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Gouveri E, Gkouveri A, Popovic DS, Papazoglou D, Papanas N. Intentional Insulin Overdose and Depression in Subjects with and Without Diabetes Mellitus: A Commentary. Diabetes Ther 2024; 15:1845-1854. [PMID: 39046697 PMCID: PMC11330432 DOI: 10.1007/s13300-024-01623-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/09/2024] [Indexed: 07/25/2024] Open
Abstract
Insulin is an essential medication for people with type 1 diabetes mellitus and for some people with type 2 diabetes. Interestingly, insulin abuse has been reported as a mode of suicide, not only among people with diabetes, but also among their relatives, and among medical and paramedical personnel who have access to insulin. The aim of the present commentary was to raise awareness of potential depression-related intentional insulin overdose and its complications, as well as of the diagnosis and treatment of this entity. Insulin overdose may lead to severe and prolonged hypoglycemia, hypoglycemic coma, and death. Moreover, hypokalemia, hypomagnesemia, hypophosphatemia, and elevated liver enzymes are common. Insulin overdose should be suspected among people with diabetes in case of unexplained prolonged hypoglycemia and among people without diabetes who exhibit hypoglycemia and may have access to diabetic medications. The ratio of insulin to C-peptide helps distinguish exogenous insulin administration from endogenous secretion. The cornerstone of therapy is prompt administration of concentrated glucose infusions for days with simultaneous oral intake, when possible, and intense glucose monitoring to prevent hypoglycemia. Moreover, monitoring of serum electrolyte levels is recommended. Finally, psychiatric evaluation aiming at early identification of depression and suicidality is of paramount importance.
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Affiliation(s)
- Evanthia Gouveri
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | | | - Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Novi Sad, Serbia
- Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Dimitrios Papazoglou
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, 68100, Alexandroupolis, Greece.
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Kulzer B, Freckmann G, Ziegler R, Schnell O, Glatzer T, Heinemann L. Nocturnal hypoglycemia in the era of continuous glucose monitoring. J Diabetes Sci Technol 2024:19322968241267823. [PMID: 39158988 DOI: 10.1177/19322968241267823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2024]
Abstract
Nocturnal hypoglycemia is a common acute complication of people with diabetes on insulin therapy. In particular, the inability to control glucose levels during sleep, the impact of external factors such as exercise, or alcohol and the influence of hormones are the main causes. Nocturnal hypoglycemia has several negative somatic, psychological, and social effects for people with diabetes, which are summarized in this article. With the advent of continuous glucose monitoring (CGM), it has been shown that the number of nocturnal hypoglycemic events was significantly underestimated when traditional blood glucose monitoring was used. The CGM can reduce the number of nocturnal hypoglycemia episodes with the help of alarms, trend arrows, and evaluation routines. In combination with CGM with an insulin pump and an algorithm, automatic glucose adjustment (AID) systems have their particular strength in nocturnal glucose regulation and the prevention of nocturnal hypoglycemia. Nevertheless, the problem of nocturnal hypoglycemia has not yet been solved completely with the technologies currently available. The CGM systems that use predictive models to warn of hypoglycemia, improved AID systems that recognize hypoglycemia patterns even better, and the increasing integration of artificial intelligence methods are promising approaches in the future to significantly minimize the risk of a side effect of insulin therapy that is burdensome for people with diabetes.
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Affiliation(s)
- Bernhard Kulzer
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany
- Diabetes Center Mergentheim, Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
| | - Guido Freckmann
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Ralph Ziegler
- Diabetes Clinic for Children and Adolescents, Muenster, Germany
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Helmholtz Zentrum, Munich, Germany
| | | | - Lutz Heinemann
- Science Consulting in Diabetes GmbH, Düsseldorf, Germany
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Zucchini S, Tumini S, Scaramuzza AE, Bonfanti R, Delvecchio M, Franceschi R, Iafusco D, Lenzi L, Mozzillo E, Passanisi S, Piona C, Rabbone I, Rapini N, Rigamonti A, Ripoli C, Salzano G, Savastio S, Schiaffini R, Zanfardino A, Cherubini V. Recommendations for recognizing, risk stratifying, treating, and managing children and adolescents with hypoglycemia. Front Endocrinol (Lausanne) 2024; 15:1387537. [PMID: 38894740 PMCID: PMC11183505 DOI: 10.3389/fendo.2024.1387537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024] Open
Abstract
There has been continuous progress in diabetes management over the last few decades, not least due to the widespread dissemination of continuous glucose monitoring (CGM) and automated insulin delivery systems. These technological advances have radically changed the daily lives of people living with diabetes, improving the quality of life of both children and their families. Despite this, hypoglycemia remains the primary side-effect of insulin therapy. Based on a systematic review of the available scientific evidence, this paper aims to provide evidence-based recommendations for recognizing, risk stratifying, treating, and managing patients with hypoglycemia. The objective of these recommendations is to unify the behavior of pediatric diabetologists with respect to the timely recognition and prevention of hypoglycemic episodes and the correct treatment of hypoglycemia, especially in patients using CGM or advanced hybrid closed-loop systems. All authors have long experience in the specialty and are members of the Italian Society of Pediatric Endocrinology and Diabetology. The goal of treating hypoglycemia is to raise blood glucose above 70 mg/dL (3.9 mmol/L) and to prevent further decreases. Oral glucose at a dose of 0.3 g/kg (0.1 g/kg for children using "smart pumps" or hybrid closed loop systems in automated mode) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate (e.g., sucrose, which consists of glucose and fructose, or honey, sugary soft drinks, or fruit juice) containing glucose may be used. Using automatic insulin delivery systems, the oral glucose dose can be decreased to 0.1 g/kg. Practical flow charts are included to aid clinical decision-making. Although representing the official position of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED), these guidelines are applicable to the global audience and are especially pertinent in the era of CGM and other advanced technologies.
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Affiliation(s)
- Stefano Zucchini
- Study Group of Diabetology of the Italian Society for Pediatric Endocrinology and Diabetes (I.S.P.E.D.,) University Hospital of Ferrara, Ferrara, Italy
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Annunziata Hospital, Chieti, Italy
| | - Andrea Enzo Scaramuzza
- Division of Pediatrics, Pediatric Diabetes, Endocrinology and Nutrition, Azienda Socio Sanitaria Territoriale (ASST) Cremona, Cremona, Italy
| | - Riccardo Bonfanti
- UO Pediatric Diabetes Research Institute, Ospedale San Raffaele, Milan, Italy
| | - Maurizio Delvecchio
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Roberto Franceschi
- Department of Pediatrics, S. Chiara Hospital of Trento, APSS, Trento, Italy
| | - Dario Iafusco
- Department of Woman, Child and General and Specialistic Surgery, Regional Center of Pediatric Diabetes, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Lorenzo Lenzi
- Diabetology Unit, Pediatric Department, Anna Meyer Children’s Hospital, Florence, Italy
| | - Enza Mozzillo
- Section of Pediatrics, Regional Center of Pediatric Diabetes, University Federico II, Naples, Italy
| | - Stefano Passanisi
- Department of Human Pathology of Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Claudia Piona
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, Verona, Italy
| | - Ivana Rabbone
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Novella Rapini
- Diabetes Unit, Bambino Gesú Childrens’ Hospital, Rome, Italy
| | - Andrea Rigamonti
- UO Pediatric Diabetes Research Institute, Ospedale San Raffaele, Milan, Italy
| | - Carlo Ripoli
- Pediatric Diabetology Unit, Department of Pediatrics, ASL 8 Cagliari, Cagliari, Italy
| | - Giuseppina Salzano
- Department of Human Pathology of Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Silvia Savastio
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | | | - Angela Zanfardino
- Department of Woman, Child and General and Specialistic Surgery, Regional Center of Pediatric Diabetes, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Valentino Cherubini
- Department of Women’s and Children’s Health, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, ‘Salesi Hospital’, Ancona, Italy
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El Mlili N, Ahabrach H, Bahri H, Kerkeb A, Mafla-España MA, Cauli O. Psychological Alterations in Youths with Type I Diabetes: Associations with Salivary Cortisol Concentration. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:19. [PMID: 38276053 PMCID: PMC10818808 DOI: 10.3390/medicina60010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/27/2024]
Abstract
Background and Objectives: Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in children and adolescents, and is associated with stress and other psychological alterations. This study aims to assess psychological and sleep disorders and health-related quality of life in young people with T1DM and to determine the relationship between these parameters and levels of salivary cortisol, a hormone widely associated with stress and several psychological symptoms. Materials and Methods: In our cross-sectional study performed in 60 Moroccan children and adolescents with T1DM, detailed psychological evaluations were performed to assess symptoms of anxiety, attention-deficit hyperactivity disorder (ADHD), sleep quality and diabetes-specific quality of life (using the RCMAS-2, ADHD rating scale, Pittsburgh scale and the DQoL scale, respectively), and cortisol concentration was measured from saliva samples taken mid-morning. Results: A total of 60 children and adolescents with T1DM were recruited. The mean age was 11.05 ± 0.35 (6-17). The mean salivary cortisol level in ng/mL was 4.7 ± 0.49 (0.7-20.2) and was significantly associated with an anxiety RCMAS2 score for the Worry subdomain and DQoL subdomain "Anxiety". Linear regression analysis showed that salivary cortisol was significantly higher in girls compared to boys (p = 0.004) (beta coefficient: 3.384 CI95%: 1.137-5.630) and with Hb1AC level as a continuous variable (p = 0.0001) (beta coefficient: 1.135 CI95%: 0.509-1.760). The other variables included in the model were not significant (p > 0.05). There was an association between salivary cortisol concentration with anxiety RCMAS2 score for Worry subdomain and QoL sub-domain "Anxiety". Still, a significant (p = 0.018) association emerged for anxiety RCMAS2 score Worry subdomain and QoL anxiety subdomain (p = 0.044). Conclusions: Children and adolescents with T1DM experienced significantly elevated symptoms of anxiety and sleep disturbances, particularly in girls, and frequent symptoms of ADHD, particularly in boys. Salivary cortisol concentration collected in the morning is associated with anxiety burden but not with other psychological alterations. Further studies are needed to clarify the associations between salivary cortisol concentration and anxiety in type 1 diabetes in order to propose the hormone as a biomarker for interventions aimed to reduce anxiety levels in these patients.
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Affiliation(s)
- Nisrin El Mlili
- Institute of Nursing and Health Technology (ISPITS), Tetouan 93000, Morocco; (N.E.M.); (H.A.); (H.B.)
- Department of Biology and Health, Faculty of Sciences, Abdelmalek Essaâdi University, Tetouan 93000, Morocco
| | - Hanan Ahabrach
- Institute of Nursing and Health Technology (ISPITS), Tetouan 93000, Morocco; (N.E.M.); (H.A.); (H.B.)
- Department of Biology and Health, Faculty of Sciences, Abdelmalek Essaâdi University, Tetouan 93000, Morocco
| | - Hind Bahri
- Institute of Nursing and Health Technology (ISPITS), Tetouan 93000, Morocco; (N.E.M.); (H.A.); (H.B.)
- Interdisciplinary Laboratory for Research in Pedagogical Engineering (LIRIP), Ecole Normale Supérieure, Abdelmalek Essaâdi University, Tetouan 93000, Morocco
| | | | | | - Omar Cauli
- Department of Nursing, University of Valencia, 46010 Valencia, Spain;
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