trial (RCT) setting and allows healthcare professionals (HCPs) to determine if RCT data are applicable to their patients in routine clinical practice. This review provides a discussion of the value of RWE in T2D management in day-to-day clinical practice, with a focus on RWE with sulfonylureas (SUs), and presents two examples of a new generation of international real-world studies in people with T2D managed in routine clinical practice. RWE plays a valuable role in advising HCPs in the day-to-day management of T2D, informing regulatory authorities with regard to pharmacovigilance and post-approval updates, and providing insights with regard to patients' treatment adherence and preference. RWE should be used alongside RCTs to increase HCP awareness and understanding of their patients' perspectives, potentially allowing for improvements in treatment adherence, glycaemic control and health-related quality of life (HRQoL). In addition, real-world studies must be conducted in a way that generates robust RWE by limiting the risks of bias and confounding as much as possible. A growing body of RWE is emerging from Asia. For example, in a preliminary HRQoL analysis of the Joint Asia Diabetes Evaluation (JADE) Register, Asian people with T2D had better HRQoL with gliclazide-based treatment than with other SU agents, despite being older and having more diabetes-related complications.

Development and validation of a real-world model to predict 1-year Level 3 (severe) hypoglycaemia risk in adults with diabetes (the iNPHORM study, United States)

AIMS

We aimed to develop and internally validate a real-world prognostic model for Level 3 hypoglycaemia risk compatible with outpatient care in the United States.

MATERIALS AND METHODS

iNPHORM is a 12-month, US-based panel survey. Adults (18-90 years old) with type 1 diabetes mellitus or insulin- and/or secretagogue-treated type 2 diabetes mellitus were recruited from a nationwide, probability-based internet panel. Among participants completing ≥ 1 follow-up questionnaire(s), we modelled 1-year Level 3 hypoglycaemia risk using Andersen and Gill's Cox survival and penalized regression with multiple imputation. Candidate variables were selected for their clinical relevance and ease of capture at point-of-care.

RESULTS

In total, 986 participants [type 1 diabetes mellitus: 17%; men: 49.6%; mean age: 51 (SD: 14.3) years] were analysed. Across follow-up, 035.1 (95% CI: 32.2-38.1)% reported ≥1 Level 3 event(s), and the rate was 5.0 (95% CI: 4.1-6.0) events per person-year. Our final model showed strong discriminative validity and parsimony (optimism corrected c-statistic: 0.77). Numerous variables were selected: age; sex; body mass index; marital status; level of education; insurance coverage; race; ethnicity; food insecurity; diabetes type; glycated haemoglobin value; glycated haemoglobin variability; number, type and dose of various medications; number of SH events requiring hospital care (past year and over follow-up); type and number of comorbidities and complications; number of diabetes-related health care visits (past year); use of continuous/flash glucose monitoring; and general health status.

CONCLUSIONS

iNPHORM is the first US-based primary prognostic study on Level 3 hypoglycaemia. Future model implementation could potentiate risk-tailored strategies that reduce real-world event occurrence and overall diabetes burden.

Knowledge Regarding Hypoglycemia and Its Management Among Patients With Insulin-Requiring Diabetes Mellitus in Al-Ahsa, Saudi Arabia

BACKGROUND

Hypoglycemia has a negative influence on patients with diabetes mellitus (DM) using insulin, and a lack of knowledge about hypoglycemia is one of the main causes of hypoglycemia. We aim to assess the level of knowledge about hypoglycemia and its management among insulin-requiring DM patients in Al-Ahsa, Saudi Arabia.

METHODS

A cross-sectional study was conducted on patients with insulin-requiring DM in Al-Ahsa, Saudi Arabia, from November 2021 to March 2022. A questionnaire was filled out by the participants to assess their level of knowledge about hypoglycemia, which was categorized as good, fair, or poor if participants scored >7, 6-7, or <6, respectively.

RESULTS

A total of 238 participants were recruited. Among participants, 55% were males, mainly in the age group of 40-65 years, and had higher education degrees. Doctors were the main source of information among participants. Most patients had no chronic illnesses other than DM or DM-related complications, although hypertension was reported in 37% of patients. The majority of participants had a good level of knowledge regarding hypoglycemia, and the main factors that increased it were getting information from doctors, social media, or a booklet or pamphlet (p-value <0.05).

CONCLUSION

Our participants generally had a good level of knowledge about hypoglycemia, and doctors delivering information about hypoglycemia contributed significantly to this knowledge level.

Clinical characteristics and influencing factors of hypoglycemia in hospitalized patients with type 2 diabetes mellitus: A cross-sectional study

AIM

Analysed clinical characteristics and influencing factors for hypoglycemia in hospitalized patients with type 2 diabetes mellitus (T2DM), and providing a scientific reference for precision nursing care of hypoglycemia in hospitalized patients with T2DM.

DESIGN

A cross-sectional study.

METHODS

This study involved 378 hospitalized patients diagnosed with T2DM who have suffered hypoglycemia. Through questionnaires and electronic medical records to obtain the data concerning the general information, clinical symptoms, all recorded blood glucose information, and the diabetes knowledge and self-management level of the patients. The clinical characteristics and influencing factors for hypoglycemia were analysed on the basis of the classification of hypoglycemia published by the American Diabetes Association in 2020.

RESULTS

Among 378 patients, 207 patients (54.76%) were experiencing Grade 1 hypoglycemia and 171 patients (45.24%) were experiencing Grade 2 hypoglycemia. Hypoglycemia and Grade 2 hypoglycemia in patients with T2DM occurred predominantly within the first 3 days of hospitalization. Hypoglycemia occurred most frequently after breakfast (74 cases, 19.6%), of which Grade 1 hypoglycemia and Grade 2 hypoglycemia accounted for 50%, respectively. Multivariable logistic regression identified risk factors for Grade 2 hypoglycemia in hospitalized patients with type 2 diabetes: older age, longer duration of diabetes, low body weight, diabetic nephropathy stages 4-5, diabetic autonomic neuropathy, inadequate self-management ability and diabetes knowledge, and lower educational background.

CONCLUSIONS

Hypoglycemia in type 2 diabetes occurs in the first 3 days during the hospitalization and most often after breakfast during the full day. Identifying high-risk individuals and providing a scientific reference for precision nursing care of hypoglycemia in hospitalized patients with T2DM.

Identification of Risk Factors and Development of a Predictive Model for Postoperative Hypoglycemia among Diabetic Patients during the Perioperative Period

Objective

To explore the incidence and influencing factors of postoperative hypoglycemia in diabetic patients during the perioperative period and to construct a risk prediction model for postoperative hypoglycemia.

Methods

Patients with T2DM admitted to the nonendocrinology department of Nanjing Drum Tower Hospital from December 2019 to January 2022 were included as research subjects. Basic information, hospital blood glucose management methods, laboratory indicators, and surgery-related indicators were collected. A risk prediction model and scoring table for postoperative hypoglycemia in patients with perioperative diabetes mellitus were established.

Results

A total of 440 patients were included, of which 109 had hypoglycemia, resulting in an incidence of postoperative hypoglycemia of 24.78%. The results show that preoperative C-peptide and operation duration were risk factors for postoperative hypoglycemia, while BMI and preoperative fasting blood glucose were protective factors.

Conclusion

The model constructed in this study is a good method for evaluating the risk of postoperative hypoglycemia. The scoring table intuitively quantifies the risk of risk factors for outcome variables and has strong clinical practicability.

The association between dementia and the risk of hypoglycaemia events among patients with diabetes mellitus: a propensity-score matched cohort analysis

Background

Hypoglycaemia commonly occurs in patients diagnosed with diabetes mellitus (DM) and dementia. The impact of dementia on hypoglycaemic events is controversial. Thus, we evaluated whether dementia increases the risk of hypoglycaemic events in older patients diagnosed with DM.

Design

A retrospective cohort study.

Setting

We used the IQVIA Medical Research Data (IMRD-UK) database (formerly known as the THIN database).

Participants

All patients aged ≥55 years and diagnosed with DM who were prescribed at least two prescriptions of antidiabetic medication between 2000 and 2017. Two groups of patients, dementia and non-dementia group, were propensity-score (PS) matched at 1:2. The risk of hypoglycaemia was assessed through a Cox regression analysis.

Main outcome and measures

Hypoglycaemic events were determined during the follow-up period by Read codes.

Results

From the database, 133,664 diabetic patients were identified, with a mean follow-up of 6.11 years. During the study period, 7,762 diabetic patients diagnosed with dementia were matched with 12,944 diabetic patients who had not been diagnosed with dementia. The PS-matched Cox regression analysis showed that patients diagnosed with dementia were at a 2-fold increased risk for hypoglycaemic events compared with those not diagnosed with dementia (hazard ratio [HR], 2.00; 95% CI, 1.63-2.66). A similar result was shown for a multivariable analysis using all patient data (adjusted HR, 2.25; 95% CI, 2.22-2.32).

Conclusion

Our findings suggest that diabetic patients with a diagnosis of dementia have a statistically significant higher risk of experiencing hypoglycaemia.

Association between severe hypoglycaemia and risk of dementia in patients with type 2 diabetes mellitus: A systematic review and meta-analysis

The aim of this systematic review was to analyse whether there is an association between severe hypoglycaemia and the incidence of dementia in patients with type 2 diabetes mellitus. We systematically searched the MEDLINE, Scopus, and Cochrane databases from their inception until September 2022 for observational studies on the association between hypoglycaemia and the risk of dementia. The DerSimonian and Laird method was used to compute a pooled estimate of the risk for such association. Risk ratio (RR) and its respective 95% confidence interval (95% CI). Two analyses were performed to estimate the risk of dementia: (i) any hypoglycaemia versus no hypoglycaemia and (ii) a dose-response analysis for one, two, or more than three hypoglycemic events versus no hypoglycaemia. PROSPERO registration number CRD42020219200. Seven studies were included. The pooled RR for the association of severe hypoglycaemia and risk of dementia was 1.47 (95% CI: 1.24-1.74). When the dose-response trend was analysed, the pooled RR for the risk of dementia was increased according to the hypoglycaemia events as follows: 1.29 (95% CI: 1.15-1.44) for one hypoglycemic event; 1.68 (95% CI: 1.38-2.04) for two hypoglycemic events; and 1.99 (95% CI: 1.48-2.68) for three or more hypoglycemic events. Our study demonstrates a 54% higher risk of dementia among people who suffer a hypoglycaemia event compared to nonhypoglycaemia. Considering our results and the prevalence of people suffering from diabetes mellitus, health education for both newly diagnosed and already diagnosed people could be a useful tool for glycaemic control, thus avoiding hypoglycaemic events.

Cost-Effectiveness Analysis of Flash Glucose Monitoring System for People with Type 2 Diabetes Receiving Intensive Insulin Treatment

AIMS

For people with type 2 diabetes (T2D) on intensive insulin therapy, the use of flash continuous glucose monitoring ("flash monitoring") is associated with improved average glucose control and/or reduced hypoglycemic exposure. This study assessed the cost-effectiveness of flash monitoring versus traditional blood glucose monitoring (BGM) in people with T2D using intensive insulin in the United Kingdom (UK).

METHODS

The IQVIA CORE Diabetes Model (IQVIA CDM; v9.0) was used to analyze the impact of flash monitoring versus BGM over a 40-year time horizon from the UK payer perspective. Model inputs included baseline characteristics, intervention effects, resource utilization, costs, and utilities, based on recently published literature and national databases. UK National Health Service reimbursed costs of flash monitoring and BGM were used. An intervention-related health utility was obtained from a time trade-off study. Alternative scenarios were explored to assess the impact of key assumptions on base case results.

RESULTS

In base-case analysis, flash monitoring compared with BGM resulted in an incremental cost of £5781 and an additional 0.47 quality-adjusted life years (QALYs). This provides an incremental cost-effectiveness ratio (ICER) of £12,309/QALY. HbA1c and the intervention-related health utility were the key drivers of differentiation. All scenario analyses, including different discount rates, time horizons, effects on HbA1c and on the intervention-related health utility, as well as glycemic emergencies, generated ICERs of less than £20,000 per QALY.

CONCLUSIONS

The consistent results across base case and a range of scenario analyses indicate that long-term flash glucose monitoring use is cost-effective compared with BGM in a UK population of T2D on intensive insulin therapy based on updated clinical effects and a cost-effectiveness threshold of £20,000-30,000 per QALY.

Self-reported Severe and Nonsevere Hypoglycemia in Type 1 Diabetes: Population Surveillance Through the BETTER Patient Engagement Registry: Development and Baseline Characteristics

OBJECTIVES

The BETTER (BEhaviors, Therapies, TEchnologies and hypoglycemic Risk in Type 1 diabetes) registry is a type 1 diabetes population surveillance system codeveloped with patient partners to address the burden of hypoglycemia and assess the impact of new therapies and technologies. The aim of this report was to describe the baseline characteristics of the BETTER registry cohort.

METHODS

A cross-sectional baseline evaluation was performed of a Canadian clinical cohort established after distribution of an online questionnaire. Participants were recruited through clinics, public foundations, advertising and social media. As of February 2021, 1,430 persons ≥14 years of age and living with type 1 diabetes or latent-autoimmune diabetes (LADA) were enrolled. The trial was registered on ClinicalTrials.gov (NCT03720197).

RESULTS

Participants were (mean ± standard deviation) 41.2±15.7 years old with a diabetes duration of 22.0±14.7 years, 62.0% female, 92.1% Caucasian and 7.8% self-reporting as LADA, with 40.9% using a continuous subcutaneous insulin infusion (CSII) system and 78.0% using a continuous glucose monitoring (CGM) system. The most recent glycated hemoglobin ≤7% was reported by 29.7% of participants. At least 1 episode of hypoglycemia <3.0 mmol/L (level 2-H) in the last month was reported by 78.4% of participants, with a median (interquartile range) of 5 (3, 10) episodes. The occurrence of severe hypoglycemia (level 3-H) in the last 12 months was reported by 13.3% of participants. Among these, the median number of episodes was 2 (1, 3).

CONCLUSIONS

We have established the first surveillance registry for people living with type 1 diabetes in Canada relying on patient-reported outcomes and experiences. Hypoglycemia is a highly prevalent burden despite a relatively wide adoption of CSII and CGM use.

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

BACKGROUND

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

OBJECTIVE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Assessment of the Knowledge and Self- Care Practice on Hypoglycemia among Patients with Diabetic Mellitus Attending Medical Opd at Smch

Introduction: Hypoglycemia is a clinical emergency that needs to be recognized and treated promptly to avoid organ damage and death. Knowledge of hypoglycemia prevention is an essential step in self-care practices due to the fact knowledgeable individuals are much more likely to practice hypoglycemia prevention. Prevention of hypoglycemia relies on adequate awareness and rightself-care. Objectives: To evaluate the level of knowledge and to self - care practice of hypoglycemia with their selected demographic variables among diabetic patients. Methods: A cross sectional descriptive research design was adopted with hundred samples who met the inclusion criteria in the hospital setting. Self-structured questionnaire method was used to acquire the data. Data have been through descriptive and inferential statistics. Result: Of 100 samples, 76(76%) had adequate knowledge and 63(63%)had good self-care practice on hypoglycemia. Spearman’s correlation showed positive relationship between knowledge and self-care practice of hypoglycemia (r value = 0.720, p<0.001). In respect to level of knowledge, there was a significant association noted among age, education, occupation, income, religion, marital status, family history and with regards to self-care practice along with all variables including gender is significant at p<0.05. Conclusion: This study result emphasized that majority of the diabetic patients had adequate knowledge and good self-care practice on hypoglycemia. Enlightening the patients further with regular self-monitoring of blood glucose level and obtain medical guidance and support may help the patients to stay fit.

Trends of severe hypoglycemia in patients with type 2 diabetes in Korea: A longitudinal nationwide cohort study

To estimate the trends in the prevalence of severe hypoglycemia (SH) in patients with type 2 diabetes in Korea, we investigated the total number of SH episodes among type 2 diabetes patients aged ≥30 years who visited the emergency department between 2002 and 2019, using the Korean National Health Insurance Service database. The prevalence of SH events increased from 2002 to 2012; however, it has decreased gradually since 2012. In 2019, the prevalence of SH was 0.6%, with an incidence rate of 4.43 per 1,000 person-years. Approximately 23,000 SH events occur every year in Korea. Although the incidence is steadily decreasing, there are a considerable number of SH events in type 2 diabetes patients. The decline in the incidence of SH seems to most likely be due to the increased prescription rate of hypoglycemic agents without hypoglycemia risk, less-strict treatment goals and the individualization of therapy.

2022 update to the position statement by Primary Care Diabetes Europe: a disease state approach to the pharmacological management of type 2 diabetes in primary care

Type 2 diabetes and its associated comorbidities are growing more prevalent, and the complexity of optimising glycaemic control is increasing, especially on the frontlines of patient care. In many countries, most patients with type 2 diabetes are managed in a primary care setting. However, primary healthcare professionals face the challenge of the growing plethora of available treatment options for managing hyperglycaemia, leading to difficultly in making treatment decisions and contributing to treatment and therapeutic inertia. This position statement offers a simple and patient-centred clinical decision-making model with practical treatment recommendations that can be widely implemented by primary care clinicians worldwide through shared-decision conversations with their patients. It highlights the importance of managing cardiovascular disease and elevated cardiovascular risk in people with type 2 diabetes and aims to provide innovative risk stratification and treatment strategies that connect patients with the most effective care.

Continuous glucose monitoring demonstrates low risk of clinically significant hypoglycemia associated with sulphonylurea treatment in an African type 2 diabetes population: results from the OPTIMAL observational multicenter study

INTRODUCTION

People living with diabetes in low-resource settings may be at increased hypoglycemia risk due to food insecurity and limited access to glucose monitoring. We aimed to assess hypoglycemia risk associated with sulphonylurea (SU) and insulin therapy in people living with type 2 diabetes in a low-resource sub-Saharan African setting.

RESEARCH DESIGN AND METHODS

This study was conducted in the outpatients' diabetes clinics of two hospitals (one rural and one urban) in Uganda. We used blinded continuous glucose monitoring (CGM) and self-report to compare hypoglycemia rates and duration in 179 type 2 diabetes patients treated with sulphonylureas (n=100) and insulin (n=51) in comparison with those treated with metformin only (n=28). CGM-assessed hypoglycemia was defined as minutes per week below 3mmol/L (54mg/dL) and number of hypoglycemic events below 3.0 mmol/L (54 mg/dL) for at least 15 minutes.

RESULTS

CGM recorded hypoglycemia was infrequent in SU-treated participants and did not differ from metformin: median minutes/week of glucose <3 mmol/L were 39.2, 17.0 and 127.5 for metformin, sulphonylurea and insulin, respectively (metformin vs sulphonylurea, p=0.6). Hypoglycemia risk was strongly related to glycated haemoglobin (HbA1c) and fasting glucose, with most episodes occurring in those with tight glycemic control. After adjusting for HbA1c, time <3 mmol/L was 2.1 (95% CI 0.9 to 4.7) and 5.5 (95% CI 2.4 to 12.6) times greater with sulphonylurea and insulin, respectively, than metformin alone.

CONCLUSIONS

In a low-resource sub-Saharan African setting, hypoglycemia is infrequent among people with type 2 diabetes receiving sulphonylurea treatment, and the modest excess occurs predominantly in those with tight glycemic control.

Dasiglucagon demonstrates reduced costs in the treatment of severe hypoglycemia in a budget impact model

BACKGROUND: Approximately 7.3 million people with type 1 or type 2 diabetes (T1D/T2D) are treated with insulin, placing them at higher risk of severe hypoglycemia (SH). SH requires assistance of another individual and often necessitates the prompt administration of intravenous glucose, injectable glucagon, or both. Untreated, SH can progress to unconsciousness, seizures, coma, or death. Before 2018, all glucagon rescue treatments required reconstitution. The complexity of reconstitution is often a barrier to successful administration during a severe hypoglycemic event. Studies suggest successful administration of glucagon emergency kits range from 6%-56% of the time. Second-generation glucagon treatments and glucagon analogs do not require reconstitution and have caregiver administration success rates ranging from 94%-100%. Dasiglucagon is a glucagon analog administered via autoinjector or prefilled syringe and has been shown to result in rapid hypoglycemia recovery. Moreover, the autoinjector can be administered successfully 94% of the time by trained caregivers. Previous evaluation of costs in budget impact models (BIMs) demonstrated the potential for second-generation glucagon treatments to reduce the cost of SH events (SHEs). The current model expands on those findings with a treatment pathway and accompanying assumptions reflecting important aspects of real-world SHE treatment. OBJECTIVE: To evaluate the economic impact of dasiglucagon compared with available glucagon treatments for SHE management, considering direct cost of treatment and health care resource utilization. METHODS: A 1-year BIM with a hypothetical US commercial health plan of 1 million lives was developed with a target population of individuals with diabetes at risk of SHE. The treatment pathway model included initial and secondary treatment attempts, treatment administration success and failure, plasma glucose (PG) recovery within 15 minutes, emergency medical services, emergency department (ED) visits, and hospitalizations. A 1-way sensitivity analysis was conducted to assess the sensitivity of the model to changes in parameter values. RESULTS: In a 1 million-covered lives population, it was estimated that 12,006 SHEs would occur annually. The higher rate of initial treatment success and PG recovery within 15 minutes associated with dasiglucagon treatment resulted in lower total health care costs. Total SHE treatment costs with dasiglucagon were estimated at $13.4 million, compared with $16.7 million for injectable native glucagon, $20.7 million for nasal glucagon, $35.3 million for reconstituted glucagon, and $43.8 million for untreated individuals. Compared with untreated people, the number needed to treat (NNT) with dasiglucagon was 6 individuals to avoid 1 hospitalization. NNT for this same comparison was 59 for injectable native glucagon and 27 for nasal glucagon. CONCLUSIONS: Treatment of SH with dasiglucagon decreased total direct medical costs by reducing health care resource utilization (emergency calls, emergency transports, ED visits, and hospitalizations) and accompanying costs associated with the treatment of SH. DISCLOSURES: This research was funded by Zealand Pharma. Bromley, Hinahara, and Goss are employed by Boston Healthcare Associates, Inc., which received funding from Zealand Pharma for development of the health economic model and the manuscript. Kendall and Hammer are employed by Zealand Pharma. Weinzimer has received consulting fees from Zealand Pharma.

Severe Hypoglycemia and Incident Heart Failure Among Adults With Type 2 Diabetes

CONTEXT

The association of severe hypoglycemia on the incidence of heart failure (HF) is unclear.

OBJECTIVE

We evaluated the association of severe hypoglycemia with incident HF among individuals with type 2 diabetes.

METHODS

We included participants with type 2 diabetes from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study. Severe hypoglycemia episodes were assessed during the initial 24 months following randomization and defined using 2 methods: (1) symptomatic, severe hypoglycemic event requiring medical assistance (first definition); or (2) requiring any assistance (second definition). Participants without HF at baseline and during the first 24 months of the study were prospectively followed for incident HF hospitalization. Multivariable Cox regression was used to generate adjusted hazard ratios (HR) for the association of severe hypoglycemia and incident HF.

RESULTS

Among 9208 participants (mean age 63 years, 38% female, 62% White), 365 had ≥ 1 episode of severe hypoglycemic. Over a median follow-up duration of 3 years, there were 249 incident HF events. After multivariable adjustment for relevant confounders, participants with severe hypoglycemia requiring medical assistance had a 68% higher relative risk of incident HF (HR 1.68; 95% CI, 1.06-2.66), as compared with individuals who never experienced any episode of hypoglycemia. Severe hypoglycemia requiring any assistance was also associated with a 49% higher relative risk of HF (HR 1.49; 95% CI, 1.01-2.21).

CONCLUSION

In a large cohort of adults with type 2 diabetes, severe hypoglycemia was independently associated with greater risk of incident HF.

Predicting Real-world Hypoglycemia Risk in American Adults With Type 1 or 2 Diabetes Mellitus Prescribed Insulin and/or Secretagogues: Protocol for a Prospective, 12-Wave Internet-Based Panel Survey With Email Support (the iNPHORM [Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-world Models] Study)

BACKGROUND

Hypoglycemia prognostic models contingent on prospective, self-reported survey data offer a powerful avenue for determining real-world event susceptibility and interventional targets.

OBJECTIVE

This protocol describes the design and implementation of the 1-year iNPHORM (Investigating Novel Predictions of Hypoglycemia Occurrence Using Real-world Models) study, which aims to measure real-world self-reported severe and nonsevere hypoglycemia incidence (daytime and nocturnal) in American adults with type 1 or 2 diabetes mellitus prescribed insulin and/or secretagogues, and develop and internally validate prognostic models for severe, nonsevere daytime, and nonsevere nocturnal hypoglycemia. As a secondary objective, iNPHORM aims to quantify the effects of different antihyperglycemics on hypoglycemia rates.

METHODS

iNPHORM is a prospective, 12-wave internet-based panel survey that was conducted across the United States. Americans (aged 18-90 years) with self-reported type 1 or 2 diabetes mellitus prescribed insulin and/or secretagogues were conveniently sampled via the web from a pre-existing, closed, probability-based internet panel (sample frame). A sample size of 521 baseline responders was calculated for this study. Prospective data on hypoglycemia and potential prognostic factors were self-assessed across 14 closed, fully automated questionnaires (screening, baseline, and 12 monthly follow-ups) that were piloted using semistructured interviews (n=3) before fielding; no face-to-face contact was required as part of the data collection. Participant responses will be analyzed using multivariable count regression and machine learning techniques to develop and internally validate prognostic models for 1-year severe and 30-day nonsevere daytime and nocturnal hypoglycemia. The causal effects of different antihyperglycemics on hypoglycemia rates will also be investigated.

RESULTS

Recruitment and data collection occurred between February 2020 and March 2021 (ethics approval was obtained on December 17, 2019). A total of 1694 participants completed the baseline questionnaire, of whom 1206 (71.19%) were followed up for 12 months. Most follow-up waves (10,470/14,472, 72.35%) were completed, translating to a participation rate of 179% relative to our target sample size. Over 70.98% (856/1206) completed wave 12. Analyses of sample characteristics, quality metrics, and hypoglycemia incidence and prognostication are currently underway with published results anticipated by fall 2022.

CONCLUSIONS

iNPHORM is the first hypoglycemia prognostic study in the United States to leverage prospective, longitudinal self-reports. The results will contribute to improved real-world hypoglycemia risk estimation and potentially safer, more effective clinical diabetes management.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04219514; https://clinicaltrials.gov/ct2/show/NCT04219514.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/33726.

Small molecule SWELL1 complex induction improves glycemic control and nonalcoholic fatty liver disease in murine Type 2 diabetes

Type 2 diabetes is associated with insulin resistance, impaired pancreatic β-cell insulin secretion, and nonalcoholic fatty liver disease. Tissue-specific SWELL1 ablation impairs insulin signaling in adipose, skeletal muscle, and endothelium, and impairs β-cell insulin secretion and glycemic control. Here, we show that I_Cl,SWELL and SWELL1 protein are reduced in adipose and β-cells in murine and human diabetes. Combining cryo-electron microscopy, molecular docking, medicinal chemistry, and functional studies, we define a structure activity relationship to rationally-design active derivatives of a SWELL1 channel inhibitor (DCPIB/SN-401), that bind the SWELL1 hexameric complex, restore SWELL1 protein, plasma membrane trafficking, signaling, glycemic control and islet insulin secretion via SWELL1-dependent mechanisms. In vivo, SN-401 restores glycemic control, reduces hepatic steatosis/injury, improves insulin-sensitivity and insulin secretion in murine diabetes. These findings demonstrate that SWELL1 channel modulators improve SWELL1-dependent systemic metabolism in Type 2 diabetes, representing a first-in-class therapeutic approach for diabetes and nonalcoholic fatty liver disease.

Type 2 diabetes is associated with insulin resistance, impaired insulin secretion and liver steatosis. Here the authors report a proof-of-concept study for small molecule SWELL1 modulators as a therapeutic approach to treat diabetes and associated liver steatosis by enhancing systemic insulin-sensitivity and insulin secretion in mice.

Analysis of Severe Hypoglycemia Among Adults With Type 2 Diabetes and Nonalcoholic Fatty Liver Disease

IMPORTANCE

Previous studies have indicated that liver cirrhosis is associated with hypoglycemia, but there have been no studies investigating the association between nonalcoholic fatty liver disease (NAFLD) and hypoglycemia in noncirrhotic populations with type 2 diabetes.

OBJECTIVE

To explore the association of NAFLD with severe hypoglycemia among patients with type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide population-based retrospective cohort study using the National Health Insurance System of South Korea included individuals aged 20 years or older who had undergone a medical health examination between January 1, 2009, and December 31, 2012, and were diagnosed with type 2 diabetes. Participants were followed up until December 31, 2015. Data analyses were performed between January 1, 2019, and February 2, 2021.

EXPOSURES

The baseline fatty liver index (FLI) was used as a surrogate marker for NAFLD.

MAIN OUTCOMES AND MEASURES

The outcome of interest, severe hypoglycemia, was measured using hospital admission and emergency department visit records with a primary diagnosis of hypoglycemia.

RESULTS

Among 1 946 581 individuals with type 2 diabetes, 1 125 187 (57.8%) were male. During a median (IQR) follow-up of 5.2 (4.1-6.1) years, 45 135 (2.3%) experienced 1 or more severe hypoglycemia events. Participants with severe hypoglycemia, vs those without severe hypoglycemia, were older (mean [SD] age, 67.9 [9.9] years vs 57.2 [12.3] years; P < .001) and had lower mean (SD) body mass index (24.2 [3.43] vs 25.1 [3.4]; P < .001). Patients with NAFLD tended to have less severe hypoglycemia without consideration of obesity status. However, after adjustment of multiple clinical covariates, including body mass index, there was a J-shaped association between FLI and severe hypoglycemia (5th decile: adjusted hazard ratio [aHR], 0.86; 95% CI, 0.83-0.90; 9th decile: aHR, 1.02; 95% CI, 0.96-1.08; 10th decile: aHR, 1.29; 95% CI, 1.22-1.37), and the estimated risk of hypoglycemia was higher in participants with NAFLD (aHR, 1.26; 95% CI, 1.22-1.30). The association was more prominent in female participants (aHR, 1.29; 95% CI, 1.23-1.36) and those with underweight (aHR, 1.71; 95% CI, 1.02-2.88).

CONCLUSIONS AND RELEVANCE

In this study, NAFLD was associated with a higher risk of severe hypoglycemia in patients with type 2 diabetes independent of obesity status. Presence of NAFLD should be considered when evaluating vulnerability to hypoglycemia in patients with type 2 diabetes.

Development of a Measure to Assess Attitudes Towards Nasal versus Autoinjector Glucagon Delivery Devices for Treatment of Severe Hypoglycemia

BACKGROUND

For individuals managing diabetes, the administration of glucagon for severe hypoglycemia can be lifesaving, yet, until recently, there were no easy-to-use devices for these stressful emergencies. New products have emerged to meet this need, including nasal glucagon (NG) and auto-injector glucagon (AI). This study evaluated the psychometric properties of a new measure, the Glucagon Device Attitudes Questionnaire (GDAQ), in assessing attitudes toward NG and AI from the perspectives of persons with diabetes on insulin (PWDs), caregivers, and acquaintances.

METHODS

Developed based on qualitative research, the GDAQ consists of 38 rating items for each device and 16 direct-elicitation of attitudes of device relative to each other. It was administered to participants via a cross-sectional online survey. Twenty-six rating items were included in principal component analysis and confirmatory factor analysis. Items comprising each factor were averaged to form scales. Additionally, 12 direct elicitation items were averaged to form an overall "Attitudes" scale. Reliability and validity analyses were conducted. Descriptive statistics were provided for the rating items not included in the factor analysis.

RESULTS

A total of 405 PWDs, 313 caregivers, and 305 acquaintances participated. Three factors were identified: "Prepared and Protected" (7 items), "Hesitation" (12 items), and "Device Perceptions by Others" (7 items); factor loadings ranged from 0.13 to 0.92, 0.50 to 0.89, and 0.16 to 0.92, respectively. Cronbach's alpha for the four scales ranged from 0.76 to 0.96. Correlations of the scales with their global item ranged from 0.30 to 0.90. The items outside of the factor analysis showed good distribution in responses and differentiation between the two devices.

DISCUSSION

This study supports the validity and reliability of the GDAQ, which successfully conceptualizes attitudes towards devices for administering glucagon among different respondent groups. Use of the GDAQ can help guide the development and testing of new glucagon drug/device combinations.

American Medical Society for Sports Medicine Position Statement on the Care of the Athlete and Athletic Person With Diabetes

ABSTRACT

The American Medical Society for Sports Medicine (AMSSM) developed this position statement to assist physicians and other health professionals in managing athletes and active people with diabetes. The AMSSM selected the author panel through an application process to identify members with clinical and academic expertise in the care of active patients with diabetes. This article reviews the current knowledge and gaps regarding the benefits and risks of various types of exercise and management issues for athletes and physically active people with diabetes, including nutrition and rehabilitation issues. Resistance exercises seem to be beneficial for patients with type 1 diabetes, and the new medications for patients with type 2 diabetes generally do not need adjustment with exercise. In preparing this statement, the authors conducted an evidence review and received open comment from the AMSSM Board of Directors before finalizing the recommendations.

Cost-Effectiveness of Flash Glucose Monitoring for the Management of Patients with Type 1 and Patients with Type 2 Diabetes in China

INTRODUCTION

To compare the cost-effectiveness of flash glucose monitoring versus self-monitoring of blood glucose/point of care testing (SMBG/POCT) in both patients with type 1 and patients with type 2 diabetes (T1D/T2D) receiving insulin therapy.

METHODS

The IQVIA CORE Diabetes Model (version 9.5) was used to project the lifetime costs and health outcomes of flash glucose monitoring and SMBG/POCT from a Chinese societal perspective. We considered both hospital and individual version flash glucose monitoring to reflect the clinical practice in China. The clinical inputs leveraged the outcomes from both clinical trials and real-world studies. Cohort characteristics, intervention costs, treatment-related disutility and mortality were extracted from the literature. We also conducted scenario analyses and probabilistic sensitivity analyses to test the robustness of results.

RESULTS

Compared with SMBG/POCT using efficacy results from clinical trial, flash glucose monitoring brought the incremental costs of Chinese yuan (CNY) 58,021 and CNY 90,997 and additional quality-adjusted life years (QALYs) of 1.22 and 0.65 for patients with T1D and patients with T2D, respectively. According to the "WHO-CHOICE threshold" of three times the gross domestic product per capita in China (CNY 217,341 in 2020) as cost-effectiveness threshold, flash glucose monitoring was cost-effective for both patients with T1D and patients with T2D with incremental cost-effectiveness ratios (ICER) of CNY 47,636 and CNY 140,297 per QALY gained, respectively. According to the real-world effectiveness data, flash glucose monitoring was dominant for patients with T1D (lower costs and better effectiveness) and cost-effective for patients with T2D with an ICER of CNY 124,169 per QALY gained compared with SMBG/POCT. Scenario analyses and probabilistic sensitivity analyses confirmed the robustness of the results.

CONCLUSION

Flash glucose monitoring is likely to be considered as a cost-effective strategy compared to SMBG/POCT for Chinese patients with T1D and patients with T2D receiving insulin therapy.

Cost-Effectiveness of the FreeStyle Libre® System Versus Blood Glucose Self-Monitoring in Individuals with Type 2 Diabetes on Insulin Treatment in Sweden

INTRODUCTION

Frequent glucose monitoring is essential to obtain glucose control. This is done by periodic self-monitoring of blood glucose (SMBG) using finger-prick testing, or by using continuous glucose monitoring devices, wherein a sensor records interstitial glucose data automatically. This study assessed the cost-effectiveness of using the FreeStyle Libre Flash Continuous Glucose Monitoring System (FSL) compared to SMBG in individuals with type 2 diabetes (T2D) treated with insulin from a Swedish societal perspective.

METHODS

Cost-effectiveness analysis was conducted using the IQVIA Core Diabetes model v9.5, with demographic and clinical inputs from a real-world study using Swedish National Diabetes Register data. Two cohorts of individuals with T2D were considered based on baseline HbA1C (HbA1c: 8-9% [64-75 mmol/mol]; HbA1c: 9-12% [75-108 mmol/mol]). HbA1c reductions with FSL were - 0.41% (- 4 mmol/mol; SD: 0.94%-10 mmol/mol) and - 1.30% (- 14 mmol/mol; SD: 1.40%-15 mmol/mol) for the two cohorts, respectively. Utilities, treatment costs and diabetes-related complication costs were obtained from published sources. Analyses were conducted over a lifetime horizon, applying annual discounting of 3% on costs and effects. Scenario analyses and probabilistic sensitivity analyses were performed.

RESULTS

Individuals with T2D who had a baseline HbA1c of 8-9% (64-75 mmol/mol) and 9-12% (75-108 mmol/mol) and used FSL gained 0.50 and 0.57 quality-adjusted life-years (QALYs), respectively, at an incremental cost of SEK109,957 and SEK82,170 compared to SMBG, generating an incremental cost-utility ratio of SEK219,127 and SEK144,412 per QALY gained. Assuming a willingness-to-pay threshold of SEK300,000 per QALY gained, FSL use was considered cost-effective compared to SMBG for the majority of the individuals in both the lower and higher HbA1c cohorts. The key driver identified was the additional quality-of-life benefit that applied to FSL use.

CONCLUSION

The FreeStyle Libre Flash Continuous Glucose Monitoring System is a cost-effective glucose monitoring alternative to SMBG for individuals with T2D in Sweden who are treated with insulin but are not reaching their glycaemic goals.

Hospital utilization for hypoglycemia among patients with type 2 diabetes using pooled data from six health systems

INTRODUCTION

Hypoglycemia is the most common serious adverse effect of diabetes treatment and a major cause of medication-related hospitalization. This study aimed to identify trends and predictors of hospital utilization for hypoglycemia among patients with type 2 diabetes using electronic health record data pooled from six academic health systems.

RESEARCH DESIGN AND METHODS

This retrospective open cohort study included 549 041 adults with type 2 diabetes receiving regular care from the included health systems between 2009 and 2019. The primary outcome was the yearly event rate for hypoglycemia hospital utilization: emergency department visits, observation visits, or inpatient admissions for hypoglycemia identified using a validated International Classification of Diseases Ninth Revision (ICD-9) algorithm from 2009 to 2014. After the transition to ICD-10 in 2015, we used two ICD-10 code sets (limited and expanded) for hypoglycemia hospital utilization from prior studies. We identified independent predictors of hypoglycemia hospital utilization using multivariable logistic regression analysis with data from 2014.

RESULTS

Yearly rates of hypoglycemia hospital utilization decreased from 2.7 to 1.6 events per 1000 patients from 2009 to 2014 (p-trend=0.023). From 2016 to 2019, yearly event rates were stable ranging from 5.6 to 6.6, or 6.3 to 7.3, using the limited and expanded ICD-10 code sets, respectively. In 2014, the strongest independent risk factors for hypoglycemia hospital utilization were chronic kidney disease (OR 2.86, 95% CI 2.33 to 3.57), ages 18-39 years (OR 2.43 vs age 40-64 years, 95% CI 1.78 to 3.31), and insulin use (OR 2.13 vs no diabetes medications, 95% CI 1.67 to 2.73).

CONCLUSIONS

Rates of hypoglycemia hospital utilization decreased from 2009 to 2014 and varied considerably by clinical risk factors such that younger adults, insulin users, and those with chronic kidney disease were at especially high risk. There is a need to validate hypoglycemia ascertainment using ICD-10 codes, which detect a substantially higher number of events compared with ICD-9.

Identifying Patients with Hypoglycemia Using Natural Language Processing: A Systematic Literature Review (Preprint)

Background

Accurately identifying patients with hypoglycemia is key to preventing adverse events and mortality. Natural language processing (NLP), a form of artificial intelligence, uses computational algorithms to extract information from text data. NLP is a scalable, efficient, and quick method to extract hypoglycemia-related information when using electronic health record data sources from a large population.

Objective

The objective of this systematic review was to synthesize the literature on the application of NLP to extract hypoglycemia from electronic health record clinical notes.

Methods

Literature searches were conducted electronically in PubMed, Web of Science Core Collection, CINAHL (EBSCO), PsycINFO (Ovid), IEEE Xplore, Google Scholar, and ACL Anthology. Keywords included hypoglycemia, low blood glucose, NLP, and machine learning. Inclusion criteria included studies that applied NLP to identify hypoglycemia, reported the outcomes related to hypoglycemia, and were published in English as full papers.

Results

This review (n=8 studies) revealed heterogeneity of the reported results related to hypoglycemia. Of the 8 included studies, 4 (50%) reported that the prevalence rate of any level of hypoglycemia was 3.4% to 46.2%. The use of NLP to analyze clinical notes improved the capture of undocumented or missed hypoglycemic events using International Classification of Diseases, Ninth Revision (ICD-9), and International Classification of Diseases, Tenth Revision (ICD-10), and laboratory testing. The combination of NLP and ICD-9 or ICD-10 codes significantly increased the identification of hypoglycemic events compared with individual methods; for example, the prevalence rates of hypoglycemia were 12.4% for International Classification of Diseases codes, 25.1% for an NLP algorithm, and 32.2% for combined algorithms. All the reviewed studies applied rule-based NLP algorithms to identify hypoglycemia.

Conclusions

The findings provided evidence that the application of NLP to analyze clinical notes improved the capture of hypoglycemic events, particularly when combined with the ICD-9 or ICD-10 codes and laboratory testing.

Mental Wellbeing and Quality of Life Among Patients With Diabetes Suffering From Hypoglycaemia in Saudi Arabia

Background Diabetes mellitus is a global burden that is considered a major public health concern for many countries. Saudi Arabia is ranked second among the highest percentages of diabetes worldwide, with more than 7 million patients with diabetes reported in 2017, with an estimated prevalence to be around 14%. Psychological and mental health outcomes are poorer in patients with diabetes who are suffering from hypoglycaemia. The aim of the study was to investigate the mental wellbeing and quality of life of patients with diabetes suffering from hypoglycaemia in Saudi Arabia. Methods A cross-sectional study using an online self-administered questionnaire was conducted between the 13^th of June and the 19^th of July 2021 in Saudi Arabia. Results A total of 69.7% of the study participants scored below 13 on the WHO-5 scale, which indicates poor mental wellbeing status and possible depression, and reduced quality of life. A total of 67.8% of the study participants scored equal to or greater than 8 on the PAID-5 scale, which indicates possible diabetes-related emotional distress that warrants further assessment. The majority of the study participants (83.4%) scored equal to or greater than 28 on the fear of hypoglycaemia scale, which is classified as having fear of hypoglycaemia. Conclusion Depressive symptoms and reduced quality of life are common among patients with diabetes mellitus suffering from hypoglycaemia in Saudi Arabia.

Hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada: a population-based retrospective cohort study

BACKGROUND

People with diabetes mellitus commonly experience hypoglycemia, but they may not necessarily present to hospital after severe hypoglycemia requiring paramedic assistance. We sought to describe the incidence and characteristics of calls for hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada, and to determine predictors of hospital transport.

METHODS

This population-based retrospective cohort study used data extracted from ambulance call reports (ACRs) of 8 paramedic services of the Southwest Ontario Regional Base Hospital Program from January 2008 to June 2014. We described calls in which treatment for hypoglycemia was administered, summarized the incidence of hypoglycemia calls and performed logistic regression to determine predictors of hospital transport.

RESULTS

Out of 470 467 ACRs during the study period, 9185 paramedic calls occurred in which hypoglycemia treatment was administered to an adult (mean age 60.2 yr, 56.8% male, 81.1% with documented diabetes). Refusal of hospital transport occurred in 2243 (24.4%) of calls. Documented diabetes diagnosis (adjusted odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69-0.96), higher capillary blood glucose (adjusted OR 0.31, 95% CI 0.22-0.44) and overnight calls (adjusted OR 0.80, 95% CI 0.72-0.91) were associated with lower odds of hospital transport. Higher-acuity calls (adjusted OR 2.05, 95% CI 1.58-2.66) were associated with higher odds of transport. The estimated annual incidence rate of hypoglycemia requiring paramedic assistance was 108 per 10 000 people with diabetes per year.

INTERPRETATION

Hypoglycemia requiring paramedic assistance in southwestern Ontario is common, and close to 25% of calls do not result in hospital transport. Physicians managing diabetes care may be unaware of patients' hypoglycemia requiring paramedic care, suggesting a potential gap in follow-up care; we suggest that paramedics play an important role in identifying those at high recurrence risk and communicating with their care providers.

Felix dies natalis, insulin… ceterum autem censeo "beta is better"

One hundred years after its discovery, insulin remains the life-saving therapy for many patients with diabetes. It has been a 100-years-old success story thanks to the fact that insulin therapy has continuously integrated the knowledge developed over a century. In 1982, insulin becomes the first therapeutic protein to be produced using recombinant DNA technology. The first "mini" insulin pump and the first insulin pen become available in 1983 and 1985, respectively. In 1996, the first generation of insulin analogues were produced. In 1999, the first continuous glucose-monitoring device for reading interstitial glucose was approved by the FDA. In 2010s, the ultra-long action insulins were introduced. An equally exciting story developed in parallel. In 1966. Kelly et al. performed the first clinical pancreas transplant at the University of Minnesota, and now it is a well-established clinical option. First successful islet transplantations in humans were obtained in the late 1980s and 1990s. Their ability to consistently re-establish the endogenous insulin secretion was obtained in 2000s. More recently, the possibility to generate large numbers of functional human β cells from pluripotent stem cells was demonstrated, and the first clinical trial using stem cell-derived insulin producing cell was started in 2014. This year, the discovery of this life-saving hormone turns 100 years. This provides a unique opportunity not only to celebrate this extraordinary success story, but also to reflect on the limits of insulin therapy and renew the commitment of the scientific community to an insulin free world for our patients.

COVID-19 hinterland: surveilling the self-reported impacts of the pandemic on diabetes management in the USA (cross-sectional results of the iNPHORM study)

MAIN OBJECTIVE

To determine how and to what extent COVID-19 has affected real-world, self-reported glycaemic management in Americans with type 1 or type 2 diabetes taking insulin and/or secretagogues, with or without infection.

DESIGN

A cross-sectional substudy using data from the Investigating Novel Predictions of Hypoglycemia Occurrence using Real-world Models panel survey.

SETTING

USA.

PARTICIPANTS

Americans 18-90 years old with type 1 or 2 diabetes taking insulin and/or secretagogues were conveniently sampled from a probability-based internet panel.

PRIMARY OUTCOME MEASURE

A structured, COVID-19-specific questionnaire was administered to assess the impact of the pandemic (irrespective of infection) on socioeconomic, behavioural/clinical and psychosocial aspects of glycaemic management.

RESULTS

Data from 667 respondents (type 1 diabetes: 18%; type 2 diabetes: 82%) were analysed. Almost 25% reported A1c values ≥8.1%. Rates of severe and non-severe hypoglycaemia were 0.68 (95% CI 0.5 to 0.96) and 2.75 (95% CI 2.4 to 3.1) events per person-month, respectively. Ten respondents reported a confirmed or probable COVID-19 diagnosis. Because of the pandemic, 24% of respondents experienced difficulties affording housing; 28% struggled to maintain sufficient food to avoid hypoglycaemia; and 19% and 17% reported challenges accessing diabetes therapies and testing strips, respectively. Over one-quarter reported issues retrieving antihyperglycaemics from the pharmacy and over one-third reported challenges consulting with diabetes providers. The pandemic contributed to therapeutic non-adherence (14%), drug rationing (17%) and reduced monitoring (16%). Many struggled to keep track, and in control, of hypoglycaemia (12%-15%) and lacked social support to help manage their risk (19%). Nearly half reported decreased physical activity. Few statistically significant differences were observed by diabetes type.

CONCLUSIONS

COVID-19 was found to cause substantial self-reported deficiencies in glycaemic management. Study results signal the need for decisive action to restabilise routine diabetes care in the USA.

TRIAL REGISTRATION NUMBER

NCT04219514.

Patient and paramedic experiences with a direct electronic referral programme for focused hypoglycaemia education following paramedic service assist-requiring hypoglycaemia in London and Middlesex County, Ontario, Canada

AIMS

Hypoglycaemia is a common treatment consequence in diabetes mellitus. Prior studies have shown that a large proportion of people with paramedic assist-requiring hypoglycaemia prefer not to be transported to hospital. Thus, these episodes are "invisible" to their usual diabetes care providers. A direct electronic referral programme where paramedics sent referrals focused hypoglycaemia education at the time of paramedic assessment was implemented in our region for 18 months; however, referral programme uptake was low. In this study, we examined patient and paramedic experiences with a direct electronic referral programme for hypoglycaemia education postparamedic assist-requiring hypoglycaemia, including barriers to programme referral and education attendance.

METHODS

We surveyed paramedics and conducted semistructured telephone interviews of patients with paramedic-assisted hypoglycaemia who consented to the referral programme and were scheduled for an education session in London and Middlesex County, Canada.

RESULTS

Paramedics and patient participants felt that the direct referral programme was beneficial. A third of paramedics who responded to our survey used the referral programme for each encounter where they treated patients for hypoglycaemia. Patients felt very positive about the referral programme and their paramedic encounter; however, they described embarrassment, guilt and prior negative experience as key barriers to attending education.

CONCLUSIONS

Paramedics and patients felt that direct referral for focused hypoglycaemia education postparamedic assist-requiring hypoglycaemia was an excellent strategy. Despite this, referral programme participation was low and thus there remain ongoing barriers to implementation and attendance. Future iterations should consider how best to meet patient needs through innovative delivery methods.

History of Severe Hypoglycemia in Type 2 Diabetes Mellitus Unmasked Significant Atherosclerotic Coronary Artery Disease: A Comparative Case Control Study

Objectives

A history of severe hypoglycemia (SH) is associated with cardiovascular (CV) events among patients with type 2 diabetes mellitus (T2DM). In this study, we compared the severity of atherosclerotic coronary artery disease (ACAD) in T2DM patients with and without a history of SH.

Methodology

We conducted a comparative case-control study involving 28 T2DM patients with a history of SH within the last 5 years with no documented ACAD, and matched them with 28 T2DM patients with no history of SH. All subjects underwent coronary artery calcium scoring (CACS) with or without coronary computed tomographic angiography (CCTA) to evaluate the severity of ACAD.

Results

A history of SH in T2DM was associated with a higher prevalence of significant ACAD (79% versus 46%, p=0.026). A high CACS (≥100) was seen in a greater number of patients with a history of SH compared to those without (75% versus 43%, p=0.029). Similarly, there was a higher prevalence of obstructive CAD in those with a history of SH compared to those without (72% versus 39%, p=0.036). Median C-reactive protein level was also higher among patients with a history of SH (0.41 mg/dL versus 0.16 mg/dL, p=0.029).

Conclusion

In patients with T2DM, a history of SH is significantly associated with ACAD compared to those without SH. A history of SH warrants screening for ACAD.

Developing the hypoglycemia-nursing early warning score system (Hy-NEWSS): A pilot study

Background: Severe hypoglycemia occurs in 6% of type 2 DM patients with a 6 to 7% mortality rate. Amidst the COVID-19 pandemic, there has been a higher rate of fatality among diabetes patients, at least 22% of COVID-19 deaths in Wuhan, China. Furthermore, the condition impairs physiological defense against recurrent hypoglycemia in the future. Accordingly, the innovation in this study aims to prevent severe hypoglycemia among type 2 patients through early risk screening, the use of preventative protocols, and patient and family empowerment. This intervention bundle is called Hypoglycemia-Nursing Early Warning Score System (Hy-NEWSS).

Design and Methods: The innovation was implemented in inpatient and outpatient settings, within two weeks with the following sequence: i) internal training, ii) Hy-NEWSS implementation, iii) outcomes evaluation.

Results: Of the twenty-eight patients involved in the study, 3 patients (19%) had a high risk of hypoglycemia, while the remaining had a low risk for the condition. However, at the end of the study there was no event of severe hypoglycemia (0%), and only 1 event (6.33%) of mild hypoglycemia. The results also showed that the accuracy of nurses in implementing the protocols was 93% and that during the evaluation, 95.62% of the responses of the nurses from the inpatient and outpatient settings were positive. Finally, the scores of the sensitivity and specificity evaluation were 99% and 88%, respectively.

Conclusion: It may be concluded from this initial study that Hy-NEWSS is effective in preventing severe hypoglycemia, accurate in identifying patient risk level for the condition, and has high applicability to be implemented in hospital settings.

Hipoglucemia tumoral dependiente y no dependiente de células β-pancreáticas, un reto diagnóstico

La hipoglucemia es una urgencia médica frecuente que en la mayoría de los casos es secundaria al uso de fármacos hipoglucemiantes, orales o inyectados, indicados en pacientes con diabetes mellitus. No obstante, puede presentarse en forma espontánea y severa relacionándose con múltiples condiciones clínicas, incluyendo las neoplasias. Ante una hipoglucemia de origen paraneoplásico se deben reconocer los mecanismos fisiopatológicos que la generan y establecer el diagnóstico oportuno y preciso para disminuir las complicaciones propias de este síndrome clínico. Presentamos dos pacientes con cuadro de hipoglucemia refractaria al manejo médico inicial, de aparición similar con patologías diferentes. El primer caso corresponde a un paciente con insulinoma y el segundo con un hemangiopericitoma.

Association between trajectory of severe hypoglycemia and dementia in patients with type 2 diabetes: A population-based study

Background

We aimed to investigate associations between exposure to various trajectories of severe hypoglycemic events and risk of dementia in patients with type 2 diabetes.

Methods

In 2002–2003, 677,618 patients in Taiwan were newly diagnosed as having type 2 diabetes. Among them, 35,720 (5.3%) experienced severe hypoglycemic events during the 3-year baseline period following diagnosis. All patients were followed from the first day after baseline period to the date of dementia diagnosis, death, or the end of 2011. A group-based trajectory model was used to classify individuals with severe hypoglycemic events during the baseline period. Cox proportional hazard models with the competing risk method were used to relate dementia risk to various severe hypoglycemia trajectories.

Results

After a median follow-up 6.70 and 6.10 years for patients with and without severe hypoglycemia at baseline, respectively, 1,952 (5.5%) individuals with severe hypoglycemia and 23,492 (3.7%) without developed dementia during follow-up, for incidence rates of 109.80 and 61.88 per 10,000 person-years, respectively. Four groups of severe hypoglycemia trajectory were identified with a proportion of 18.06%, 33.19%, 43.25%, and 5.50%, respectively, for Groups 1 to 4. Groups 3 (early manifestation but with later decrease) and 4 (early and sustained manifestation) were associated with a significantly increased risk of dementia diagnosis, with a covariate-adjusted subdistribution hazard ratio of 1.22 (95% confidence interval, 1.14–1.31) and 1.25 (95% confidence interval, 1.02–1.54), respectively.

Conclusion

Our analysis highlighted that early manifestation of severe hypoglycemic events may contribute more than does late manifestation to the risk of dementia among individuals newly diagnosed as having type 2 diabetes.