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Arshad MF, Walkinshaw E, Solomon AL, Bernjak A, Rombach I, Leelarathna L, Little SA, Evans M, Shaw JAM, Heller SR, Iqbal A. Diabetic autonomic neuropathy does not impede improvement in hypoglycaemia awareness in adults: Sub-study results from the HypoCOMPaSS trial. Diabet Med 2024; 41:e15340. [PMID: 38741266 DOI: 10.1111/dme.15340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/22/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
AIMS Impaired awareness of hypoglycaemia (IAH) increases the risk of severe hypoglycaemia in people with type 1 diabetes mellitus (T1DM). IAH can be reversed through meticulous avoidance of hypoglycaemia. Diabetic autonomic neuropathy (DAN) has been proposed as an underlying mechanism contributing to IAH; however, data are inconsistent. The aim of this study was to examine the effects of cardiac autonomic neuropathy (CAN) on IAH reversibility inT1DM. METHODS Participants with T1DM and IAH (Gold score ≥4) recruited to the HypoCOMPaSS (24-week 2 × 2 factorial randomised controlled) trial were included. All underwent screening for cardiac autonomic function testing at baseline and received comparable education and support aimed at avoiding hypoglycaemia and improving hypoglycaemia awareness. Definite CAN was defined as the presence of ≥2 abnormal cardiac reflex tests. Participants were grouped according to their CAN status, and changes in Gold score were compared. RESULTS Eighty-three participants (52 women [62.7%]) were included with mean age (SD) of 48 (12) years and mean HbA1c of 66 (13) mmol/mol (8.2 [3.3] %). The mean duration of T1DM was 29 (13) years. The prevalence of CAN was low with 5/83 (6%) participants having definite autonomic neuropathy with 11 (13%) classified with possible/early neuropathy. All participants, regardless of the autonomic function status, showed a mean improvement in Gold score of ≥1 (mean improvement -1.2 [95% CI -0.8, -1.6]; p < 0.001). CONCLUSIONS IAH can be improved in people with T1DM, and a long duration of disease, with and without cardiac autonomic dysfunction. These data suggest that CAN is not a prime driver for modulating IAH reversibility.
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Affiliation(s)
- Muhammad Fahad Arshad
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Emma Walkinshaw
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | | | | | | | - Lala Leelarathna
- Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London
| | - Stuart A Little
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Mark Evans
- MRC Institute of Metabolic Science, University of Cambridge, Cambridge, London
| | - James A M Shaw
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Simon R Heller
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Ahmed Iqbal
- University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
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Xie J, Yu X, Chen L, Cheng Y, Li K, Song M, Chen Y, Feng F, Cai Y, Tong S, Qian Y, Xu Y, Zhang H, Yang J, Xu Z, Cui C, Yu H, Deng B. Whether coagulation dysfunction influences the onset and progression of diabetic peripheral neuropathy: A multicenter study in middle-aged and aged patients with type 2 diabetes. CNS Neurosci Ther 2024; 30:e70040. [PMID: 39258827 PMCID: PMC11388410 DOI: 10.1111/cns.70040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Nearly half of patients with diabetes experience diabetic peripheral neuropathy (DPN), resulting in a mere 53% survival rate within 3 years. Aberrations in coagulation function have been implicated in the pathogenesis of microvascular complications, prompting the need for a thorough investigation into its role as a contributing factor in the development and progression of DPN. METHODS Data were gathered from 1211 type 2 diabetes patients admitted to five centers from September 2018 to October 2022 in China. DPN was evaluated by symptoms and electromyography. Motor and sensory nerve conduction velocity (NCV) was appraised and the NCV sum score was calculated for the median, ulnar, and peroneal motor or sensory nerves. RESULTS Patients with DPN exhibited alterations in coagulation function. (i) Specifically, they exhibited prolonged thrombin time (p = 0.012), elevated fibrinogen (p < 0.001), and shortened activated partial thromboplastin time (APTT; p = 0.026) when compared to the control group. (ii) After accounting for potential confounders in linear regression, fibrinogen, and D-dimer were negatively related to the motor NCV, motor amplitude values, and mean velocity and amplitude. Also, fibrinogen was associated with higher Michigan neuropathy screening instrument (MNSI) scores (β 0.140; p = 0.001). This result of fibrinogen can be validated in the validation cohort with 317 diabetic patients. (iii) Fibrinogen was independently associated with the risk of DPN (OR 1.172; p = 0.035). In the total age group, DPN occurred at a slower rate until the predicted fibrinogen level reached around 3.75 g/L, after which the risk sharply escalated. CONCLUSIONS Coagulation function is warranted to be concerned in patients with type 2 diabetes to predict and prevent the occurrence of DPN in clinical practice.
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Affiliation(s)
- Jiali Xie
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
- Department of Neurology, Shanghai East HospitalTongji University School of MedicineShanghaiP.R. China
| | - Xinyue Yu
- Alberta InstituteWenzhou Medical UniversityWenzhouChina
| | - Luowei Chen
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
- Department of NeurologyThe Second Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Yifan Cheng
- Department of NeurologyCenter for Rehabilitation Medicine Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical CollegeHangzhouChina
| | - Kezheng Li
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
| | - Mengwan Song
- Department of Neurology, First Clinical College of Wenzhou Medical UniversityWenzhouP.R. China
- Department of NeurologyRuian People's HospitalWenzhouP.R. China
| | - Yinuo Chen
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
- Department of Neurology, First Clinical College of Wenzhou Medical UniversityWenzhouP.R. China
| | - Fei Feng
- Department of Neurology, First Clinical College of Wenzhou Medical UniversityWenzhouP.R. China
- Department of NeurologyShaoxing People's HospitalShaoxingP.R. China
| | - Yunlei Cai
- Department of Neurology, Anyang District Hospital, Beiguan DistrictAnyangHenanChina
| | - Shuting Tong
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
| | - Yuqin Qian
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
- Department of NeurologyInstitute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yiting Xu
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
| | - Haiqin Zhang
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
- Department of Neurology, First Clinical College of Wenzhou Medical UniversityWenzhouP.R. China
| | - Junjie Yang
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
- Department of Neurology, First Clinical College of Wenzhou Medical UniversityWenzhouP.R. China
| | - Zirui Xu
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
- Department of Neurology, First Clinical College of Wenzhou Medical UniversityWenzhouP.R. China
| | - Can Cui
- Institute of Environmental MedicineKarolinska InstitutetStockholmSweden
| | - Huan Yu
- Department of PediatricsSecond Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical UniversityWenzhouP.R. China
| | - Binbin Deng
- Department of NeurologyFirst Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
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Baxter F, Baillie N, Dover A, Stimson RH, Gibb F, Forbes S. A cross-sectional questionnaire study: Impaired awareness of hypoglycaemia remains prevalent in adults with type 1 diabetes and is associated with the risk of severe hypoglycaemia. PLoS One 2024; 19:e0297601. [PMID: 38875308 PMCID: PMC11178233 DOI: 10.1371/journal.pone.0297601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/14/2024] [Indexed: 06/16/2024] Open
Abstract
OBJECTIVE Impaired awareness of hypoglycaemia (IAH) is a risk factor for severe hypoglycaemia (SH) in type 1 diabetes (T1D). Much of the IAH prevalence data comes from older studies where participants did not have the benefit of the latest insulins and technologies. This study surveyed the prevalence of IAH and SH in a tertiary adult clinic population and investigated the associated factors. METHODS Adults (≥18 years) attending a tertiary T1D clinic completed a questionnaire, including a Gold and Clarke score. Background information was collected from health records. RESULTS 189 people (56.1% female) with T1D (median [IQR] disease duration 19.3 [11.5, 29.1] years and age of 41.0 [29.0, 52.0] years) participated. 17.5% had IAH and 16.0% reported ≥1 episode of SH in the previous 12 months. Those with IAH were more likely to report SH (37.5% versus 11.7%, p = 0.001) a greater number of SH episodes per person (median [IQR] 0 [0,2] versus 0 [0,0] P<0.001) and be female (72.7% versus 52.6%, p = 0.036). Socio-economic deprivation was associated with IAH (p = 0.032) and SH (p = 0.005). Use of technology was the same between IAH vs aware groups, however, participants reporting SH were more likely to use multiple daily injections (p = 0.026). Higher detectable C-peptide concentrations were associated with a reduced risk of SH (p = 0.04). CONCLUSION Insulin pump and continuous glucose monitor use was comparable in IAH versus aware groups. Despite this, IAH remains a risk factor for SH and is prevalent in females and in older people. Socioeconomic deprivation was associated with IAH and SH, making this an important population to target for interventions.
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Affiliation(s)
- Faye Baxter
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Nicola Baillie
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Anna Dover
- Department of Diabetes and Endocrinology, Outpatient Department 2, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Roland H Stimson
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- Department of Diabetes and Endocrinology, Outpatient Department 2, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Fraser Gibb
- Department of Diabetes and Endocrinology, Outpatient Department 2, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Shareen Forbes
- BHF Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- Department of Diabetes and Endocrinology, Outpatient Department 2, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Oraibi O, Alameer A, Dalak M, Alsharif S, Hakami SA, Sumayli M, Shami A, Mohrag M, Madkhali MA, Madkhali MA, Alhazmi L, Darraj M. Impaired Awareness of Hypoglycemia and its Risk Factors among Diabetic Patients in Jazan, Saudi Arabia: A Cross-Sectional Study. Curr Diabetes Rev 2024; 20:124-137. [PMID: 38243952 DOI: 10.2174/0115733998288242240104054438] [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: 10/24/2023] [Revised: 12/21/2023] [Accepted: 12/28/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Impaired awareness of hypoglycemia (IAH) is related to a three- to sixfold increase in the risk of severe hypoglycemia in adults with type 1 diabetes mellitus (T1D). This study aimed to assess the prevalence of IAH and its risk factors and determine the frequency of hypoglycemic symptoms. OBJECTIVE This study aimed to assess the prevalence of IAH and its risk factors and determine the frequency of hypoglycemic symptoms. METHODOLOGY A cross-sectional study was conducted among T1D patients attending Jazan Endocrine and Diabetes Center in Jazan province, Saudi Arabia. A total of 151 patients participated, using the interview-based Clarke questionnaire, a validated eight-item questionnaire to evaluate IAH. Scoring four or more answers as reduced awareness categorizes the participant as having IAH. RESULTS The prevalence of IAH was 25.2% among the T1D patients. IAH was significantly associated with body mass index (BMI; p = 0.034), occupation (p = 0.014), and blood glucose monitoring methods (p = 0.027). Shaking and sweating were the most commonly reported symptoms of hypoglycemia. A BMI of <25 kg/m2 was higher linked to hunger and speech difficulty compared to a BMI of ≥25 kg/m2 (p < 0.05). Changing the insulin injection site was associated with confusion, odd behavior, and speech difficulty (p < 0.05). Monitoring blood glucose four times daily was associated with sweating, odd behavior, and incoordination (p = 0.024) compared to monitoring less than four times daily (p < 0.05). A hemoglobin A1c (HbA1c) reading of ≥7 was linked to odd behavior compared to an HbA1c reading of <7 (p = 0.032). Patients committed to insulin injections were more likely to experience palpitations than non-committed patients (p = 0.038). Each one-unit increase in age, monitoring blood glucose, and income was associated with a decrease in the odds of IAH (OR of Age = 0.89, 95% CI: 0.83-0.95) (OR of income = 0.10, 95% CI: 0.01-0.55). Moreover, individuals with a Body Mass Index (BMI) greater than or equal to 25 (OR = 2.99, 95% CI: 1.13-8.25), employed individuals (OR = 18.2, 95% CI: 3.75-105), and diabetes duration of more than ten years (OR = 3.96, 95% CI: 1.31- 13.2) exhibited an increase in the higher risk of IAH. CONCLUSION IAH was prevalent among T1D patients attending Jazan Endocrine and Diabetes Center. The main associated factors included BMI, blood glucose monitoring method, and occupation. Future research should investigate the underlying causes of the observed associations and explore strategies to enhance the awareness of hypoglycemia.
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Affiliation(s)
- Omar Oraibi
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | - Abdulelah Alameer
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | - Mohammed Dalak
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | - Sawsan Alsharif
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | - Shatha A Hakami
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | - Mohammed Sumayli
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | - Ayman Shami
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | - Mostafa Mohrag
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | | | | | - Luai Alhazmi
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
| | - Majid Darraj
- Department of Internal Medicine, Jazan University, Jazan, Saudi Arabia
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Gad H, Elgassim E, Mohammed I, Yaser Alhaddad A, Ahmed Hussein Zaky Aly H, Cabibihan JJ, Al-Ali A, Kumar Sadasivuni K, Petropoulos IN, Ponirakis G, Abuhelaiqa W, Jayyousi A, AlMohanadi D, Baagar K, Malik RA. Cardiovascular autonomic neuropathy is associated with increased glycemic variability driven by hyperglycemia rather than hypoglycemia in patients with diabetes. Diabetes Res Clin Pract 2023; 200:110670. [PMID: 37169307 DOI: 10.1016/j.diabres.2023.110670] [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: 02/13/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 05/13/2023]
Abstract
AIM Cardiac autonomic neuropathy (CAN) has been suggested to be associated with hypoglycemia and impaired hypoglycemia unawareness. We have assessed the relationship between CAN and extensive measures of glucose variability (GV) in patients with type 1 and type 2 diabetes. METHODS Participants with diabetes underwent continuous glucose monitoring (CGM) to obtain measures of GV and the extent of hyperglycemia and hypoglycemia and cardiovascular autonomic reflex testing. RESULTS Of the 40 participants (20 T1DM and 20 T2DM) (aged 40.70±13.73 years, diabetes duration 14.43±7.35 years, HbA1c 8.85±1.70%), 23 (57.5%) had CAN. Despite a lower coefficient of variation (CV) (31.26±11.87 vs. 40.33±11.03, P=0.018), they had a higher CONGA (8.42±2.58 vs. 6.68±1.88, P=0.024) with a lower median LBGI (1.60 (range: 0.20-3.50) vs. 4.90 (range: 3.20-7.40), P=0.010) and percentage median time spent in hypoglycemia (4 (range:4-13) vs. 1 (range:0-5), P=0.008), compared to those without CAN. The percentage GRADEEuglycemia (3.30±2.78 vs. 5.69±3.09, P=0.017) and GRADEHypoglycemia (0.3 (range: 0 - 3.80) vs. 1.8 (range: 0.9-6.5), P=0.036) were significantly lower, while the percentage median GRADEHyperglycemia (95.45 (range:93-98) vs. 91.6 (82.8-95.1), P=0.013) was significantly higher in participants with CAN compared to those without CAN. CONCLUSION CAN was associated with increased glycemic variability with less time in euglycemia attributed to a greater time in hyperglycemia but not hypoglycemia.
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Affiliation(s)
- Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Einas Elgassim
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ibrahim Mohammed
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar; Internal Medicine, Albany Medical Center Hospital, Albany, New York, USA
| | - Ahmad Yaser Alhaddad
- Department of Mechanical and Industrial Engineering, Qatar University, Doha, Qatar
| | | | - John-John Cabibihan
- Department of Mechanical and Industrial Engineering, Qatar University, Doha, Qatar
| | - Abdulaziz Al-Ali
- KINDI Center for computing research, Qatar University, Doha, Qatar
| | | | | | | | | | - Amin Jayyousi
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Dabia AlMohanadi
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Khaled Baagar
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar; Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK.
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Sakane N, Kato K, Hata S, Nishimura E, Araki R, Kouyama K, Hatao M, Matoba Y, Matsushita Y, Domichi M, Suganuma A, Sakane S, Murata T, Wu FL. Protective and risk factors of impaired awareness of hypoglycemia in patients with type 1 diabetes: a cross-sectional analysis of baseline data from the PR-IAH study. Diabetol Metab Syndr 2023; 15:79. [PMID: 37095537 PMCID: PMC10127054 DOI: 10.1186/s13098-023-01024-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/11/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Hypoglycemia in type 1 diabetes (T1D) is associated with mortality and morbidity, especially when awareness of hypoglycemia is impaired. This study aimed to investigate the protective and risk factors for impaired awareness of hypoglycemia (IAH) in adults with T1D. METHODS This cross-sectional study enrolled 288 adults with T1D (mean age, 50.4 ± 14.6 years; male, 36.5%; diabetes duration, 17.6 ± 11.2 years; mean HbA1c level, 7.7 ± 0.9%), who were divided into IAH and non-IAH (control) groups. A survey was conducted to assess hypoglycemia awareness using the Clarke questionnaire. Diabetes histories, complications, fear of hypoglycemia, diabetes distress, hypoglycemia problem-solving abilities, and treatment data were collected. RESULTS The prevalence of IAH was 19.1%. Diabetic peripheral neuropathy was associated with an increased risk of IAH (odds ratio [OR] 2.63; 95% confidence interval [CI] 1.13-5.91; P = 0.014), while treatment with continuous subcutaneous insulin infusion and hypoglycemia problem-solving perception scores were associated with a decreased risk of IAH (OR, 0.48; 95% CI, 0.22-0.96; P = 0.030; and OR, 0.54; 95% CI, 0.37-0.78; P = 0.001, respectively). There was no difference in continuous glucose monitoring use between the groups. CONCLUSION We identified protective factors in addition to risk factors for IAH in adults with T1D. This information may help manage problematic hypoglycemia. TRIAL REGISTRATION University hospital Medical Information Network (UMIN) Center: UMIN000039475). Approval date 13 February 2020.
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Affiliation(s)
- Naoki Sakane
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan.
| | - Ken Kato
- Diabetes center, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, 540-0006, Osaka, Japan
| | - Sonyun Hata
- Diabetes center, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, 540-0006, Osaka, Japan
| | - Erika Nishimura
- Diabetes center, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, 540-0006, Osaka, Japan
| | - Rika Araki
- Department of Diabetes and Endocrinology, National Hospital Organization Mie National Hospital, 357 Ozatokubota-cho, 514-0125, Tsu, Mie, Japan
| | - Kunichi Kouyama
- Department of Diabetes and Metabolism, National Hospital Organization Hyogo-Chuo National Hospital, 1314Ohara, 669-1515, Sanda, Hyogo, Japan
| | - Masako Hatao
- Department of Diabetes and Endocrinology, National Hospital Organization Himeji Medical Center, 68 Honmachi, 670-0012, Himeji, Hyogo, Japan
| | - Yuka Matoba
- Department of Diabetes, Endocrinology and Metabolism, National Hospital Organization Kokura Medical Center, 10-1 Harugaoka, Kitakyushu Kokuraminami-ku, 802-0803, Fukuoka, Japan
| | - Yuichi Matsushita
- Department of Diabetology and Metabolism, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Okayama Kita-ku, 701-1192, Okayama, Japan
| | - Masayuki Domichi
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
| | - Akiko Suganuma
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
| | - Seiko Sakane
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
| | - Takashi Murata
- Department of Clinical Nutrition, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
- Diabetes Center, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, 612-8555, Kyoto, Japan
| | - Fei Ling Wu
- Department of Nursing, Chang Gung University of Science and Technology, No. 261, Wenhua 1st Rd, Guishan District, 333, Taoyuan City, Taiwan
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Seaquist ER, Teff K, Heller SR. Impaired Awareness of Hypoglycemia in Type 1 Diabetes: A Report of An NIDDK Workshop in October 2021. Diabetes Care 2022; 45:2799-2805. [PMID: 36455118 PMCID: PMC9763030 DOI: 10.2337/dc22-1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/14/2022] [Indexed: 12/03/2022]
Abstract
Hypoglycemia remains a limiting factor in the optimal treatment of type 1 diabetes. Repeated episodes of hypoglycemia result in impaired awareness of subsequent hypoglycemic events, inducing a vicious feed-forward cycle and increasing the risk of morbidity and mortality. Why this occurs and how to manage the problem in clinical practice remain uncertain. To address the obstacles and barriers that have hindered progress in this clinically important area, the National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on 14-15 October 2021. This perspective offers a summary of this outstanding meeting, which brought clinical and basic scientists from the fields of diabetes, neuroscience, psychology, psychiatry, and imaging together, on how to best advance the field of impaired awareness of hypoglycemia and hypoglycemia in general in patients with diabetes.
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Affiliation(s)
| | - Karen Teff
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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Kaze AD, Yuyun MF, Ahima RS, Rickels MR, Echouffo-Tcheugui JB. Autonomic dysfunction and risk of severe hypoglycemia among individuals with type 2 diabetes. JCI Insight 2022; 7:156334. [PMID: 36318703 PMCID: PMC9762508 DOI: 10.1172/jci.insight.156334] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 10/05/2022] [Indexed: 11/22/2022] Open
Abstract
There are limited data on the link between cardiac autonomic neuropathy (CAN) and severe hypoglycemia in type 2 diabetes. Here, we evaluated the associations of CAN with severe hypoglycemia among 7,421 adults with type 2 diabetes from the Action to Control Cardiovascular Risk in Diabetes study. CAN was defined using ECG-derived measures. Cox's and Andersen-Gill regression models were used to generate HRs (HRs) for the first and recurrent severe hypoglycemic episodes, respectively. Over 4.7 years, there were 558 first and 811 recurrent hypoglycemic events. Participants with CAN had increased risks of a first episode or recurrent episodes of severe hypoglycemia. The intensity of glycemic management modified the CAN association with hypoglycemia. In the standard glycemic management group, compared with those of participants without CAN, HRs for a first severe hypoglycemia event and recurrent hypoglycemia were 1.58 and 1.96, respectively. In the intensive glycemic management group, HRs for a first severe hypoglycemia event and recurrent hypoglycemia were 1.10 and 1.24, respectively. In summary, CAN was independently associated with higher risks of a first hypoglycemia event and recurrent hypoglycemia among adults with type 2 diabetes, with the highest risk observed among those on standard glycemic management.
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Affiliation(s)
- Arnaud D Kaze
- Department of Medicine, University of Maryland Medical Center, Baltimore, Maryland, USA.,Department of Medicine, LifePoint Health, Danville, Virginia, USA
| | - Matthew F Yuyun
- Department of Medicine, Division of Cardiology, Veteran Affairs Boston Healthcare System/Harvard Medical School, Boston, Massachusetts, USA
| | - Rexford S Ahima
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin B Echouffo-Tcheugui
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Racca C, Bouman EJ, Van Beers CAJ, Smits MM, van Raalte DH, Serné EH. Association between hypoglycaemic glucose variability and autonomic function in type1 diabetes with impaired hypoglycaemia awareness. Diabetes Res Clin Pract 2022; 189:109964. [PMID: 35716850 DOI: 10.1016/j.diabres.2022.109964] [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: 04/05/2022] [Revised: 06/03/2022] [Accepted: 06/12/2022] [Indexed: 11/23/2022]
Abstract
Cardiovascular autonomic neuropathy (CAN) is suggested to underlie hypoglycaemic risk in impaired awareness of hypoglycaemia (IAH). We assessed the prevalence of CAN and the association between glucose variability (GV) and cardiovascular autonomic function in patients with type 1 diabetes (T1DM) and IAH. This study is a post-hoc-analysis of results obtained with the IN-CONTROL-trial, designed to assess the effects of continuous glucose monitoring (CGM) on glycaemia. Forty participants (aged 46.4 ± 11.4 years, diabetes duration 29.1 ± 13.5 years, HbA1c 7.5 ± 0.8%(58.2 ± 8.8 mmol/mol)) underwent 2-week blinded CGM measurements to obtain GV indices. Standardized cardiovascular reflex tests were used to determine the presence of CAN. Cardiovascular autonomic function was assessed with heart rate variability (HRV) measures. 14(35%) participants were classified as having CAN. Participants with CAN had lower percentage time spent in hypoglycaemic range and low blood glucose index(LBGI). After correction for confounders, a significant positive association was found between the coefficient of variation (CV) or time spent in hypoglycaemic range and HRV measures SDRR or RMSSD, and between LBGI and RMSSD. In patients with T1DM and IAH, hypoglycaemic parameters were associated with better cardiovascular autonomic function and lower prevalence of CAN. This suggests that autonomic neuropathy does not seem to further deteriorate hypoglycaemic risk in patients with IAH.
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Affiliation(s)
- Caterina Racca
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands.
| | - Emma J Bouman
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Epidemiology and Data Science, The Netherlands
| | - Cornelis A J Van Beers
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - Mark M Smits
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - Daniel H van Raalte
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
| | - Erik H Serné
- Department of Internal Medicine, Diabetes Center, Amsterdam University Medical Center, location VUMC, Amsterdam, The Netherlands
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10
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Hassounah G, Abdullah Aljohani AE, Al Sharhani R, Al Aljoulni M, Robert AA, Al Goudah AH, Al Turki AA. Prevalence of impaired awareness of hypoglycemia and its risk factors among patients with type 1 diabetes in Saudi Arabia. Diabetes Metab Syndr 2022; 16:102351. [PMID: 34920195 DOI: 10.1016/j.dsx.2021.102351] [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: 10/07/2021] [Revised: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS To determine the prevalence of impaired awareness of hypoglycemia (IHA) and self-identification of symptoms in patients with type 1 diabetes (T1D). METHODS A cross-sectional study was conducted on 242 patients with T1D at the Diabetes Treatment Center, Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia from May 2021 to September 2021. In addition to the demographic data, patients' HbA1c level was also collected. Awareness and symptoms of hypoglycemia were assessed using two validated questionnaire-based methods, namely the Gold and Edinburgh methods. RESULTS The prevalence of IAH among patients with T1D was 62.8% and the presence of IAH was significantly associated with the duration of T1D (p = 0.019). Compared to males, females had significantly higher (p < 0.05) levels of warmth, pounding heart, and inability to concentrate. Compared to unmarried, married patients had significantly higher levels of (p < 0.05) drowsiness, dizziness, and blurred vision. Similarly, compared to school educated, college-educated showed a higher hunger level (p < 0.05). Patients with HbA1c ≥ 7% possess a significantly higher level of drowsiness, dizziness, and hunger. Dizziness, warmth, difficulty speaking, pounding heart, and blurred vision were significantly higher among patients with diabetes duration ≥10 yrs. Nausea was significantly higher among smokers than non-smokers (p < 0.05). CONCLUSION The prevalence of IAH is high among patients with T1D in Saudi Arabia. Focused and evidence-based interventions are essential to minimize the hypoglycemia risk among patients with T1D.
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Affiliation(s)
- Ghadeer Hassounah
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Amal Eid Abdullah Aljohani
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Reham Al Sharhani
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Momen Al Aljoulni
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Asirvatham Alwin Robert
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Al Hanouf Al Goudah
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Al Anoud Al Turki
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
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11
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Ashok A, Abusamaan MS, Parker P, Pilla SJ, Mathioudakis NN. Provider Response to Critical Action Values for Hypoglycemia in the Ambulatory Setting: a Retrospective Cohort Study. J Gen Intern Med 2021; 36:1244-1249. [PMID: 32935316 PMCID: PMC8131438 DOI: 10.1007/s11606-020-06225-y] [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: 05/09/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The blood glucose level triggering a critical action value (CAV) for hypoglycemia is not standardized, and associated outcomes are unknown. OBJECTIVE To evaluate the clinical consequences of, and provider responses to, CAVs for hypoglycemia. DESIGN Retrospective cohort study at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between April 1, 2013, and January 31, 2017. PARTICIPANTS Patients with an ambulatory serum glucose < 50 mg/dL. Point-of-care capillary glucose and whole blood glucose samples were excluded. MAIN MEASURES Electronic medical record (EMR) review for providers' documented response to CAV, associated patient symptoms, and serious adverse events. KEY RESULTS We analyzed 209 CAVs for hypoglycemia from 154 patients. The median age (IQR) was 59 years (46, 69), 89 (57.8%) were male, and 96 (62.3%) were black. Provider-to-patient contact occurred in 128 of 209 (61.2%) episodes, among which no documented etiology was observed for 81 of 128 (63.3%), no recommendations were provided in 32 of 128 (25.0%), and no patient-reported hypoglycemic symptoms were documented in 103 of 128 (80.5%). Serious adverse events were documented in 4 of 128 episodes (3.1%), two required glucagon administration, and three required an ED visit. Provider-to-patient contact was associated with the patient having malignant neoplasm (adjusted OR 3.63, p = 0.045) or a hypoglycemic disorder (adjusted OR 7.70, p = 0.018) and inversely associated with a longer time from specimen collection to EMR result (adjusted OR 0.90 per hour, p = 0.016). CONCLUSIONS There is inconsistent provider-to-patient contact following CAVs for hypoglycemia, and the etiology and symptoms of hypoglycemia were infrequently documented. There were few serious documented adverse events associated with hypoglycemia, although undocumented events may have occurred, and the incidence of serious adverse events in non-contacted patients remains unknown. These findings demonstrate a need to standardize provider response to CAVs for hypoglycemia. Decreasing the lag time between sample collection and laboratory result reporting may increase provider-to-patient contact.
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Affiliation(s)
- Aditya Ashok
- Division of General Internal Medicine, Johns Hopkins University School of Medicine , Baltimore, MD, USA
| | - Mohammed S Abusamaan
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Penelope Parker
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott J Pilla
- Division of General Internal Medicine, Johns Hopkins University School of Medicine , Baltimore, MD, USA
| | - Nestoras N Mathioudakis
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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12
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Guo K, Tian Q, Yang L, Zhou Z. The Role of Glucagon in Glycemic Variability in Type 1 Diabetes: A Narrative Review. Diabetes Metab Syndr Obes 2021; 14:4865-4873. [PMID: 34992395 PMCID: PMC8710064 DOI: 10.2147/dmso.s343514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 12/01/2021] [Indexed: 01/20/2023] Open
Abstract
Type 1 diabetes mellitus (T1DM) is a progressive disease as a result of the severe destruction of islet β-cell function, which leads to high glucose variability in patients. However, α-cell function is also compromised in patients with T1DM, characterized by aberrant fasting and postprandial glucagon secretion. According to recent studies, this aberrant glucagon secretion plays an increasing role in hyperglycemia, insulin-induced hypoglycemia and exercise-associated hypoglycemia in patients with T1DM. With application of continuous glucose monitoring system, dozens of metrics enable the assessment of glycemic variability, which is an integral component of glycemic control for patients with T1DM. There is growing evidences to illustrate the contribution of glucagon secretion to the glycemic variability in patients with T1DM, which may promote the development of new treatment strategies aiming to mitigate glycemic variability associated with aberrant glucagon secretion.
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Affiliation(s)
- Keyu Guo
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Qi Tian
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People’s Republic of China
| | - Lin Yang
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People’s Republic of China
- Correspondence: Lin Yang; Zhiguang Zhou Email ;
| | - Zhiguang Zhou
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, People’s Republic of China
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13
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Lin YK, Fisher SJ, Pop‐Busui R. Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies. J Diabetes Investig 2020; 11:1388-1402. [PMID: 32403204 PMCID: PMC7610104 DOI: 10.1111/jdi.13290] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 12/18/2022] Open
Abstract
Impaired awareness of hypoglycemia (IAH) is a reduction in the ability to recognize low blood glucose levels that would otherwise prompt an appropriate corrective therapy. Identified in approximately 25% of patients with type 1 diabetes, IAH has complex pathophysiology, and might lead to serious and potentially lethal consequences in patients with diabetes, particularly in those with more advanced disease and comorbidities. Continuous glucose monitoring systems can provide real-time glucose information and generate timely alerts on rapidly falling or low blood glucose levels. Given their improvements in accuracy, affordability and integration with insulin pump technology, continuous glucose monitoring systems are emerging as critical tools to help prevent serious hypoglycemia and mitigate its consequences in patients with diabetes. This review discusses the current knowledge on IAH and effective diagnostic methods, the relationship between hypoglycemia and cardiovascular autonomic neuropathy, a practical approach to evaluating cardiovascular autonomic neuropathy for clinicians, and recent evidence from clinical trials assessing the effects of the use of CGM technologies in patients with type 1 diabetes with IAH.
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Affiliation(s)
- Yu Kuei Lin
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Simon J Fisher
- Division of Endocrinology, Metabolism and DiabetesDepartment of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Rodica Pop‐Busui
- Division of Metabolism, Endocrinology and DiabetesDepartment of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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14
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Paes T, Rolim LC, Filho CS, de Sa JR, Dib SA. Awareness of hypoglycemia and spectral analysis of heart rate variability in type 1 diabetes. J Diabetes Complications 2020; 34:107617. [PMID: 32546420 DOI: 10.1016/j.jdiacomp.2020.107617] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 04/17/2020] [Accepted: 05/03/2020] [Indexed: 01/26/2023]
Abstract
AIMS To investigate the relationship of unawareness of hypoglycemia with spectral analysis of heart rate variability (HRV) and clinical variables in type 1 diabetes (T1D) individuals. METHODS Participants with type 1 diabetes mellitus (type 1 diabetes) were prospectively assessed for hypoglycemia awareness using the Pedersen-Bjergaard method and were classified as normal hypoglycemia awareness, impaired hypoglycemia awareness and hypoglycemia unawareness. Indices of HRV in frequency domain were evaluated and Ewing tests were used for the diagnosis of cardiovascular autonomic neuropathy (CAN). RESULTS Ninety-eight participants with T1D (mean age 26 years, average diabetes duration 13 years, and mean HbA1c 8.4%) were included in this study. The prevalence of hypoglycemia unawareness was 28%. No significant difference was observed on the prevalence of CAN among groups of different hypoglycemia awareness (p = 0.740). On regression analyses, abnormal results of HRV in frequency domain were not associated with unawareness of hypoglycemia. On univariable regression analysis, age, diabetes duration and estimated creatinine clearance were associated with unawareness of hypoglycemia. CONCLUSION CAN as assessed by Ewing tests and spectral analysis of HRV is not associated with unawareness of hypoglycemia. There is association of age, diabetes duration and renal deficit with unawareness of hypoglycemia.
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Affiliation(s)
- Ticiana Paes
- Division of Endocrinology and Metabolism, Escola Paulista de Medicina of Federal University of São Paulo, São Paulo, Brazil
| | - L Clemente Rolim
- Division of Endocrinology and Metabolism, Escola Paulista de Medicina of Federal University of São Paulo, São Paulo, Brazil
| | - Celso Sallum Filho
- Division of Endocrinology and Metabolism, Escola Paulista de Medicina of Federal University of São Paulo, São Paulo, Brazil
| | - João Roberto de Sa
- Division of Endocrinology and Metabolism, Escola Paulista de Medicina of Federal University of São Paulo, São Paulo, Brazil
| | - Sérgio A Dib
- Division of Endocrinology and Metabolism, Escola Paulista de Medicina of Federal University of São Paulo, São Paulo, Brazil.
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15
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Flatt AJS, Little SA, Speight J, Leelarathna L, Walkinshaw E, Tan HK, Bowes A, Lubina-Solomon A, Holmes-Truscott E, Chadwick TJ, Wood R, McDonald TJ, Kerr D, Flanagan D, Brooks A, Heller SR, Evans ML, Shaw JAM. Predictors of Recurrent Severe Hypoglycemia in Adults With Type 1 Diabetes and Impaired Awareness of Hypoglycemia During the HypoCOMPaSS Study. Diabetes Care 2020; 43:44-52. [PMID: 31484666 DOI: 10.2337/dc19-0630] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/06/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The HypoCOMPaSS study was designed to test the hypothesis that successful avoidance of biochemical hypoglycemia without compromising overall glycemic control would restore sufficient hypoglycemia awareness to prevent recurrent severe hypoglycemia in the majority of participants with established type 1 diabetes. Before starting the study, we planned to investigate associations between baseline characteristics and recurrent severe hypoglycemia over 2 years' follow-up. RESEARCH DESIGN AND METHODS A total of 96 adults with type 1 diabetes and impaired awareness of hypoglycemia participated in a 24-week 2 × 2 factorial randomized controlled trial comparing insulin delivery and glucose monitoring modalities, with the goal of rigorous biochemical hypoglycemia avoidance. The analysis included 71 participants who had experienced severe hypoglycemia in the 12-month prestudy with confirmed absence (complete responder) or presence (incomplete responder) of severe hypoglycemia over 24 months' follow-up. RESULTS There were 43 (61%) complete responders and 28 (39%) incomplete responders experiencing mean ± SD 1.5 ± 1.0 severe hypoglycemia events/person-year. At 24 months, incomplete responders spent no more time with glucose ≤3 mmol/L (1.4 ± 2.1% vs. 3.0 ± 4.8% for complete responders; P = 0.26), with lower total daily insulin dose (0.45 vs. 0.58 units/24 h; P = 0.01) and greater impairment of hypoglycemia awareness (Clarke score: 3.8 ± 2.2 vs. 2.0 ± 1.9; P = 0.01). Baseline severe hypoglycemia rate (16.9 ± 16.3 vs. 6.4 ± 10.8 events/person-year; P = 0.002) and fear of hypoglycemia were higher in incomplete responders. Peripheral neuropathy was more prevalent in incomplete responders (11 [39%] vs. 2 [4.7%]; P < 0.001) with a trend toward increased autonomic neuropathy. CONCLUSIONS Recurrent severe hypoglycemia was associated with higher preintervention severe hypoglycemia rate, fear of hypoglycemia, and concomitant neuropathy.
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Affiliation(s)
- Anneliese J S Flatt
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, U.K.,Newcastle Diabetes Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, U.K
| | - Stuart A Little
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, U.K.,Newcastle Diabetes Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, U.K
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia.,The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia.,AHP Research, Hornchurch, U.K
| | - Lalantha Leelarathna
- Wellcome Trust-MRC Institute of Metabolic Science Metabolic Research Laboratories, University of Cambridge, Cambridge, U.K
| | - Emma Walkinshaw
- School of Medicine and Biomedical Sciences, The University of Sheffield, Sheffield, U.K
| | - Horng Kai Tan
- Peninsula College of Medicine and Dentistry, Plymouth, U.K
| | - Anita Bowes
- Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth, U.K
| | | | - Elizabeth Holmes-Truscott
- Newcastle Diabetes Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, U.K.,School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Thomas J Chadwick
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, U.K
| | - Ruth Wood
- Newcastle Clinical Trials Unit, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, U.K
| | - Timothy J McDonald
- Institute of Biomedical and Clinical Science, College of Medicine and Health, University of Exeter, Exeter, U.K
| | - David Kerr
- Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth, U.K.,Sansum Diabetes Research Institute, Santa Barbara, CA
| | | | - Augustin Brooks
- Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth, U.K
| | - Simon R Heller
- School of Medicine and Biomedical Sciences, The University of Sheffield, Sheffield, U.K
| | - Mark L Evans
- Wellcome Trust-MRC Institute of Metabolic Science Metabolic Research Laboratories, University of Cambridge, Cambridge, U.K
| | - James A M Shaw
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, U.K. .,Newcastle Diabetes Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, U.K
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16
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de Rodez Benavent SA, Nygaard GO, Nilsen KB, Etholm L, Sowa P, Wendel-Haga M, Harbo HF, Drolsum L, Laeng B, Kerty E, Celius EG. Neurodegenerative Interplay of Cardiovascular Autonomic Dysregulation and the Retina in Early Multiple Sclerosis. Front Neurol 2019; 10:507. [PMID: 31156539 PMCID: PMC6529954 DOI: 10.3389/fneur.2019.00507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/26/2019] [Indexed: 11/27/2022] Open
Abstract
Introduction: Autonomic nervous system (ANS) symptoms are prevalent in multiple sclerosis (MS) as is neurodegeneration. Our aim was to explore the occurrence of ANS symptoms and retinal neurodegeneration in a newly diagnosed MS population with tools available in a clinical setting. Methods: Forty-three MS patients and 44 healthy controls took part in the study. We employed a bedside cardiovascular ANS test battery together with classical pupillometry, optical coherence tomography (OCT) evaluation of retinal neurodegeneration in eyes without previous optic neuritis (MSNON) and patients' self-report forms on fatigue, orthostatic and ANS symptoms. Results: Half of the patients presented with ANS symptoms and a high level of fatigue. There was a significant difference in ganglion cell layer thickness (mean GCIPL) evaluated by OCT in MSNON compared to healthy control eyes. We found a negative linearity of mean GCIPL on group level with increasing disease duration. Three patients fulfilled the criteria of postural orthostatic tachycardia syndrome (POTS). Conclusion: Our results demonstrate retinal neurodegeneration in MSNON, a high frequency of fatigue and a high prevalence of ANS symptoms in newly diagnosed patients. Whether neurodegeneration precedes ANS dysfunction or vice versa is still open to debate, but as unveiled by the presence of POTS in this MS population, differences in stress-response regulation add to the understanding of variation in onset-time of ANS dysfunction in early MS.
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Affiliation(s)
- Sigrid A de Rodez Benavent
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Gro O Nygaard
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Kristian B Nilsen
- Section for Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Oslo, Norway.,Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lars Etholm
- Section for Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Piotr Sowa
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Marte Wendel-Haga
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Department of Neurology, Telemark Hospital, Skien, Norway
| | - Hanne F Harbo
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Liv Drolsum
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bruno Laeng
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Emilia Kerty
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Elisabeth G Celius
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
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17
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Jun JE, Lee SE, Lee YB, Ahn JY, Kim G, Hur KY, Lee MK, Jin SM, Kim JH. Continuous glucose monitoring defined glucose variability is associated with cardiovascular autonomic neuropathy in type 1 diabetes. Diabetes Metab Res Rev 2019; 35:e3092. [PMID: 30345631 DOI: 10.1002/dmrr.3092] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/06/2018] [Accepted: 10/15/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this study was to establish the association between continuous glucose monitoring (CGM)-defined glycaemic variability (GV) and cardiovascular autonomic neuropathy (CAN) in type 1 diabetes independent of mean glucose and to examine the relative contribution of each internationally standardized CGM parameter to this association. MATERIALS AND METHODS This study included 80 adults with type 1 diabetes who underwent 3-day CGM and autonomic function tests within 3 months. The degree of association between internationally standardized CGM parameters and CAN, defined as at least two abnormal parasympathetic tests or the presence of orthostatic hypotension, were analysed by logistic regression, receiver operating characteristics (ROC), and dominance analysis. RESULTS A total of 36 subjects (45.0%) were diagnosed with CAN. When adjusted with mean glucose and clinical risk factors of CAN, standard deviation, coefficient of variation, mean amplitude of glycaemic excursion, percent time in level 1 (glucose 54-69 mg/dL) and level 2 (glucose < 54 mg/dL) hypoglycaemia, area under the curve in level 2 hypoglycaemia, low blood glucose index, high blood glucose index, and percent time in glucose 70 to 180 mg/dL were independently associated with CAN. Multivariable ROC analysis and dominance analysis revealed the highest relative contribution of percent time in level 2 hypoglycaemia to the independent associations between CGM parameters and presence of CAN. CONCLUSIONS CGM-defined GV was associated with CAN independent of mean glucose in adults with type 1 diabetes. Among internationally standardized CGM parameters, those describing the degree of level 2 hypoglycaemia were the most significant contributors to this association.
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Affiliation(s)
- Ji Eun Jun
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Endocrinology and Metabolism, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - Seung-Eun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - You-Bin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeon Ahn
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gyuri Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Moon-Kyu Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang-Man Jin
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
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18
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Alkhatatbeh MJ, Abdalqader NA, Alqudah MAY. Impaired Awareness of Hypoglycaemia in Insulin-treated Type 2 Diabetes Mellitus. Curr Diabetes Rev 2019; 15:407-413. [PMID: 30081789 DOI: 10.2174/1573399814666180806144937] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with Type 2 Diabetes Mellitus (T2DM) may develop hypoglycemia as an adverse effect of insulin therapy. Hypoglycemia has dangerous consequences that result from neuroglycopenia and hypersecretion of counter-regulatory hormones. Patients who recognize early symptoms of hypoglycemia can initiate self-treatment and rectify the situation. Impaired Awareness of Hypoglycemia (IAH) predisposes patients to severe hypoglycemia and unconsciousness. OBJECTIVE To assess the prevalence of IAH, the intensity of hypoglycaemic symptoms, the frequency of severe hypoglycemia and factors associated with IAH in patients with insulin-treated T2DM. METHODS This is a cross-sectional study that used Clarke's and Gold's surveys to assess IAH and Edinburgh survey to assess the intensity of hypoglycemic symptoms in patients with insulin-treated T2DM (n= 388). The frequency of hypoglycemia and other data were collected by self-reporting or from medical records. RESULTS The prevalence (95% confidence interval) of IAH was 17.01% (13.27%-20.75%) as determined by Clarke's method and 5.93% (3.58-8.28) by Gold's method (Odds= 3.25, p-value<0.00001). Drowsiness, hunger, sweating, tiredness, trembling and weakness, were the most intense hypoglycaemic symptoms, and 6.19% of participants reported at least one episode of severe hypoglycaemia within the past year. Regardless of classification method used, IAH is not dependent on age, gender, duration of T2DM or duration of insulin therapy (p-values>0.05). Instead, IAH is positively associated with frequency of hypoglycaemia during the previous six months (p-value<0.05) and development of severe hypoglycaemia within the past year (p-value <0.05). CONCLUSION This study highlights large variability in IAH depending on the method used for assessment. Increased hypoglycaemia frequency may increase the prevalence of IAH and thus the development of severe hypoglycemia.
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Affiliation(s)
- Mohammad J Alkhatatbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Nedaa A Abdalqader
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Mohammad A Y Alqudah
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
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Namba M, Iwakura T, Nishimura R, Akazawa K, Matsuhisa M, Atsumi Y, Satoh J, Yamauchi T. The current status of treatment-related severe hypoglycemia in Japanese patients with diabetes mellitus: A report from the committee on a survey of severe hypoglycemia in the Japan Diabetes Society. J Diabetes Investig 2018; 9:642-656. [PMID: 29498232 PMCID: PMC5934273 DOI: 10.1111/jdi.12790] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 01/17/2023] Open
Abstract
Despite great strides in pharmacotherapy for diabetes, there is increasing concern over the risk of hypoglycemia in patients with diabetes receiving pharmacotherapy as they become increasingly older. This has prompted the Japan Diabetes Society (JDS) to initiate a survey on the current status of severe hypoglycemia in clinical settings. In July 2015, following approval from the JDS Scientific Survey/Research Ethics Committee, the JDS extended an invitation to executive educators, who represented a total of 631 healthcare facilities accredited by the JDS for diabetes education, to participate in the proposed survey. Of these, those who expressed their willingness to participate in the survey were sent an application form required for obtaining ethical approval at these healthcare facilities and were then asked, following approval, to enter relevant clinical data on an unlinked, anonymous basis in a web-based registry. The current survey was fully funded by the JDS Scientific Survey/Research Committee. A case registry (clinical case database) was launched after facility-specific information (healthcare facility database) was collected from all participating facilities and after informed consent was obtained from all participating patients. With severe hypoglycemia defined as the "presence of hypoglycemic symptoms requiring assistance from another person to treat and preferably venous plasma glucose levels at onset/diagnosis of disease or at presentation clearly less than 60 mg/dL (capillary whole blood glucose, less than 50 mg/dL)", the current survey was conducted between April 1, 2014 and March 31, 2015, during which facility-specific information was collected from a total of 193 facilities with a total of 798 case reports collected from 113 facilities. Of the 193 respondent facilities, 149 reported having an emergency department as well, with the median number of patients who required emergency transportation services to reach these facilities totaling 4,962 annually, of which those with severe hypoglycemia accounted for 0.34% (17). The respondent facilities accommodated a total of 2,237 patients with severe hypoglycemia annually, with the number of patients thus accommodated being 6.5 patients per site. A total of 1,171 patients were admitted for severe hypoglycemia, with the number of patients thus admitted being 4.0 per site, who accounted for 52.3% of all patients visiting annually for severe hypoglycemia. A review of the 798 case reports collected during the survey revealed that 240, 480 and 78 patients had type 1 diabetes, type 2 diabetes, and other types of diabetes, respectively; those with type 2 diabetes were shown to be significantly older (median [interquartile range], 77.0 [68.0-83.0]) than those with type 1 diabetes (54.0 [41.0-67.0]) (P < 0.001); and the BMI was shown to be significantly higher for those with type 2 diabetes (22.0 [19.5-24.8] kg/m2 ) than for those with type 1 diabetes (21.3 [18.9-24.0] kg/m2 ) (P = 0.003). It was also found that the median estimated glomerular filtration rate (eGFR) was significantly lower among those with type 2 diabetes (50.6 mL [31.8-71.1]/min/1.73 m2 ) than among those with type 1 diabetes (73.3 [53.5-91.1] mL/min/1.73 m2 ) (P < 0.001). Again, the median HbA1c value at onset of severe hypoglycemia was shown to be 7.0 (6.3-8.1)% among all patients examined, 7.5 (6.9-8.6)% among those with type 1 diabetes, and 6.8 (6.1-7.6)% among those with type 2 diabetes, with the HbA1c value at onset of hypoglycemia being significantly lower among those with type 2 diabetes (P < 0.001). Antecedent symptoms of severe hypoglycemia were shown to be present, absent and unknown in 35.5, 35.6, and 28.9% of all patients, respectively, with the incidence of symptomatic hypoglycemia being significantly lower among those with type 1 diabetes (41.0%) than among those with type 2 diabetes (56.9%). The antidiabetic agents used in those with type 2 diabetes were insulin preparations (292 patients including 29 receiving concomitant sulfonylureas [SUs]) (60.8%), SUs (159 insulin-naïve patients) (33.1%), and no insulin preparations or SUs (29 patients) (6.0%). Of the 798 patients surveyed, 296 patients (37.2%) were shown to have required emergency transportation services for severe hypoglycemia before. Thus, the survey revealed, for the first time, the current status of treatment-related severe hypoglycemia in Japan and clearly highlights the acute need for implementing preventive measures against hypoglycemia not only through education on hypoglycemia but through optimization of antidiabetic therapy for those at high risk of severe hypoglycemia or those with a history of severe hypoglycemia.
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Affiliation(s)
| | - Toshio Iwakura
- Diabetes and EndocrinologyKobe City Medical Center General HospitalKobeJapan
| | - Rimei Nishimura
- Department of Diabetes, Metabolism and EndocrinologyJikei University School of MedicineTokyoJapan
| | - Kohei Akazawa
- Department of Medical InformaticsNiigata University Medical & Dental HospitalNiigataJapan
| | - Munehide Matsuhisa
- Diabetes Therapeutics and Research CenterInstitute of Advanced Medical SciencesTokushima UniversityTokushimaJapan
| | | | - Jo Satoh
- Tohoku Medical and Pharmaceutical University Wakabayashi HospitalSendaiJapan
| | - Toshimasa Yamauchi
- Department of Diabetes and Metabolic DiseasesGraduate School of MedicineUniversity of TokyoTokyoJapan
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The current status of treatment-related severe hypoglycemia in Japanese patients with diabetes mellitus: a report from the committee on a survey of severe hypoglycemia in the Japan Diabetes Society. Diabetol Int 2018; 9:84-99. [PMID: 30603355 DOI: 10.1007/s13340-018-0346-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Indexed: 01/21/2023]
Abstract
Despite great strides in pharmacotherapy for diabetes, there is increasing concern over the risk of hypoglycemia in patients with diabetes receiving pharmacotherapy as they become increasingly older. This has prompted the Japan Diabetes Society (JDS) to initiate a survey on the current status of severe hypoglycemia in clinical settings. In July 2015, following approval from the JDS Scientific Survey/Research Ethics Committee, the JDS extended an invitation to executive educators, who represented a total of 631 health-care facilities accredited by the JDS for diabetes education, to participate in the proposed survey. Of these, those who expressed their willingness to participate in the survey were sent an application form required for obtaining ethical approval at these health-care facilities and were then asked, following approval, to enter relevant clinical data on an unlinked, anonymous basis in a Web-based registry. The current survey was fully funded by the JDS Scientific Survey/Research Committee. A case registry (clinical case database) was launched after facility-specific information (healthcare facility database) was collected from all participating facilities and after informed consent was obtained from all participating patients. With severe hypoglycemia defined as the "presence of hypoglycemic symptoms requiring assistance from another person to treat and preferably venous plasma glucose levels at onset/diagnosis of disease or at presentation clearly less than 60 mg/dL (capillary whole blood glucose, less than 50 mg/dL)", the current survey was conducted between April 1, 2014 and March 31, 2015, during which facility-specific information was collected from a total of 193 facilities with a total of 798 case reports collected from 113 facilities. Of the 193 respondent facilities, 149 reported having an emergency department as well, with the median number of patients who required emergency transportation services to reach these facilities totaling 4962 annually, of which those with severe hypoglycemia accounted for 0.34% (17). The respondent facilities accommodated a total of 2237 patients with severe hypoglycemia annually, with the number of patients thus accommodated being 6.5 patients per site. A total of 1171 patients were admitted for severe hypoglycemia, with the number of patients thus admitted being 4.0 per site, who accounted for 52.3% of all patients visiting annually for severe hypoglycemia. A review of the 798 case reports collected during the survey revealed that 240, 480, and 78 patients had type 1 diabetes, type 2 diabetes, and other types of diabetes, respectively; those with type 2 diabetes were shown to be significantly older [median (interquartile range), 77.0 (68.0-83.0)] than those with type 1 diabetes [54.0 (41.0-67.0)] (P < 0.001); and the BMI was shown to be significantly higher for those with type 2 diabetes [22.0 (19.5-24.8) kg/m2] than for those with type 1 diabetes [21.3 (18.9-24.0) kg/m2] (P = 0.003). It was also found that the median estimated glomerular filtration rate (eGFR) was significantly lower among those with type 2 diabetes [50.6 mL (31.8-71.1)/min/1.73 m2] than among those with type 1 diabetes [73.3 (53.5-91.1) mL/min/1.73 m2] (P < 0.001). Again, the median HbA1c value at onset of severe hypoglycemia was shown to be 7.0 (6.3-8.1)% among all patients examined, 7.5 (6.9-8.6)% among those with type 1 diabetes, and 6.8 (6.1-7.6)% among those with type 2 diabetes, with the HbA1c value at onset of hypoglycemia being significantly lower among those with type 2 diabetes (P < 0.001). Antecedent symptoms of severe hypoglycemia were shown to be present, absent, and unknown in 35.5, 35.6, and 28.9% of all patients, respectively, with the incidence of symptomatic hypoglycemia being significantly lower among those with type 1 diabetes (41.0%) than among those with type 2 diabetes (56.9%). The antidiabetic agents used in those with type 2 diabetes were insulin preparations (292 patients including 29 receiving concomitant sulfonylureas [SUs]) (60.8%), SUs (159 insulin-naïve patients) (33.1%), and no insulin preparations or SUs (29 patients) (6.0%). Of the 798 patients surveyed, 296 patients (37.2%) were shown to have required emergency transportation services for severe hypoglycemia before. Thus, the survey revealed, for the first time, the current status of treatment-related severe hypoglycemia in Japan and clearly highlights the acute need for implementing preventive measures against hypoglycemia, not only through education on hypoglycemia but also through optimization of antidiabetic therapy for those at high risk of severe hypoglycemia or those with a history of severe hypoglycemia.
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Nyiraty S, Pesei F, Orosz A, Coluzzi S, Vági OE, Lengyel C, Ábrahám G, Frontoni S, Kempler P, Várkonyi T. Cardiovascular Autonomic Neuropathy and Glucose Variability in Patients With Type 1 Diabetes: Is There an Association? Front Endocrinol (Lausanne) 2018; 9:174. [PMID: 29725320 PMCID: PMC5916962 DOI: 10.3389/fendo.2018.00174] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/03/2018] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The oxidative stress associated with glucose variability might be responsible for neuronal damage while autonomic neuropathy (AN) has a detrimental effect on metabolism. The aim of the study was to find relationship between AN and GV in type 1 diabetic patients and to identify further factors that affect GV. PATIENTS AND METHODS Twenty type 1 diabetic patients were involved (age: 39.5 ± 3.4 years, duration of diabetes: 17.5 ± 2.5 years; HbA1c: 8.1 ± 0.2%, mean ± SE). AN was assessed by the cardiovascular reflex tests. The interstitial glucose levels were determined following insertion of a subcutaneous electrode during the continuous glucose monitoring (CGM) method on six consecutive days. GV was characterized by calculation of four parameters. RESULTS SD of interstitial glucose values correlated positively with the overall AN score and the degree of the orthostatic reduction of systolic blood pressure (AN-score-SD ρ = 0.47, p < 0.05; orthostasis-SD: ρ = 0.51, p < 0.05). Mean absolute glucose (MAG) correlated with three parameters of AN (AN-score-MAG: ρ = 0.62, p < 0.01; 30/15 ratio-MAG: ρ = -0.50, p < 0.05; orthostasis-MAG: ρ = 0.59, p < 0.01). The HbA1c also correlated with two parameters of GV (HbA1c-continuous overlapping net glycemic action: ρ = 0.56, p < 0.05; HbA1c-MAG: ρ = 0.45, p < 0.05). The frequency of hypoglycemia did not exhibit any correlation with measures of GV. CONCLUSION Severity of glucose variability but not overall glucose load correlates with both parasympathetic and sympathetic dysfunctions in type 1 diabetes. Higher HbA1c is associated with more severe glucose variability. The observed correlation between increased glucose variability and the severity of AN necessitates the further exploration of this relationship.
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Affiliation(s)
- Szabolcs Nyiraty
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Fruzsina Pesei
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Andrea Orosz
- Department of Pharmacology and Pharmacotherapy, University of Szeged, Szeged, Hungary
| | - Sara Coluzzi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Unit of Endocrinology, Diabetes and Metabolism, S. Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
| | | | - Csaba Lengyel
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - György Ábrahám
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Simona Frontoni
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Unit of Endocrinology, Diabetes and Metabolism, S. Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
| | - Peter Kempler
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Tamás Várkonyi
- First Department of Medicine, University of Szeged, Szeged, Hungary
- *Correspondence: Tamás Várkonyi,
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Karter AJ, Warton EM, Lipska KJ, Ralston JD, Moffet HH, Jackson GG, Huang ES, Miller DR. Development and Validation of a Tool to Identify Patients With Type 2 Diabetes at High Risk of Hypoglycemia-Related Emergency Department or Hospital Use. JAMA Intern Med 2017; 177:1461-1470. [PMID: 28828479 PMCID: PMC5624849 DOI: 10.1001/jamainternmed.2017.3844] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable. OBJECTIVE To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D. DESIGN, SETTING, AND PARTICIPANTS Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D. EXPOSURES Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records. MAIN OUTCOMES AND MEASURES Hypoglycemia-related ED or hospital use during 12 months of follow-up. RESULTS The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (>5%), intermediate (1%-5%), or low (<1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79). CONCLUSIONS AND RELEVANCE This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.
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Affiliation(s)
- Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland.,Department of General Internal Medicine, University of California, San Francisco.,Department of Epidemiology, University of Washington, Seattle.,Department of Health Services, University of Washington, Seattle
| | - E Margaret Warton
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - James D Ralston
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Howard H Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Elbert S Huang
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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Hansen TI, Olsen SE, Haferstrom ECD, Sand T, Frier BM, Håberg AK, Bjørgaas MR. Cognitive deficits associated with impaired awareness of hypoglycaemia in type 1 diabetes. Diabetologia 2017; 60:971-979. [PMID: 28280899 PMCID: PMC5423963 DOI: 10.1007/s00125-017-4233-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 02/03/2017] [Indexed: 01/21/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to compare cognitive function in adults with type 1 diabetes who have impaired awareness of hypoglycaemia with those who have normal awareness of hypoglycaemia. A putative association was sought between cognitive test scores and a history of severe hypoglycaemia. METHODS A total of 68 adults with type 1 diabetes were included: 33 had impaired and 35 had normal awareness of hypoglycaemia, as confirmed by formal testing. The groups were matched for age, sex and diabetes duration. Cognitive tests of verbal memory, object-location memory, pattern separation, executive function, working memory and processing speed were administered. RESULTS Participants with impaired awareness of hypoglycaemia scored significantly lower on the verbal and object-location memory tests and on the pattern separation test (Cohen's d -0.86 to -0.55 [95% CI -1.39, -0.05]). Participants with impaired awareness of hypoglycaemia had reduced planning ability task scores, although the difference was not statistically significant (Cohen's d 0.57 [95% CI 0, 1.14]). Frequency of exposure to severe hypoglycaemia correlated with the number of cognitive tests that had not been performed according to instructions. CONCLUSIONS/INTERPRETATION Impaired awareness of hypoglycaemia was associated with diminished learning, memory and pattern separation. These cognitive tasks all depend on the hippocampus, which is vulnerable to neuroglycopenia. The findings suggest that hypoglycaemia contributes to the observed correlation between impaired awareness of hypoglycaemia and impaired cognition.
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Affiliation(s)
- Tor I Hansen
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Sandra E Olsen
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, PO Box 8905, N-7491, Trondheim, Norway
| | - Elise C D Haferstrom
- Department of Radiology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Trond Sand
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurology and Clinical Neurophysiology, St Olavs Hospital, Trondheim University Hospital Trondheim, Trondheim, Norway
| | - Brian M Frier
- British Heart Foundation Centre for Cardiovascular Science, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Asta K Håberg
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Radiology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marit R Bjørgaas
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, PO Box 8905, N-7491, Trondheim, Norway.
- Department of Endocrinology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
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Jin HY, Lee KA, Park TS. The impact of glycemic variability on diabetic peripheral neuropathy. Endocrine 2016; 53:643-8. [PMID: 27383181 DOI: 10.1007/s12020-016-1005-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/26/2016] [Indexed: 01/25/2023]
Abstract
Mean glucose values alone cannot explain the patterns of morbidity and mortality due to dysglycemia in diabetes. Development of continuous glucose monitoring systems has improved the analysis and interpretation of glycemic variability. The roles of glycemic components other than constant hyperglycemia in diabetic complications must be investigated because large clinical studies have indicated that risk factors besides the average glucose value of HbA1c are involved in chronic macrocomplications/microcomplications of diabetes. Among these complications, the pathogenesis of diabetic peripheral neuropathy is particularly complex, and several factors related to glucose and nonglucose pathways have been suggested as risk factors. There is little information regarding the effect of glycemic variability on diabetic peripheral neuropathy, unlike other microvascular complications of retinopathy and nephropathy, and whether glycemic variability causes harmful effects is still a matter of debate. In this review, we discuss the relationships between glycemic variability and diabetic peripheral neuropathy, focusing on somatosensory peripheral neuropathies rather than autonomic neuropathies.
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Affiliation(s)
- Heung Yong Jin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, South Korea
| | - Kyung Ae Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, South Korea
| | - Tae Sun Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, South Korea.
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25
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Kern W. [Hypoglycemia--simply annoying or dangerous?]. MMW Fortschr Med 2016; 158:67-70. [PMID: 27271419 DOI: 10.1007/s15006-016-8385-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Werner Kern
- Endokrinologikum Ulm, Keltergasse 1, D-89073, Ulm, Deutschland.
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