Risk Factors and Adverse Outcomes of Severe Hypoglycemia in Type 2 Diabetes Mellitus

Cardiac autonomic neuropathy modified the association between obesity and hypoglycemia in type 2 diabetes

BACKGROUND

Previous studies have shown that increasing body mass index (BMI) was associated with decreased hypoglycemia in type 2 diabetes, but it remains uncertain whether this finding could be applied to patients with and without cardiac autonomic neuropathy (CAN).

METHODS

The study included 7789 participants with type 2 diabetes from action to control cardiovascular risk in diabetes (ACCORD) trail. CAN was defined as SDNN < 8.2 ms and RMSSD < 8.0 ms. Obesity was defined as BMI ≥ 30 kg/m2. Outcomes were identified as severe hypoglycemia requiring any assistance (HAA) or requiring medical assistance (HMA). We assessed the association between obesity and severe hypoglycemia in type 2 diabetes with or without CAN using COX regression models adjusted for baseline characteristics.

RESULTS

Over a median follow-up of 4.7 years, a total of 893 participants developed HAA and 584 participants developed HMA. Compared with non-obesity, obesity was associated with lower risk of severe hypoglycemia (HAA: hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.38-0.68, P < 0.001; HMA: HR 0.57, 95% CI 0.40-0.82, P = 0.002) in CAN present group, but not in CAN absent group (HAA: HR 0.98, 95% CI 0.83-1.16, P = 0.830; HMA: HR 0.97, 95% CI 0.79-1.19, P = 0.754). Similarly, increasing BMI was associated with reduced severe hypoglycemic events in participants with CAN, but not in participants without CAN.

CONCLUSIONS

CAN modifies the association between obesity and hypoglycemia in type 2 diabetes. Type 2 diabetic individuals with CAN who are under weight control should pay attention to hypoglycemic events.

TRIAL REGISTRY

http://www.

CLINICALTRIALS

gov . Unique identifier: NCT00000620.

Holistic and Personalized Strategies for Managing in Elderly Type 2 Diabetes Patients

Due to increased life expectancy and lifestyle changes, the prevalence of diabetes among the elderly in Korea is continuously rising, as is the associated public health burden. Diabetes management in elderly patients is complicated by age-related physiological changes, sarcopenia characterized by loss of muscle mass and function, comorbidities, and varying levels of functional, cognitive, and mobility abilities that lead to frailty. Moreover, elderly patients with diabetes frequently face multiple chronic conditions that elevate their risk of cardiovascular diseases, cancer, and mortality; they are also prone to complications such as hyperglycemic hyperosmolar state, diabetic ketoacidosis, and severe hypoglycemia. This review examines the characteristics of and management approaches for diabetes in the elderly, and advocates for a comprehensive yet personalized strategy.

A novel electronic health record-based, machine-learning model to predict severe hypoglycemia leading to hospitalizations in older adults with diabetes: A territory-wide cohort and modeling study

BACKGROUND

Older adults with diabetes are at high risk of severe hypoglycemia (SH). Many machine-learning (ML) models predict short-term hypoglycemia are not specific for older adults and show poor precision-recall. We aimed to develop a multidimensional, electronic health record (EHR)-based ML model to predict one-year risk of SH requiring hospitalization in older adults with diabetes.

METHODS AND FINDINGS

We adopted a case-control design for a retrospective territory-wide cohort of 1,456,618 records from 364,863 unique older adults (age ≥65 years) with diabetes and at least 1 Hong Kong Hospital Authority attendance from 2013 to 2018. We used 258 predictors including demographics, admissions, diagnoses, medications, and routine laboratory tests in a one-year period to predict SH events requiring hospitalization in the following 12 months. The cohort was randomly split into training, testing, and internal validation sets in a 7:2:1 ratio. Six ML algorithms were evaluated including logistic-regression, random forest, gradient boost machine, deep neural network (DNN), XGBoost, and Rulefit. We tested our model in a temporal validation cohort in the Hong Kong Diabetes Register with predictors defined in 2018 and outcome events defined in 2019. Predictive performance was assessed using area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve (AUPRC) statistics, and positive predictive value (PPV). We identified 11,128 SH events requiring hospitalization during the observation periods. The XGBoost model yielded the best performance (AUROC = 0.978 [95% CI 0.972 to 0.984]; AUPRC = 0.670 [95% CI 0.652 to 0.688]; PPV = 0.721 [95% CI 0.703 to 0.739]). This was superior to an 11-variable conventional logistic-regression model comprised of age, sex, history of SH, hypertension, blood glucose, kidney function measurements, and use of oral glucose-lowering drugs (GLDs) (AUROC = 0.906; AUPRC = 0.085; PPV = 0.468). Top impactful predictors included non-use of lipid-regulating drugs, in-patient admission, urgent emergency triage, insulin use, and history of SH. External validation in the HKDR cohort yielded AUROC of 0.856 [95% CI 0.838 to 0.873]. Main limitations of this study included limited transportability of the model and lack of geographically independent validation.

CONCLUSIONS

Our novel-ML model demonstrated good discrimination and high precision in predicting one-year risk of SH requiring hospitalization. This may be integrated into EHR decision support systems for preemptive intervention in older adults at highest risk.

Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition)

With the deepening of aging in China, the prevalence of diabetes in older people has increased noticeably, and standardized diabetes management is critical for improving clinical outcomes of diabetes in older people. In 2021, the National Center of Gerontology, Chinese Society of Geriatrics, and Diabetes Professional Committee of Chinese Aging Well Association organized experts to write the first guideline for diabetes diagnosis and treatment in older people in China, the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2021 Edition). The guideline emphasizes that older patients with diabetes are a highly heterogeneous group requiring comprehensive assessment and stratified and individualized management strategies. The guideline proposes simple treatments and de-intensified treatment strategies for older patients with diabetes. This edition of the guideline provides clinicians with practical and operable clinical guidance, thus greatly contributing to the comprehensive and full-cycle standardized management of older patients with diabetes in China and promoting the extensive development of clinical and basic research on diabetes in older people and related fields. In the past 3 years, evidence-based medicine for older patients with diabetes and related fields has further advanced, and new treatment concepts, drugs, and technologies have been developed. The guideline editorial committee promptly updated the first edition of the guideline and compiled the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition). More precise management paths for older patients with diabetes are proposed, for achieving continued standardization of the management of older Chinese patients with diabetes and improving their clinical outcomes.

Systematic Literature Review and Indirect Treatment Comparison of Three Ready-to-Use Glucagon Treatments for Severe Hypoglycemia

INTRODUCTION

Ready-to-use glucagon represents a significant advancement in the management of severe hypoglycemia for people with diabetes and their caregivers. This indirect treatment comparison (ITC) evaluated the efficacy and safety differences among the three ready-to-use glucagon treatments, Baqsimi® (nasal glucagon), Gvoke® (glucagon injection) and Zegalogue® (dasiglucagon injection), in adults and children with type 1 diabetes (T1D) or type 2 diabetes (T2D).

METHODS

A systematic literature review was conducted to identify randomized clinical trials assessing the efficacy and safety of Baqsimi, Gvoke or Zegalogue versus reconstituted, injectable glucagon (IG) in reversing insulin-induced hypoglycemia. Bayesian fixed-effect network meta-analysis was used to perform the ITC. Study endpoints included proportion of participants achieving treatment success, maximum blood glucose achieved, time to achieve treatment success and maximum blood glucose and treatment-emergent adverse events (TEAE).

RESULTS

Ten clinical trials were included in the ITC (four for Baqsimi, three for Gvoke, and three for Zegalogue). All three treatments achieved high proportions of treatment success (> 98%). In adults, the efficacy results from combined T1D and T2D analysis were consistent with the T1D analysis, except statistically significantly faster in achieving treatment success for Baqsimi vs Gvoke in the combined analysis (13.96 vs 14.66 min). The mean maximum blood glucose values were also statistically significantly lower for Baqsimi (168 mg/dl) vs Gvoke (220 mg/dl) and Zegalogue (190 mg/dl). There was a trend towards a lower number of adults experiencing ≥ 1 TEAE with Baqsimi compared to Gvoke or Zegalogue, but no statistical significance was reached.

CONCLUSION

Baqsimi, Gvoke and Zegalogue had comparable high proportions of treatment success in reversing insulin-induced hypoglycemia. Baqsimi achieved a lower mean maximum blood glucose value, which may have implications for the re-establishment of euglycemia. These findings may help support patients, caregivers and health care providers in their decision-making process when discussing various ready-to-use glucagon treatment options.

A prediction model for assessing hypoglycemia risk in critically ill patients with sepsis

BACKGROUND

Few studies have reported the risk factors or developed a risk predictive model of hypoglycemia patients with sepsis.

OBJECTIVE

To develop a predictive model to assess the hypoglycemia risk in critically ill patients with sepsis.

METHODS

For this retrospective study, we collected the data from the Medical Information Mart for Intensive Care III and IV (MIMIC-III and MIMIC-IV). All eligible patients from the MIMIC-III were randomly divided into the training set for development of predictive model and testing set for internal validation of the predictive model at a ratio of 8:2. Patients from the MIMIC-IV database were used as the external validation set. The primary endpoint was the occurrence of hypoglycemia. Univariate and multivariate logistic model was used to screen predictors. Adopted receiver operating characteristics (ROC) and calibration curves to estimate the performance of the nomogram.

RESULTS

The median follow-up time was 5.13 (2.61-9.79) days. Diabetes, dyslipidemia, mean arterial pressure, anion gap, hematocrit, albumin, sequential organ failure assessment, vasopressors, mechanical ventilation and insulin were identified as the predictors for hypoglycemia risk in critically ill patients with sepsis. We constructed a nomogram for predicting hypoglycemia risk in critically ill patients with sepsis based on these predictors. An online individualized predictive tool: https://ghongyang.shinyapps.io/DynNomapp/. The established nomogram had a good predictive ability by ROC and calibration curves in the training set, testing set and external validation cohort.

CONCLUSION

A predictive model of hypoglycemia risk was constructed, with a good ability in predicting the risk of hypoglycemia in critically ill patients with sepsis.

Evaluation of Computer-Based Insulin Infusion Algorithm Compared With a Paper-Based Protocol in the Treatment of Diabetic Ketoacidosis

Background: Development of computer-based software, termed electronic glucose management system (eGMS), offers an alternative strategy to manage diabetic ketoacidosis (DKA) compared with institution-specific paper protocols by integrating glucose and insulin titration into the electronic medical record. Objective: To evaluate the safety and efficacy of eGMS versus a paper-based DKA protocol in an urban academic medical center. Methods: Single-center, retrospective analysis of patients admitted for DKA. The primary objective of this study was the time to transition from intravenous to subcutaneous insulin after resolution of DKA pre- and post-eGMS implementation. Secondary outcomes included incidence of hypoglycemia while on an insulin infusion, intensive care unit (ICU) length of stay, and total hospital length of stay. Results: Time to DKA resolution was similar in both groups with a median time of 8.6 versus 8.8 hours in the paper-based (n = 133) and eGMS groups (n = 84), respectively ( P = 0.43). Hypoglycemia occurred more frequently in the paper-based group compared with eGMS during insulin infusion (14 vs 3 patients, P = 0.06). The median ICU (36.5 vs 41.4 hours; P = 0.05) and hospital length of stay (67.9 vs 77.8 hours; P = 0.05) were shorter in the paper-based group compared with the eGMS group. Conclusion and Relevance: Similar rates of DKA resolution were seen for patients managed with a paper-based protocol compared with eGMS. Patients in the paper-based protocol had a shorter ICU and hospital length of stay; however, eGMS had improved clinically relevant safety outcomes.

Use of Second-Generation Basal Insulin Gla-300 in Special Populations: A Narrative Mini-Review

BACKGROUND AND AIMS

Hypoglycemia and insulin-related adverse events are crucial barriers to effective diabetes management, particularly in the elderly, people with renal impairment, people with diabetes fasting during Ramadan, or people with type 1 diabetes mellitus (T1DM). There is a scarcity of clinical and real-world evidence assessing the effectiveness and safety of insulin glargine 300 U/mL (Gla-300) in these special populations. To understand the entirety of evidence, this mini-review elaborates on the use of Gla-300 in diabetes management among special populations.

METHODS

Clinical and real-world evidence related to the use of Gla-300 among special populations with diabetes were retrieved using PUBMED and Google Scholar.

RESULTS

Gla-300 has shown improved glycemic control with stable insulin action and low risk of hypoglycemia in diverse groups with diabetes. It also appears to have an acceptable safety profile during Ramadan fasting. However, adequate monitoring and adjustment of insulin dose on an individual basis should be considered.

CONCLUSION

Gla-300 is a second-generation basal insulin with proven benefits of reduced risk of hypoglycemia and improved glycemic control in special populations of people with diabetes.

Real-World Effectiveness and Safety of Insulin Glargine 300 U/mL in Insulin-Naïve People with Type 2 Diabetes: the ATOS Study

INTRODUCTION

The clinical benefits of insulin glargine 300 U/mL (Gla-300) have been confirmed in randomised clinical trials (EDITION programme and BRIGHT) and real-world studies in the USA and Western Europe. ATOS evaluated the real-world effectiveness and safety of Gla-300 in wider geographic regions (Asia, the Middle East, North Africa, Latin America and Eastern Europe).

METHODS

This prospective observational, international study enrolled adults (≥ 18 years) with type 2 diabetes mellitus (T2DM) uncontrolled [haemoglobin A1c (HbA1c) > 7% to ≤ 11%] on one or more oral anti-hyperglycaemic drugs (OADs) who had been advised by their treating physician to add Gla-300 to their existing treatment. The primary endpoint was achievement of a pre-defined individualised HbA1c target at month 6.

RESULTS

Of the 4550 participants included, 4422 (51.8% female) were eligible for assessment. The mean ± standard deviation (SD) age was 57.2 ± 10.8 years, duration of diabetes was 10.2 ± 6.2 years and baseline HbA1c was 9.28 ± 1.0%. The proportion of participants reaching their individualised glycaemic target was 25.2% [95% confidence interval (CI) 23.8-26.6%] at month 6 and 44.5% (95% CI 42.9-46.1%) at month 12. At months 6 and 12, reductions were observed in HbA1c (-1.50% and -1.87%) and fasting plasma glucose (-3.42 and -3.94 mmol/L). Hypoglycaemia incidence was low, and body weight change was minimal. Adverse events were reported in 283 (6.4%) participants, with 57 (1.3%) experiencing serious adverse events.

CONCLUSION

In a real-world setting, initiation of Gla-300 in people with T2DM uncontrolled on OADs resulted in improved glycaemic control and low rates of hypoglycaemia with minimal weight change.

TRIAL REGISTRATION

Clinicaltrials.gov number NCT03703869.

Role of polyphenols in combating Type 2 Diabetes and insulin resistance

Compromised carbohydrate metabolism leading to hyperglycemia is the primary metabolic disorder of non-insulin-dependent diabetes mellitus. Reformed digestion and altered absorption of carbohydrates, exhaustion of glycogen stock, enhanced gluconeogenesis and overproduced hepatic glucose, dysfunction of β-cell, resistance to insulin in peripheral tissue, and impaired insulin signaling pathways are essential reasons for hyperglycemia. Although oral anti-diabetic drugs like α-glucosidase inhibitors, sulfonylureas and insulin therapies are commonly used to manage Type 2 Diabetes (T2D) and hyperglycemia, natural compounds in diet also play a significant role in combating the effect of diabetes. Due to their vast bioavailability and anti-hyperglycemic effect with least or no side effects, polyphenolic compounds have gained wide popularity. Polyphenols such as flavonoids and tannins play a significant role in carbohydrate metabolism by inhibiting key enzymes responsible for the digestion of carbohydrates to glucose like α-glucosidase and α-amylase. Several polyphenols such as resveratrol, epigallocatechin-3-gallate (EGCG) and quercetin enhanced glucose uptake in the muscle and adipocytes by translocating GLUT4 to plasma membrane mainly by the activation of the AMP-activated protein kinase (AMPK) pathway. This review provides an insight into the protective role of polyphenols in T2D, highlighting the aspects of insulin resistance.

A Cross-Sectional study on risk factors for severe hypoglycemia among Insulin-Treated elderly type 2 diabetes Mellitus (T2DM) patients in Singapore

OBJECTIVE

This study investigates the risk factors for severe hypoglycemia among Southeast Asian T2DM patients.

METHODS

Insulin-treated T2DM patients greater than 65 years old with HbA1c < 8% were recruited. They completed questionnaires detailing their experience of hypoglycemia and presence of impaired hypoglycemia awareness (IAH). Data on insulin treatment regimens, glycated haemoglobin (Hba1c) and comorbidities were also collected.

RESULTS

Of the 92 participants, 15.2% had at least one episode of severe hypoglycemia over the past year. Comparison between both groups showed that patients with severe hypoglycemia had lower Hba1c, higher Gold score (3.9 ± 1.9 vs. 2.5 ± 1.4; p < .05) and higher Hypoglycemia Fear Survey (HFS) worry score (39.1 ± 14.3 vs. 31.8 ± 11.8; p < .05). There were no significant differences in duration of diabetes and insulin treatment, treatment regimens and diabetes associated comorbidities except peripheral vascular disease. Furthermore, no significant differences were noted in HFS behavior score, hypoglycemia risk modifying behavior and social economic status.

CONCLUSIONS

Patients with severe hypoglycemia had tighter glycemic control, greater IAH and higher worry scores regardless of treatment regimens. Clinicians may play a significant role in tightening glycemic control and influencing the risk of severe hypoglycemia. Standard structured diabetes education may help reduce the risk of severe hypoglycemia among this group of patients.

External validation and clinical application of the predictive model for severe hypoglycemia

OBJECTIVE

An internally validated, one-year risk prediction model for severe hypoglycemia (SH) in type 2 diabetes was evaluated in a general hospital setting to externally verify and validate its performance.

RESEARCH DESIGN AND METHODS

Between December 2017 to December 2019, 2,645 adult patients with type 2 diabetes who visited the diabetes center were enrolled. The receiver operating characteristics curve and Harrell C-statistics were compared to identify the discrimination of the model. The predicted and actual incidence of SH for one year in the development and validation cohorts were compared by ranking participants by deciles of predicted risk.

RESULTS

The concordance index was 0.878 in the external validation cohort. The sensitivity and specificity of the predictive model were 0.833 and 0.847, respectively. Based on the predicted risk, we stratified the groups into four categories: low (<0.05%), intermediate (0.05% to <0.5%), high (0.5% to <2.0%), and very high-risk group (≥2.0%). The actual annual incidence of SH gradually increased with the increased risk score level for the decile group (P for trend <0.001). The actual annual SH incidence significantly increased with increase in SH risk scores, which proportionately increased with age, duration of diabetes, glycated hemoglobin, and albuminuria and decreased with body mass index, renal function (p for trends <0.001 for all) in type 2 diabetes.

CONCLUSION

On external validation, the novel one-year SH prediction model showed excellent discrimination in participants with type 2 diabetes and can effectively screen high-risk patients for SH, even in the general hospital setting.

Hypoglycemia: Elucidating its circadian propensity and recovery time based on clinical parameters

BACKGROUND

Hypoglycemia is frequently associated with insulin therapy in diabetic patients; it leads to many short and long-term complications and even death if not addressed in time. This study was undertaken to observe the circadian propensity of hypoglycemia and its recovery time based on type 2 diabetes mellitus patients' clinical parameters.

METHODS

We included type 2 diabetes mellitus (DM) hospitalized patients with the exclusion of patients suffering from critical illness. Data were collected for a period of three months (September to November 2019).

RESULTS

A total of 120 patients were included, comprising 60% males and 40% females. Approximately 55% of patients had hypoglycemic episodes at around 12 am- 6 am. The most common comorbidity present in these patients was hypertension (43.3%, P=0.931). Anemia (OR-3.765, CI-1.350-5.500, P=0.011), retinopathy (OR 6.066, CI-2.031-8.113, P=0.001), and duration of DM (OR-6.266, CI-2.209-7.774, P=0.001) were significantly associated with the recovery time of hypoglycemia, around 50±14.14min in the elderly population of age 60-70. People with BMI 22.5- 27.5 Kg/m2 took around 45.66 ± 19.37 min to recover after treatment.

CONCLUSION

Time taken to recover from hypoglycemic episodes vary with age and BMI. Associated comorbidities such as anemia, retinopathy, and DM duration had a significant bearing on the time taken to recover from hypoglycemia. Recovery time was directly proportional to BMI, a new finding that needs further molecular level evaluation. Circadian propensity of hypoglycemia in these patients have been identified in the early morning hours of the day.

Severe Hypoglycemia Risk With Long-Acting Insulin Analogs vs Neutral Protamine Hagedorn Insulin

IMPORTANCE

Previous studies have found that the risk of severe hypoglycemia does not differ between long-acting insulin analogs and neutral protamine Hagedorn (NPH) insulin in patients with type 2 diabetes. However, these studies did not focus on patients 65 years or older, who are at an increased risk for hypoglycemia, or did not include patients with concomitant prandial insulin use.

OBJECTIVE

To examine the risk of emergency department (ED) visits or hospitalizations for hypoglycemia among older community-residing patients with type 2 diabetes who initiated long-acting insulin or NPH insulin in real-world settings.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, new-user cohort study assessed Medicare beneficiaries 65 years or older who initiated insulin glargine (n = 407 018), insulin detemir (n = 141 588), or NPH insulin (n = 26 402) from January 1, 2007, to July 31, 2019.

EXPOSURES

Insulin glargine, insulin detemir, and NPH insulin.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to first ED visit or hospitalization for hypoglycemia, defined using a modified validated algorithm. Propensity score-weighted Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% CIs. The risk of recurring hypoglycemia events was estimated using the Andersen-Gill model. Post hoc analyses were conducted investigating possible effect modification by age.

RESULTS

Of the 575 008 patients initiating use of insulin (mean [SD] age 74.9 [6.7] years; 53% female), 407 018 used glargine, 141 588 used detemir, and 26 402 used NPH insulin. The study included 7347 ED visits or hospitalizations for hypoglycemia (5194 for glargine, 1693 for detemir, and 460 for NPH insulin, with a median follow-up across the 3 cohorts of 0.37 years (interquartile range, 0.20-0.76 years). Initiation of glargine and detemir use was associated with a reduced risk of hypoglycemia compared with NPH insulin use (HR for glargine vs NPH insulin, 0.71; 95% CI, 0.63-0.80; HR, detemir vs NPH insulin, 0.72; 95% CI, 0.63-0.82). The HRs were similar for the recurrent event analysis. The protective association of long-acting insulin analogs varied by age and was not seen with concomitant prandial insulin use.

CONCLUSIONS AND RELEVANCE

In this cohort study, initiation of long-acting analogs was associated with a lower risk of ED visits or hospitalizations for hypoglycemia compared with NPH insulin in older patients with type 2 diabetes in Medicare. However, this association was not seen with concomitant prandial insulin use.

Severe hypoglycemia and the risk of end stage renal disease in type 2 diabetes

We investigated the association between the incidence of severe hypoglycemia and the risk of end-stage renal disease (ESRD) in patients with type 2 diabetes. Baseline and follow-up data for 988,333 participants with type 2 diabetes were retrieved from the National Health Insurance System database. The number of severe hypoglycemia episodes experienced from 2007 to 2009 was determined. The primary outcome was the development of ESRD after the baseline evaluation. Participants were followed from the baseline until death or December 31, 2016, during this period 14,545 participants (1.5%) developed ESRD. In the crude model, compared with those who experienced no severe hypoglycemia, the hazard ratios (95% confidential intervals) for developing ESRD were 4.96 (4.57–5.39), 6.84 (5.62–8.32), and 9.51 (7.14–12.66) in participants who experienced one, two, and three or more episodes of severe hypoglycemia, respectively. Further adjustment for various confounding factors attenuated the association between severe hypoglycemia and ESRD; the significance of the association between severe hypoglycemia and ESRD was maintained. Having three or more severe hypoglycemia episodes was associated with a nearly two-fold increased risk of developing ESRD. Prior episodes of severe hypoglycemia were associated with an increased risk of ESRD among Korean adults with type 2 diabetes.

Hypoglycemia Among Type 1 Diabetes Patients After Insulin Use in Southwest Ethiopia

INTRODUCTION

Glycemic control is a valuable goal for people with diabetes; however, the greatest challenge to achieving tight glycemic control is hypoglycemia. Hypoglycemic events are probably common in type 1 diabetes; however, little is known about hypoglycemia in Ethiopia. Therefore, this study aimed to assess the prevalence and the associated factors of hypoglycemia among type 1 diabetes (T1D) patients after insulin use at Metu Karl Referral Hospital in southwest Ethiopia.

MATERIALS AND METHODS

A hospital-based cross-sectional study was conducted among 242 T1D patients at Metu Karl Referral Hospital in southwest Ethiopia. The prevalence of hypoglycemia was assessed by a structured questionnaire through a face-to-face interview in which all the possible symptoms of hypoglycemia were included. If the patients reported that they had experienced the symptoms at least two times in a month and the symptoms were relieved upon consuming sugar/candy/honey, such cases were considered to have had a hypoglycemic episode. Binary logistic regression analysis was done to identify the factors associated with the occurrence of hypoglycemia.

RESULTS

Out of 242 T1D patients interviewed, 114 (47.1%) had self-reported hypoglycemia. The most reported symptom of hypoglycemia was sweating (91.7%), followed by dizziness and hunger and nausea with a prevalence of 24.8 and 14.5%, respectively. The study also found that educational level with reading and writing skills up to primary level [adjusted odds ratio, AOR = 0.41; 95% confidence interval, CI (0.19-0.88)] and secondary level and above [AOR = 0.32, 95% CI (0.14-0.70)], poor knowledge of diabetes [AOR = 2.26, 95% CI (1.06-4.84)], good knowledge of insulin self-administration [AOR = 0.54, 95% CI (0.30-0.99)], and duration of insulin use ≥5 years [AOR = 3.93, 95% CI (1.44-10.7)] were factors associated with hypoglycemia.

CONCLUSIONS

The prevalence of hypoglycemia was found remarkable. We can conclude that hypoglycemia is of public health importance among T1D patients. Since the study assesses hypoglycemia after insulin injection, this prevalence may be due to the poor practice of insulin injection. Therefore, imparting education on the proper technique of insulin administration should be considered at each follow-up visit.

Development of a hypoglycaemia risk score to identify high-risk individuals with advanced type 2 diabetes in DEVOTE

AIMS

The ability to differentiate patient populations with type 2 diabetes at high risk of severe hypoglycaemia could impact clinical decision making. The aim of this study was to develop a risk score, using patient characteristics, that could differentiate between populations with higher and lower 2-year risk of severe hypoglycaemia among individuals at increased risk of cardiovascular disease.

MATERIALS AND METHODS

Two models were developed for the risk score based on data from the DEVOTE cardiovascular outcomes trials. The first, a data-driven machine-learning model, used stepwise regression with bidirectional elimination to identify risk factors for severe hypoglycaemia. The second, a risk score based on known clinical risk factors accessible in clinical practice identified from the data-driven model, included: insulin treatment regimen; diabetes duration; sex; age; and glycated haemoglobin, all at baseline. Both the data-driven model and simple risk score were evaluated for discrimination, calibration and generalizability using data from DEVOTE, and were validated against the external LEADER cardiovascular outcomes trial dataset.

RESULTS

Both the data-driven model and the simple risk score discriminated between patients at higher and lower hypoglycaemia risk, and performed similarly well based on the time-dependent area under the curve index (0.63 and 0.66, respectively) over a 2-year time horizon.

CONCLUSIONS

Both the data-driven model and the simple hypoglycaemia risk score were able to discriminate between patients at higher and lower risk of severe hypoglycaemia, the latter doing so using easily accessible clinical data. The implementation of such a tool (http://www.hyporiskscore.com/) may facilitate improved recognition of, and education about, severe hypoglycaemia risk, potentially improving patient care.

The Safety and Efficacy of Second-Generation Basal Insulin Analogues in Adults with Type 2 Diabetes at Risk of Hypoglycemia and Use in Other Special Populations: A Narrative Review

Hypoglycemia is a major barrier impeding glycemic control in persons with type 2 diabetes mellitus and creates a substantial burden on the healthcare system. Certain populations that require special attention, such as older adults and individuals with renal impairment, a longer duration of diabetes or those who have experienced prior hypoglycemia, may be at a higher risk of hypoglycemia, particularly with insulin treatment. Second-generation basal insulin analogues (insulin glargine 300 U/mL and degludec) have demonstrated reductions in hypoglycemia compared with insulin glargine 100 U/mL although evidence of this benefit across specific populations is less clear. In this review we summarize the literature with respect to the efficacy and safety data for second-generation basal insulin analogues in adults with type 2 diabetes mellitus who are at risk of hypoglycemia or who require special attention. Randomized controlled trials, meta-analyses and real-world evidence demonstrate that the use of second-generation basal insulin analogues is associated with less hypoglycemia compared with insulin glargine 100 U/mL without compromising glycated hemoglobin control. A reduced risk of hypoglycemia with second-generation basal insulin analogues was evident in older adults and in individuals with obesity, renal impairment, a history of cardiovascular disease or a long duration of insulin use. Further studies are needed in other populations, including those with more severe renal impairment or hepatic dysfunction, the hospitalized population and those with cognitive impairment. Overall, less hypoglycemia associated with second-generation basal insulin analogues may help reduce barriers for insulin use, improve adherence and offset the costs of hypoglycemia-related healthcare resource utilization.

Real-world risk of hypoglycemia-related hospitalization in Japanese patients with type 2 diabetes using SGLT2 inhibitors: a nationwide cohort study

INTRODUCTION

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are believed to lower glucose levels and inhibit cardiovascular events related to type 2 diabetes (T2D). To maximize their benefits, the risk of resultant hypoglycemia has to be minimized; however, the magnitude of this risk remains unclear. Here, we aimed to identify clinical factors linked to an increased risk of hypoglycemia among Japanese patients with T2D and treated with SGLT2 inhibitors.

RESEARCH DESIGN AND METHODS

This was a real-world retrospective cohort study conducted using the Japanese Medical Data Vision database. We identified patients with T2D and treated with SGLT2 inhibitors who were enrolled in the database from April 2014 to October 2019. Cox multivariate regression analyses were performed to determine demographical and clinical factors linked to SGLT2 inhibitor-associated hypoglycemia-related hospitalization.

RESULTS

Of 171 622 patients prescribed SGLT2 inhibitors, hypoglycemia-related hospitalization occurred in 216 (0.13%), with 0.60 incidences per 100 person-years. The risk of SGLT2 inhibitor-associated hypoglycemia was higher with each 10-year increase in age (HR 1.49; 95% CI 1.32 to 1.68) and high in patients with body mass index <25 kg/m² (HR 1.98; 95% CI 1.50 to 2.61), insulin use (HR 3.26; 95% CI 2.43 to 4.38), and sulfonylurea use (HR 1.44; 95% CI 1.02 to 2.03). The risk was lower in women than in men (HR 0.73; 95% CI 0.54 to 0.98) and low in concomitant metformin users (HR 0.52; 95% CI 0.37 to 0.74).

CONCLUSIONS

These findings may help minimize the risk of hypoglycemia-related hospitalization due to T2D treatment with SGLT2 inhibitors. We revealed that the risk of hypoglycemia may be higher when combining SGLT2 inhibitors with sulfonylureas and/or insulin. Furthermore, we discovered a high risk of hypoglycemia in older and non-obese patients. These findings may assist in maximizing the benefits of SGLT2 inhibitors for the treatment of T2D.

Effects of Co-administration of Sulfonylureas and Antimicrobial Drugs on Hypoglycemia in Patients with Type 2 Diabetes Using a Case-Crossover Design

OBJECTIVES

The purpose of this study was to investigate the effect of sulfonylureas (SUs) and antimicrobial co-administration on hypoglycemia in patients with type 2 diabetes mellitus (T2DM).

METHODS

We conducted a case-crossover study using the Korean Health Insurance Review and Assessment Service-National Inpatient Sample database, using data from 2014 to 2016. Hospitalized adult patients with T2DM who were diagnosed with hypoglycemia and prescribed SUs for at least 120 days were included. Different risk ratings of severity of drug-drug interactions were considered, including "level X, D, or C" in Lexi-Interact online and "contraindicated, major, or moderate" in Micromedex. Exposure to antimicrobials in the 30-day period before the first hypoglycemia diagnosis was assessed. Two control periods (61-90 and 91-120 days) were matched before the diagnosis date. Conditional logistic regression analysis was conducted to compare the odds of antimicrobial exposure.

RESULTS

A total of 9339 patients were included. The mean age of the patients was 71.3 ± 10.6 years, and 4818 (51.6%) were women. An increased risk of hypoglycemia was associated with co-administration of SUs and certain antimicrobials (adjusted odds ratio [aOR] 2.56, 95% confidence interval [CI] 2.34-2.80). The antimicrobial agents that were associated with an increased risk of hypoglycemia, when co-administered with SUs, were sulfonamides (aOR 2.99, 95% CI 1.99-4.52), fluoroquinolones (aOR 2.62, 95% CI 2.38-2.89), macrolides (aOR 2.48, 95% CI 1.88-3.27), and tetracyclines (aOR 1.56, 95% CI 1.05-2.33).

CONCLUSIONS

Co-administration with SUs and certain antimicrobials increased the risk of hypoglycemia. Thus, clinically relevant interactions in patients concurrently using SUs and antimicrobials should be monitored, especially within 30 days after co-administration.

Deterioration of Sleep Quality According to Glycemic Status

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a progressive disease with multiple complications. The present study aimed to determine the effects of glycemic status on sleep quality in individuals with T2DM, prediabetes, and normal glucose tolerance (NGT).

METHODS

A total of 90 participants were categorized into three groups, T2DM (n=30), prediabetes (n=30), and NGT (n=30). Objective sleep quality was measured with the actigraph wrist-worn device over 3 nights and subjective sleep quality was evaluated with a questionnaire.

RESULTS

The duration of diabetes in the T2DM group was 2.23 years and the glycosylated hemoglobin (HbA1c) levels in the T2DM, prediabetes, and NGT groups were 7.83%, 5.80%, and 5.31%, respectively. Sleep efficiency decreased across the T2DM, prediabetes, and NGT groups (86.25%, 87.99%, and 90.22%, respectively; P=0.047). Additionally, HbA1c levels revealed a significant negative correlation with sleep efficiency (r=-0.348, P=0.001). The sleep quality questionnaire results were similar among the three groups.

CONCLUSION

Although the participants in the present study were not necessarily conscious of their sleep disturbances, deterioration in sleep quality progressed according to glycemic status.

Integrating oral semaglutide into clinical practice in primary care: for whom, when, and how?

Oral semaglutide is the first US Food and Drug Administration-approved oral glucagon-like peptide-1 receptor agonist (GLP-1RA) for the treatment of type 2 diabetes (T2D). Prior articles within this supplement reviewed the PIONEER trial program, which demonstrated that oral semaglutide reduced glycated hemoglobin and body weight when given to patients with uncontrolled T2D on various background therapies, and had a safety profile consistent with subcutaneous GLP-1RAs. This article provides guidance on integrating oral semaglutide into clinical practice in primary care. Patient populations with T2D who may gain benefit from oral semaglutide include those with inadequate glycemic control taking one or more oral glucose-lowering medication (e.g. after metformin), patients for whom weight loss would be beneficial, patients at risk of hypoglycemia, those who would historically have been considered for treatment with a subcutaneous GLP-1RA, and those receiving basal insulin who require treatment intensification. Like other GLP-1RAs, oral semaglutide is contraindicated in those with personal/family history of medullary thyroid carcinoma, and in those with multiple endocrine neoplasia syndrome type 2, as noted in a boxed warning in the prescribing information. Oral semaglutide has not been studied in those with a history of pancreatitis, is not recommended in patients with suspected/confirmed pancreatitis, and is not indicated in type 1 diabetes. When initiating oral semaglutide, gradual dose escalation is recommended to minimize the risk of gastrointestinal adverse events. As food and excess liquid reduce oral semaglutide absorption, patients should swallow the tablet with up to 4 fl oz/120 mL of water on an empty stomach upon waking, and should wait at least 30 minutes before eating, drinking, or taking other oral medications. Those managing patients should be aware of the potential impact of these dosing conditions on concomitant medications. When counseling patients, it is important to discuss these administration instructions, realistic therapeutic expectations, and strategies for mitigation of gastrointestinal events. Oral semaglutide provides a new option for add-on to initial T2D therapy (or later in the treatment paradigm), with the potential to enable more patients to benefit from the improvements in glycemic control, reductions in body weight, and low risk of hypoglycemia afforded by GLP-1RAs.

Higher versus standard starting dose of insulin glargine 100 U/mL in overweight or obese Chinese patients with type 2 diabetes: Results of a multicentre, open-label, randomized controlled trial (BEYOND VII)

AIM

To determine the safety of a higher starting dose of basal insulin in overweight/obese patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

This 16-week, randomized, multicentre, open-label trial enrolled adults with T2D (body mass index 25-40 kg/m² ) and suboptimal glycaemic control (glycated haemoglobin [HbA1c] 7.5-11.0% [58-97 mmol/mol] and fasting plasma glucose [FPG] >9.0 mmol/L) with two to three oral anti-hyperglycaemic drugs at 51 centres in China. Patients were randomized (1:1) to a higher (0.3 U/kg) or standard (0.2 U/kg) starting dose of insulin glargine 100 U/mL, which was then titrated to achieve a self-monitored fasting blood glucose (FBG) of 4.4 to 5.6 mmol/L. The primary endpoint was the percentage of patients with ≥1 episode of overall confirmed hypoglycaemia (≤3.9 mmol/L or severe).

RESULTS

At the end of study (n = 866), 11.0% patients treated with the 0.3 U/kg starting insulin dose experienced overall confirmed hypoglycaemia versus 8.6% of patients treated with 0.2 U/kg (estimated difference 2.1%, 95% confidence interval - 1.68, 5.89). The proportions of patients with symptomatic (9.8% vs 7.0%; P = 0.128) and nocturnal hypoglycaemia (2.7% vs 1.2%; P = 0.102) were similar in the two groups. There were no events of severe hypoglycaemia or FBG <3.0 mmol/L during the 16-week treatment, and achievement of HbA1c <7.0% (53 mmol/mol) (37.1% vs 37.1%) or FPG <5.6 mmol/L (15.9% vs 16.3%), <6.1 mmol/L (27.6% vs 26.1%), or < 7.0 mmol/L (48.8% vs 48.3%) without hypoglycaemia were comparable in the two groups. Moreover, the mean time was shorter (4.53, 3.95 and 2.74 weeks vs 5.51, 5.21 and 3.64 weeks) and number of titrations was lower (3.5, 3.0 and 2.0 vs 4.3, 4.0 and 2.8) to achieve self-monitored FBG targets of <5.6, <6.1 and <7.0 mmol/L in the higher versus the standard insulin dose group (all P < 0.01).

CONCLUSIONS

Among overweight/obese patients with T2D, a higher insulin starting dose was as safe as the standard starting dose, and self-monitored FBG targets were achieved earlier with the higher versus the standard dose.

The use of statins in the elderly is associated with less severe hypoglycemia in patient with diabetes

Three hundred and eighty-nine older patients with diabetes attending an ambulatory diabetes center were included to determine risk factors of severe hypoglycemia (SH). Thirty-three (8.5%) patients had at least one severe hypoglycemia. In multivariate analyze, statin was associated with lower risk and insulin was associated with higher risk of SH.

Outcomes for Inappropriate Renal Dose Adjustment of Dipeptidyl Peptidase-4 Inhibitors in Patients With Type 2 Diabetes Mellitus: Population-Based Study

OBJECTIVES

To estimate inappropriate dosing of dipeptidyl peptidase-4 (DPP-4) inhibitors and to assess the risk of emergency department visits, hypoglycemia, and mortality in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) prescribed inappropriate DPP-4 inhibitor doses because limited real-world information is available regarding rates of DPP-4 inhibitor dose adjustment and its safety in patients with T2DM and CKD.

PATIENTS AND METHODS

We performed a retrospective observational cohort study of 82,332 patients aged 30 to 75 years with T2DM and CKD being treated with DPP-4 inhibitors from January 1, 2012, through December 31, 2014, using the Korean National Health Information Database. We divided the patients according to the prescription of DPP-4 inhibitor with or without dose adjustment according to estimated glomerular filtration rate. The incidences of emergency department visits, hypoglycemia, and mortality were assessed using hazard ratios estimated using Cox proportional hazards regression modeling.

RESULTS

Approximately 40% of patients with T2DM and CKD were prescribed an inappropriate dose of DPP-4 inhibitor from 2009 through 2011; this proportion decreased to 24.4% in 2015. Hazard ratios (95% CIs) for inappropriate vs appropriate dosing of DPP-4 inhibitors were 1.115 (1.005-1.237) for mortality, 1.074 (1.018-1.133) for emergency department visits, and 1.192 (1.054-1.349) for severe hypoglycemia after multivariable adjustment for confounding factors.

CONCLUSION

One of every 3 patients with T2DM and CKD received inappropriate dosing of DPP-4 inhibitor, which was associated with high risk of emergency department visits, severe hypoglycemia, and mortality.

Impact of Carbohydrate on Glucose Variability in Patients with Type 1 Diabetes Assessed Through Professional Continuous Glucose Monitoring: A Retrospective Study

INTRODUCTION

The aim of this study was to objectively analyze the correlation between dietary components and blood glucose variation by means of continuous glucose monitoring (CGM).

METHODS

Patients with type 1 diabetes mellitus (T1DM) who received CGM to manage their blood glucose levels were enrolled into the study, and the components of their total caloric intake were analyzed. Glycemic variation parameters were calculated, and dietary components, including percentages of carbohydrate, protein and fat in the total dietary intake, were analyzed by a dietitian. The interaction between parameters of glycemic variability and dietary components was analyzed.

RESULTS

Sixty-one patients with T1DM (33 females, 28 males) were enrolled. The mean age of the participants was 34.7 years, and the average duration of diabetes was 14 years. Glycated hemoglobin before CGM was 8.54%. Participants with a carbohydrate intake that accounted for < 50% of their total caloric intake had a longer DM duration and a higher protein and fat intake than did those with a carbohydrate intake that accounted for ≥ 50% of total caloric intake, but there was no between-group difference in total caloric intake per day. The group with a carbohydrate intake that accounted for < 50% of their total caloric intake also had lower nocturnal continuous overlapping net glycemic action (CONGA) 1, - 2 and - 4 values. The percentage of protein intake had a slightly negative correlation with mean amplitude of glycemic excursions (MAGE) (r = - 0.286, p < 0.05) and a moderately negative correlation with coefficient of variation (CV) (r = 0.289, p < 0.05). One additional percentage of protein calories of total calories per day decreased the MAGE to 4.25 mg/dL and CV to 0.012 (p < 0.05). The optimal dietary protein percentage for MAGE < 140 mg/dL was 15.13%. The performance of predictive models revealed the beneficial effect of adequate carbohydrate intake on glucose variation when combined with protein consumption.

CONCLUSIONS

Adequate carbohydrate consumption-but not more than half the daily total calories-combined with protein calories that amount to approximately 15% of the daily caloric intake is important for glucose stability and beneficial for patients with T1DM.

Attitudes and perceptions towards hypoglycaemia in patients with diabetes mellitus: A multinational cross-sectional study

Background

Preventing hypoglycaemia is an essential component of diabetes self-management that is affected by patients’ attitudes and perceptions. This study aimed to explore the hypoglycaemia problem-solving ability of patients who have diabetes mellitus and factors that determine their attitudes and perceptions towards their previous events.

Methodology

A cross-sectional study was conducted between October 2017 and May 2018 in three Arab countries (Jordan, Saudi Arabia and Kuwait) in patients with diabetes mellitus, who were prescribed antidiabetic therapy and had experienced hypoglycaemic events in the past six months. The Hypoglycaemia Problem-Solving Scale was used in this study. This scale contains two subscales, problem orientation (six questions) and problem-solving skills (eighteen questions), using a five-point Likert scale (range 0–4). Multiple linear regression analysis was used to identify predictors of hypoglycaemia problem-solving abilities.

Results

A total of 895 patients participated in this study from the three countries (300 in Jordan, 302 in Saudi Arabia, and 293 in Kuwait). The average age of the patients was 53.5 years (standard deviation = 13.7) and 52.4% (n = 469) were males. Patients had moderate overall problem-solving ability with a median score of 63.00 (interquartile range = 13.00). Patients’ problem-solving skills score (68.1%) was better than their problem-orientation skills score (58.3%). The highest sub-scale scores were for detection control, setting problem-solving goals, and evaluating strategies, 75.0%. The lowest sub-scale score was for problem-solving perception and immediate management, 50.0%. Older age, being educated, being married, having T2DM, prescribed insulin therapy, and not having been admitted to hospital for hypoglycaemia were important predictors of patients’ problem-solving ability (p < 0.05).

Conclusions

Healthcare professionals are advised to provide more education to patients on how to self-manage hypoglycaemic events. Specifically, they should focus on the overall problem-solving perception of hypoglycaemia and its immediate management.

Severe hypoglycemia and the risk of cardiovascular disease and mortality in type 2 diabetes: a nationwide population-based cohort study

BACKGROUND

We investigated the association regarding severe hypoglycemia episodes with cardiovascular disease risk and all-cause mortality in patients with type 2 diabetes.

METHODS

Baseline and follow-up data (n = 1,568,097) from patients with type 2 diabetes were retrieved from the National Health Insurance System database (covering the entire Korean population). Type 2 diabetes, severe hypoglycemia, and major comorbidities were identified using International Classification of Diseases 10 codes and medication information. Individuals who were classified as type 2 diabetes in the year of 2009 were screened, and we counted severe hypoglycemia episodes from 2007 to 2009. The primary outcome was newly developed myocardial infarction (MI), stroke, heart failure, or all-cause mortality. Participants were followed from the baseline index date to the date of death or until December 31, 2015.

RESULTS

In total, 19,660 (1.2%) patients developed at least one severe hypoglycemia event during the period from 2007 to 2009. Mean follow-up was 5.7 years. After adjustment for confounding factors, the hazard ratio (HR) of MI significantly and sequentially increased: 0 vs. 1 episode, HR 1.56, 95% CI 1.46-1.64; 0 vs. 2 episodes, HR 1.86, 95% CI 1.61-2.15; 0 vs. 3 or more episodes, HR 1.86, 95% CI 1.48-2.35, P for trend < 0.001. Similar findings were noted regarding the relationship of severe hypoglycemia episodes with stroke, heart failure, and all-cause mortality. Risks for all outcomes were highest within 1 year from the index date and showed decreasing trends with follow-up. Sensitivity analyses of the data from the subgroup population and 797,544 subjects who received a national health examination did not change the significance of the main findings.

CONCLUSION

Among adult Korean patients with type 2 diabetes, a severe hypoglycemia episode is associated with increased risk for cardiovascular outcomes and all-cause mortality. Significant results from dose-response, temporal, and sensitivity analyses may suggest the possibility of direct causality between severe hypoglycemia and cardiovascular outcomes and mortality.

Non-invasive marker-independent high content analysis of a microphysiological human pancreas-on-a-chip model

The increasing prevalence of diabetes, its heterogeneity, and the limited number of treatment options drive the need for physiologically relevant assay platforms with human genetic background that have the potential to improve mechanistic understanding and e\xpedite diabetes-related research and treatment. In this study, we developed an endocrine pancreas-on-a-chip model based on a tailored microfluidic platform, which enables self-guided trapping of single human pseudo-islets. Continuous, low-shear perfusion provides a physiologically relevant microenvironment especially important for modeling and monitoring of the endocrine function as well as sufficient supply with nutrients and oxygen. Human pseudo-islets, generated from the conditionally immortalized EndoC-βH3 cell line, were successfully injected by hydrostatic pressure-driven flow without altered viability. To track insulin secretion kinetics in response to glucose stimulation in a time-resolved manner, dynamic sampling of the supernatant as well as non-invasive real-time monitoring using Raman microspectroscopy was established on-chip. Dynamic sampling indicated a biphasic glucose-stimulated insulin response. Raman microspectroscopy allowed to trace glucose responsiveness in situ and to visualize different molecular structures such as lipids, mitochondria and nuclei. In-depth spectral analyses demonstrated a glucose stimulation-dependent, increased mitochondrial activity, and a switch in lipid composition of insulin secreting vesicles, supporting the high performance of our pancreas-on-a-chip model.

The association between hypoglycemia and hospital use, food insufficiency, and unstable housing conditions: a cross-sectional study among patients with type 2 diabetes in Sudan

Objectives

Hypoglycemia is associated with mortality and healthcare utilization. We aimed to assess hypoglycemia risk and Hospital use among Sudanese patients with type 2 diabetes.

Results

One hundred and fifty-nine patients with type 2 diabetes attending a diabetes center in Omdurman, Sudan during the period from June to September 2018were approached. A structured questionnaire based on hypoglycemia risk and Hospital use, Fasting plasma glucose (FPG) and the glycated hemoglobin (HbA_1c) was used to interview the patients. Participants (age 58.13 ± 9.96 years), 4.4%, 14.5%, and 81.1% were at high, moderate, and low hypoglycemia respectively, 66% reported food insufficiency, while 15.1% had unstable housing conditions. No relationship was evident between the hypoglycemia risk, gender, unstable housing conditions, food insufficiency, fasting plasma glucose,HbA_1c, and the duration since the diagnosis of diabetes. A considerable number (18.9%) of Sudanese patients with diabetes were at moderate/high risk of hypoglycemia and Hospital use, including hypoglycemia risk and hospital use assessment in the holistic care of diabetes are recommended.

Management of hypoglycemia in older adults with type 2 diabetes

Treatment of older adults with type 2 diabetes (T2D) is complex because they represent a heterogeneous group with a broad range of comorbidities, functional abilities, socioeconomic status, and life expectancy. Older adults with T2D are at high risk of recurring hypoglycemia, a condition associated with marked morbidity and mortality, because their counter-regulatory mechanism to hypoglycemia is attenuated, and recurring hypoglycemic episodes can lead to hypoglycemia unawareness. In addition, polypharmacy, a result of multiple chronic comorbidities (including heart disease, stroke, and chronic kidney disease), can increase the risk of severe hypoglycemia, especially when patients are taking sulfonylureas or insulin. Often the signs of hypoglycemia are nonspecific (sweating, dizziness, confusion, visual disturbances) and are mistaken for neurological symptoms or dementia. Consequences of hypoglycemia include acute and long-term cognitive changes, cardiac arrhythmia and myocardial infarction, serious falls, frailty, and death, often resulting in hospitalization, which come at a high economic cost. The American Diabetes Association has recently added three new recommendations regarding hypoglycemia in the elderly, highlighting individualized pharmacotherapy with glucose-lowering agents with a low risk of hypoglycemia and proven cardiovascular safety, avoidance of overtreatment, and simplifying treatment regimens while maintaining HbA1c targets. Thus, glycemic goals can be relaxed in the older population as part of individualized care, and physicians must make treatment decisions that best serve their patients' circumstances. This article highlights the issues faced by older people with T2D, the risk factors for hypoglycemia in this population, and the challenges faced by health care providers regarding glycemic management in this patient group.

Common inpatient hypoglycemia phenotypes identified from an automated electronic health record-based prediction model

PURPOSE

Common inpatient hypoglycemia risk factor patterns (phenotypes) from an electronic health record (EHR)-based prediction model and preventive strategies were identified.

METHODS

Patients admitted to 2 large academic medical centers who were in the top fifth percentile of a previously developed hypoglycemia risk score and developed hypoglycemia (blood glucose [BG] of <50mg/dL) were included in the study. Frequencies of all combinations of ≥4 risk factors contributing to the risk score among these patients were determined to identify common risk patterns. Clinical pharmacists developed clinical vignettes for each common pattern and formulated medication therapy management recommendations for hypoglycemia prevention.

RESULTS

A total of 401 admissions with a hypoglycemic event were identified among 1,875 admissions whose hypoglycemic risk was in the top fifth percentile among all admissions that received antihyperglycemic drugs and evaluated. Five distinct phenotypes emerged: (1) frail patients with history of hypoglycemia receiving insulin on hospital day 1, (2) a rapid downward trend in BG values in patients receiving an insulin infusion or with a history of hypoglycemia, (3) administration of insulin in the presence of an active nothing by mouth order in frail patients, (4) repeated low BG level in frail patients, and (5) inadequate night-time BG monitoring for patients on long-acting insulin. The 5 themes jointly described 53.0% of high-risk patients who experienced hypoglycemia.

CONCLUSION

Five distinct phenotypes that are prevalent in patients at greatest risk for inpatient hypoglycemia were identified.

Associations Between the Knowledge of Different Food Categories and Glycemia in Chinese Adult Patients With Type 2 Diabetes

This study aims to evaluate the levels of knowledge of different food categories and analyze the association between the levels of dietary knowledge and glycemia in Chinese adult patients with type 2 diabetes mellitus (T2DM). A cross-sectional study design was adopted. A total of 334 patients with T2DM were recruited from six hospitals from July to October 2014 in China. The Diabetes Dietary Knowledge Scale was utilized to obtain dietary knowledge. The results showed the item examining knowledge of carbohydrates received the highest score, whereas the item examining knowledge of healthy fats received the lowest score. The item "nuts" (B = -0.49; 95% confidence interval [CI] = [0.38, 0.99]) was associated with the incidence of hyperglycemia. The item "foods when hypoglycemic" (B = 0.42; 95% CI = [1.22, 2.07]) was associated with the incidence of hypoglycemia. There were different knowledge levels of different food categories in patients with T2DM, and these have implications for blood glucose control.

A Retrospective Time Trend Study Of Diabetes Overtreatment In Geriatric Patients

PURPOSE

We assessed changes in diabetes mellitus (DM) overtreatment prevalence in geriatric patients that had taken place after the introduction of the rule of therapy individualization in the Polish diabetes treatment guidelines.

PATIENTS AND METHODS

This time-trend assessment comprised two retrospective cross-sectional cohort studies of type 2 DM patients admitted to a geriatric ward in 2009-2010 (1st round) and in 2014-2015 (2nd round). A high-risk group was defined as patients on antihyperglycemic medications prior to admission, who were 80+ years old, diagnosed with dementia, end-stage renal disease, or had a history of macrovascular complications. The primary outcome measure was glycosylated A_1C hemoglobin (HbA_1C) ≤7.0% (53 mmol/mol).

RESULTS

213 patients in the 1st round and 83 in the 2nd round were included. Groups did not differ in age, gender, health and functional characteristics. The percentage of dementia (36.1% versus 18.8%, P=0.002) and of the high-risk cases (79.3% versus 67.7%, P=0.05) was higher in the 2nd round of the study. During the study, tight glycemic control prevalence in the high-risk group decreased significantly from 73.1% to 58.5%, P=0.04 (odds ratio 0.68, 95% CI 0.47-0.97), and the median value of HbA_1c increased significantly from 6.4%, IQR 5.7-7.3 (46 mmol/mol, IQR 39-56) to 6.7%, IQR 6.1-7.9 (50 mmol/mol, IQR 43-63), P=0.03.

CONCLUSION

Despite the principle of individualization of DM therapy that was in force, after a five-year observation, the problem of DM overtreatment still concerned a large percentage of geriatric patients, although a positive trend was noted in this respect.

Development and validation of a risk prediction model for severe hypoglycemia in adult patients with type 2 diabetes: a nationwide population-based cohort study

Purpose

There is a scarcity of long-term prediction models for severe hypoglycemia (SH) in subjects with type 2 diabetes mellitus (T2DM). In this study, a model was developed and validated to predict the risk of SH in adult patients with T2DM.

Patients and methods

Baseline and follow-up data from patients with T2DM who received health evaluations from January 1, 2009, to December 31, 2010 (n=1,676,885) were analyzed as development (n=1,173,820) and validation (n=503,065) cohorts using the National Health Insurance Database (DB) in Korea. New SH episodes were identified using ICD-10 codes. A Cox proportional hazards regression model and Cox model coefficients were used to derive a risk scoring system, and 14 predictive variables were selected. A risk score nomogram based on the risk prediction model was created to estimate the 1-year risk of SH.

Results

In the development cohort, a total of 5,325 (0.45%) patients experienced SH episodes during the follow-up period. After multivariable adjustment, older age, female sex, current smoker, drinking, low body mass index, lack of exercise, previous SH events, insulin or multiple oral hypoglycemic agent use, presence of hypertension or chronic kidney disease, longer duration of diabetes, low or high glucose level, and high Charlson Comorbidity Index score were found to be significant risk factors for the development of SH and were incorporated into the risk model. The concordance indices were 0.871 (95% confidence interval, 0.863-0.881) in development cohort and 0.866 (95% CI, 0.856-0.879) in the validation cohort. The calibration plot showed a nearly 45° line, which indicates that this model predicts well an absolute SH event.

Conclusion

This 14-variable prediction model for SH events may be a useful tool to identify high-risk patients and guide prevention of SH in adult patients with T2DM.

Analysis of the characteristics of patients with diabetes mellitus who attend a tertiary hospital emergency department for a hypoglycemic event

INTRODUCTION AND OBJECTIVE

Hypoglycemia associated to insulin or other glucose-lowering agents is one of the most common causes of visits to the emergency department for adverse drug reactions. The study objective was to analyze the characteristics of patients with diabetes mellitus (DM) who attend a tertiary hospital emergency department for a hypoglycemic event.

PATIENTS AND METHODS

A 3-year retrospective analysis was conducted of patients with DM who attended the emergency department of Hospital Universitari de Bellvitge for a hypoglycemic event. An analysis was made of epidemiological and diabetes-related characteristics, prevalence of chronic diabetic complications and other comorbidities, the glucose-lowering treatment and the result of the hypoglycemic episode.

RESULTS

Of the 149 hypoglycemic events analyzed, 81.9% occurred in patients with type 2 DM. Mean age of patients with type 2 DM was 75.4 years. DM duration was longer than 10 years in 69.4% of patients. The prevalence rates of chronic kidney disease and cognitive decline were 38.5% and 19.7% respectively in patients with type 2 DM. Insulin with or without other concomitant glucose-lowering agents was associated to 78.7% of episodes in type 2 DM patients. The remaining 21.3% were associated to oral hypoglycemic agents, mainly glibenclamide. After the event, 13.4% of patients required hospital admission, and in 36.8% of these hypoglycemia was associated to use of glibenclamide.

CONCLUSIONS

A majority of hypoglycemic events occurred in elderly patients with type 2 DM, with a high prevalence of associated comorbidities and treated with insulin and sulfonylureas, particularly glibenclamide.

Association between BMI and risk of severe hypoglycaemia in type 2 diabetes

AIM

This study aimed to assess the association between body mass index (BMI) and the development of severe hypoglycaemia in patients with type 2 diabetes (T2D), using nationwide data for the entire South Korean population.

METHODS

The association between BMI and severe hypoglycaemia was retrospectively examined from claims and National Health examination data registered between 2002 and 2015. A total of 1,366,692 subjects assigned clinical codes for T2D and prescribed antihypoglycaemic agents were included. The primary outcome was an episode of severe hypoglycaemia after the baseline health examination.

RESULTS

A total of 37,682 subjects (2.7%) experienced a new severe hypoglycaemic event during the follow-up period (mean: 8.6 years). An inverse J-shaped association was observed between BMI and severe hypoglycaemic events. The association between low BMI and high risk of severe hypoglycaemia was similar in subjects who had never smoked, did not consume alcohol, did not use insulin and had no major comorbidities, after adjusting for multiple confounding variables. This association was also found to be intensified in men, young people aged 30-49 years, those with major comorbidities and insulin users.

CONCLUSION

BMI and severe hypoglycaemia were found to be inversely associated. Thus, those who fall into the category of having low BMI and high risk of severe hypoglycaemia should be warned about the risk of having a hypoglycaemic event and be properly informed about hypoglycaemia to minimize the risk of fatal hypoglycaemia-related outcomes.

Antihyperglycemic agent therapy for adult patients with type 2 diabetes mellitus 2017: a position statement of the Korean Diabetes Association

In 2017, the Korean Diabetes Association (KDA) published a position statement on the use of antihyperglycemic agents for patients with type 2 diabetes mellitus (T2DM). The KDA regularly updates its Clinical Practice Guidelines, but since the last update in 2015, many results from clinical trials have been introduced, and domestic data from studies performed in Korean patients with T2DM have been published. Recently, evidence from large clinical studies assessing cardiovascular outcomes following the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in patients with T2DM were incorporated into the recommendations. Additionally, new data from clinical trials using dipeptidyl peptidase 4 inhibitors and thiazolidinediones in Korean patients with T2DM were added. Following a systematic review and assessment of recent evidence, the KDA updated and modified its clinical practice recommendations regarding the use of antihyperglycemic agents and revised the treatment algorithm for Korean adult patients with T2DM.

Monotherapy in patients with type 2 diabetes mellitus

In order to improve the quality of life and to prevent chronic complications related to diabetes mellitus, intensive lifestyle modification and proper medication are needed from the early stage of diagnosis of type 2 diabetes mellitus (T2DM). When using the first medication for diabetic patients, the appropriate treatment should be selected considering the clinical characteristics of the patient, efficacy of the drug, side effects, and cost. In general, the use of metformin as the first treatment for oral hypoglycemic monotherapy is recommended because of its excellent blood glucose-lowering effect, relatively low side effects, long-term proven safety, low risk of hypoglycemia, and low weight gain. If metformin is difficult to use as a first-line treatment, other appropriate medications should be selected in view of the clinical situation. If the goal of achieving glycemic control is not achieved by monotherapy, a combination therapy with different mechanisms of action should be initiated promptly.

Monotherapy in Patients with Type 2 Diabetes Mellitus

In order to improve the quality of life and to prevent chronic complications related to diabetes mellitus, intensive lifestyle modification and proper medication are needed from the early stage of diagnosis of type 2 diabetes mellitus (T2DM). When using the first medication for diabetic patients, the appropriate treatment should be selected considering the clinical characteristics of the patient, efficacy of the drug, side effects, and cost. In general, the use of metformin as the first treatment for oral hypoglycemic monotherapy is recommended because of its excellent blood glucose-lowering effect, relatively low side effects, long-term proven safety, low risk of hypoglycemia, and low weight gain. If metformin is difficult to use as a first-line treatment, other appropriate medications should be selected in view of the clinical situation. If the goal of achieving glycemic control is not achieved by monotherapy, a combination therapy with different mechanisms of action should be initiated promptly.

Antihyperglycemic Agent Therapy for Adult Patients with Type 2 Diabetes Mellitus 2017: A Position Statement of the Korean Diabetes Association

In 2017, the Korean Diabetes Association (KDA) published a position statement on the use of antihyperglycemic agents for patients with type 2 diabetes mellitus (T2DM). The KDA regularly updates its Clinical Practice Guidelines, but since the last update in 2015, many results from clinical trials have been introduced, and domestic data from studies performed in Korean patients with T2DM have been published. Recently, evidence from large clinical studies assessing cardiovascular outcomes following the use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in patients with T2DM were incorporated into the recommendations. Additionally, new data from clinical trials using dipeptidyl peptidase 4 inhibitors and thiazolidinediones in Korean patients with T2DM were added. Following a systematic review and assessment of recent evidence, the KDA updated and modified its clinical practice recommendations regarding the use of antihyperglycemic agents and revised the treatment algorithm for Korean adult patients with T2DM.