Hypoglycemia unawareness in older compared with middle-aged patients with type 2 diabetes

Implementation of a Behavioral Economics Electronic Health Record (BE-EHR) Module to Reduce Overtreatment of Diabetes in Older Adults

BACKGROUND

Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence.

OBJECTIVE

This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults.

DESIGN

A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019.

PARTICIPANTS

Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes.

INTERVENTIONS

A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification.

MAIN MEASURES

Patient-level CW compliance.

KEY RESULTS

CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)-16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%).

CONCLUSIONS

The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics.

NIH TRIAL REGISTRY NUMBER

NCT03409523.

Challenges and Strategies for Inpatient Diabetes Management in Older Adults

Adults older than 65 years of age are the fastest growing segment of the U.S. population. Aging is also one of the most important risk factors for diabetes, and about one-third of all individuals with diabetes are in this age-group. Older people with diabetes are more likely to have comorbidities such as hypertension, ischemic heart disease, chronic kidney disease, and cognitive impairment, which lead to higher rates of hospital admissions compared with individuals without diabetes. Professional organizations have recommended patient-centric individualized glycemic reduction approaches, with an emphasis on potential harms of intensive glycemic control and overtreatment in older adults. Insulin therapy remains a mainstay of diabetes management in the inpatient setting regardless of patients' age; however, there is uncertainty about optimal glycemic targets during the hospital stay. Increasing evidence supports selective use of dipeptidyl peptidase-4 inhibitors, alone or in combination with low-dose basal insulin, in older noncritically ill patients with mild to moderate hyperglycemia. This article reviews the prevalence, diagnosis, and monitoring of, and the available treatment strategies for, diabetes among elderly patients in the inpatient setting.

Hypoglycemia in Older Patients

Hypoglycemia is a serious problem in older patients with diabetes mellitus. This chapter discusses risk factors associated with hypoglycemia and approaches to mitigation of the risk for hypoglycemia. Specific considerations include selection of glucose lowering agents, comorbid conditions and the implications of declining cognitive dysfunction.

Hypoglycemia awareness and burden among hospitalized patients at high risk for hypoglycemia

BACKGROUND

Hypoglycemia, a common complication of insulin therapy in patients with diabetes, is associated with increased hospital morbidity and mortality. Hypoglycemia may be underrecognized in hospitalized patients due to impaired counter regulation or reduced recognition. Beta blocker (BB) use may also affect hypoglycemia recognition.

AIM

To characterize hypoglycemia unawareness and patient perceived hypoglycemia burden in hospitalized patients.

MATERIALS AND METHODS

Over a 2-month period, we prospectively identified non-critically ill cognitively intact hospitalized insulin-requiring patients who were undergoing bedside glucose monitoring. Participants were included if they reported any episode of hypoglycemia in the 30 days prior to admission and either had no BB use or were on stable BB for 90 days. Hypoglycemia unawareness was assessed using the Clarke score and burden of hypoglycemia was assessed with the (TRIM-HYPO) score.

RESULTS

Of the 46 participants, 20 were not taking a BB and 26 were taking a BB. Predictors of hypoglycemia during admission included glucose coefficient of variation and hospital length of stay. Nine participants (20%) had hypoglycemia unawareness (Clarke score ≥4). Participants with a history of coronary artery disease were less likely to have impaired awareness. Burden of hypoglycemia was associated with more hypoglycemia and longer hospital length of stay. There were no differences in measures of hypoglycemia unawareness or burden according to BB use.

CONCLUSIONS

BB use was not related to hypoglycemia unawareness, or burden in hospitalized high risk patients. Hypoglycemia burden may identify patients at higher risk of hypoglycemia during admission.

Glycemic control and use of glucose-lowering medications in hospital-admitted type 2 diabetes patients over 80 years

Treatment guidelines for type 2 diabetes (T2D) recommend avoidance of hypoglycemia and less stringent glycemic control in older patients. We examined the relation of glycemic control to glucose-lowering medications use in a cohort of patients aged>80 years with a diagnosis of T2D and a hospital admission in the Capital Region of Denmark in 2012-2016. We extracted data on medication use, diagnoses, and biochemistry from the hospitals' records. We identified 5,172 T2D patients with high degree of co-morbidity and where 17% had an HbA_1c in the range recommended for frail, comorbid, older patients with type 2 diabetes (58-75 mmol/mol (7.5-9%)). Half of the patients (n = 2,575) had an HbA_1c <48 mmol/mol (<6.5%), and a majority of these (36% of all patients) did not meet the diagnostic criteria for T2D. Of patients treated with one or more glucose-lowering medications (n = 1,758), 20% had HbA_1c-values <42 mmol/mol (<6%), and 1% had critically low Hba_1c values <30 mmol/mol (<4.9%), In conclusion, among these hospitalized T2D patients, few had an HbA_1c within the generally recommended glycemic targets. One third of patients did not meet the diagnostic criteria for T2D, and of the patients who were treated with glucose-lowering medications, one-fifth had HbA_1c-values suggesting overtreatment.

Safety and effectiveness of tofogliflozin in elderly Japanese patients with type 2 diabetes mellitus: A subanalysis of a post-marketing study (J-STEP/EL Study)

AIMS/INTRODUCTION

This subanalysis aimed to assess the safety and effectiveness of tofogliflozin by using data from the Japanese Study of Tofogliflozin with Type 2 Diabetes Mellitus Patients in an Observational Study of the Elderly to categorize elderly Japanese patients with type 2 diabetes mellitus by the number of concomitant oral antidiabetic drugs (OADs) and insulin use at baseline.

MATERIALS AND METHODS

Japanese Study of Tofogliflozin with Type 2 Diabetes Mellitus Patients in an Observational Study of the Elderly is a 1-year prospective, observational and multicenter post-marketing study that enrolled all patients with type 2 diabetes mellitus aged ≥65 years who started tofogliflozin during the first 3 months after its launch in May 2014 in Japan.

RESULTS

The safety and effectiveness analysis sets included 1,497 and 1,422 patients, respectively. Overall, 18.10 and 2.20% of the patients experienced adverse drug reactions (ADRs) and serious ADRs, respectively. ADRs of special interest in the total, 0 OAD, one OAD, two OADs, three or more OADs and insulin groups occurred in 12.22, 10.04, 12.35, 13.32, 11.27 and 14.91% of patients, respectively. Volume depletion-related events were the most frequently observed ADRs of special interest. Hypoglycemia occurred in 1.07% of patients. Overall, glycated hemoglobin and bodyweight were significantly decreased, but the estimated glomerular filtration rate was not significantly changed.

CONCLUSIONS

Our finding suggests that tofogliflozin could be safely and effectively used in elderly Japanese patients with type 2 diabetes mellitus, irrespective of the number of OADs and the use of insulin.

Benefits and Challenges of Diabetes Technology Use in Older Adults

With successful aging of adults with type 1 diabetes, there is an increased opportunity to use technology for diabetes management. Technology can ease the burden of self-care and provide a sense of security. However, age-related cognitive and physical decline can make technology use difficult. Guidelines using technology in the aging population are urgently needed, along with educational material for the clinicians and caregivers. In this article, we review the evidence supporting the use of diabetes-related technologies in the older population and discuss recommendations based on current data and the authors' clinical knowledge and experience.

The assessment and management of quality of life of older adults with diabetes mellitus

Introduction: As the population ages, the number of older adults with diabetes mellitus will continue to rise. The burden of diabetes on older adults is significant due to the disease itself, its complications, and its treatments. This is compounded by geriatric syndromes such as frailty and cognitive dysfunction. Consequently, health and diabetes-related quality of life (QoL) are diminished.Areas covered: This article reviews the value of assessing QoL in providing patient-centered care and the associations between QoL measures and health outcomes. The determinants of QoL particular to diabetes and the older population are reviewed, including psychosocial, physical, and cognitive burdens of diabetes and aging and the impact of hypoglycemia on QoL. Strategies are described to alleviate these burdens and improve QoL, and barriers to multidisciplinary patient-centered care are discussed. QoL measurement instruments are reviewed.Expert opinion: The goals of treating diabetes and its complications should be considered carefully along with each patient's capacity to withstand the burdens of treatment. This capacity is reduced by socioeconomic, psychological, cognitive, and physical factors reduces this capacity. Incorporating measurement of HRQoL into clinical practices is possible, but deficiencies in the systems of health-care delivery need to be addressed to facilitate their use.

Type 2 diabetes in older patients: an analysis of the DPV and DIVE databases

BACKGROUND

The clinical profile differs between old and young patients with type 2 diabetes mellitus (T2DM). We explored, based on a large real-world database, patient and disease characteristics and actual treatment patterns by age.

METHODS

The analysis was based on the DIVE and DPV registries of patients with T2DM. Patients were analyzed by age groups 50-59 (middle-young), 60-69 (young-old), 70-79 (middle-old), 80-89 (old), and 90 years or more (oldest-old).

RESULTS

A total of 396,719 patients were analyzed, of which 17.7% were 50-59 years, 27.7% 60-69 years, 34.3% 70-79 years, 18.3% 80-89 years and 2.0% at least 90 years. We found that (a) T2DM in old and oldest-old patients was characterized much less by the presence of metabolic risk factors such as hypertension, obesity, dyslipidemia and smoking than in younger patients; (b) the HbA1c was much lower in oldest-old than in middle-young patients (7.2 ± 1.6% versus 8.0 ± 2.2%; p < 0.001), but it was associated with higher proportions of patients with severe hypoglycemia (7.0 versus 1.6%; p < 0.001); (c) this was potentially associated with the higher and increasing rates of insulin use in older patients (from 17.6% to 37.6%, p < 0.001) and the particular comorbidity profile of these patients, for example, chronic kidney disease (CKD); (d) patients with late diabetes onset had lower HbA1c values, lower bodyweight and less cardiovascular risk factors; (e) patients with a longer diabetes duration had a considerable increase in macrovascular and even more microvascular complications.

CONCLUSION

In very old patients there is a need for frequent careful routine assessment and a tailored pharmacotherapy in which patient safety is much more important than blood-glucose-lowering efficacy.

Risk of any hypoglycaemia with newer antihyperglycaemic agents in patients with type 2 diabetes: A systematic review and meta-analysis

OBJECTIVES

For patients with type 2 diabetes, newer antihyperglycaemic agents (AHA), including the dipeptidyl peptidase IV inhibitors (DPP4i), glucagon-like peptide-1 receptor agonists (GLP1RA) and sodium glucose co-transporter 2 inhibitors (SGLT2i) offer a lower risk of hypoglycaemia relative to sulfonylurea or insulin. However, it is not clear how AHA compare to placebo on risk of any hypoglycaemia. This study evaluates the risk of any and severe hypoglycaemia with AHA and metformin relative to placebo.

DESIGN

A systematic review and meta-analysis was conducted of randomized, placebo-controlled trials ≥12 weeks in duration. MEDLINE, Embase and the Cochrane Library were searched up to April 16, 2019. Studies allowing use of other diabetes medications were excluded. Mantel-Haenszel risk ratio with 95% confidence intervals were used to pool estimates based on class of AHA and number of concomitant therapies used.

PATIENTS

Eligible studies enrolled patients with type 2 diabetes ≥18 years of age.

RESULTS

144 studies met our inclusion criteria. Any hypoglycaemia was not increased with AHA when used as monotherapy (DPP4i (RR 1.12; 95% CI 0.81-1.56), GLP1RA (1.77; 0.91-3.46), SGLT2i (1.34; 0.83-2.15)), or as add-on to metformin (DPP4i (0.95; 0.67-1.35), GLP1RA (1.24; 0.80-1.91), SGLT2i (1.29; 0.91-1.83)) or as triple therapy (1.13; 0.67-1.91). However, metformin monotherapy (1.73; 1.02-2.94) and dual therapy initiation (3.56; 1.79-7.10) was associated with an increased risk of any hypoglycaemia. Severe hypoglycaemia was rare not increased for any comparisons.

CONCLUSIONS

Metformin and the simultaneous initiation of dual therapy, but not AHA used alone or as single add-on combination therapy, was associated with an increased risk of any hypoglycaemia relative to placebo.

Benefit-Risk Assessment of Alogliptin for the Treatment of Type 2 Diabetes Mellitus

The dipeptidyl peptidase-4 inhibitor (DPP-4i) alogliptin is an oral, antidiabetic treatment that is approved in many countries to treat patients with type 2 diabetes mellitus (T2DM), including the USA, Europe, and Japan. Alogliptin is efficacious both as monotherapy and as add-on/combination therapy with other commonly prescribed T2DM treatments, such as metformin and pioglitazone. Overall, alogliptin is well-tolerated in patients with T2DM, including older patients, those with renal and/or hepatic impairment, and those at high risk of cardiovascular events. There is a low risk of hypoglycemia, weight gain, acute pancreatitis, and gastrointestinal adverse events with alogliptin treatment, as demonstrated in long-term trials (lasting up to 4.5 years) and in a real-world setting. Additionally, alogliptin has a generally favorable or similar safety profile in comparison to other antidiabetic agents (metformin, thiazolidinediones, sulfonylureas, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, α-glucosidase inhibitors, and insulin). However, further evaluation would be required to determine the mechanism and effect of alogliptin on heart failure, bullous pemphigoid, and inflammatory bowel disease. Of note, due to the ethnic diversity in the epidemiology of T2DM, alogliptin has been shown to be more efficacious in Asian patients than in non-Asian patients with T2DM, but with a similar tolerability profile. These data indicate that DPP-4is, including alogliptin, are important treatment options, especially for Asian patients with T2DM, for whom they have potential as a first-line therapy. This benefit-risk assessment aims to place alogliptin within the current armamentarium of T2DM and aid physicians when choosing optimal diabetes treatment for their patients.

Assessing hypoglycemia frequency using flash glucose monitoring in older Japanese patients with type 2 diabetes receiving oral hypoglycemic agents

AIM

It is important to consider hypoglycemia for glycemic control in elderly patients with type 2 diabetes. Continuous blood glucose monitoring system is an effective method to investigate blood glucose fluctuation. This study examined hypoglycemia frequency using continuous blood glucose monitoring system in older patients with type 2 diabetes.

METHODS

A total of 70 patients with type 2 diabetes aged >65 years, receiving oral treatment only and having a glycated hemoglobin (HbA1c) level of <8% were enrolled. Flash glucose monitoring system was used for the device. Patients were classified into three groups according to the type of medicine administered, in addition to other oral hypoglycemics, and were compared: (i) those taking sulfonylureas (SU); (ii) those taking glinides; and (iii) those who did not take either SU or glinides.

RESULTS

There was a significant positive correlation between the coefficient of variation and hypoglycemic frequency in all the patients, and a significant negative correlation between HbA1c and hypoglycemia in those receiving SU. When hypoglycemia was defined as glucose levels <54 mg/dL and <70 mg/dL, the cut-off HbA1c values for developing hypoglycemia were 6.3% and 6.7%, sensitivity was 75.0% and 76.2%, and specificity was 90.9% and 77.6%, respectively.

CONCLUSIONS

In older patients with type 2 diabetes receiving SU, hypoglycemic frequency increases with decreases in HbA1c level. In particular, in patients with HbA1c levels of <6.3% receiving SU, it is necessary to consider medication modification. Geriatr Gerontol Int 2019; 19: 1030-1035.

[Successful treatment of severe sulfonylurea-induced hypoglycemia by the subcutaneous administration of octreotide in an elderly patient with diabetes: A case report]

Sulfonylureas, a potent stimulator of insulin release from pancreatic β cells, can cause hypoglycemia, which is apt to recur with a prolonged duration in elderly patients. Octreotide acetate, a long-acting somatostatin analogue, suppresses the secretion of insulin and is recognized as a possible treatment for sulfonylurea-induced hypoglycemia. However, there are few reports on its use in an actual clinical setting, especially in the elderly. We herein report a case in which subcutaneous injection of octreotide was effective for treating prolonged and recurrent hypoglycemia caused by sulfonylureas in an elderly man. An 89-year-old man was transported to the emergency department of our hospital for disturbance of consciousness in the morning. He had been treated for type 2 diabetes with 0.5 mg glimepiride, with the most recent HbA1c measurement being 5.7%. His plasma glucose level was low (22 mg/dL), and he was in a coma (Japan Coma Scale: 300). Under a diagnosis of hypoglycemic coma caused by sulfonylurea, we dripped 10% glucose solution and administered 50% glucose solution every 1 to 2 h through a peripheral vein, but his hypoglycemia recurred several times. Finally, 50 μg octreotide was subcutaneously injected. Thereafter, hypoglycemia did not recur, and additional injections of 50% glucose solution were not required. The same dose of octreotide was additionally administered after 8 h. In conclusion, the subcutaneous injection of octreotide can be an effective and safe method of treating prolonged hypoglycemia caused by sulfonylureas in the elderly.

Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range

Improvements in sensor accuracy, greater convenience and ease of use, and expanding reimbursement have led to growing adoption of continuous glucose monitoring (CGM). However, successful utilization of CGM technology in routine clinical practice remains relatively low. This may be due in part to the lack of clear and agreed-upon glycemic targets that both diabetes teams and people with diabetes can work toward. Although unified recommendations for use of key CGM metrics have been established in three separate peer-reviewed articles, formal adoption by diabetes professional organizations and guidance in the practical application of these metrics in clinical practice have been lacking. In February 2019, the Advanced Technologies & Treatments for Diabetes (ATTD) Congress convened an international panel of physicians, researchers, and individuals with diabetes who are expert in CGM technologies to address this issue. This article summarizes the ATTD consensus recommendations for relevant aspects of CGM data utilization and reporting among the various diabetes populations.

Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range

Improvements in sensor accuracy, greater convenience and ease of use, and expanding reimbursement have led to growing adoption of continuous glucose monitoring (CGM). However, successful utilization of CGM technology in routine clinical practice remains relatively low. This may be due in part to the lack of clear and agreed-upon glycemic targets that both diabetes teams and people with diabetes can work toward. Although unified recommendations for use of key CGM metrics have been established in three separate peer-reviewed articles, formal adoption by diabetes professional organizations and guidance in the practical application of these metrics in clinical practice have been lacking. In February 2019, the Advanced Technologies & Treatments for Diabetes (ATTD) Congress convened an international panel of physicians, researchers, and individuals with diabetes who are expert in CGM technologies to address this issue. This article summarizes the ATTD consensus recommendations for relevant aspects of CGM data utilization and reporting among the various diabetes populations.

Lower rates of hypoglycaemia in older individuals with type 2 diabetes using insulin degludec versus insulin glargine U100: Results from SWITCH 2

AIM

This study aimed to investigate the safety of insulin degludec (degludec) in relation to age and risk of hypoglycaemia post hoc in individuals with type 2 diabetes (T2D) (SWITCH 2 trial).

METHODS

In this crossover study, individuals with T2D who were at risk of hypoglycaemia were randomized to double-blind treatment with degludec or insulin glargine 100 units/mL (glargine U100) ± oral antidiabetic drugs. After 32 weeks, patients crossed over to the other treatment. Primary endpoint was number of overall severe (positively adjudicated) or glucose-confirmed (plasma glucose <56 mg/dL; 3.1 mmol/L) symptomatic hypoglycaemia events during the two 16-week maintenance periods.

RESULTS

For individuals ≤65 (n = 450) and >65 (n = 270) years, baseline median (range) duration of diabetes was 12 (1-40) vs 15 (1-54) years, mean HbA1c was 7.7% vs 7.4% and mean estimated glomerular filtration rate was 87.0 vs 63.7 mL/min/1.73 m² , respectively. No significant differences in HbA1c reduction were seen in individuals ≤65 or >65 years. During both maintenance periods, treatment with degludec lowered rates of hypoglycaemia (overall/nocturnal symptomatic) vs those with glargine U100 in individuals ≤65 (31% vs 43%) and >65 (30% vs 41%) years. With degludec and glargine U100, respectively, six vs nine severe hypoglycaemic events occurred in individuals ≤65 years and four vs eight events occurred in those >65 years. Adverse event rates were 3.2 and 3.3 events/patient-year for individuals ≤65 years and were 3.5 and 4.1 events/patient-year for individuals >65 years with degludec and glargine U100, respectively.

CONCLUSION

Treatment with degludec was safe and effective, with a frequency of hypoglycaemia lower than that with glargine U100 in both younger and older individuals (>65 years) with T2D.

Paradoxical Relationship Between Glycated Hemoglobin and Longitudinal Change in Physical Functioning in Older Adults: A Prospective Cohort Study

BACKGROUND

Hyperglycemia with high hemoglobin A1c (HbA1c) levels is associated with significant health risks. However, the relationship between HbA1c levels and the physical functioning status in later life remains uncertain and so is the possible underlying mechanism.

METHODS

We conducted a prospective study of 2,565 initially well-functioning community-dwelling older adult aged 55 years and older from the Healthy Aging Longitudinal Study in Taiwan. Each participant received baseline measurements of blood HbA1c and inflammatory markers levels and repeated assessments of physical functioning over a mean follow-up period of 5.3 years. We used generalized linear mixed-effects regression to estimate the adjusted changes in the odds ratio for self-reported physical functioning impairment and Short Physical Performance Battery (SPPB) score according to baseline HbA1c levels (categorized into 0.5% increments from <5.5% to ≥7.0%).

RESULTS

HbA1c levels showed a U-shaped relationship with changes in the odds ratio for physical functioning impairment and SPPB score (p for quadratic term < .001). Compared with participants with an HbA1c of 5.5% to <6.0%, those with an HbA1c of <5.5% or ≥7.0% had a higher annual increase in the odds ratio for physical functioning impairment (odds ratio [95% confidence interval] per year, 1.25 [1.04-1.50] and 1.21 [1.04-1.41]) and a higher annualized decrease in SPPB score (coefficient [95% confidence interval], -0.05 [-0.10 to 0.00] and -0.04 [-0.08 to 0.00]). These relationships were nonlinear only in participants with high soluble interleukin-6 receptor levels (>48,124 pg/mL; p for interaction < .05).

CONCLUSIONS

High and low HbA1c levels at baseline are associated with faster physical functioning decline, particularly among individuals with elevated circulating soluble interleukin-6 receptor, a sign of enhanced interleukin-6 trans-signaling.

Association of high circulating testosterone with increased glycaemic variability in type 2 diabetes: A cross-sectional study in China

BACKGROUND

Testosterone affects insulin resistance, but the effect of testosterone treatment on type 2 diabetes (T2D) remains controversial. We aimed to investigate the association between circulating total testosterone (TT) and glycaemic variability using continuous glucose monitoring (CGM) in patients with T2D.

METHODS

A total of 248 men with T2D were enrolled in the study. Clinical characteristics and plasma for glycated haemoglobin (HbA1c) and C-peptide assessment were collected. TT was measured using a chemiluminescent immunometric assay. All patients were subjected to a 3-day CGM before making adjustments for hypoglycaemic therapy.

RESULTS

TT positively correlated with the standard deviation of mean blood glucose (SDBG) (P < 0.05), especially in older patients. Linear regression analysis showed that SDBG was associated with HbA1c (β = 0.354, P < 0.001) and TT (β = 0.164, P = 0.008) after adjusting for age, duration of diabetes, body mass index, fasting/postprandial C-peptide, and use of different hypoglycaemic drugs. The cut-off value of TT for predicting glycaemic variability was 14.76 mmol/L according to receiver operating characteristic (ROC) analysis. SDBG, the coefficient of variation, the incremental area under the curve of glucose (AUC) > 10 mmol/L, and AUC night were increased in the group with TT > 14.76 nmol/L (P < 0.01 for all variables). Body mass index and fasting/postprandial C-peptide were lower in the group with TT > 14.76 nmol/L than in the group with TT ≤ 14.76 nmol/L (P < 0.05).

CONCLUSIONS

Circulating TT levels should be assessed in patients with T2D in addition to HbA1c for predicting glycaemic variability. More frequent blood glucose monitoring or CGM is suggested for patients with T2D and high testosterone levels.

CLINICAL TRIALS REGISTRATION

NCT03519529, ClinicalTrials.gov.

Comparative effect of saxagliptin and glimepiride with a composite endpoint of adequate glycaemic control without hypoglycaemia and without weight gain in patients uncontrolled with metformin therapy: Results from the SPECIFY study, a 48-week, multi-centre, randomized, controlled trial

AIMS

To compare the efficacy and safety of saxagliptin and glimepiride in type 2 diabetes (T2D) patients who are inadequately controlled with metformin monotherapy.

MATERIALS AND METHODS

In this 48-week, multi-centre, open-label, randomized, parallel trial (NCT02280486, clinicaltrials.gov), a total of 388 T2D patients were randomized 1:1 to saxagliptin or glimepiride groups. The primary endpoint was achievement of HbA1c <7.0%, without hypoglycaemia, defined as blood glucose <3.9 mmol/L and weight gain <3.0% after 48 weeks of treatment.

RESULTS

Over 48 weeks, a greater proportion of patients achieved the primary endpoint with saxagliptin compared with glimepiride (43.3% vs 31.3%; odds ratio, 1.38, 95% CI, 1.05-1.82; P = 0.019), especially among patients with baseline HbA1c <8.0%, duration <5 years or baseline BMI ≥25 kg/m2 . Mean reduction in HbA1c was similar in the two treatment groups at Week 48 (-0.94% with saxagliptin vs -0.98% with glimepiride; P = 0.439). Bodyweight decreased with saxagliptin, but increased with glimepiride over the treatment period, and the treatment difference was -1.6 kg (P < 0.001) at Week 48. The proportion of patients experiencing hypoglycaemia was much lower with saxagliptin vs glimepiride (3.1% vs 12.8%; P < 0.001).

CONCLUSIONS

This study provides evidence that, compared to glimepiride, saxagliptin more effectively achieves a composite endpoint of adequate glycaemic control without hypoglycaemia and without weight gain in T2D patients who are inadequately controlled with metformin monotherapy, especially in overweight patients with moderate hyperglycaemia and a relatively short duration of diabetes.

Prevalence and associated factors of hospitalization for dysglycemia among elderly type 2 diabetes patients: A nationwide study

BACKGROUND

The prevalence of older individuals with type 2 diabetes mellitus (T2DM) is increasing due to the aging population and improved medical care. These patients are very susceptible to disease and treatment-related hospitalizations, resulting in higher health care costs, morbidity, and decreased quality of life. However, data of treatment-related complications, especially dysglycemia-related hospitalizations, are lacking.

AIM

To assess the prevalence and associated factors for dysglycemia-related hospitalizations among elderly diabetic patients in Thailand using nationwide patient sample.

METHODS

T2DM patients aged ≥ 65 years who received medical care at public hospitals in Thailand in the year 2014 were included. The prevalence of hospitalization due to dysglycemia within one year was examined. Multivariable logistic regression was performed to assess the independent factors associated with hospitalization due to hypoglycemia and hyperglycemia.

RESULTS

A total of 11404 elderly T2DM patients were enrolled in this study. The mean age was 72.9 ± 5.5 years. The prevalence of hospital admissions due to diabetic ketoacidosis, hyperosmolar hyperglycemic state, hyperglycemic dehydration syndrome, and hypoglycemia among elderly T2DM patients in the year 2014 was 0.1%, 0.1%, 1.7% and 3.1%, respectively. Increased hospitalization due to hypoglycemia was associated with older age, female sex, had hypertension, dementia, lower body mass index, elevated hemoglobin A1C (HbA1C), decreased kidney function, insulin use. Increased hospitalization due to hyperglycemia was associated with dementia, depression, lower body mass index, elevated HbA1C, and insulin use.

CONCLUSION

The prevalence of dysglycemia-related hospitalization in elderly T2DM patients in Thailand was 4.9%. Close monitoring of blood glucose should be provided in high-risk patients for prevention and early detection for these complications.

Cognitive Frailty in Older People with Type 2 Diabetes Mellitus: the Central Role of Hypoglycaemia and the Need for Prevention

PURPOSE OF REVIEW

To highlight the central role of hypoglycaemia in the causation of cognitive frailty and explore ways of recognition and prevention of hypoglycaemia.

RECENT FINDINGS

Cognitive frailty is an emerging new concept defined as the concomitant presence of physical frailty and cognitive impairment. In older people with diabetes, cognitive frailty is associated with an increased risk of mortality greater than from either physical frailty or cognitive impairment alone. Hypoglycaemia is directly associated with increased risk of cognitive impairment and physical frailty which are the two components of cognitive frailty. The incidence of hypoglycaemia in older people with diabetes is rising and hypoglycaemia-related hospitalisation has overtaken that of hyperglycaemia. Recognition of hypoglycaemic episodes in old age remains challenging which leads to misdiagnoses and under-reporting. Therefore, hypoglycaemia prevention strategies are needed. Research is still required to investigate whether prevention of hypoglycaemia would lead to a reduction in the incidence of cognitive frailty.

Designing for implementation: user-centered development and pilot testing of a behavioral economic-inspired electronic health record clinical decision support module

Background

Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden.

Methods

We will apply a systematic, user-centered design approach to incorporate BE “nudges” into a CDS module and will perform user testing in two “vanguard” sites. To accomplish this, we will conduct (1) semi-structured interviews with key informants (n = 8), (2) a 2-h, design-thinking workshop to derive and refine initial module ideas, and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics.

Discussion

We hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0403-z) contains supplementary material, which is available to authorized users.

Diabetes Management in Older Adults With Chronic Kidney Disease

PURPOSE OF REVIEW

Older adults often live with chronic disease including diabetes and its complications. In this review, we examine the complexity and heterogeneity of older adults with diabetes and chronic kidney disease, explore the nuances in their diabetes-related monitoring, and discuss their best diabetes management.

RECENT FINDINGS

Although there remains an overall lack of studies in older adults with diabetes and chronic kidney disease, recent reports have highlighted their vulnerabilities. These individuals face an increased risk of cognitive impairment and dementia, frailty, dysglycemia, polypharmacy, declining kidney function, and acute kidney injury. Their diabetes management should focus upon safer antihyperglycemic medications, close monitoring, and care individualization. Older adults with diabetes and chronic kidney disease are a complex population who requires careful diabetes management and monitoring. Research efforts might focus on improving the care and outcomes of these patients.

Efficacy and safety of switching to insulin glargine 300 U/mL from 100 U/mL in Japanese patients with type 2 diabetes: A 12-month retrospective analysis

Aims

To evaluate the efficacy and safety of switching to insulin glargine 300 U/mL (Gla-300) from insulin glargine 100 U/mL (Gla-100) in Japanese patients with type 2 diabetes (T2DM).

Methods

This was a 12-month retrospective study comprising 109 patients. Primary endpoint was glycated hemoglobin (HbA1c) level at month 12. Secondary endpoints were hypoglycemia for the overall study period as well as body weight and insulin dose at month 12.

Results

Similar glycemic control was achieved with mean (standard deviation) HbA1c level of 7.7 (1.1)% (61 [12] mmol/mol) at baseline and 7.7 (1.3)% (61 [14] mmol/mol) at month 12. Fewer confirmed (<3.0 mmol/L [< 54 mg/dL]) or severe hypoglycemic events were observed (0.52 vs. 0.85 events per patient-year; rate ratio 0.61; 95% confidence interval 0.38–0.97; p = 0.037), but the percent of patients experiencing ≥1 hypoglycemic event did not differ. There was no difference in confirmed (≤3.9 mmol/L [≤ 70 mg/dL]) or severe hypoglycemia and nocturnal hypoglycemia.

Conclusions

In Japanese patients with T2DM who switched to Gla-300 from Gla-100, similar glycemic control was achieved with fewer confirmed (<3.0 mmol/L [< 54 mg/dL]) or severe hypoglycemic events over a 12-month period, although the absolute benefit was marginal.

Approach to Using Trend Arrows in the FreeStyle Libre Flash Glucose Monitoring Systems in Adults

The use of personal continuous glucose monitoring (CGM) has expanded dramatically among individuals with diabetes. CGM systems provide retrospective data, as well as the current glucose value and trend arrow data, which indicate the direction and velocity of changing glucose. In 2017, Aleppo and colleagues developed a simplified approach for adults with diabetes to safely adjust rapid-acting insulin doses using trend arrow information in the Dexcom G5 CGM system. Since then, the FreeStyle Libre and FreeStyle Libre 14-day CGM systems have become available in the United States; however, guidance on using trend arrow data that take the unique features of these systems into consideration is lacking. Specifically, the FreeStyle Libre systems do not have automatic alarms, which impact how the system and trend arrow data are used. The Endocrine Society convened an expert panel to address this gap and develop an approach to adjusting rapid-acting insulin doses for adults using trend arrows in the FreeStyle Libre systems. We based our approach on previous work and expanded upon engagement and scanning recommendations, and we incorporated pre-exercise planning specific to these systems. Our approach provides insulin dose adjustments as discrete insulin units based on an individual’s insulin sensitivity and directionality of the trend arrow. We focus on the needs of patients treated with multiple daily injections because these individuals currently make up a greater proportion of individuals on intensive insulin therapy. Our recommendations are intended to provide a safe, practical approach to using trend arrows in the FreeStyle Libre systems.

Risk Factors for Hypoglycemic Coma: A Study of 33 Patients on Insulin Therapy Who Were Transported to the Hospital by Ambulance

Objective Patients on outpatient insulin therapy are at a high risk of severe hypoglycemia and a high incidence of hypoglycemic coma. However, only a few studies have explored the risk factors for hypoglycemic coma in such patients. We retrospectively analyzed the clinical characteristics of diabetic patients who had developed hypoglycemic coma during outpatient insulin therapy. Methods This study included 33 diabetic patients on insulin therapy who were transported to the hospital by ambulance for severe hypoglycemia. Patients with a Japan Coma Scale score <100 were classified as the non-coma group (n=18), while those with a score ≥100 (n=15) were classified into the coma group. Results Patients in the coma group were significantly older, with a higher proportion of elderly patients ( ≥65 years of age), than those in the non-coma group. Although no marked difference in the basal insulin dose was observed between the two groups, the bolus insulin dose was significantly higher in the coma group. However, no marked differences in the disease type or renal function were noted between the two groups. Conclusion An advanced age and bolus insulin dose are risk factors for hypoglycemic coma in diabetic patients on insulin therapy. Bolus insulin dose minimization should be performed in order to prevent hypoglycemic coma, especially in elderly diabetic patients.

Male Patients with Longstanding Type 2 Diabetes Have a Higher Incidence of Hypoglycemia Compared with Female Patients

INTRODUCTION

To explore whether there was a gender difference in the risk of hypoglycemia during intensive insulin therapy in patients with longstanding type 2 diabetes (T2D). This was a post hoc analysis of a single-center, open-label and prospective trial.

METHODS

All subjects were admitted as inpatients, underwent a standard bread meal test at baseline and received a 7-day continuous subcutaneous insulin infusion (CSII) therapy for achieving glycemic control. Patients then were randomized 1:1 to two groups receiving (1) 4 days of Novo Mix 30 followed by 2 days of Humalog Mix 50; (2) 4 days of Humalog Mix 50 followed by 2 days of Novo Mix 30. All patients were subjected to 4-day retrospective continuous glucose monitoring (CGM) during the last 4 days in this study. The primary outcome was the incidences of hypoglycemia monitored by CGM at the end point.

RESULTS

A total of 102 patients met the inclusion criteria and completed the study. Our data revealed that 29 patients (28%) experienced hypoglycemia as detected by CGM at the end point. Binary logistic stepwise regression analysis showed that only gender significantly correlated with hypoglycemia (B = 1.17, p = 0.017). Importantly, male patients had a significantly higher incidence of hypoglycemia than female patients (male = 20/52, female = 9/50, p = 0.022), although male patients required significantly lower insulin doses to maintain glycemic control than female patient (p = 0.00).

CONCLUSION

Male patients with longstanding T2D had a higher incidence of hypoglycemia than female patients during intensive insulin therapy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, ChiCTR-IPR-15007340.

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.

Managing diabetes in people with dementia: a realist review

BACKGROUND

Dementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.

OBJECTIVES

To identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.

DESIGN

Realist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.

PARTICIPANTS

Twenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.

DATA SOURCES

The following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing - UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).

RESULTS

We included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context-mechanism-outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.

LIMITATIONS

There is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.

CONCLUSIONS

This review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020625.

FUNDING

The NIHR HTA programme.

A Retrospective Cohort Study of Patients with Type 2 Diabetes in China: Associations of Hypoglycemia with Health Care Resource Utilization and Associated Costs

INTRODUCTION

This study aimed to examine the associations of hypoglycemia with health care resource utilization (HCRU) and health care costs among patients with type 2 diabetes mellitus (T2DM) in China.

METHODS

This retrospective cohort study was conducted with 23,680 T2DM patients >18 years old who visited the Second Affiliated Hospital of Nanchang University between 1 January 2011 and 31 December 2015. Univariate descriptive statistics were used to relate the HCRU and associated costs to patient characteristics, and regression analysis was used to examine the association between hypoglycemia and HCRU, controlling for other confounding factors.

RESULTS

In the T2DM patients with or without insulin treatment, when compared with nonhypoglycemic patients, hypoglycemia was associated with more medical visits (all T2DM patients 19.48 vs. 10.46, insulin users 23.45 vs. 14.12) and higher diabetes-related medical costs (all T2DM patients ¥5187.54 vs. ¥3525.00, insulin users ¥6948.84 vs. ¥3401.15) and medication costs (T2DM patients ¥1349.40 vs. ¥641.92, insulin users: ¥1363.87 vs. ¥853.96). Controlling for age, gender, and Charlson comorbidity index (CCI) score, hypoglycemia and insulin intake were associated with greater health care resource utilization. As compared to nonhypoglycemic patients, hypoglycemic T2DM patients and those on insulin therapy performed more outpatient visits (proportions of hypoglycemic vs nonhypoglycemic T2DM patients performing 3+ visits: 72.69% vs. 65.49%; proportions of hypoglycemic vs nonhypoglycemic patients on insulin therapy performing 3+ visits: 78.26% vs. 71.73%) and were hospitalized more often (proportions of hypoglycemic vs nonhypoglycemic T2DM patients with 3+ admissions 75.90% vs. 50.24%; proportions of hypoglycemic vs nonhypoglycemic patients on insulin therapy with 3+ admissions: 83.19% vs. 58.51%).

CONCLUSION

Hypoglycemia in diabetes patients was associated with increased healthcare resource utilization and health-related expenditure, especially for patients on insulin treatment. Insulin treatment regimens should be more individualized and account for hypoglycemia risk.

[The status of glycemic control and hypoglycemia in elderly patients visiting the outpatient department specializing in diabetes]

AIM

The Japan Diabetes Society (JDS)/Japan Geriatrics Society (JGS) Joint Committee reported 'Glycemic Targets for Elderly Patients with Diabetes' in 2016. Based on this recommendation, we aimed to clarify 1) the achievement status of glycemic targets in the elderly and 2) the presence of hypoglycemia in real life among elderly individuals with an HbA1c below the lower limit.

SUBJECTS AND METHODS

[Analysis I] In 326 elderly with diabetes ≥65 years of age visiting the outpatient department specializing in diabetes, the proportions of patients with HbA1c values below the lower limit and the use of drugs potentially associated with severe hypoglycemia (e.g. insulin formulations, sulfonylureas, glinides) were investigated. [Analysis II] Of the patients with HbA1c values below the lower limit, seven were tested for hypoglycemia in real life using a continuous glucose monitoring system (CGM).

RESULTS

[Analysis I] Among the 326 subjects, 235 (72.1%) were using drugs potentially associated with severe hypoglycemia, and 63 (19.3%) had an HbA1c value below the lower limit. [Analysis II] In the seven patients examined using CGM, hypoglycemia was detected in five, all of whom were unaware.

CONCLUSIONS

A considerable number of elderly patients were taking drugs associated with hypoglycemic risks and had an HbA1c value below the lower limit, some of whom actually had hypoglycemia as detected by CGM. Using tools such as CGM, preventive measures against hypoglycemia should be taken.

Clinical and Cost Implications of Insulin Degludec in Patients with Type 1 Diabetes and Problematic Hypoglycemia: A Quality Improvement Project

INTRODUCTION

To assess the real-life clinical benefits and cost implications of switching from another basal insulin to insulin degludec (degludec) in patients with type 1 diabetes (T1D) on basal-bolus regimens with recurrent hypoglycemia and/or hypoglycemia unawareness.

METHODS

Patients with T1D who were aged ≥ 18 years, were on a basal-bolus regimen, and had switched to degludec plus bolus insulin for at least 6 months were included. Patients had to have switched to degludec as a result of recurrent hypoglycemia and/or hypoglycemia unawareness.

RESULTS

Six months of follow-up data were available for 42 patients. At 6 months, there was a significant reduction in median (interquartile range) HbA_1c, from 8.6 (8.0-9.3)% [70 (64-78) mmol/mol] to 8.4 (7.9-8.9)% [68 (63-74) mmol/mol]; p < 0.05. Median daily basal insulin dose reduced significantly from 30.0 (14.7-45.0) to 25.5 (14.0-30.2) units; p < 0.0001. Data from hospital records showed reductions in the frequency of episodes of severe hypoglycemia from eight in the 6 months preceding degludec initiation to two in the 6 months following initiation. In the same period, diabetic ketoacidosis (DKA) episodes reduced from two before degludec initiation to no episodes after initiation. No patients reported worsening treatment satisfaction after switching to degludec. Considering the reductions in the basal dose required and the frequency of hypoglycemia episodes, we estimate that switching such patients to degludec from other basal insulins could provide significant savings in direct healthcare costs.

CONCLUSION

In patients with T1D, switching to degludec was associated with an improvement in HbA_1c and reductions in basal insulin dose, severe hypoglycemia, and DKA. When used in appropriate patients, degludec could lead to significant cost savings.

FUNDING

Novo Nordisk.

Are we missing hypoglycaemia? Elderly patients with insulin-treated diabetes present to primary care frequently with non-specific symptoms associated with hypoglycaemia

INTRODUCTION

We assessed if patients with known hypoglycaemia present on other occasions with non-specific symptoms associated with (but not diagnosed as) hypoglycaemia, potentially representing missed hypoglycaemia.

METHODS

335 primary care records (5/2/12-4/2/13) from patients aged >65 (79 on insulin, 85 on sulphonylureas, 121 on metformin only, 50 without diabetes) were assessed for hypoglycaemia episodes and consultations with non-specific symptoms, "hypo clues".

RESULTS

27/79(34%) insulin-treated patients had >1 documented hypoglycaemia episode, compared to 4/85(5%) sulphonylurea-treated patients, 2/121(2%) metformin-only treated patients, and none without diabetes, p<0.001. "Hypo clue" consultations were common: 1.37 consultations/patient/year in insulin-treated patients, 0.98/patient/year in sulphonylurea-treated, 0.97/patient/year in metformin only-treated, and 0.78/patient/year in non-diabetic patients, p=0.34. In insulin-treated patients with documented hypoglycaemia, 20/27(74%) attended on another occasion with a "hypo clue" symptom, compared to 21/52(40%) of those without hypoglycaemia, p=0.008. No significant difference in the other treatment groups. Nausea, falls and unsteadiness were the most discriminatory symptoms: 7/33(21%) with hypoglycaemia attended on another occasion with nausea compared to 14/302(5%) without hypoglycaemia, p=0.002; 10/33(30%) vs 36/302(12%) with falls, p=0.007; and 5/33(15%) vs 13/302(4%) with unsteadiness, p=0.023.

CONCLUSIONS

Non-specific symptoms are common in those >65 years. In insulin-treated patients at high hypoglycaemia risk, nausea, falls and unsteadiness should prompt consideration of hypoglycaemia.

[Treatment of type 2 diabetes mellitus in elderly patients]

The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.

Treatment of type 2 diabetes mellitus in elderly patients

The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.

Safety and efficacy of long-term treatment with teneligliptin: Interim analysis of a post-marketing surveillance of more than 10,000 Japanese patients with type 2 diabetes mellitus

BACKGROUND

This post-marketing surveillance examined the safety and efficacy of long-term teneligliptin therapy in Japanese patients.

RESEARCH DESIGN AND METHODS

We report interim results (cut-off date: 28 June 2017) of a 3-year PMS undertaken in subjects with type 2 diabetes mellitus (T2DM). Survey items included demographics, treatments, adverse drug reactions (ADRs), and laboratory variables. A subgroup analysis was also performed across three age groups (<65 years; 65 to <75 years; ≥75 years). Main outcome measures were incidence of ADRs, laboratory variables, and change in glycated hemoglobin (HbA1c) from baseline over time.

RESULTS

Of 11,677 patients registered, data from 10,532 patients (6,338 males/4,194 females) were analyzed for the safety analysis set; the median administration period was 731 days. Overall, ADRs and serious ADRs were reported in 364 (3.46%) and 91 patients (0.86%), respectively. The most common ADRs were all hypoglycemia (0.32%), constipation (0.27%), and hepatic function abnormal (0.24%). No change in mean body weight occurred, and a reduction in mean HbA1c was observed until 2 years. The safety and efficacy profiles did not differ markedly among the three age groups.

CONCLUSIONS

These interim results show that teneligliptin was well tolerated and improved hyperglycemia in Japanese patients with T2DM in clinical practice.

Hypoglycemia incidence and awareness among insulin-treated patients with diabetes: the HAT study in Brazil

BACKGROUND

Hypoglycemia affects patient safety and glycemic control during insulin treatment of both type 1 (T1DM) and type 2 diabetes mellitus (T2DM). The Hypoglycemia Assessment Tool study in Brazil aimed to determine the proportion of patients experiencing hypoglycemic events and to characterize patient awareness and fear about hypoglycemia, among insulin-treated T1DM or T2DM patients.

METHODS

This was a non-interventional, multicenter study, with a 6-month retrospective and a 4-week prospective evaluation of hypoglycemic events. Patients completed a questionnaire at baseline and at the end of the study, and also a patient diary. The answers 'occasionally' and 'never' to the question 'Do you have symptoms when you have a low sugar level?' denoted impaired hypoglycemia awareness. Fear was reported on a 10-point scale, from 'not afraid at all' to 'absolutely terrified'.

RESULTS

From 679 included patients, 321 with T1DM and 293 T2DM, median age of 33.0 and 62.0 years, 59% and 56% were female, and median diabetes duration was 15.0 and 15.0 years, respectively. Median time of insulin use was 14.0 and 6.0 years. During the prospective period, 91.7% T1DM and 61.8% T2DM patients had at least one hypoglycemic event. In the same period, 54.0% T1DM and 27.4% T2DM patients had nocturnal hypoglycemia, 20.6% T1DM and 10.6% T2DM patients had asymptomatic hypoglycemia, and severe events occurred in 20.0% and 10.3%, respectively. At baseline, 21.4% T1DM and 34.3% T2DM had hypoglycemia unawareness. The mean score of hypoglycemia fear was 5.9 ± 3.1 in T1DM and 5.4 ± 3.9 in T2DM. The most common attitude after hypoglycemic events were to increase calorie intake (60.3%) and blood glucose monitoring (58.0%) and to reduce or skip insulin doses (30.8%).

CONCLUSIONS

Referred episodes of hypoglycemia were high, in both T1DM and T2DM insulin users. Patient attitudes after hypoglycemia, such as reduction in insulin and increase in calorie intake, can affect diabetes management. These findings may support clinicians in tailoring diabetes education and insulin treatment for patients with diabetes, in order to improve their glycemic control while reducing the risk of hypoglycemic events.

The GesTIO protocol experience: safety of a standardized order set for subcutaneous insulin regimen in elderly hospitalized patients

BACKGROUNDS

In non-critical hospitalized patients with diabetes mellitus, guidelines suggest subcutaneous insulin therapy with basal-bolus regimen, even in old and vulnerable inpatients.

AIM

To evaluate safety, efficacy, and benefit on clinical management of the GesTIO protocol, a set of subcutaneous insulin administration rules, in old and vulnerable non-ICU inpatients.

METHODS

Retrospective, observational study. Patients admitted to Geriatric Clinic of Padua were studied. 88 patients matched the inclusion criteria: type 2 diabetes or hospital-related hyperglycemia, ≥65 years, regular measurements of capillary glycemia, and basal-bolus subcutaneous insulin regimen managed by "GesTIO protocol" for five consecutive days.

MAIN OUTCOME MEASURES

ratio of patients with blood glucose (BG) <3.9 mmol/l; number of BG per patient in target range (5-11.1 mmol/l); daily mean BG; and calls to physicians for adjusting insulin therapy.

RESULTS

Mean age was 82 ± 7 years. 9.1% patients experienced mild hypoglycaemia, and no severe hypoglycaemia was reported. The median number of BG per patients in target range increased from 2.0 ± 2 to 3.0 ± 2 (p < 0.001). The daily mean BG decreased from 11.06 ± 3.03 to 9.64 ± 2.58 mmol/l (-12.8%, p < 0.005). The mean number of calls to physicians per patient decreased from 0.83 to 0.45 (p < 0.05).

CONCLUSIONS

Treatment with GesTIO protocol allows a safe and effective treatment even in very old and vulnerable inpatients with a faster management insulin therapy.

[Individualized diabetes therapy in older persons]

BACKGROUND

A majority of older people with type 2 diabetes are multimorbid, frail or have limitations in functions. Polypharmacotherapy is unfortunately a frequent occurrence and dangerous. In particular the administration of antihyperglycemic therapy must be carefully weighed up against the risks associated with hypoglycemia.

AIM

The conditions and characteristics of older persons with diabetes are highlighted with respect to the use of individualized therapy of diabetes.

RESULTS AND CONCLUSION

The advantages and disadvantages of oral antidiabetic agents, insulins and substances with novel active principles, such as gliflozin drugs are discussed. Established oral therapeutic drugs, such as metformin as well as the new substance groups, such as gliptins are advantageous in this patient group. Injection-based therapies with glucagon-like peptide 1 (GLP-1) mimetics and the new insulins can also expand the spectrum of therapy if they are prudently used.