Nocturnal hypoglycemia: clinical manifestations and therapeutic strategies toward prevention

Impact of hypoglycemia after gastrectomy on Global Leader Initiative on Malnutrition-defined malnutrition: a retrospective study

PURPOSE

The Global Leader Initiative on Malnutrition (GLIM) criteria were developed in 2018 as a global indicator of malnutrition, and the term 'malnutrition-sarcopenia syndrome' was established. Recently, it has been reported that fluctuations in blood glucose are related to sarcopenia. In this study, we investigated the effects of glucose fluctuations on malnutrition after gastrectomy using a continuous glucose monitoring (CGM) device.

METHODS

We analyzed the data of 69 patients with gastric cancer (GC) who underwent curative gastrectomy between November 2017 and December 2020. CGM was performed over a 2-week period at 1 month and 1 year after surgery. The GLIM criteria included weight loss, the body mass index (BMI), and the psoas muscle mass index (PMI).

RESULTS

One year after surgery, 25 and 35 patients had severe and moderate malnutrition, respectively. The time below range (TBR) (percent of time the glucose concentration was < 70 mg/dL) and nocturnal (00:00-06:00) TBR were significantly higher in the severe malnutrition group than in the other groups (TBR: normal/moderate 17.9% vs. severe 21.6%, P = 0.039, nocturnal TBR; normal/moderate 30.6% vs. severe 41.1%, P = 0.034).

CONCLUSIONS

Post-gastrectomy hypoglycemia, including long nocturnal hypoglycemia, was higher in severely malnourished patients than in other patients even 1 year after surgery. Prevention of nocturnal hypoglycemia may be the key to improving malnutrition following gastrectomy.

Frequency of Hypoglycemia Assessed by Continuous Glucose Monitoring in Advanced CKD

BACKGROUND

Hypoglycemia represents a risk for serious morbidity. We evaluated the prevalence and risk factors of hypoglycemia by continuous glucose monitoring (CGM) in patients with CKD with or without diabetes.

METHODS

In this cross-sectional study, outpatients with CKD stages G3-G5 (including hemodialysis) and type 2 diabetes without CKD were enrolled and underwent intermittently scanned CGM measurements for 7 days. The burden of CGM-measured hypoglycemia was assessed using the 7-day sum of area over the curve with glucose levels <70 mg/dl and the sum of time spent <54  mg/dl.

RESULTS

A total of 366 participants (148 participants with CKD and diabetes, 115 with CKD and without diabetes, and 103 without CKD and with diabetes) were included. Glucose levels of <54  mg/dl were observed in 41% of participants with CKD and diabetes, 48% of participants with CKD and without diabetes, and 14% of participants with diabetes and without CKD. However, only two participants reported hypoglycemic symptoms during CGM measurements, which were confirmed and documented by capillary blood glucose measurements. Between-group differences of 7-day area over the curve (<70 mg/dl) were as follows: hemodialysis group versus CKD stage G4 and G5 groups, -0.25 min·mg/dl per hour (95% confidence interval [CI], -6.40 to -0.59) P <0.001; CKD stage G4 and G5 groups versus CKD stage G3 group, -0.08 min·mg/dl per hour (95% CI, -0.0 to -0.50) P =0.15; and CKD stage G3 group versus diabetes without CKD group, -0.14 min·mg/dl per hour (95% CI, -0.0 to -0.20) P =0.01. In addition, the subgroup analysis of the diabetic or nondiabetic and at daytime or nighttime showed that the 7-day area over the curve (<70 mg/dl) and time spent (<54 mg/dl) was larger with worse kidney function.

CONCLUSIONS

The lowering level of kidney function was strongly associated with the burden of hypoglycemia in patients with CKD.

Nocturnal hypoglycemia is underdiagnosed in older people with insulin-treated type 2 diabetes: The HYPOAGE observational study

BACKGROUND

There is a lack of real-life data regarding the frequency and predictive factors of hypoglycemia in older patients with type 2 diabetes (T2D). This study aimed to determine the frequency and predictors of hypoglycemia in older patients with insulin-treated T2D.

METHODS

This prospective multicenter study included 155 insulin-treated T2D patients aged 75 years and older with ≥2 self-monitoring of blood glucose (SMBG) daily controls. Participants underwent a geriatric and diabetic assessment and received ambulatory blinded continuous glucose monitoring (CGM) for 28 consecutive days with FreeStyle Libre Pro® sensor. Study population (n = 141) has >70% CGM active time. Multivariable logistic regressions were used to identify factors associated with SMBG confirmed hypoglycemia (≥70 mg/dL) and with nocturnal level 2 time below range (glucose concentration <54 mg/dL during ≥15 consecutive min between 0.00 and 6.00 am).

RESULTS

The mean age of the 141 analyzed patients was 81.5 ± 5.3 years and 56.7% were male. The mean baseline HbA_1c was 7.9% ± 1.0%. After geriatric assessment, 102 participants (72.3%) were considered as complex and 39 (27.7%) as healthy. The primary endpoint (confirmed SMBG <70 mg/dL) occurred in 37.6% patients. In multivariable analysis, the risk of SMBG-confirmed hypoglycemia was positively associated with a longer duration of diabetes (OR (+1 year) =1.04, (1.00-1.08), p = 0.04) and glycemic variability assessed by CGM (CV %) (OR (+1%) = 1.12, [1.05-1.19], p = <0.001). Nighty-two patients (65.2%) experienced nocturnal time in hypoglycemia (i.e., <54 mg/dL during ≥15 consecutive min between midnight and 6 a.m.). In multivariable analyses, cognitive impairment (OR: 9.31 [2.59-33.4]), heart failure (OR: 4.81 [1;48-15.6]), and depressive disorder (OR: 0.19 [0.06-0.53]) were associated with nocturnal time in hypoglycemia.

CONCLUSION

Nocturnal hypoglycemia is very common and largely underdiagnosed in older patients with insulin-treated T2D. CGM is a promising tool to better identify hypoglycemia and adapt diabetes management in this population.

Unmanned Aerial Vehicle Mediated Drug Delivery for First Aid

Timely administration of key medications toward patients with sudden diseases is critical to saving lives. However, slow transport of first-aid therapeutics and the potential absence of trained people for drug usage can lead to severe injuries or even death. Herein, an unmanned aerial vehicle (UAV)-mediated first-aid system for targeted delivery (uFAST) is developed. It allows unattended administration of emergency therapeutics-loaded transdermal microneedle (MN) patches toward patients to relieve symptoms by a contact-triggered microneedle applicator (CTMA). The implementability and safety of the uFAST for first aid is demonstrated in a severe hypoglycemic pig model by automatically delivering a glucagon patch with immediate and bioresponsive dual release modes. This platform technique may facilitate the development of UAV-mediated first-aid treatments for other sudden diseases.

Scientific advisory on nocturnal hypoglycemia in insulin-treated patients with diabetes: Recommendations from Indian experts

INTRODUCTION

Insulin is one of the commonly prescribed glucose lowering agents in diabetes. Hypoglycemia is the most common complication, and severe hypoglycemia is the most serious complication of insulin therapy. Almost half of all severe hypoglycemia episodes (HEs) occur at night. However, patients are often unaware of their nocturnal hypoglycaemia (NH) risk. Additionally, both healthcare professionals and patients find it difficult to manage NH. The purpose of this expert group meeting is to improve NH awareness and provide guidance for the physicians to recognize and manage NH.

METHOD

The panel of experts in an e-board deliberated extensively upon the available literature and guidelines on hypoglycemia and NH discussed the consensus on definition, detection, reporting, monitoring, treatment, and optimization of therapy in NH.

RESULT

& Conclusion: Though there are many guidelines on the management of HEs in patients with diabetes, very few touch the topic of NH. This scientific advisory on management of NH in insulin treated patients with diabetes is formulated to address this gap in understanding regarding management of NH. The experts provide recommendations for the nocturnal window, defining NH based on blood glucose values, recognition, prevention and management of NH.

Machine Learning Models for Nocturnal Hypoglycemia Prediction in Hospitalized Patients with Type 1 Diabetes

Nocturnal hypoglycemia (NH) is a dangerous complication of insulin therapy that often goes undetected. In this study, we aimed to generate machine learning (ML)-based models for short-term NH prediction in hospitalized patients with type 1 diabetes (T1D). The models were trained on continuous glucose monitoring (CGM) data obtained from 406 adult patients admitted to a tertiary referral hospital. Eight CGM-derived metrics of glycemic control and glucose variability were included in the models. Combinations of CGM and clinical data (23 parameters) were also assessed. Random Forest (RF), Logistic Linear Regression with Lasso regularization, and Artificial Neuron Networks algorithms were applied. In our models, RF provided the best prediction accuracy with 15 min and 30 min prediction horizons. The addition of clinical parameters slightly improved the prediction accuracy of most models, whereas oversampling and undersampling procedures did not have significant effects. The areas under the curve of the best models based on CGM and clinical data with 15 min and 30 min prediction horizons were 0.97 and 0.942, respectively. Basal insulin dose, diabetes duration, proteinuria, and HbA1c were the most important clinical predictors of NH assessed by RF. In conclusion, ML is a promising approach to personalized prediction of NH in hospitalized patients with T1D.

Nocturnal hypoglycemia in type 1 and type 2 diabetes: an update on prevalence, prevention, pathophysiology and patient awareness

INTRODUCTION

Despite considerable progress in diabetes treatment, prevalence of nocturnal hypoglycemia in type 1 diabetes mellitus (T1DM) and advanced insulin treated type 2 diabetes mellitus (T2DM) remains high.

AREAS COVERED

The present manuscript describes the prevalence of night-time hypoglycemia as reported in observational and randomized controlled trials. Factors that affect the risk of hypoglycemia are highlighted. The authors also describe impaired awareness of hypoglycemia and available preventive methods.

EXPERT OPINION

Prevention of nocturnal hypoglycemia includes behavioral, dietary and pharmacologic interventions. The most recent development with the lowest rate of hypoglycemia is sensor-augmented pumps with predictive low glucose suspend technology. These pumps combine continuous subcutaneous insulin infusion with continuous glucose monitoring and use various algorithms to predict and stop hypoglycemia before it develops.

Intestinal Microbiota Play an Important Role in the Treatment of Type I Diabetes in Mice With BefA Protein

More and more studies have shown that the intestinal microbiota is the main factor in the pathogenesis of type 1 diabetes mellitus (T1DM). Beta cell expansion factor A (BefA) is a protein expressed by intestinal microorganisms. It has been proven to promote the proliferation of β-cells and has broad application prospects. However, as an intestinal protein, there have not been studies and reports on its application in diabetes and its mechanism of action. In this study, a T1DM model induced by multiple low-dose STZ (MLD-STZ) injections was established, and BefA protein was administered to explore its therapeutic effect in T1DM and the potential mechanism of intestinal microbiota. BefA protein significantly reduced the blood glucose, maintained the body weight, and improved the glucose tolerance of the mice. At the same time, the BefA protein significantly increased the expression of ZO-1, Occludin, and significantly reduced the expression of TLR-4, Myd88, and p-p65/p65. BefA protein significantly reduced the relative expression of pro-inflammatory cytokines IL-1β, IL-6 and TNF-α. In addition, our high-throughput sequencing shows for the first time that the good hypoglycemic effect of BefA protein is strongly related to the increase in the abundance of the beneficial gut bacteria Lactobacillus, Bifidobacterium and Oscillospria and the decrease in the abundance of the opportunistic pathogen Acinetobacter. Our group used animal models to verify the hypoglycemic effect of BefA protein, and first explored the potential mechanism of intestinal microbiota in BefA protein treatment.

Glucose Regulation Beyond HbA1c in Type 2 Diabetes Treated With Insulin: Real-World Evidence From the DIALECT-2 Cohort

OBJECTIVE

To investigate glucose variations associated with glycated hemoglobin (HbA1c) in insulin-treated patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Patients included in Diabetes and Lifestyle Cohort Twente (DIALECT)-2 (n = 79) were grouped into three HbA1c categories: low, intermediate, and high (≤53, 54-62, and ≥63 mmol/mol or ≤7, 7.1-7.8, and ≥7.9%, respectively). Blood glucose time in range (TIR), time below range (TBR), time above range (TAR), glucose variability parameters, day and night duration, and frequency of TBR and TAR episodes were determined by continuous glucose monitoring (CGM) using the FreeStyle Libre sensor and compared between HbA1c categories.

RESULTS

CGM was performed for a median (interquartile range) of 10 (7-12) days/patient. TIR was not different for low and intermediate HbA1c categories (76.8% [68.3-88.2] vs. 76.0% [72.5.0-80.1]), whereas in the low category, TBR was higher and TAR lower (7.7% [2.4-19.1] vs. 0.7% [0.3-6.1] and 8.2% [5.7-17.6] vs. 20.4% [11.6-27.0], respectively, P < 0.05). Patients in the highest HbA1c category had lower TIR (52.7% [40.9-67.3]) and higher TAR (44.1% [27.8-57.0]) than the other HbA1c categories (P < 0.05), but did not have less TBR during the night. All patients had more (0.06 ± 0.06/h vs. 0.03 ± 0.03/h; P = 0.002) and longer (88.0 [45.0-195.5] vs. 53.4 [34.4-82.8] minutes; P < 0.001) TBR episodes during the night than during the day.

CONCLUSIONS

In this study, a high HbA1c did not reduce the occurrence of nocturnal hypoglycemia, and low HbA1c was not associated with the highest TIR. Optimal personalization of glycemic control requires the use of newer tools, including CGM-derived parameters.

Comparison of insulin glargine 300 U/mL versus glargine 100 U/mL on glycemic control and hypoglycemic events in East Asian patients with type 2 diabetes: A Patient-level meta-analysis of phase 3 studies

AIMS

To evaluate efficacy and safety of Gla-300 with Gla-100 in a patient-level meta-analysis among large East Asian patients with type 2 diabetes mellitus (T2DM).

METHODS

A patient level meta-analysis of three EDITION studies with similar design and endpoints were conducted over 6-months treatment period. The analysis included 547 patients treated with Gla-300 and 348 patients treated with Gla-100.

RESULTS

Over 6-month treatment period, mean change in HbA1c was similar for Gla-300 [Least square (LS) mean, (SE): -1.13 (0.05) % and Gla-100: -1.14 (0.05) %], showing non-inferiority of Gla-300 to Gla-100 (LS mean difference: 0.02%, 95% CI: -0.08 to 0.11). Gla-300 was associated with reduced risk of hypoglycemic event (confirmed ≤ 3.9 mmol/L or severe) vs Gla-100 at any time of day or at night (00:00-05:59 h). The event rates of hypoglycemia were consistently lower with Gla-300 than Gla-100. Severe hypoglycemia was rare in both treatment groups. Weight gain was minimal in both treatment groups.

CONCLUSION

Gla-300 provides comparable glycemic control to Gla-100 in East Asian patients with broad clinical spectrum of T2DM, with consistently less hypoglycemia at any time of the day and night.

Hypoglycaemia and Cardiovascular Disease Risk in Patients with Diabetes

Hypoglycaemia represents an important side effect of insulin therapy and insulin secretagogues. It can occur in both type 1 and type 2 diabetes mellitus patients. Also, some associations between hypoglycaemia and cardiovascular (CV) risk have been reported. Several mechanisms may be involved, including the sympathoadrenal system, hypokalaemia, endothelial dysfunction, coagulation, platelets, inflammation, atherothrombosis and impaired autonomic cardiac reflexes. This narrative review discusses the associations of hypoglycaemia with CV diseases, including coronary heart disease (CHD), cardiac arrhythmias, stroke, carotid disease and peripheral artery disease (PAD), as well as with dementia. Severe hypoglycaemia has been related to CHD, CV and all-cause mortality. Furthermore, there is evidence supporting an association between hypoglycaemia and cardiac arrhythmias, potentially predisposing to sudden death. The data linking hypoglycaemia with stroke, carotid disease and PAD is limited. Several factors may affect the hypoglycaemia-CV relationships, such as the definition of hypoglycaemia, patient characteristics, co-morbidities (including chronic kidney disease) and antidiabetic drug therapy. However, the association between hypoglycaemia and dementia is bilateral. Both the disorders are more common in the elderly; thus, glycaemic goals should be carefully selected in older patients. Further research is needed to elucidate the impact of hypoglycaemia on CV disease.

Value of Capillary Glucose Profiles in Assessing Risk of Nocturnal Hypoglycemia in Type 1 Diabetes Based on Continuous Glucose Monitoring

INTRODUCTION

This study aimed to evaluate the occurrence of nocturnal hypoglycemia in type 1 diabetes (T1D) based on continuous glucose monitoring (CGM), and to explore the value of capillary glucose profiles in assessing the risk of nocturnal hypoglycemia. The study also intended to develop a predictive model to identify people with high risk of nocturnal hypoglycemia.

METHODS

A total of 169 participants with T1D received 3 days of blinded CGM; meanwhile, their self-monitoring blood glucose (SMBG) profiles were recorded. Logistic regression analyses were used to evaluate contributory factors of nocturnal hypoglycemia. Potential indicators were estimated using area under receiver operator curve (AUC) analyses.

RESULTS

During the retrospective CGM period, 95 (56.2%) participants with T1D reported 238 events of hypoglycemia, and 69 (29.0%) of these episodes occurred during the nighttime. Increased risk of nocturnal hypoglycemia correlated with lower HbA1c, glycated albumin, and mean blood glucose (OR = 0.790, 0.940, 0.651, respectively; P < 0.05) and higher standard deviation, mean amplitude of glycemic excursions, and low blood glucose index (OR = 1.463, 1.168, 4.035, respectively; P < 0.05) after adjustment for age and duration. Of the daily SMBG profiles, fasting blood glucose (OR = 0.643, P = 0.001) and blood glucose at bedtime (OR = 0.851, P = 0.037) were associated with the occurrence of nocturnal hypoglycemia. The BGn model, which was derived from the variation of capillary glucose, could discriminate individuals with increased risk of nocturnal hypoglycemia (AUC = 0.774).

CONCLUSIONS

Nocturnal hypoglycemia constitutes nearly one-third of hypoglycemic events in people with T1D. Strict glycemic control and great fluctuation of glucose are potential contributory factors. Daily SMBG profiles and the BGn model could help assess the risk of nocturnal hypoglycemia in T1D, which may support further development of preventive strategies.

Sex differences in factors associated with poor subjective sleep quality in athletes

BACKGROUND

Sleep is an important recovery period for athletes. In general, women are not satisfied with their sleep quality, which is also true for female soccer players, although the reasons remain to be elucidated. This study aimed to confirm sex difference in sleep quality among athletes from various fields of sport, and to investigate factors related to poor subjective sleep quality in male and female athletes.

METHODS

We collected data concerning subjective sleep quality, measured by Pittsburgh Sleep Quality Index (PSQI), from athletes who were 16 to 40 years of age and played various types of sports. Data concerning their sports, lifestyle, and sleep issues and sleep environments, and also menstrual issues for females, were collected.

RESULTS

Data from 207 male athletes and 215 female athletes were assessed. Among them, 31.4% of men and 48.8% of women had poor subjective sleep quality (i.e., PSQI≥6). In male athletes, witnessed apnea, episodes of disorientation or confusion during the time of sleep, long time gap between dinner and bedtime, and turning on the heating in the winter, were identified as factors associated with poor sleep quality by multivariate analysis, whereas in female athletes, bathing close to bedtime, habitual drinking, and being annoyed by noises at bedtime were identified.

CONCLUSIONS

In both populations, females had poorer subjective sleep quality than males. Sex differences exist in factors associated with poor subjective sleep quality. Thus, different approaches should be considered to improve their sleep quality.

Novel ambulatory glucose-sensing technology improves hypoglycemia detection and patient monitoring adherence in children and adolescents with type 1 diabetes

Purpose

Glucose monitoring [GM] is a mainstay of diabetes control and management. Improving glycemic control is essential to prevent microvascular complications. However, adherence to GM can be a challenge in children and adolescents. Detecting hypoglycemia is essential for its prevention and treatment. We aim to study the impact of the flash ambulatory glucose monitoring in detecting hypoglycemia and enhancing adherence in children and adolescents with type 1 diabetes.

Methods

The study is prospective involving 3 hospital visits. Children and adolescents with diabetes were enrolled in the study which involved a period on conventional glucose self-monitoring [glucometers] followed by a similar period of monitoring using the flash glucose monitoring device (FreeStyle Libre). Frequency of GM, duration and frequency of hypoglycemia were compared on conventional and the flash monitoring.

Results

75 subjects were studied. Age mean (range) was 11.9 years (2-19). Significant difference was seen in hypoglycemia detection between both testing devices. 68 (94%) and 65 (90%) patients detected nocturnal and diurnal hypoglycemia respectively on Flash monitoring compared to 12 (16.6%) and 30 (41%) on glucometer testing (p < 0.00). Mean (range) duration of hypoglycemia was 95 min (15-330). Statistically-significant difference was found between the frequency of GM on glucometer testing compared with Flash monitoring (2.87 and 11.6/day) (p < 0.001).

Conclusions

Flash monitoring is a useful tool to improve adherence to GM and detecting hypoglycemia [diurnal and nocturnal] in children and adolescents with type 1 diabetes.

Glucose Response during the Night Is Suppressed by Wheat Albumin in Healthy Participants: A Randomized Controlled Trial

Postprandial blood glucose excursions are important for achieving optimal glycemic control. In normal-weight individuals, glucose tolerance is diminished in the evening compared to glucose tolerance in the morning. Wheat albumin (WA) has the potential to suppress the postprandial glucose response with a relatively small dose, compared to the dose required when using dietary fiber. In the present study, the effect of WA on glycemic control during the night was investigated after a late evening meal. A randomly assigned crossover trial involving a single oral ingestion in healthy male participants was performed in a double-blind placebo-controlled manner. The participants ingested the placebo (PL) tablets or the WA (1.5 g)-containing tablets 3 min before an evening meal at 22:00 hour, and blood samples were drawn during the night until 07:00 hour using an intravenous cannula. The participants slept from 00:30 hour to 06:30 hour. Glucose response, as a primary outcome during the night, was suppressed significantly by the WA treatment compared to the PL treatment, but the insulin response was not. Plasma glucose-dependent insulinotropic polypeptide concentration during the night was lowered significantly by the WA treatment compared to the PL treatment. In conclusion, WA may be a useful food constituent for glycemic control during the night.

Estimating the utility value of hypoglycaemia according to severity and frequency using the visual analogue scale (VAS) and time trade-off (TTO) survey

OBJECTIVES

The primary objective of this study was to estimate the health utility values for hypoglycaemia events according to their severity and frequency. The secondary objective was to compare the health utilities between those with Type 2 Diabetes Mellitus and the general population.

METHOD

The health utilities of hypoglycaemia event were measured using Visual Analogue Scale (VAS) and Time Trade-Off (TTO) methods among conveniently sampled consenting adults (>18 years and literate in either English or Malay language), which were then divided into two groups: those in the general population (GP) and those with Type 2 Diabetes Mellitus (T2DM). Each respondent was required to value 13 different health states, including frequencies of daytime hypoglycaemia and nocturnal hypoglycaemia, each depending on its severity (non-severe or severe).

RESULTS

256 respondents from the GP and 99 respondents with T2DM completed the survey. The T2DM group gave higher VAS-values compared to the GP group. The highest mean VAS-utility value for non-severe nocturnal hypoglycaemia occurring once monthly was 0.543 (SD 0.161), and for severe daytime hypoglycaemia occurring once quarterly was 0.293 (SD 0.162) which was the lowest utility value compared to other health states. However, non-severe nocturnal hypoglycaemia occurring once quarterly was 0.537 (SD 0.284) and has the highest TTO-utility value. Severe nocturnal hypoglycaemia occurring once quarterly has the lowest utility value which was -0.104 (SD 0.380). Daytime hypoglycaemia has lower utility value compared to nocturnal hypoglycaemia. Severe hypoglycaemia has a greater disutility compared with the non-severe hypoglycaemia in both studied groups.

CONCLUSION

The findings show that as a health utility, hypoglycaemia has a substantial impact on utility with severe hypoglycaemia having a greater negative impact compared to non-severe events across the board. This highlights the importance of preventing development of severe hypoglycaemia in patients with Type 2 Diabetes Mellitus at any time of the day.

Hypoglycaemia Remains the Key Obstacle to Optimal Glycaemic Control - Continuous Glucose Monitoring is the Solution

We queried PubMed and other internet databases to identify studies, meta-analyses, review articles and other data sources regarding hypoglycaemia incidence/costs/impacts and continuous glucose monitoring (CGM) use. Our analysis of the evidence showed that hypoglycaemia remains a significant health concern and a primary obstacle to optimal adherence to prescribed diabetes treatment. In addition to its adverse clinical consequences, hypoglycaemia negatively impacts quality of life and places additional financial burdens on patients, patient families, employers and healthcare payers. Clinical trials have shown that the use of CGM can reduce the incidence and duration of hypoglycaemic episodes. This article reviews relevant CGM studies, discusses the prevalence and clinical/financial implications of hypoglycaemia, and explores the strengths and limitations of current CGM systems in minimising the burden of hypoglycaemia.

Chronic hyperglycemia mediated physiological alteration and metabolic distortion leads to organ dysfunction, infection, cancer progression and other pathophysiological consequences: An update on glucose toxicity

Chronic exposure of glucose rich environment creates several physiological and pathophysiological changes. There are several pathways by which hyperglycemia exacerbate its toxic effect on cells, tissues and organ systems. Hyperglycemia can induce oxidative stress, upsurge polyol pathway, activate protein kinase C (PKC), enhance hexosamine biosynthetic pathway (HBP), promote the formation of advanced glycation end-products (AGEs) and finally alters gene expressions. Prolonged hyperglycemic condition leads to severe diabetic condition by damaging the pancreatic β-cell and inducing insulin resistance. Numerous complications have been associated with diabetes, thus it has become a major health issue in the 21st century and has received serious attention. Dysregulation in the cardiovascular and reproductive systems along with nephropathy, retinopathy, neuropathy, diabetic foot ulcer may arise in the advanced stages of diabetes. High glucose level also encourages proliferation of cancer cells, development of osteoarthritis and potentiates a suitable environment for infections. This review culminates how elevated glucose level carries out its toxicity in cells, metabolic distortion along with organ dysfunction and elucidates the complications associated with chronic hyperglycemia.

The effect of exercise on sleep in adults with type 1 diabetes

The aim of this pilot study was to investigate the effect of exercise on sleep and nocturnal hypoglycaemia in adults with type 1 diabetes (T1D). In a 3-week crossover trial, 10 adults with T1D were randomized to perform aerobic, resistance or no exercise. During each exercise week, participants completed 2 separate 45-minutes exercise sessions at an academic medical center. Participants returned home and wore a continuous glucose monitor and a wrist-based activity monitor to estimate sleep duration. Participants on average lost 70 (±49) minutes of sleep (P = .0015) on nights following aerobic exercise and 27 (±78) minutes (P = .3) following resistance exercise relative to control nights. The odds ratio with confidence intervals of nocturnal hypoglycaemia occurring on nights following aerobic and resistance exercise was 5.4 (1.3, 27.2) and 7.0 (1.7, 37.3), respectively. Aerobic exercise can cause sleep loss in T1D possibly from increased hypoglycaemia.

Clinical Aspects of Human Circadian Rhythms

Circadian rhythmicity can be important in the pathophysiology, diagnosis, and treatment of clinical disease. Due to the difficulties in conducting the necessary experimental work, it remains unknown whether ~24-h changes in pathophysiology or symptoms of many diseases are causally linked to endogenous circadian rhythms or to other diurnal factors that change across the day, such as changes in posture, activity, sleep or wake state, or metabolic changes associated with feeding or fasting. Until the physiology is accurately known, appropriate treatment cannot be designed. This review includes an overview of clinical disorders that are caused or affected by circadian or diurnal rhythms. The clinical side effects of disruption of circadian rhythmicity, such as in shiftwork, including the public health implications of the disrupted alertness and performance, are also discussed.

The Hypoglycaemia-Hyperglycaemia Minimizer System in the Management of Type 1 Diabetes

Living with type 1 diabetes (T1D) presents many challenges in terms of daily living. Insulin users need to frequently monitor their blood glucose levels and take multiple injections per day and/or multiple boluses through an insulin infusion pump, with the consequences of failing to match the insulin dose to the body's needs resulting in hypoglycaemia and hyperglycaemia. The former can result in seizures, coma and even death; the latter can have both acute and long-term health implications. Many patients with T1D also fail to meet their treatment goals. In order to reduce the burdens of self-administering insulin, and improve efficacy and safety, there is a need to at least partially remove the patient from the loop via a closed-loop 'artificial pancreas’ system. The Hypoglycaemia-Hyperglycaemia Minimizer (HHM) System, comprising a continuous, subcutaneous insulin infusion pump, continuous glucose monitor (CGM) and closed-loop insulin dosing algorithm, is able to predict changes in blood glucose and adjust insulin delivery accordingly to help keep the patient at normal glucose levels. Early clinical data indicate that this system is feasible, effective and safe, and has the potential to dramatically improve the therapeutic outcomes and quality of life for people with T1D.

Mechanisms of hypoglycemia unawareness and implications in diabetic patients

Hypoglycemia unawareness (HU) is defined at the onset of neuroglycopenia before the appearance of autonomic warning symptoms. It is a major limitation to achieving tight diabetes and reduced quality of life. HU occurs in approximately 40% of people with type 1 diabetes mellitus (T1DM) and with less frequency in T2DM. Though the aetiology of HU is multifactorial, possible mechanisms include chronic exposure to low blood glucose, antecedent hypoglycaemia, recurrent severe hypoglycaemia and the failure of counter-regulatory hormones. Clinically it manifests as the inability to recognise impeding hypoglycaemia by symptoms, but the mechanisms and mediators remain largely unknown. Prevention and management of HU is complex, and can only be achieved by a multifactorial intervention of clinical care and structured patient education by the diabetes team. Less know regarding the impact of medications on the development or recognition of this condition in patients with diabetes. Several medications are thought to worsen or promote HU, whereas others may have an attenuating effect on the problem. This article reviews recent advances in how the brain senses and responds to hypoglycaemia, novel mechanisms by which people with insulin-treated diabetes develop HU and impaired counter-regulatory responses. The consequences that HU has on the person with diabetes and their family are also described. Finally, it examines the evidence for prevention and treatment of HU, and summarizes the effects of medications that may influence it.

Avoiding or coping with severe hypoglycemia in patients with type 2 diabetes

Hypoglycemia is a major barrier to achieving the glycemic goal in patients with type 2 diabetes. In particular, severe hypoglycemia, which is defined as an event that requires the assistance of another person to actively administer carbohydrates, glucagon, or take other corrective actions, is a serious clinical concern in patients with diabetes. If severe hypoglycemia is not managed promptly, it can be life threatening. Hypoglycemia-associated autonomic failure (HAAF) is the main pathogenic mechanism behind severe hypoglycemia. Defective glucose counter-regulation (altered insulin secretion, glucagon secretion, and an attenuated increase in epinephrine during hypoglycemia) and a lack of awareness regarding hypoglycemia (attenuated sympathoadrenal activity) are common components of HAAF in patients with diabetes. There is considerable evidence that hypoglycemia is an independent risk factor for cardiovascular disease. In addition, hypoglycemia has a significant influence on the quality of life of patients with diabetes. To prevent hypoglycemic events, the setting of glycemic goals should be individualized, particularly in elderly individuals or patients with complicated or advanced type 2 diabetes. Patients at high-risk for the future development of severe hypoglycemia should be selected carefully, and intensive education with reinforcement should be implemented.

Hypoglycaemia in diabetes mellitus: epidemiology and clinical implications

Hypoglycaemia is a frequent adverse effect of treatment of diabetes mellitus with insulin and sulphonylureas. Fear of hypoglycaemia alters self-management of diabetes mellitus and prevents optimal glycaemic control. Mild (self-treated) and severe (requiring help) hypoglycaemia episodes are more common in type 1 diabetes mellitus but people with insulin-treated type 2 diabetes mellitus are also exposed to frequent hypoglycaemic events, many of which occur during sleep. Hypoglycaemia can disrupt many everyday activities such as driving, work performance and leisure pursuits. In addition to accidents and physical injury, the morbidity of hypoglycaemia involves the cardiovascular and central nervous systems. Whereas coma and seizures are well-recognized neurological sequelae of hypoglycaemia, much interest is currently focused on the potential for hypoglycaemia to cause dangerous and life-threatening cardiac complications, such as arrhythmias and myocardial ischaemia, and whether recurrent severe hypoglycaemia can cause permanent cognitive impairment or promote cognitive decline and accelerate the onset of dementia in middle-aged and elderly people with diabetes mellitus. Prevention of hypoglycaemia is an important part of diabetes mellitus management and strategies include patient education, glucose monitoring, appropriate adjustment of diet and medications in relation to everyday circumstances including physical exercise, and the application of new technologies such as real-time continuous glucose monitoring, modified insulin pumps and the artificial pancreas.

Hypoglycemia

Hypoglycemia is a common, potentially avoidable consequence of diabetes treatment and is a major barrier to initiating or intensifying antihyperglycemic therapy in efforts to achieve better glycemic control. Therapy regimen and a history of hypoglycemia are the most important predictors of future events. Other risk factors include renal insufficiency, older age, and history of hypoglycemia-associated autonomic failure. Reported rates of hypoglycemia vary considerably among studies because of differences in study design, definitions used, and population included, among other factors. Although occurring more frequently in type 1 diabetes, hypoglycemia also is clinically important in type 2 diabetes. Symptoms experienced by patients vary among individuals, and many events remain undiagnosed. The incidence of severe events is unevenly distributed, with only a small proportion (∼ 5%) of individuals accounting for >50% of events. Consequently, clinicians must be conscientious in obtaining thorough patient histories, because an accurate picture of the frequency and severity of hypoglycemic events is essential for optimal diabetes management. Severe hypoglycemia in particular is associated with an increased risk of mortality, impairments in cognitive function, and adverse effects on patients' quality of life. Economically, hypoglycemia burdens the healthcare system and adversely affects workplace productivity, particularly after a nocturnal event. Ongoing healthcare reform efforts will result in even more emphasis on reducing this side effect of diabetes treatment. Therefore, improving patients' self-management skills and selecting or modifying therapy to reduce the risk of hypoglycemia will increase in importance for clinicians and patients alike.

Identifying and meeting the challenges of insulin therapy in type 2 diabetes

Type 2 diabetes mellitus (T2DM) is a chronic illness that requires clinical recognition and treatment of the dual pathophysiologic entities of altered glycemic control and insulin resistance to reduce the risk of long-term micro- and macrovascular complications. Although insulin is one of the most effective and widely used therapeutic options in the management of diabetes, it is used by less than one-half of patients for whom it is recommended. Clinician-, patient-, and health care system-related challenges present numerous obstacles to insulin use in T2DM. Clinicians must remain informed about new insulin products, emerging technologies, and treatment options that have the potential to improve adherence to insulin therapy while optimizing glycemic control and mitigating the risks of therapy. Patient-related challenges may be overcome by actively listening to the patient’s fears and concerns regarding insulin therapy and by educating patients about the importance, rationale, and evolving role of insulin in individualized self-treatment regimens. Enlisting the services of Certified Diabetes Educators and office personnel can help in addressing patient-related challenges. Self-management of diabetes requires improved patient awareness regarding the importance of lifestyle modifications, self-monitoring, and/or continuous glucose monitoring, improved methods of insulin delivery (eg, insulin pens), and the enhanced convenience and safety provided by insulin analogs. Health care system-related challenges may be improved through control of the rising cost of insulin therapy while making it available to patients. To increase the success rate of treatment of T2DM, the 2012 position statement from the American Diabetes Association and the European Association for the Study of Diabetes focused on individualized patient care and provided clinicians with general treatment goals, implementation strategies, and tools to evaluate the quality of care.

Diminishing marginal disutility of hypoglycaemic events: results from a time trade-off survey in five countries

INTRODUCTION

The negative impact of hypoglycaemic events on health-related quality of life (HRQoL) may be evaluated by attaching published disutilities to these events. It is suggested that the marginal negative impact of individual hypoglycaemic events on HRQoL may decrease as the overall frequency increases.

METHODS

Using disutility values from a large-scale (>8,000 respondents), time trade-off (TTO) study, nonlinear regression curves were fitted to the total disutility of different frequencies of non-severe daytime and nocturnal hypoglycaemic events. Nonparametric bootstrapping was applied to characterise the uncertainty of the marginal disutility.

RESULTS

Power function regression curves were estimated at U d = 0.0141x (0.3393) and U d = 0.0221x (0.3277). An increase from 0 to 1 hypoglycaemic event per year produced a utility decrease of 0.0141 and 0.0221 for non-severe daytime and nocturnal events, respectively. An increase from 25 to 26 events per year produced a marginal impact of 0.0006 and 0.0008 for non-severe daytime and nocturnal events, respectively.

DISCUSSION

These data concur with the noted phenomenon of "first being worst" as regards hypoglycaemic events. This finding may reflect a coping mechanism on the part of patients, a maximum limit for trading off remaining lifetime or the nature of the study.

CONCLUSION

Applying nonlinear functions to the TTO data might improve the precision of the measured impact of hypoglycaemic events.

The Impact of Nocturnal Hypoglycemia on Clinical and Cost-Related Issues in Patients With Type 1 and Type 2 Diabetes

PURPOSE

This article provides an overview of the clinical and economic issues associated with hypoglycemia in patients with type 1 and type 2 diabetes mellitus. Current research regarding hypoglycemia is comprehensively reviewed, with special emphasis on nocturnal hypoglycemia, as almost 50% of all severe hypoglycemic episodes occur at nighttime during sleep. Current findings on the economic and human burden of hypoglycemia are presented.

CONCLUSIONS

Poor diabetes self-management leads to an increased risk for hypoglycemia and the development of long-term complications associated with poor glycemic control. Hypoglycemia is also associated with increased health care costs and resources required to treat hypoglycemic events, as well as personal financial costs and loss of productivity at school or work. In addition, fear, anxiety, and worry about hypoglycemic episodes are shown to interfere with patients' quality of life. Nocturnal hypoglycemia can cause a number of immediate clinical consequences, including convulsions, coma, and even death. Repeated long-term exposure to nocturnal hypoglycemia can blunt counterregulatory mechanisms that maintain glucose levels, leading to reduced cognitive function, impaired awareness of hypoglycemia, and hypoglycemia-associated autonomic failure. Clinicians must be aware of the impact of hypoglycemia, particularly nocturnal hypoglycemia, so that they can prescribe appropriate glucose-lowering therapy and educate patients about the prevention and management of hypoglycemic events to reduce anxiety and improve quality of life.

Association between excessive daytime sleepiness and severe hypoglycemia in people with type 2 diabetes: the Edinburgh Type 2 Diabetes Study

OBJECTIVE

Sleep-disordered breathing and sleepiness cause metabolic, cognitive, and behavioral disturbance. Sleep-disordered breathing is common in type 2 diabetes, a condition that requires adherence to complex dietary, behavioral, and drug treatment regimens. Hypoglycemia is an important side effect of treatment, causing physical and psychological harm and limiting ability to achieve optimal glycemic control. We hypothesized that sleep disorder might increase the risk of hypoglycemia through effects on self-management and glucose regulation.

RESEARCH DESIGN AND METHODS

People with type 2 diabetes (n = 898) completed questionnaires to assess sleep-disordered breathing, daytime sleepiness, and occurrence of severe hypoglycemia.

RESULTS

Subjects who scored highly on the Epworth Sleepiness Scale were significantly more likely to have suffered from severe hypoglycemia. This was a significant predictor of severe hypoglycemia in regression analysis including the variables age, sex, duration of diabetes, HbA1c, BMI, and treatment type.

CONCLUSIONS

Daytime sleepiness may be a novel risk factor for hypoglycemia.

Evaluation of insulin use and value for money in type 2 diabetes in the United kingdom

INTRODUCTION

It is unclear as to whether human or long-acting analog insulins represent the most efficient use of health and non-healthcare resources in the management of type 2 diabetes mellitus (T2DM). The aim of this study was to evaluate the value for money relationship associated with the use of these insulins in the UK setting.

METHODS

A literature search was performed for studies reporting expenditure associated with the use of human and analog insulins. Data from this review informed a budget impact assessment model. Costs were converted to a common currency and results are reported in 2011 British pounds sterling (GBP) values.

RESULTS

Annual diabetes-related medication expenditure and patients total expenditure associated with the management of T2DM were estimated to be £397 million and £3,901 million, respectively. Substitution of human insulin for analog insulins was associated with a drug acquisition cost saving of between £5 million and £23 million each year. Overall, though, total expenditure increased significantly with increased use of human insulin by £34 million to £136 million each year depending on the degree of substitution.

CONCLUSIONS

On the face of it, analog insulins are more expensive, prompting questions about potential cost savings to health services in the UK from direct substitution to the less expensive human preparation. The current analysis illustrates that the increased use of human insulin and decreased use of analog insulin would, however, increase the overall net societal cost of managing insulin-treated patients with T2DM. Governments and decision makers should consider that total healthcare expenditure would not necessarily fall when decisions are based solely on the use of cheaper products.

Impact of nocturnal hypoglycemic events on diabetes management, sleep quality, and next-day function: results from a four-country survey

OBJECTIVES

Non-severe nocturnal hypoglycemic events (NSNHEs) may have a major impact on patients. The objective was to determine how NSNHEs affect diabetes management, sleep quality, functioning, and to assess if these impacts differ by diabetes type or country.

METHODS

An internet survey to adults with diabetes in the US, UK, Germany, and France.

RESULTS

Of 6756 screened respondents, 1086 reported an NSNHE in the past month. For this last event, respondents with type 2 required significantly more time than type 1 to recognize and respond to the event (1.5 vs 1.1 hours), 25.7% (T1) and 18.5% (T2) decreased their normal insulin dose due to their most recent NSNHE. All respondents were likely to take 1-2 additional self-monitored blood glucose measurements on the day following. NSNHEs were associated with a high proportion of respondents contacting a healthcare professional (18.6% T1, 27.8% T2) reporting they could not return to sleep at night (13.3% T1, 13.4% T2), and tiredness on the day following the event (71.2% for both). Of the respondents working for pay, 18.4% T1 and 28.1% T2 reported being absent from work due to the NSNHE, and a substantial proportion of respondents (8.7% T1, 14.4% T2) also reported missing a meeting or work appointment or not finishing a task on time. Compared with other countries, respondents from France may experience a more substantial impact on diabetes management and daily functioning following an NSNHE. Potential limitations in this study include recall and selection bias; however, these biases are not believed to have impacted findings in any meaningful way.

CONCLUSIONS

NSNHEs are associated with a substantial impact on diabetes management, sleep quality, and next-day functioning.

Hypoglycemia: an overview of fear of hypoglycemia, quality-of-life, and impact on costs

BACKGROUND

The clinical goal in the treatment of diabetes is to achieve good glycemic control. Tight glycemic control achieved with intensive glucose lowering treatment reduces the risk of long-term micro- and macro-vascular complications of diabetes, resulting in an improvement in quality-of-life for the patient and decreased healthcare costs. The positive impact of good glycemic control is, however, counterbalanced by the negative impact of an increased incidence of hypoglycemia.

METHODS

A search of PubMed was conducted to identify published literature on the impact of hypoglycemia, both on patient quality-of-life and associated costs to the healthcare system and society.

RESULTS

In people with type 1 or type 2 diabetes, hypoglycemia is associated with a reduction in quality-of-life, increased fear and anxiety, reduced productivity, and increased healthcare costs. Fear of hypoglycemia may promote compensatory behaviors in order to avoid hypoglycemia, such as decreased insulin doses, resulting in poor glycemic control and an increased risk of serious health consequences. Every non-severe event may be associated with a utility loss in the range of 0.0033-0.0052 over 1 year, further contributing to the negative impact.

LIMITATIONS

This review is intended to provide an overview of hypoglycemia in diabetes and its impact on patients and society, and consequently it is not a comprehensive evaluation of all studies reporting hypoglycemic episodes.

CONCLUSION

To provide the best possible care for patients and a cost-effective treatment strategy for healthcare decision-makers, a treatment that provides good glycemic control with a limited risk of hypoglycemia would be a welcome addition to diabetes management options.

Confirmation of hypoglycemia in the "dead-in-bed" syndrome, as captured by a retrospective continuous glucose monitoring system

OBJECTIVE

To report a case that substantiates the presence of hypoglycemia at the time of death of a young man with type 1 diabetes, who was found unresponsive in his undisturbed bed in the morning.

METHODS

We describe a 23-year-old man with a history of type 1 diabetes treated with an insulin pump, who had recurrent severe hypoglycemia. In an effort to understand these episodes better and attempt to eliminate them, a retrospective (non-real-time) continuous subcutaneous glucose monitoring system (CGMS) was attached to the patient. He was found dead in his undisturbed bed 20 hours later. The insulin pump and CGMS were both downloaded for postmortem study.

RESULTS

Postmortem download of the data in the CGMS demonstrated glucose levels below 30 mg/dL around the time of his death, with only a minimal counter-regulatory response. This finding corresponded to a postmortem vitreous humor glucose of 25 mg/dL. An autopsy showed no major anatomic abnormalities that could have contributed to his death.

CONCLUSION

To our knowledge, this is the first documentation of hypoglycemia at the time of death in a patient with the "dead-in-bed" syndrome. This report should raise the awareness of physicians to the potentially lethal effects of hypoglycemia and provide justification for efforts directed at avoiding nocturnal hypoglycemia.

Glycemic instability in type 1 diabetic patients: Possible role of ketosis or ketoacidosis at onset of diabetes

AIMS

In type 1 diabetic patients, some have glycemic instability while others glycemic stability. We have developed criteria for evaluating glycemic instability and investigated the factors responsible.

METHODS

Glycemic instability in 52 type 1 diabetic patients was assessed by the mean amplitude of glycemic excursions (MAGE) and M-value, and clinical characteristics of good, fair and poor control groups were compared.

RESULTS

The median MAGE and M-value was 6.6mmol/L and 18.7, respectively. Then MAGE >or=6.6mmol/L and M-value >or=18.7 was defined as poor control. In the 32 patients without detectable C-peptide levels, 18 patients (56%) showed poor control. The frequency of ketosis or ketoacidosis at onset of diabetes was dramatically higher in the poor control group not only in the patients as a whole but also in those without detectable C-peptide levels.

CONCLUSIONS

A decreased level of C-peptide is a significant factor in glycemic instability. However, some patients have glycemic stability though beta-cell function is completely depleted. The presence of ketosis or ketoacidosis at onset of diabetes may be a factor in later glycemic instability, suggesting the importance of examining patients in detail at onset of diabetes for careful follow-up to prevent progression of acute and chronic complications of diabetes.

Impact of therapeutic advances on hypoglycaemia in type 2 diabetes

Patients with type 2 diabetes experience hypoglycaemia less frequently than those with type 1 diabetes. Some protection against hypoglycaemia is afforded by the relatively intact glucose counter-regulatory pathways that characterize the pathophysiology of early type 2 diabetes. To some extent, this protection explains why hypoglycaemic episodes in intensively treated individuals with type 2 diabetes, when they occur, are rarely severe. As diabetes progresses and therapy intensifies to achieve recommended glycaemic goals, hypoglycaemia frequency and severity increase. Thus, when it comes to instituting intensive therapy, fear of hypoglycaemia may contribute to health-care providers' 'clinical inertia'. Because maintaining glycaemic control is so important to both public and individual health, many new therapies and technologies have been developed. This manuscript reviews and considers whether these advancements in therapy make glycaemic goals easier to achieve by minimizing hypoglycaemia. Putting the hypoglycaemia experienced by type 2 diabetes patients into appropriate clinical perspective, the impact of recent progress made in pharmacotherapy, drug delivery systems, and BG monitoring on hypoglycaemia incidence is largely positive. The extent to which this progress can effect improvement over traditional therapies will, however, depend upon patient (and provider) education, motivation and behaviour change.

Short-term nocturnal hypoglycaemia increases morning food intake in healthy humans

AIMS

Hypoglycaemia during wakefulness increases hunger and food intake. Patients with Type 1 diabetes mellitus are at high risk of recurrent hypoglycaemia and weight gain. Given the background of frequent hypoglycaemic episodes during night-time sleep in diabetic patients, we investigated morning food intake after nocturnal hypoglycaemia.

METHODS

We tested 16 healthy normal-weight subjects (eight women) on three nights. A linear fall in plasma glucose to a nadir of 2.2 mmol/l within 60 min was induced by insulin infusion immediately after sleep onset ('early hypo') or after about 3.5 h of sleep ('late hypo'). On a control night, no hypoglycaemia was induced. Spontaneous food intake at a breakfast buffet was registered on the subsequent morning.

RESULTS

Compared with the control condition (700 +/- 93 kcal), subjects ate more after 'late hypo' (867 +/- 108 kcal; P = 0.041), but not after 'early hypo' (852 +/- 111 kcal; P = 0.130). Analyses of macronutrient fractions revealed that in comparison with the control condition, subjects ate significantly more carbohydrates after both 'late hypo' (277 +/- 25 kcal vs. 206 +/- 23 kcal, P < 0.001) and 'early hypo' (245 +/- 23 kcal, P = 0.048), with this effect being more pronounced after late than early nocturnal hypoglycaemia (P = 0.026).

CONCLUSIONS

In healthy subjects, nocturnal hypoglycaemia during sleep stimulates spontaneous food intake the following morning, with carbohydrate intake being especially affected. Effects were more pronounced after 'late hypo', suggesting the influence of temporal dynamics. Although healthy non-diabetic subjects were studied, similar mechanisms may contribute to the frequently observed body weight gain in insulin-treated diabetic patients.

Physiological and behavioral aspects of glycemic control and hypoglycemia in diabetes

Homeostatic mechanisms that maintain blood glucose concentration within a narrow physiologic range are complex and redundant. Elaborate feedback loops involving insulin, glucagon, sympathoadrenal mediators, growth hormone, amylin, and incretins normally operate synchronously to keep blood glucose within a narrow set point. Individuals with diabetes have defects in glucose homeostatic pathways, including the counterregulatory pathways that oppose hypoglycemia and ensure sufficient glucose is available to serve the brain's metabolic needs. Because available interventions to manage hyperglycemia do not precisely mimic physiologic insulin secretion patterns, hypoglycemia can occur any time dosing exceeds demand. Focusing on the practical implications, we review the endocrinological principles underlying normal glucose homeostasis and the defects in regulation and counterregulation, including hypoglycemia unawareness, that occur with diabetes. Iatrogenic and behavioral factors that contribute to hypoglycemia risk and nocturnal hypoglycemia are discussed. A companion manuscript reviews the clinical symptoms and fundamentals of hypoglycemia prevention, recognition, and management.

Management of diabetes-related hypoglycemia

Iatrogenic hypoglycemia is the main factor limiting aggressive and optimal diabetes management. Rather than being an inevitable consequence of optimal glycemic control, however, hypoglycemia is avoidable and generally straightforward to manage when it occurs. Professional caregivers, patients, and their families are often fearful of hypoglycemia, even though most episodes are minor and easily self-treated. Understanding the factors contributing to hypoglycemia risk and how to minimize its occurrence is an essential part of diabetes care. Building on the physiologic fundamentals presented in the accompanying review, the incidence, mortality/morbidity, clinical symptoms, severity classification, and psychosocial impact of hypoglycemia are described here. Appropriate selection and titration of therapeutic agents, including insulin analogs with more predictable time-action profiles than human insulin formulations, can reduce hypoglycemia risk. Patient education about hypoglycemia prevention, including symptom recognition and necessity of rapid treatment, behavioral modification, and the importance of frequent blood glucose monitoring should accompany all therapeutic interventions.

A single transplantation of the islets can produce glycemic stability and reduction of basal insulin requirement

We investigated glycemic stability and insulin requirement 1 month after a single transplantation of the islets from non-heart-beating donors or a living donor. Overall blood glucose levels decreased immediately after transplantation. The M-value and mean amplitude of glycemic excursions (MAGE) decreased significantly from 53.0 (range, 8.9-91.0) to 4.2 (0.6-8.8, P<0.05) and from 8.5 mM (4.8-11.7) to 3.3 mM (2.0-4.5, P<0.05), respectively. The values after transplantation were lower than the first quartile of 102 type 2 diabetic control patients. The estimated HbA1c level decreased significantly from 7.9% (5.7-10.9) to 5.4% (4.7-5.9, P<0.05). The supplement of basal insulin decreased 43% from 0.31 units/kg/day (0.16-0.37) to 0.18 units/kg/day (0-0.22, P<0.05), while that of stimulated insulin did not decrease significantly, from 0.28 units/kg/day (0.13-0.51) to 0.21 units/kg/day (0-0.41). Thus, only one islet transplantation can be sufficient to attain metabolic stability, probably by effective supply of basal insulin secretion, sufficient to avoid life-threatening severe hypoglycemia and prevent or delay the progress of secondary complications of diabetes by decreasing the HbA1c level.

[Glycemic control and new prospects on insulinotherapy in diabetes mellitus type 1]

Except for contraindications, current treatment of DM1 is based on what we know as insulin intensive treatment. This modality includes the utilization of rapid insulins for controlling the postprandial hyperglycemic peaks, and insulins of intermediate or slow action with the objective of contributing some basal levels of insulin (bolus/basal type therapy). Although the intensive treatment does not avoid completely the appearance nor the progression of the microvascular complications, improvement of glycemic control reduces the risk of developing microvascular complications approximately between 35% and 75%, and its worsening diminishes the risk between 50% and 75%. New insulin analogues has possibly many and obvious advantages. New insulin analogues are a potentially effective alternative in the intensive treatment of the patients with DM1, and they represent the best way for implementing a <<bolus-basal>> type therapeutic regimen. Its balanced and individualized application can contribute for improvement metabolic control, including a reduction in the incidence of hypoglycemia.

Can we reduce hypoglycaemia with insulin detemir?

Tight glycaemic control is essential for reducing the risk of long-term diabetic complications in people with type I or II diabetes. Intensive blood-glucose control attempts to normalise both pre- and postprandial glycaemia, while avoiding severe hypoglycaemia. A basal insulin, providing a low level of insulin to cover postprandial and overnight fasting periods, is central to intensive blood-glucose control. However, hypoglycaemia, particularly nocturnal hypoglycaemia, is a major treatment-related complication of therapy with most basal insulins currently available for use in clinical practice. This is a result of pronounced peaks in absorption, which lead to inappropriate hyperinsulinaemia following evening administration, and especially poorly reproducible pharmacokinetic profiles when injected subcutaneously. Indeed, for many patients and health-care providers, concern around hypoglycaemia forms a critical barrier to the attainment of tight glycaemic control. Insulin detemir is a novel long-acting analogue of human insulin designed to overcome these practical limitations. Clinical evidence from comparative studies with NPH insulin shows that insulin detemir provides a consistent and clinically relevant reduction in hypoglycaemic risk, especially for nocturnal events, at equivalent or better levels of glycaemic control.