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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:e15340. [PMID: 38741266 DOI: 10.1111/dme.15340] [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: 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, UK
| | - 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, UK
| | - 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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Sanchez-Rangel E, Deajon-Jackson J, Hwang JJ. Pathophysiology and management of hypoglycemia in diabetes. Ann N Y Acad Sci 2022; 1518:25-46. [PMID: 36202764 DOI: 10.1111/nyas.14904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jelani Deajon-Jackson
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Janice Jin Hwang
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA.,Division of Endocrinology, Department of Internal Medicine, University of North Carolina - Chapel Hill, Chapel Hill, North Carolina, USA
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Rubin NT, Seaquist ER, Eberly L, Kumar A, Mangia S, Öz G, Moheet A. Relationship Between Hypoglycemia Awareness Status on Clarke/Gold Methods and Counterregulatory Response to Hypoglycemia. J Endocr Soc 2022; 6:bvac107. [PMID: 35935070 PMCID: PMC9351372 DOI: 10.1210/jendso/bvac107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Indexed: 11/29/2022] Open
Abstract
Context Impaired awareness of hypoglycemia (IAH) is characterized by the diminished ability to perceive symptoms of hypoglycemia. Gold and Clark questionnaires are commonly used to identify patients with IAH. The relationship between IAH status on questionnaires and a person’s symptom and epinephrine responses to hypoglycemia are not well understood. Objective We aimed to examine the relationship between hypoglycemia awareness status on Clarke and Gold questionnaires with both hormonal and symptomatic responses to experimental hypoglycemia. Methods In this university medical center study, we examined data from 78 subjects with type 1 diabetes (T1D) who completed both questionnaires and underwent a hyperinsulinemic hypoglycemic clamp (target glucose 50 mg/dL). Results Clarke and Gold scores were highly correlated with one another (r = 0.82) and each had a moderate negative relationship with epinephrine (Clarke: r = -0.51, Gold: r = -0.50) and total symptom response (Clarke: r = −0.59, Gold: r = −0.57). However, 32% of the subjects were classified inconsistently by Clark vs Gold. A clustering analysis was done to examine how disagreement between the 2 questionnaires on IAH classification relates to epinephrine and symptoms responses during hypoglycemia. Subjects who had partial loss of symptoms or of epinephrine response were more likely to be classified inconsistently. Conclusion Our results show that IAH classification may be discordant between Clark and Gold questionnaires and that hypoglycemia awareness status on Clarke and Gold questionnaires poorly predicts hormonal and symptomatic responses to hypoglycemia in subjects with T1D and moderate blunting of symptoms or epinephrine.
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Affiliation(s)
- Nathan T Rubin
- Division of Biostatistics, School of Public Health, University of Minnesota , Minneapolis, MN 55455 , USA
- Biostatistics Core, Masonic Cancer Center, University of Minnesota , Minneapolis, MN 55455 , USA
| | - Elizabeth R Seaquist
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota , Minneapolis, MN 55455 , USA
| | - Lynn Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota , Minneapolis, MN 55455 , USA
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota , Minneapolis, MN 55455 , USA
| | - Anjali Kumar
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota , Minneapolis, MN 55455 , USA
| | - Silvia Mangia
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota , Minneapolis, MN 55455 , USA
| | - Gülin Öz
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota , Minneapolis, MN 55455 , USA
| | - Amir Moheet
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota , Minneapolis, MN 55455 , USA
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Zhang Y, Öz G, Moheet A, Kumar A, Alvear A, Mangia S, Eberly L, Seaquist ER. Heterogeneity in epinephrine response to experimental hypoglycemia in type 1 diabetes and controls. J Endocr Soc 2022; 6:bvac046. [PMID: 35475026 PMCID: PMC9032637 DOI: 10.1210/jendso/bvac046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Indexed: 11/29/2022] Open
Abstract
Context The epinephrine response (Epi) to a first episode of hypoglycemia (HG) has been proposed to be predictive of Epi in subsequent HG and to provide insight into the risk for developing HG-associated autonomic failure (HAAF) in healthy controls (HCs). Objective To determine if Epi and symptom response (SR) to the first episode of HG predicts who will develop HAAF after exposure to recurrent HG in volunteers with type 1 diabetes (T1D) and in HCs. Design Review of data collected between 2013 and 2019. Setting Academic clinical research unit. Patients or Participants Volunteers with T1D and HCs. Interventions Subjects participated in a preinduction protocol where they were exposed to three 2-hour episodes of clamped HG over 2 days. Data collected during clamp 1 were compared with data collected during clamp 3. Main outcome measure Difference in Epi and SR. Results Using the standard definition of HAAF in which HG-induced Epi during clamp 3 is at least 20% lower than during clamp 1, 21/28 HCs and 13/19 volunteers with T1D developed HAAF. Epi during clamp 1 was significantly higher in those subjects who developed HAAF than in those who did not in both groups (P = 0.02). If HAAF is defined as achieving a 20% reduction in HG-induced SR measured during clamp 3 compared with clamp 1, 10/27 HCs and 10/19 volunteers with T1D developed SR-based HAAF. Conclusion There was heterogeneity in the response to the preinduction protocol. Epi during clamp 1 was higher than in clamp 3 in HCs and in those with T1D who developed HAAF.
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Affiliation(s)
- Yuan Zhang
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Gülin Öz
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Amir Moheet
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Anjali Kumar
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alison Alvear
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Silvia Mangia
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Lynn Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Elizabeth R Seaquist
- Division of Endocrinology and Diabetes, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Chacko E. Minimizing Hypoglycemia Using a Five-Step Diabetes Management Program. Clin Diabetes 2022; 40:233-239. [PMID: 35669304 PMCID: PMC9160533 DOI: 10.2337/cd21-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Geschultes Hypoglykämiebewusstsein bei Hypoglykämiewahrnehmungsstörung zeigt sich auch im Gehirnscan. DIABETOL STOFFWECHS 2021. [DOI: 10.1055/a-1317-5186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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