1
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Nakrour N, Neibling JE, Pathak A, Carbo A. Gastrointestinal pharmacoradiology, an updated review of medications and gastrointestinal contrasts in abdominal imaging. Abdom Radiol (NY) 2024:10.1007/s00261-024-04504-4. [PMID: 39225719 DOI: 10.1007/s00261-024-04504-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 07/15/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024]
Abstract
The purpose of this article is to review commonly used medications in abdominal radiology including their indications, mechanisms of action, dosages, contraindications, precautions, and adverse reactions. We will clarify common inquiries and address frequently asked questions by patients and clinicians related to their use. In addition, we will explore the indications, advantages and disadvantages, dosages, and contraindications of enteric contrast agents used for CT and fluoroscopic examinations.
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Affiliation(s)
- Nour Nakrour
- Department of Radiology, John D. Dingell VA Medical Center, Detroit, MI, USA.
| | - J E Neibling
- Department of Radiology, Wayne State University School of Medicine & Detroit Medical Center, Detroit, MI, USA
| | - Avani Pathak
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Alberto Carbo
- Department of Radiology, Ochsner- LSU Health, Shreveport, LA, USA
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2
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Magnetic Resonance Imaging and Spectroscopy Methods to Study Hepatic Glucose Metabolism and Their Applications in the Healthy and Diabetic Liver. Metabolites 2022; 12:metabo12121223. [PMID: 36557261 PMCID: PMC9788351 DOI: 10.3390/metabo12121223] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
The liver plays an important role in whole-body glucose homeostasis by taking up glucose from and releasing glucose into the blood circulation. In the postprandial state, excess glucose in the blood circulation is stored in hepatocytes as glycogen. In the postabsorptive state, the liver produces glucose by breaking down glycogen and from noncarbohydrate precursors such as lactate. In metabolic diseases such as diabetes, these processes are dysregulated, resulting in abnormal blood glucose levels. Magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) are noninvasive techniques that give unique insight into different aspects of glucose metabolism, such as glycogenesis, glycogenolysis, and gluconeogenesis, in the liver in vivo. Using these techniques, liver glucose metabolism has been studied in regard to a variety of interventions, such as fasting, meal intake, and exercise. Moreover, deviations from normal hepatic glucose metabolism have been investigated in both patients with type 1 and 2 diabetes, as well as the effects of antidiabetic medications. This review provides an overview of current MR techniques to measure hepatic glucose metabolism and the insights obtained by the application of these techniques in the healthy and diabetic liver.
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3
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Abstract
Closed-loop insulin delivery systems are fast becoming the standard of care in the management of type 1 diabetes and have led to significant improvements in diabetes management. Nevertheless, there is still room for improvement for the closed-loop systems to optimize treatment and meet target glycemic control. Adjunct treatments have been introduced as an alternative method to insulin-only treatment methods to overcome diabetes treatment challenges and improve clinical and patient reported outcomes during closed-loop treatment. The adjunct treatment agents mostly consist of medications that are already approved for type 2 diabetes treatment and aim to complete the missing physiologic factors, such as the entero-endocrine system, that regulate glycemia in addition to insulin. This paper will review many of these adjunct therapies, including the basic mechanisms of action, potential benefits, side effects, and the evidence supporting their use during closed-loop treatment.
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Affiliation(s)
- Shylaja Srinivasan
- Division of Pediatric Endocrinology and
Diabetes, University of San Francisco, CA, USA
| | - Laya Ekhlaspour
- Division of Pediatric Endocrinology and
Diabetes, Stanford University, Palo Alto, CA, USA
| | - Eda Cengiz
- Division of Pediatric Endocrinology and
Diabetes, Yale University, New Haven, NJ, USA
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4
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Moon SJ, Jung I, Park CY. Current Advances of Artificial Pancreas Systems: A Comprehensive Review of the Clinical Evidence. Diabetes Metab J 2021; 45:813-839. [PMID: 34847641 PMCID: PMC8640161 DOI: 10.4093/dmj.2021.0177] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022] Open
Abstract
Since Banting and Best isolated insulin in the 1920s, dramatic progress has been made in the treatment of type 1 diabetes mellitus (T1DM). However, dose titration and timely injection to maintain optimal glycemic control are often challenging for T1DM patients and their families because they require frequent blood glucose checks. In recent years, technological advances in insulin pumps and continuous glucose monitoring systems have created paradigm shifts in T1DM care that are being extended to develop artificial pancreas systems (APSs). Numerous studies that demonstrate the superiority of glycemic control offered by APSs over those offered by conventional treatment are still being published, and rapid commercialization and use in actual practice have already begun. Given this rapid development, keeping up with the latest knowledge in an organized way is confusing for both patients and medical staff. Herein, we explore the history, clinical evidence, and current state of APSs, focusing on various development groups and the commercialization status. We also discuss APS development in groups outside the usual T1DM patients and the administration of adjunct agents, such as amylin analogues, in APSs.
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Affiliation(s)
- Sun Joon Moon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Inha Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Cheol-Young Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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5
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Infante M, Baidal DA, Rickels MR, Fabbri A, Skyler JS, Alejandro R, Ricordi C. Dual-hormone artificial pancreas for management of type 1 diabetes: Recent progress and future directions. Artif Organs 2021; 45:968-986. [PMID: 34263961 DOI: 10.1111/aor.14023] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/09/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
Over the last few years, technological advances have led to tremendous improvement in the management of type 1 diabetes (T1D). Artificial pancreas systems have been shown to improve glucose control compared with conventional insulin pump therapy. However, clinically significant hypoglycemic and hyperglycemic episodes still occur with the artificial pancreas. Postprandial glucose excursions and exercise-induced hypoglycemia represent major hurdles in improving glucose control and glucose variability in many patients with T1D. In this regard, dual-hormone artificial pancreas systems delivering other hormones in addition to insulin (glucagon or amylin) may better reproduce the physiology of the endocrine pancreas and have been suggested as an alternative tool to overcome these limitations in clinical practice. In addition, novel ultra-rapid-acting insulin analogs with a more physiological time-action profile are currently under investigation for use in artificial pancreas devices, aiming to address the unmet need for further improvements in postprandial glucose control. This review article aims to discuss the current progress and future outlook in the development of novel ultra-rapid insulin analogs and dual-hormone closed-loop systems, which offer the next steps to fully closing the loop in the artificial pancreas.
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Affiliation(s)
- Marco Infante
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Metabolism and Diabetes, Department of Systems Medicine, CTO A. Alesini Hospital, Diabetes Research Institute Federation, University of Rome Tor Vergata, Rome, Italy.,UniCamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | - David A Baidal
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrea Fabbri
- Division of Endocrinology, Metabolism and Diabetes, Department of Systems Medicine, CTO A. Alesini Hospital, Diabetes Research Institute Federation, University of Rome Tor Vergata, Rome, Italy
| | - Jay S Skyler
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rodolfo Alejandro
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Camillo Ricordi
- Clinical Cell Transplant Program, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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6
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Laugesen C, Schmidt S, Holst JJ, Nørgaard K, Ranjan AG. The effect of preceding glucose decline rate on low-dose glucagon efficacy in individuals with type 1 diabetes: A randomized crossover trial. Diabetes Obes Metab 2021; 23:1057-1062. [PMID: 33336888 DOI: 10.1111/dom.14301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/04/2020] [Accepted: 12/13/2020] [Indexed: 11/30/2022]
Abstract
Identifying determinants of low-dose glucagon efficacy is important to optimise its utilization for prevention and treatment of hypoglycaemia in individuals with type 1 diabetes. The study objective was to investigate whether the preceding glucose decline rate affects glucose response to low-dose glucagon administration. Ten adults with insulin pump-treated type 1 diabetes were included in this randomized, single-blind, two-way crossover study. Using a hyperinsulinaemic clamp technique, plasma glucose levels were reduced with either a rapid or slow decline rate while maintaining fixed insulin levels. When the plasma glucose level reached 3.9 mmoL/L, insulin and glucose infusions were discontinued and 150 μg subcutaneous glucagon was administered, followed by 120 minutes of plasma glucose monitoring. The positive incremental area under the glucose curve after administration of low-dose glucagon did not differ between the rapid-decline and slow-decline visits (mean ± SEM: 220 ± 49 vs. 174 ± 31 mmoL/L x min; P = 0.21). Similarly, no differences in total area under the glucose curve, peak plasma glucose, incremental peak plasma glucose, time-to-peak plasma glucose or end plasma glucose were observed. Thus, preceding glucose decline rate did not significantly affect the glucose response to low-dose glucagon.
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Affiliation(s)
| | - Signe Schmidt
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Jens Juul Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Ajenthen G Ranjan
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Danish Diabetes Academy, Odense, Denmark
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7
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Ranjan AG, Schmidt S, Nørgaard K. Glucagon for hypoglycaemia treatment in type 1 diabetes. Diabetes Metab Res Rev 2020; 37:e3409. [PMID: 33090668 DOI: 10.1002/dmrr.3409] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/14/2020] [Accepted: 09/14/2020] [Indexed: 12/22/2022]
Abstract
To achieve strict glycaemic control and avoid chronic diabetes complications, individuals with type 1 diabetes (T1D) are recommended to follow an intensive insulin regimen. However, the risk and fear of hypoglycaemia often prevent individuals from achieving the treatment goals. Apart from early insulin suspension in insulin pump users, carbohydrate ingestion is the only option for preventing and treating non-severe hypoglycaemic events. These rescue treatments may give extra calories and cause overweight. As an alternative, the use of low-dose glucagon to counter hypoglycaemia has been proposed as a tool to raise glucose concentrations without adding extra calories. Previously, the commercially available glucagon formulations required reconstitution from powder to a solution before being injected subcutaneously or intramuscularly-making it practical only for treating severe hypoglycaemia. Several companies have developed more stable formulations that do not require the time-consuming reconstitution process before use. As well as treating severe hypoglycaemia, non-severe and impending hypoglycaemia can also be treated with lower doses of glucagon. Once available, low-dose glucagon can be either delivered manually, as an injection, or automatically, by an infusion pump. This review focuses on the role and perspectives of using glucagon to treat and prevent hypoglycaemia in T1D.
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Affiliation(s)
- Ajenthen G Ranjan
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Danish Diabetes Academy, Odense, Denmark
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8
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Åm MK, Dirnena-Fusini I, Fougner AL, Carlsen SM, Christiansen SC. Intraperitoneal and subcutaneous glucagon delivery in anaesthetized pigs: effects on circulating glucagon and glucose levels. Sci Rep 2020; 10:13735. [PMID: 32792580 PMCID: PMC7426268 DOI: 10.1038/s41598-020-70813-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 07/07/2020] [Indexed: 12/18/2022] Open
Abstract
Glucagon is a pancreatic hormone and increases the blood glucose levels. It may be incorporated in a dual hormone artificial pancreas, a device to automatically and continuously control blood glucose levels of individuals with diabetes. Artificial pancreas systems have been developed for use in the subcutaneous tissue; however, the systems are not fully automated due to slow dynamics. The intraperitoneal space is therefore investigated as an alternative location for an artificial pancreas. Glucose dynamics after subcutaneous and intraperitoneal glucagon delivery in ten anaesthetized pigs were investigated. The pigs received intraperitoneal boluses of 0.3 µg/kg and 0.6 µg/kg and a subcutaneous bolus of 0.6 µg/kg in randomized order. They also received an intraperitoneal bolus of 1 mg given at the end of the experiments to test the remaining capacity of rapid glucose release. Six pigs were included in the statistical analysis. The intraperitoneal glucagon bolus of 0.6 µg/kg gave a significantly higher glucose response from 14 to 30 min compared with the subcutaneous bolus. The results indicate that glucagon induces a larger glucose response after intraperitoneal delivery compared with subcutaneous delivery and is encouraging for the incorporation of glucagon in an intraperitoneal artificial pancreas.
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Affiliation(s)
- Marte Kierulf Åm
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postboks 8905, 7491, Trondheim, Norway. .,Department of Endocrinology, St Olav's Hospital, Trondheim, Norway.
| | - Ilze Dirnena-Fusini
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postboks 8905, 7491, Trondheim, Norway.,Department of Endocrinology, St Olav's Hospital, Trondheim, Norway
| | - Anders Lyngvi Fougner
- Department of Engineering Cybernetics, Faculty of Information Technology and Electrical Engineering, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Sven Magnus Carlsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postboks 8905, 7491, Trondheim, Norway.,Department of Endocrinology, St Olav's Hospital, Trondheim, Norway
| | - Sverre Christian Christiansen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Postboks 8905, 7491, Trondheim, Norway.,Department of Endocrinology, St Olav's Hospital, Trondheim, Norway
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9
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Abstract
Treatment of type 1 diabetes with exogenous insulin often results in unpredictable daily glucose variability and hypoglycemia, which can be dangerous. Automated insulin delivery systems can improve glucose control while reducing burden for people with diabetes. One approach to improve treatment outcomes is to incorporate the counter-regulatory hormone glucagon into the automated delivery system to help prevent the hypoglycemia that can be induced by the slow pharmacodynamics of insulin action. This article explores the advantages and disadvantages of incorporating glucagon into dual-hormone automated hormone delivery systems.
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Affiliation(s)
- Leah M Wilson
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA.
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Mail Code: CH13B, 3303 Southwest Bond Avenue, Portland, OR 97239, USA
| | - Jessica R Castle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University, Harold Schnitzer Diabetes Health Center, 3181 Southwest Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA
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10
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Haidar A. Insulin-and-Glucagon Artificial Pancreas Versus Insulin-Alone Artificial Pancreas: A Short Review. Diabetes Spectr 2019; 32:215-221. [PMID: 31462876 PMCID: PMC6695257 DOI: 10.2337/ds18-0097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IN BRIEF The advantage of the insulin-and-glucagon artificial pancreas is based on the rapid effect of subcutaneous glucagon delivery in preventing hypoglycemia compared to suspension of insulin delivery. In short-term studies, the dual-hormone artificial pancreas reduced daytime hypoglycemia, especially during exercise, compared to the insulin-alone artificial pancreas, but the insulin-alone system seemed sufficient in eliminating nocturnal hypoglycemia. The comparative benefits of the single- and dual-hormone systems for improving A1C and preventing severe hypoglycemia remain unknown.
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Affiliation(s)
- Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
- Division of Endocrinology and Metabolism, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
- The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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11
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Malin SK, Kullman EL, Scelsi AR, Godin JP, Ross AB, Kirwan JP. A Whole-Grain Diet Increases Glucose-Stimulated Insulin Secretion Independent of Gut Hormones in Adults at Risk for Type 2 Diabetes. Mol Nutr Food Res 2019; 63:e1800967. [PMID: 30763457 DOI: 10.1002/mnfr.201800967] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/29/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The effect of whole-grain (WG) versus refined-grain (RG) diets on glucose-stimulated insulin secretion (GSIS) and β-cell function is unclear. METHODS In a double-blind crossover randomized controlled trial, 13 prediabetic adults (37.2 ± 1.8 y, BMI: 33.6 ± 1.4 kg m-2 , 2 h glucose: 146.9 ± 11.6 mg dL-1 ) are provided isocaloric-matched WG and RG diets for 8-weeks each, with an 8-10 week washout between diets. Glucose, insulin, and C-peptide are studied over 240 min following a 75 g OGTT. Incretins (GLP-1 and GIP), PYY, and total ghrelin are assessed at 0, 30, and 60 min. Mixed-meal diets for carbohydrate (54%), fat (28%), and protein (18%) contain either WG (50 g/1000 kcal) or equivalent RG. RESULTS Both diets induce fat loss (≈2 kg). While neither diet impacts early phase GSIS, the WG diet increases total GSIS (iAUC of C-peptide0-240 /Glc0-240 , p = 0.02) and β-cell function (disposition index; GSIS × insulin sensitivity, p = 0.02). GIP and PYY are unaltered by either diet, but GLP-1 is higher at 30 min following RG versus WG (p = 0.04). Ghrelin levels are higher at 60 min of the OGTT following both interventions (p = 0.01). CONCLUSION A WG-rich diet increases β-cell function independent of gut hormones in adults with prediabetes.
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Affiliation(s)
- Steven K Malin
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.,Department of Kinesiology, University of Virginia, Charlottesville, VA, 22904, USA
| | - Emily L Kullman
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.,Department of Health and Human Performance, Cleveland State University, Cleveland, OH, 44115, USA
| | - Amanda R Scelsi
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Jean-Philippe Godin
- Institute of Food Safety and Analytical Sciences, Nestlé Research Center, 1015, Lausanne, Switzerland
| | - Alastair B Ross
- Department of Biology and Biological Engineering, Chalmers University of Technology, Chalmersplatsen 4, 412 96, Gothenburg, Sweden
| | - John P Kirwan
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.,Pennington Biomedical Research Center, Baton Rouge, LA, 70808, USA
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12
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Castle JR, El Youssef J, Wilson LM, Reddy R, Resalat N, Branigan D, Ramsey K, Leitschuh J, Rajhbeharrysingh U, Senf B, Sugerman SM, Gabo V, Jacobs PG. Randomized Outpatient Trial of Single- and Dual-Hormone Closed-Loop Systems That Adapt to Exercise Using Wearable Sensors. Diabetes Care 2018; 41:1471-1477. [PMID: 29752345 PMCID: PMC6014543 DOI: 10.2337/dc18-0228] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/13/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Automated insulin delivery is the new standard for type 1 diabetes, but exercise-related hypoglycemia remains a challenge. Our aim was to determine whether a dual-hormone closed-loop system using wearable sensors to detect exercise and adjust dosing to reduce exercise-related hypoglycemia would outperform other forms of closed-loop and open-loop therapy. RESEARCH DESIGN AND METHODS Participants underwent four arms in randomized order: dual-hormone, single-hormone, predictive low glucose suspend, and continuation of current care over 4 outpatient days. Each arm included three moderate-intensity aerobic exercise sessions. The two primary outcomes were percentage of time in hypoglycemia (<70 mg/dL) and in a target range (70-180 mg/dL) assessed across the entire study and from the start of the in-clinic exercise until the next meal. RESULTS The analysis included 20 adults with type 1 diabetes who completed all arms. The mean time (SD) in hypoglycemia was the lowest with dual-hormone during the exercise period: 3.4% (4.5) vs. 8.3% (12.6) single-hormone (P = 0.009) vs. 7.6% (8.0) predictive low glucose suspend (P < 0.001) vs. 4.3% (6.8) current care where pre-exercise insulin adjustments were allowed (P = 0.49). Time in hypoglycemia was also the lowest with dual-hormone during the entire 4-day study: 1.3% (1.0) vs. 2.8% (1.7) single-hormone (P < 0.001) vs. 2.0% (1.5) predictive low glucose suspend (P = 0.04) vs. 3.1% (3.2) current care (P = 0.007). Time in range during the entire study was the highest with single-hormone: 74.3% (8.0) vs. 72.0% (10.8) dual-hormone (P = 0.44). CONCLUSIONS The addition of glucagon delivery to a closed-loop system with automated exercise detection reduces hypoglycemia in physically active adults with type 1 diabetes.
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Affiliation(s)
- Jessica R Castle
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR.,Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Leah M Wilson
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Ravi Reddy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Navid Resalat
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Katrina Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics & Design Program, Oregon Health & Science University, Portland, OR
| | - Joseph Leitschuh
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
| | - Uma Rajhbeharrysingh
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Brian Senf
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Samuel M Sugerman
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Virginia Gabo
- Harold Schnitzer Diabetes Health Center, Division of Endocrinology, Oregon Health & Science University, Portland, OR
| | - Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR
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13
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Peters TM, Haidar A. Dual-hormone artificial pancreas: benefits and limitations compared with single-hormone systems. Diabet Med 2018; 35:450-459. [PMID: 29337384 DOI: 10.1111/dme.13581] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 12/17/2022]
Abstract
Technological advances have made the artificial pancreas a reality. This has the potential to improve the lives of individuals with Type 1 diabetes by reducing the risk of hypoglycaemia, achieving better overall glucose control, and enhancing quality of life. Both single-hormone (insulin-only) and dual-hormone (insulin and glucagon) systems have been developed; however, a focused review of the relative benefits of each artificial pancreas system is needed. We reviewed studies that directly compared single- and dual-hormone systems to evaluate the efficacy of each system for preventing hypoglycaemia and maintaining glycaemic control, as well as their utility in specific situations including during exercise, overnight and during the prandial period. We observed additional benefits with the dual-hormone artificial pancreas for reducing the risk of hypoglycaemic events overall and during exercise over the study duration. The single-hormone artificial pancreas was sufficient for maintenance of euglycaemia in the overnight period and for preventing late-onset post-exercise hypoglycaemia. Future comparative studies of longer duration are required to determine whether one system is superior for improving mean glucose control, eliminating severe hypoglycaemia, or improving quality of life.
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Affiliation(s)
- T M Peters
- Division of Endocrinology and Metabolism, Faculty of Medicine
| | - A Haidar
- Division of Endocrinology and Metabolism, Faculty of Medicine
- Department of Biomedical Engineering, McGill University
- The Research Institute of the McGill University Health Centre, Montreal, Canada
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14
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Ranjan A, Nørgaard K, Tetzschner R, Steineck IIK, Clausen TR, Holst JJ, Madsbad S, Schmidt S. Effects of Preceding Ethanol Intake on Glucose Response to Low-Dose Glucagon in Individuals With Type 1 Diabetes: A Randomized, Placebo-Controlled, Crossover Study. Diabetes Care 2018; 41:797-806. [PMID: 29358493 DOI: 10.2337/dc17-1458] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 12/20/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study investigated whether preceding ethanol intake impairs glucose response to low-dose glucagon in individuals with type 1 diabetes. RESEARCH DESIGN AND METHODS This was a randomized, crossover, placebo-controlled study in 12 insulin pump-treated individuals (median [interquartile range] age, 37 [31-51] years; HbA1c, 57 [51-59] mmol/mol or 7.3% [6.8-7.5]; and BMI, 23.9 [22-25] kg/m2). During two overnight study visits, a 6 p.m. dinner (1 g carbohydrates/kg) was served with diet drink (placebo) or diet drink and ethanol (0.8 g/kg). After 8-9 h, ethanol was estimated to be metabolized, and a subcutaneous (s.c.) insulin bolus was given to induce mild hypoglycemia. When plasma glucose (PG) was ≤3.9 mmol/L, 100 µg glucagon was given s.c., followed by another s.c. 100 µg glucagon 2 h later. Primary end point was incremental peak PG induced by the first glucagon bolus. RESULTS Ethanol was undetectable before insulin administration at both visits. The insulin doses (mean ± SEM: 2.5 ± 0.4 vs. 2.7 ± 0.4 IU) to induce hypoglycemia (3.7 ± 0.1 vs. 3.9 ± 0.1 mmol/L) did not differ and caused similar insulin levels (28.3 ± 4.6 vs. 26.1 ± 4.0 mU/L) before glucagon administration on ethanol and placebo visits (all, P > 0.05). The first glucagon bolus tended to cause lower incremental peak PG (2.0 ± 0.5 vs. 2.9 ± 0.3 mmol/L, P = 0.06), lower incremental area under the curve (87 ± 40 vs. 191 ± 37 mmol/L × min, P = 0.08), and lower 2-h PG level (3.6 ± 1.0 vs. 4.8 ± 0.4 mmol/L, P = 0.05) after ethanol compared with placebo. The second glucagon bolus had similar responses between visits, but PG remained 1.8 ± 0.7 mmol/L lower after ethanol compared with placebo. CONCLUSIONS The ability of low-dose glucagon to treat mild hypoglycemia persisted with preceding ethanol intake, although it tended to be attenuated.
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Affiliation(s)
- Ajenthen Ranjan
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark .,Danish Diabetes Academy, Odense, Denmark
| | - Kirsten Nørgaard
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Rikke Tetzschner
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Isabelle Isa Kristin Steineck
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Danish Diabetes Academy, Odense, Denmark
| | | | - Jens Juul Holst
- Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Novo Nordisk Foundation Center for Basic Metabolic Research and Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Signe Schmidt
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark.,Danish Diabetes Academy, Odense, Denmark
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Dash S, Xiao C, Stahel P, Koulajian K, Giacca A, Lewis GF. Evaluation of the specific effects of intranasal glucagon on glucose production and lipid concentration in healthy men during a pancreatic clamp. Diabetes Obes Metab 2018; 20:328-334. [PMID: 28730676 DOI: 10.1111/dom.13069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/01/2017] [Accepted: 07/13/2017] [Indexed: 01/19/2023]
Abstract
AIM To investigate the specific effects of intranasal glucagon (ING) on plasma glucose, endogenous glucose production (EGP) and lipid concentration. METHODS We conducted a single-blind, randomized, crossover study at our academic investigation unit. Under pancreatic clamp conditions with tracer infusion, 1 mg ING or intranasal placebo (INP) was administered to 10 healthy men. As pilot studies showed that ING transiently increased plasma glucagon, we infused intravenous glucagon for 30 minutes along with INP to ensure similar plasma glucagon concentrations between interventions. The main outcome measures were plasma glucose, EGP, free fatty acid (FFA) and triglyceride (TG) concentrations. RESULTS In the presence of similar plasma glucagon concentrations, the increase in plasma glucose under these experimental conditions was attenuated with ING (mean plasma glucose analysis of variance P < .001) with reduction in EGP (P = .027). No significant differences were seen in plasma FFA and TG concentrations. CONCLUSION ING raises plasma glucose but this route of administration attenuates the gluco-stimulatory effect of glucagon by reducing EGP. This observation invites speculation about a potential central nervous system effect of glucagon, which requires further investigation. If ING is developed as a treatment for hypoglycaemia, this attenuated effect on plasma glucose should be taken into account.
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Affiliation(s)
- Satya Dash
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Changting Xiao
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Priska Stahel
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Khajag Koulajian
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adria Giacca
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Gary F Lewis
- Departments of Medicine and Physiology and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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16
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Wendt SL, Ranjan A, Møller JK, Schmidt S, Knudsen CB, Holst JJ, Madsbad S, Madsen H, Nørgaard K, Jørgensen JB. Cross-Validation of a Glucose-Insulin-Glucagon Pharmacodynamics Model for Simulation Using Data From Patients With Type 1 Diabetes. J Diabetes Sci Technol 2017; 11:1101-1111. [PMID: 28654314 PMCID: PMC5951032 DOI: 10.1177/1932296817693254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Currently, no consensus exists on a model describing endogenous glucose production (EGP) as a function of glucagon concentrations. Reliable simulations to determine the glucagon dose preventing or treating hypoglycemia or to tune a dual-hormone artificial pancreas control algorithm need a validated glucoregulatory model including the effect of glucagon. METHODS Eight type 1 diabetes (T1D) patients each received a subcutaneous (SC) bolus of insulin on four study days to induce mild hypoglycemia followed by a SC bolus of saline or 100, 200, or 300 µg of glucagon. Blood samples were analyzed for concentrations of glucagon, insulin, and glucose. We fitted pharmacokinetic (PK) models to insulin and glucagon data using maximum likelihood and maximum a posteriori estimation methods. Similarly, we fitted a pharmacodynamic (PD) model to glucose data. The PD model included multiplicative effects of insulin and glucagon on EGP. Bias and precision of PD model test fits were assessed by mean predictive error (MPE) and mean absolute predictive error (MAPE). RESULTS Assuming constant variables in a subject across nonoutlier visits and using thresholds of ±15% MPE and 20% MAPE, we accepted at least one and at most three PD model test fits in each of the seven subjects. Thus, we successfully validated the PD model by leave-one-out cross-validation in seven out of eight T1D patients. CONCLUSIONS The PD model accurately simulates glucose excursions based on plasma insulin and glucagon concentrations. The reported PK/PD model including equations and fitted parameters allows for in silico experiments that may help improve diabetes treatment involving glucagon for prevention of hypoglycemia.
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Affiliation(s)
- Sabrina Lyngbye Wendt
- Zealand Pharma A/S, Glostrup, Denmark
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Ajenthen Ranjan
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - Jan Kloppenborg Møller
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Signe Schmidt
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | | | - Jens Juul Holst
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Madsen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Kirsten Nørgaard
- Department of Endocrinology, Hvidovre University Hospital, Hvidovre, Denmark
| | - John Bagterp Jørgensen
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
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17
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Ranjan A, Wendt SL, Schmidt S, Madsbad S, Holst JJ, Madsen H, Knudsen CB, Jørgensen JB, Nørgaard K. Relationship between Optimum Mini-doses of Glucagon and Insulin Levels when Treating Mild Hypoglycaemia in Patients with Type 1 Diabetes - A Simulation Study. Basic Clin Pharmacol Toxicol 2017; 122:322-330. [DOI: 10.1111/bcpt.12907] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 09/06/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Ajenthen Ranjan
- Department of Endocrinology; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
- Danish Diabetes Academy; Odense Denmark
| | - Sabrina L. Wendt
- Department of Bioanalysis and Pharmacokinetics; Zealand Pharma A/S; Glostrup Denmark
- Department of Applied Mathematics and Computer Science; Technical University of Denmark; Kgs. Lyngby Denmark
| | - Signe Schmidt
- Department of Endocrinology; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
- Danish Diabetes Academy; Odense Denmark
| | - Sten Madsbad
- Department of Endocrinology; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
- NFF Center for Basic Metabolic Research and Department of Biomedical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Jens J. Holst
- NFF Center for Basic Metabolic Research and Department of Biomedical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Henrik Madsen
- Department of Applied Mathematics and Computer Science; Technical University of Denmark; Kgs. Lyngby Denmark
| | - Carsten B. Knudsen
- Department of Bioanalysis and Pharmacokinetics; Zealand Pharma A/S; Glostrup Denmark
| | - John B. Jørgensen
- Department of Applied Mathematics and Computer Science; Technical University of Denmark; Kgs. Lyngby Denmark
| | - Kirsten Nørgaard
- Department of Endocrinology; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
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Abstract
PURPOSE OF REVIEW The review summarizes the current state of the artificial pancreas (AP) systems and introduces various new modules that should be included in future AP systems. RECENT FINDINGS A fully automated AP must be able to detect and mitigate the effects of meals, exercise, stress and sleep on blood glucose concentrations. This can only be achieved by using a multivariable approach that leverages information from wearable devices that provide real-time streaming data about various physiological variables that indicate imminent changes in blood glucose concentrations caused by meals, exercise, stress and sleep. The development of a fully automated AP will necessitate the design of multivariable and adaptive systems that use information from wearable devices in addition to glucose sensors and modify the models used in their model-predictive alarm and control systems to adapt to the changes in the metabolic state of the user. These AP systems will also integrate modules for controller performance assessment, fault detection and diagnosis, machine learning and classification to interpret various signals and achieve fault-tolerant control. Advances in wearable devices, computational power, and safe and secure communications are enabling the development of fully automated multivariable AP systems.
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Affiliation(s)
- Ali Cinar
- Department of Chemical and Biological Engineering and Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, USA.
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19
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Ward WK, Heinrich G, Breen M, Benware S, Vollum N, Morris K, Knutsen C, Kowalski JD, Campbell S, Biehler J, Vreeke MS, Vanderwerf SM, Castle JR, Cargill RS. An Amperometric Glucose Sensor Integrated into an Insulin Delivery Cannula: In Vitro and In Vivo Evaluation. Diabetes Technol Ther 2017; 19:226-236. [PMID: 28221814 PMCID: PMC5399735 DOI: 10.1089/dia.2016.0407] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Labeling prohibits delivery of insulin at the site of subcutaneous continuous glucose monitoring (CGM). Integration of the sensing and insulin delivery functions into a single device would likely increase the usage of CGM in persons with type 1 diabetes. METHODS To understand the nature of such interference, we measured glucose at the site of bolus insulin delivery in swine using a flexible electrode strip that was laminated to the outer wall of an insulin delivery cannula. In terms of sensing design, we compared H2O2-measuring sensors biased at 600 mV with redox mediator-type sensors biased at 175 mV. RESULTS In H2O2-measuring sensors, but not in sensors with redox-mediated chemistry, a spurious rise in current was seen after insulin lis-pro boluses. This prolonged artifact was accompanied by electrode poisoning. In redox-mediated sensors, the patterns of sensor signals acquired during delivery of saline and without any liquid delivery were similar to those acquired during insulin delivery. CONCLUSION Considering in vitro and in vivo findings together, it became clear that the mechanism of interference is the oxidation, at high bias potentials, of phenolic preservatives present in insulin formulations. This effect can be avoided by the use of redox mediator chemistry using a low bias potential.
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Affiliation(s)
| | | | - Matthew Breen
- Pacific Diabetes Technologies, Inc., Portland, Oregon
| | | | - Nicole Vollum
- Pacific Diabetes Technologies, Inc., Portland, Oregon
| | | | - Chad Knutsen
- Pacific Diabetes Technologies, Inc., Portland, Oregon
| | | | | | - Jerry Biehler
- Pacific Diabetes Technologies, Inc., Portland, Oregon
| | | | | | - Jessica R. Castle
- Division of Endocrinology, Diabetes and Nutrition, Oregon Health and Science University, Portland, Oregon
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20
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Taleb N, Haidar A, Messier V, Gingras V, Legault L, Rabasa-Lhoret R. Glucagon in artificial pancreas systems: Potential benefits and safety profile of future chronic use. Diabetes Obes Metab 2017; 19:13-23. [PMID: 27629286 DOI: 10.1111/dom.12789] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/09/2016] [Accepted: 09/11/2016] [Indexed: 12/17/2022]
Abstract
The role of glucagon in the pathophysiology of diabetes has long been recognized, although its approved clinical use has so far been limited to the emergency treatment of severe hypoglycaemia. A novel use of glucagon as intermittent mini-boluses is proposed in the dual-hormone version (insulin and glucagon) of the external artificial pancreas. Short-term studies suggest that the incorporation of glucagon into artificial pancreas systems has the potential to further decrease hypoglycaemic risk and improve overall glucose control; however, the potential long-term safety and benefits also need to be investigated given the recognized systemic effects of glucagon. In the present report, we review the available animal and human data on the physiological functions of glucagon, as well as its pharmacological use, according to dosing and duration (acute and chronic). Along with its main role in hepatic glucose metabolism, glucagon affects the cardiovascular, renal, pulmonary and gastrointestinal systems. It has a potential role in weight reduction through its central satiety function and its role in increasing energy expenditure. Most of the pharmacological studies investigating the effects of glucagon have used doses exceeding 1 mg, in contrast to the mini-boluses used in the artificial pancreas. The available data are reassuring but comprehensive human studies using small but chronic glucagon doses that are close to the physiological ranges are lacking. We propose a list of variables that could be monitored during long-term trials of the artificial pancreas. Such trials should address the questions about the risk-benefit ratio of chronic glucagon use.
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Affiliation(s)
- Nadine Taleb
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Department of Biomedical Sciences, Faculty of Medicine, Édouard-Montpetit, Université de Montréal, Montréal, Québec, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, Faculty of Medicine, McGill University, Montréal, Québec, Canada
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Virginie Messier
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Véronique Gingras
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, Department of Pediatrics, McGill University Health Centre, Montréal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Montreal Diabetes Research Center, Montréal, Québec, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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21
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Frandsen CS, Dejgaard TF, Madsbad S. Non-insulin drugs to treat hyperglycaemia in type 1 diabetes mellitus. Lancet Diabetes Endocrinol 2016; 4:766-780. [PMID: 26969516 DOI: 10.1016/s2213-8587(16)00039-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/10/2015] [Accepted: 01/26/2016] [Indexed: 02/06/2023]
Abstract
Insulin treatment of individuals with type 1 diabetes has shortcomings and many patients do not achieve glycaemic and metabolic targets. Consequently, the focus is on novel non-insulin therapeutic approaches that reduce hyperglycaemia and improve metabolic variables without increasing the risk of hypoglycaemia or other adverse events. Several therapies given in conjunction with insulin have been investigated in clinical trials, including pramlintide, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, sodium-glucose co-transporter inhibitors, metformin, sulfonylureas, and thiazolidinediones. These drugs have pleiotropic effects on glucose metabolism and different actions complementary to those of insulin-this Review reports the effects of these drugs on glycaemic control, glucose variability, hypoglycaemia, insulin requirements, and bodyweight. Existing studies are of short duration with few participants; evidence for the efficacy of concomitant treatments is scarce and largely clinically insignificant. A subgroup of patients with type 1 diabetes for whom non-insulin antidiabetic drugs could significantly benefit glycaemic control cannot yet be defined, but we suggest that obese patients prone to hypoglycaemia and patients with residual β-cell function are populations of interest for future trials.
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Affiliation(s)
| | - Thomas Fremming Dejgaard
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark; Steno Diabetes Center, Gentofte, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
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22
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Leclair E, Liggins RT, Peckett AJ, Teich T, Coy DH, Vranic M, Riddell MC. Glucagon responses to exercise-induced hypoglycaemia are improved by somatostatin receptor type 2 antagonism in a rat model of diabetes. Diabetologia 2016; 59:1724-31. [PMID: 27075449 DOI: 10.1007/s00125-016-3953-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/18/2016] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Regular exercise is at the cornerstone of care in type 1 diabetes. However, relative hyperinsulinaemia and a blunted glucagon response to exercise promote hypoglycaemia. Recently, a selective antagonist of somatostatin receptor 2, PRL-2903, was shown to improve glucagon counterregulation to hypoglycaemia in resting streptozotocin-induced diabetic rats. The aim of this study was to test the efficacy of PRL-2903 in enhancing glucagon counterregulation during repeated hyperinsulinaemic exercise. METHODS Diabetic rats performed daily exercise for 1 week and were then exposed to saline (154 mmol/l NaCl) or PRL-2903, 10 mg/kg, before hyperinsulinaemic exercise on two separate occasions spaced 1 day apart. In the following week, animals crossed over to the alternate treatment for a third hyperinsulinaemic exercise protocol. RESULTS Liver glycogen content was lower in diabetic rats compared with control rats, despite daily insulin therapy (p < 0.05). Glucagon levels failed to increase during exercise with saline but increased three-to-six fold with PRL-2903 (all p < 0.05). Glucose concentrations tended to be higher during exercise and early recovery with PRL-2903 on both days of treatment; this difference did not achieve statistical significance (p > 0.05). CONCLUSIONS/INTERPRETATION PRL-2903 improves glucagon counterregulation during exercise. However, liver glycogen stores or other factors limit the prevention of exercise-induced hypoglycaemia in rats with streptozotocin-induced diabetes.
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Affiliation(s)
- Erwan Leclair
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | | | - Ashley J Peckett
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - Trevor Teich
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada
| | - David H Coy
- Department of Medicine, Peptide Research Labs, Tulane University Medical Center, New Orleans, LA, USA
| | - Mladen Vranic
- Departments of Physiology and Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Riddell
- School of Kinesiology and Health Science, York University, Toronto, ON, M3J 1P3, Canada.
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23
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Blauw H, Keith-Hynes P, Koops R, DeVries JH. A Review of Safety and Design Requirements of the Artificial Pancreas. Ann Biomed Eng 2016; 44:3158-3172. [PMID: 27352278 PMCID: PMC5093196 DOI: 10.1007/s10439-016-1679-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 06/13/2016] [Indexed: 01/03/2023]
Abstract
As clinical studies with artificial pancreas systems for automated blood glucose control in patients with type 1 diabetes move to unsupervised real-life settings, product development will be a focus of companies over the coming years. Directions or requirements regarding safety in the design of an artificial pancreas are, however, lacking. This review aims to provide an overview and discussion of safety and design requirements of the artificial pancreas. We performed a structured literature search based on three search components—type 1 diabetes, artificial pancreas, and safety or design—and extended the discussion with our own experiences in developing artificial pancreas systems. The main hazards of the artificial pancreas are over- and under-dosing of insulin and, in case of a bi-hormonal system, of glucagon or other hormones. For each component of an artificial pancreas and for the complete system we identified safety issues related to these hazards and proposed control measures. Prerequisites that enable the control algorithms to provide safe closed-loop control are accurate and reliable input of glucose values, assured hormone delivery and an efficient user interface. In addition, the system configuration has important implications for safety, as close cooperation and data exchange between the different components is essential.
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Affiliation(s)
- Helga Blauw
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100 DD, Amsterdam, The Netherlands. .,Inreda Diabetic BV, Goor, The Netherlands.
| | - Patrick Keith-Hynes
- TypeZero Technologies, LLC, Charlottesville, VA, USA.,Center for Diabetes Technology, University of Virginia, Charlottesville, VA, USA
| | | | - J Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, P.O Box 22660, 1100 DD, Amsterdam, The Netherlands
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24
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Ranjan A, Schmidt S, Madsbad S, Holst JJ, Nørgaard K. Effects of subcutaneous, low-dose glucagon on insulin-induced mild hypoglycaemia in patients with insulin pump treated type 1 diabetes. Diabetes Obes Metab 2016; 18:410-8. [PMID: 26743775 DOI: 10.1111/dom.12627] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 11/22/2015] [Accepted: 12/20/2015] [Indexed: 02/06/2023]
Abstract
AIM To investigate the dose-response relationship of subcutaneous (s.c.) glucagon administration on plasma glucose and on counter-regulatory hormone responses during s.c. insulin-induced mild hypoglycaemia in patients with type 1 diabetes treated with insulin pumps. METHODS Eight insulin pump-treated patients completed a blinded, randomized, placebo-controlled study. Hypoglycaemia was induced in the fasting state by an s.c. insulin bolus and, when plasma glucose reached 3.4 mmol/l [95% confidence interval (CI) 3.2-3.5], an s.c. bolus of either 100, 200, 300 µg glucagon or saline was administered. Plasma glucose, counter-regulatory hormones, haemodynamic variables and side effects were measured throughout each study day. Peak plasma glucose level was the primary endpoint. RESULTS Plasma glucose level increased significantly by a mean (95% CI) of 2.3 (1.7-3.0), 4.2 (3.5-4.8) and 5.0 (4.3-5.6) mmol/l to 6.1 (4.9-7.4), 7.9 (6.4-9.3) and 8.7 (7.8-9.5) vs 3.6 (3.4-3.9) mmol/l (p < 0.001) after the three different glucagon doses as compared with saline, and the increase was neither correlated with weight nor insulin levels. Area under the plasma glucose curve, peak plasma glucose, time to peak plasma glucose and duration of plasma glucose level above baseline were significantly enhanced with increasing glucagon doses; however, these were not significantly different between 200 and 300 µg glucagon. Free fatty acids and heart rates were significantly lower initially after glucagon than after saline injection. Other haemodynamic variables, counter-regulatory hormones and side effects did not differ between interventions. CONCLUSIONS An s.c. low-dose glucagon bolus effectively restores plasma glucose after insulin overdosing. Further research is needed to investigate whether low-dose glucagon may be an alternative treatment to oral carbohydrate intake for mild hypoglycaemia in patients with type 1 diabetes.
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Affiliation(s)
- A Ranjan
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - S Schmidt
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - S Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Novo Nordisk Foundation Centre for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - J J Holst
- Novo Nordisk Foundation Centre for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - K Nørgaard
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Jacobs PG, Resalat N, El Youssef J, Reddy R, Branigan D, Preiser N, Condon J, Castle J. Incorporating an Exercise Detection, Grading, and Hormone Dosing Algorithm Into the Artificial Pancreas Using Accelerometry and Heart Rate. J Diabetes Sci Technol 2015; 9:1175-84. [PMID: 26438720 PMCID: PMC4667295 DOI: 10.1177/1932296815609371] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In this article, we present several important contributions necessary for enabling an artificial endocrine pancreas (AP) system to better respond to exercise events. First, we show how exercise can be automatically detected using body-worn accelerometer and heart rate sensors. During a 22 hour overnight inpatient study, 13 subjects with type 1 diabetes wearing a Zephyr accelerometer and heart rate monitor underwent 45 minutes of mild aerobic treadmill exercise while controlling their glucose levels using sensor-augmented pump therapy. We used the accelerometer and heart rate as inputs into a validated regression model. Using this model, we were able to detect the exercise event with a sensitivity of 97.2% and a specificity of 99.5%. Second, from this same study, we show how patients' glucose declined during the exercise event and we present results from in silico modeling that demonstrate how including an exercise model in the glucoregulatory model improves the estimation of the drop in glucose during exercise. Last, we present an exercise dosing adjustment algorithm and describe parameter tuning and performance using an in silico glucoregulatory model during an exercise event.
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Affiliation(s)
- Peter G Jacobs
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Navid Resalat
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Joseph El Youssef
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
| | - Ravi Reddy
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Deborah Branigan
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
| | - Nicholas Preiser
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - John Condon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland OR, USA
| | - Jessica Castle
- Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland OR, USA
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