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Troncone A, Piscopo A, Zanfardino A, Chianese A, Cascella C, Affuso G, Borriello A, Curto S, Rollato AS, Testa V, Del Giudice EM, Magliano L, Iafusco D. Fear of hypoglycemia in parents of children with type 1 diabetes trained for intranasal glucagon use. J Psychosom Res 2024; 184:111856. [PMID: 38972099 DOI: 10.1016/j.jpsychores.2024.111856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/25/2024] [Accepted: 07/02/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE To investigate fear of hypoglycemia (FoH) in parents of children with type 1 diabetes (T1D) before and after undergoing training to learn intranasal (IN) glucagon administration. METHOD In this pre-test/post-test uncontrolled study 364 caregivers of patients with T1D (6-18 years) completed questionnaires measuring sociodemographic characteristics, diabetes-related factors (e.g., type of insulin therapy, glycemic control), and parents' trait anxiety. Parents' FoH was assessed at baseline (T0, training) and after nine months (T1). Two repeated-measure mixed analyses of covariance (ANCOVA) compared the FoH at T0 and at T1 and analyzed the moderating roles of anxiety proneness and type of insulin therapy, as well as of anxiety proneness and use of sensor. Age, T1D duration, HbA1c values, and SES were included as covariates. RESULTS Parental FoH at T1 (M = 1.72; SE = 0.06/M = 1.57; SE = 0.09) was significantly lower than parental FoH at T0 (M = 1.89; SE = 0.06/M = 1.77; SE = 0.09). The group with high trait-anxiety had a higher level of FoH (M = 2.05; SE = 0.08/M = 1.89; SE = 0.12) than the group with low trait-anxiety (M = 1.57; SE = 0.08/M = 1.46; SE = 0.09) at both time points. SES was negatively associated with FoH at T0 (t = -2.87; p = .004/t = -2.87; p = .005). No other significant effects were found. CONCLUSIONS Training and educating parents on IN glucagon use can help them effectively manage hypoglycemic episodes and alleviate the fear that generally accompany such events.
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Affiliation(s)
- Alda Troncone
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy.
| | - Alessia Piscopo
- Department of the Woman, of the Child and of the General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Angela Zanfardino
- Department of the Woman, of the Child and of the General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonietta Chianese
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Crescenzo Cascella
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Gaetana Affuso
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Anna Borriello
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Stefano Curto
- Department of the Woman, of the Child and of the General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Assunta Serena Rollato
- Department of the Woman, of the Child and of the General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Veronica Testa
- Department of the Woman, of the Child and of the General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Emanuele Miraglia Del Giudice
- Department of the Woman, of the Child and of the General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Lorenza Magliano
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Dario Iafusco
- Department of the Woman, of the Child and of the General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
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2
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Zucchini S, Tumini S, Scaramuzza AE, Bonfanti R, Delvecchio M, Franceschi R, Iafusco D, Lenzi L, Mozzillo E, Passanisi S, Piona C, Rabbone I, Rapini N, Rigamonti A, Ripoli C, Salzano G, Savastio S, Schiaffini R, Zanfardino A, Cherubini V. Recommendations for recognizing, risk stratifying, treating, and managing children and adolescents with hypoglycemia. Front Endocrinol (Lausanne) 2024; 15:1387537. [PMID: 38894740 PMCID: PMC11183505 DOI: 10.3389/fendo.2024.1387537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024] Open
Abstract
There has been continuous progress in diabetes management over the last few decades, not least due to the widespread dissemination of continuous glucose monitoring (CGM) and automated insulin delivery systems. These technological advances have radically changed the daily lives of people living with diabetes, improving the quality of life of both children and their families. Despite this, hypoglycemia remains the primary side-effect of insulin therapy. Based on a systematic review of the available scientific evidence, this paper aims to provide evidence-based recommendations for recognizing, risk stratifying, treating, and managing patients with hypoglycemia. The objective of these recommendations is to unify the behavior of pediatric diabetologists with respect to the timely recognition and prevention of hypoglycemic episodes and the correct treatment of hypoglycemia, especially in patients using CGM or advanced hybrid closed-loop systems. All authors have long experience in the specialty and are members of the Italian Society of Pediatric Endocrinology and Diabetology. The goal of treating hypoglycemia is to raise blood glucose above 70 mg/dL (3.9 mmol/L) and to prevent further decreases. Oral glucose at a dose of 0.3 g/kg (0.1 g/kg for children using "smart pumps" or hybrid closed loop systems in automated mode) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate (e.g., sucrose, which consists of glucose and fructose, or honey, sugary soft drinks, or fruit juice) containing glucose may be used. Using automatic insulin delivery systems, the oral glucose dose can be decreased to 0.1 g/kg. Practical flow charts are included to aid clinical decision-making. Although representing the official position of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED), these guidelines are applicable to the global audience and are especially pertinent in the era of CGM and other advanced technologies.
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Affiliation(s)
- Stefano Zucchini
- Study Group of Diabetology of the Italian Society for Pediatric Endocrinology and Diabetes (I.S.P.E.D.,) University Hospital of Ferrara, Ferrara, Italy
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Annunziata Hospital, Chieti, Italy
| | - Andrea Enzo Scaramuzza
- Division of Pediatrics, Pediatric Diabetes, Endocrinology and Nutrition, Azienda Socio Sanitaria Territoriale (ASST) Cremona, Cremona, Italy
| | - Riccardo Bonfanti
- UO Pediatric Diabetes Research Institute, Ospedale San Raffaele, Milan, Italy
| | - Maurizio Delvecchio
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | - Roberto Franceschi
- Department of Pediatrics, S. Chiara Hospital of Trento, APSS, Trento, Italy
| | - Dario Iafusco
- Department of Woman, Child and General and Specialistic Surgery, Regional Center of Pediatric Diabetes, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Lorenzo Lenzi
- Diabetology Unit, Pediatric Department, Anna Meyer Children’s Hospital, Florence, Italy
| | - Enza Mozzillo
- Section of Pediatrics, Regional Center of Pediatric Diabetes, University Federico II, Naples, Italy
| | - Stefano Passanisi
- Department of Human Pathology of Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Claudia Piona
- Pediatric Diabetes and Metabolic Disorders Unit, Regional Center for Pediatric Diabetes, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, Verona, Italy
| | - Ivana Rabbone
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Novella Rapini
- Diabetes Unit, Bambino Gesú Childrens’ Hospital, Rome, Italy
| | - Andrea Rigamonti
- UO Pediatric Diabetes Research Institute, Ospedale San Raffaele, Milan, Italy
| | - Carlo Ripoli
- Pediatric Diabetology Unit, Department of Pediatrics, ASL 8 Cagliari, Cagliari, Italy
| | - Giuseppina Salzano
- Department of Human Pathology of Adulthood and Childhood G. Barresi, University of Messina, Messina, Italy
| | - Silvia Savastio
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | | | - Angela Zanfardino
- Department of Woman, Child and General and Specialistic Surgery, Regional Center of Pediatric Diabetes, University of Campania ‘L. Vanvitelli’, Naples, Italy
| | - Valentino Cherubini
- Department of Women’s and Children’s Health, Azienda Ospedaliero-Universitaria, Ospedali Riuniti di Ancona, ‘Salesi Hospital’, Ancona, Italy
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3
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Yu X, Wen X, Xu J, Zhou Q, Chen Y, Qu F, He M, Chang H, Zheng C. Rapid Correction of the Hypoglycemia State in Nonhuman Primates Using a Glucagon Long-Dissolving Microneedle Patch. ACS Biomater Sci Eng 2024; 10:3086-3096. [PMID: 38588325 DOI: 10.1021/acsbiomaterials.3c01962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
The timely administration of glucagon is a standard clinical practice for the treatment of severe hypoglycemia. However, the process involves cumbersome steps, including the reconstitution of labile glucagon and filling of the syringe, which cause considerable delays in emergency situations. Moreover, multiple dosages are often required to prevent the recurrence of the hypoglycemic episode because of the short half-life of glucagon in plasma. Herein, we develop a glucagon-loaded long-dissolving microneedle (GLMN) patch that exhibits the properties of fast onset and sustained activity for the effective treatment of severe hypoglycemia. Three types of MN patches were fabricated with different dimensions (long, medium, and short). The longer MN patch packaged a higher dosage of glucagon and exhibited supreme mechanical strength compared to the shorter one. Additionally, the longer MN patch could insert more deeply into the skin, resulting in higher permeability of glucagon across the skin tissue and more rapid systemic absorption as compared with the shorter MN patch. The GLMN patch was observed to reverse the effects of hypoglycemia within 15 min of application in animal models (specifically, rat and rhesus monkey models) and maintained long-term glycemic control, owing to highly efficient drug permeation and the drug reservoir effect of the MN base. The current study presents a promising strategy for the rapid reversal of severe hypoglycemia that exhibits the desirable properties of easy use, high efficiency, and sustained action.
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Affiliation(s)
- Xiang Yu
- Affiliated Huzhou Hospital, School of Medicine, Zhejiang University, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
| | - Xueyu Wen
- Hangzhou Institute of Medicine, Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
| | - Jianchen Xu
- Department of Endocrinology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310058, China
| | - Qiao Zhou
- Department of Endocrinology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310058, China
| | - Yingrong Chen
- Affiliated Huzhou Hospital, School of Medicine, Zhejiang University, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
| | - Fengli Qu
- Hangzhou Institute of Medicine, Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
| | - Min He
- Hangzhou Institute of Medicine, Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
| | - Hao Chang
- Hangzhou Institute of Medicine, Chinese Academy of Sciences, Hangzhou, Zhejiang 310022, China
| | - Chao Zheng
- Affiliated Huzhou Hospital, School of Medicine, Zhejiang University, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
- Department of Endocrinology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310058, China
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4
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Ingielewicz A, Szymczak RK. Intranasal Therapy in Palliative Care. Pharmaceutics 2024; 16:519. [PMID: 38675179 PMCID: PMC11054984 DOI: 10.3390/pharmaceutics16040519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/28/2024] Open
Abstract
In recent years, the use of the intranasal route has been actively explored as a possible drug delivery method in the palliative patient population. There are reports demonstrating the effectiveness of nasally administered medications that are routinely used in patients at the end of life. The subject of this study is the intranasal drug administration among palliative patients. The aim is to summarize currently used intranasal therapies among palliative patients, determine the benefits and difficulties, and identify potential areas for future research. A review of available medical literature published between 2013 and 2023 was performed using online scientific databases. The following descriptors were used when searching for articles: "palliative", "intranasal", "nasal", "end-of-life care", "intranasal drug delivery" and "nasal drug delivery". Out of 774 articles, 55 directly related to the topic were finally selected and thoroughly analyzed. Based on the bibliographic analysis, it was shown that drugs administered intranasally may be a good, effective, and convenient form of treatment for patients receiving palliative care, in both children and adults. This topic requires further, high-quality clinical research.
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Affiliation(s)
- Anna Ingielewicz
- Department of Emergency Medicine, Faculty of Health Science, Medical University of Gdansk, Mariana Smoluchowskiego Street 17, 80-214 Gdansk, Poland;
- Hospice Foundation, Kopernika Street 6, 80-208 Gdansk, Poland
| | - Robert K. Szymczak
- Department of Emergency Medicine, Faculty of Health Science, Medical University of Gdansk, Mariana Smoluchowskiego Street 17, 80-214 Gdansk, Poland;
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5
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Liakos A, Karagiannis T, Avgerinos I, Tsapas A, Bekiari E. Burden and Coping Strategies of Hypoglycemia in People with Diabetes. Curr Diabetes Rev 2024; 20:e201023222415. [PMID: 37867276 DOI: 10.2174/0115733998271244231010100747] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 10/24/2023]
Abstract
Hypoglycemia is a limiting adverse effect of glucose-lowering medications and particularly insulin replacement therapy. This review provides insights into the burden of hypoglycemia in the management of diabetes and outlines strategies available to reduce the risk of hypoglycemia and improve patients' well-being. People with type 1 diabetes are primarily affected by hypoglycemic episodes which are associated with direct physical harms like injuries and cardiac events as well as indirect psychosocial consequences including constant anxiety, absenteeism, increased healthcare costs and overall poorer quality of life. These complications are more prominent amongst individuals with hypoglycemia unawareness or overnight hypoglycemia and could even extend to caregivers such as parents of children with diabetes. Patients experiencing frequent or severe hypoglycemic events might also develop a pathological fear of hypoglycemia and adopt aberrant behaviors intending to maintain higher blood glucose levels. Modern pharmaceutical options with a safer profile in terms of hypoglycemia are available including novel basal insulins with lower rates of nocturnal hypoglycemia along with ultra-rapid-acting insulin analogs with a shorter duration of action that might avert late post-meal hypoglycemia. Continuous glucose monitoring and sensor-augmented insulin pump therapy with low glucose suspend technology can also prevent hypoglycemia, although concerns about cost and patient satisfaction remain. Advancements in insulin therapy and technological modalities should be coupled with ongoing education and support for patients to become co-managers of their disease and reduce the risk of hypoglycemia.
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Affiliation(s)
- Aris Liakos
- Clinical Research and Evidence Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
- Diabetes Center, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Thomas Karagiannis
- Clinical Research and Evidence Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
- Diabetes Center, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Ioannis Avgerinos
- Clinical Research and Evidence Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
- Diabetes Center, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Apostolos Tsapas
- Clinical Research and Evidence Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
- Diabetes Center, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, United Kingdom
| | - Eleni Bekiari
- Clinical Research and Evidence Based Medicine Unit, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
- Diabetes Center, Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
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6
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Lega IC, Yale JF, Chadha A, Paty B, Roscoe R, Snider M, Steier J, Bajaj HS, Barnes T, Gilbert J, Honshorst K, Kim J, Lewis J, MacDonald B, MacKay D, Mansell K, Senior P, Rabi D, Sherifali D. Hypoglycemia in Adults. Can J Diabetes 2023; 47:548-559. [PMID: 37821214 DOI: 10.1016/j.jcjd.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
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7
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Eisenhofer S, Neininger MP, Bertsche A, Kiess W, Bertsche T, Kapellen TM. Assessing Parental Competence and Self-Ratings in Management of Pediatric Type 1 Diabetes and Emergency Glucagon Administration-An Exploratory Observational Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1319. [PMID: 37628318 PMCID: PMC10453678 DOI: 10.3390/children10081319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 07/23/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Parents of pediatric patients with type I diabetes require competence in hypoglycemia management and skills in glucagon administration to deal with potentially life-threatening severe hypoglycemia. We aimed to compare parents' subjective self-ratings to an objective expert assessment of competences and skills in dealing with severe hypoglycemia. METHODS We interviewed 140 participants to assess their subjective self-ratings. The objective expert assessments used a standardized clinical case scenario of severe hypoglycemia and a practical demonstration of glucagon administration. RESULTS The participants self-rated their competence in hypoglycemia management as good (5) or very good (6), and their skills in administering glucagon as acceptable (3) [Scale: very poor (1) to very good (6)]. In the standardized clinical case scenario, 1.4% (2/140) of participants named all relevant steps of severe hypoglycemia management. In the practical demonstration of glucagon administration, 92.9% (130/140) of participants committed at least one drug handling error; 52.1% (73/140) committed at least one drug handling error rated with high clinical risk. CONCLUSIONS We found discrepancies regarding participants' subjective self-ratings compared to their performance in the respective objective expert assessments. These discrepancies indicate a lack of error awareness and the need for intervention studies to improve competence in hypoglycemia management and glucagon administration.
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Affiliation(s)
- Simone Eisenhofer
- Drug Safety Center and Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University, Bruederstr. 32, 04103 Leipzig, Germany; (S.E.); (M.P.N.)
| | - Martina P. Neininger
- Drug Safety Center and Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University, Bruederstr. 32, 04103 Leipzig, Germany; (S.E.); (M.P.N.)
| | - Astrid Bertsche
- Department of Pediatric Neurology, University Medicine Greifswald, Fleischmannstraße 6, 17489 Greifswald, Germany;
- Department of Women and Child Health, Hospital for Children and Adolescents and Center for Pediatric Research, University Hospital of Leipzig, Liebigstr. 23, 04103 Leipzig, Germany; (W.K.); (T.M.K.)
| | - Wieland Kiess
- Department of Women and Child Health, Hospital for Children and Adolescents and Center for Pediatric Research, University Hospital of Leipzig, Liebigstr. 23, 04103 Leipzig, Germany; (W.K.); (T.M.K.)
| | - Thilo Bertsche
- Drug Safety Center and Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, Leipzig University, Bruederstr. 32, 04103 Leipzig, Germany; (S.E.); (M.P.N.)
| | - Thomas M. Kapellen
- Department of Women and Child Health, Hospital for Children and Adolescents and Center for Pediatric Research, University Hospital of Leipzig, Liebigstr. 23, 04103 Leipzig, Germany; (W.K.); (T.M.K.)
- MEDIAN Kinderklinik am Nicolausholz Hospital for Children and Adolescents, Elly-Kutscher-Straße 16, 06628 Naumburg (Saale), Germany
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8
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Demirbilek H, Vuralli D, Haris B, Hussain K. Managing Severe Hypoglycaemia in Patients with Diabetes: Current Challenges and Emerging Therapies. Diabetes Metab Syndr Obes 2023; 16:259-273. [PMID: 36760580 PMCID: PMC9888015 DOI: 10.2147/dmso.s313837] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/14/2023] [Indexed: 01/28/2023] Open
Abstract
Hypoglycaemia is common in patients with diabetes mellitus and is a limiting factor for achieving adequate glycaemic control. In the vast majority of cases, hypoglycaemia develops due to the imbalance between food intake and insulin injections. As recurrent hypoglycaemia leads to significant morbidity and mortality, the recognition and immediate treatment of hypoglycaemia in diabetic patients is thus important. In the last 20 years, the introduction of improved insulin analogues, insulin pump therapy, continuous glucose monitoring (CGM), and sensor-augmented pump therapy have all made significant improvements in helping to reduce and prevent hypoglycaemia. In terms of treatment, the American Diabetes Association recommends oral glucose as the first-line treatment option for all conscious patients with hypoglycaemia. The second line of treatment (or first line in unconscious patients) is the use of glucagon. Novel formulations of glucagon include the nasal form, the Gvoke HypoPen which is a ready-to-deliver auto-injector packaged formulation and finally a glucagon analogue, Dasiglucagon. The Dasiglucagon formulation has recently been approved for the treatment of severe hypoglycaemia. It is a ready-to-use, similar to endogenous glucagon and its potency is also the same as native glucagon. It does not require reconstitution before injection and therefore ensures better compliance. Thus, significant improvements including development of newer insulin analogues, insulin pump therapy, continuous glucose monitoring (CGM), sensor-augmented pump therapy and novel formulations of glucagon have all contributed to reducing and preventing hypoglycaemia in diabetic individuals. However, considerable challenges remain as not all patients have access to diabetes technologies and to the newer glucagon formulations to help reduce and prevent hypoglycaemia.
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Affiliation(s)
- Huseyin Demirbilek
- Department of Pediatric Endocrinology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dogus Vuralli
- Department of Pediatric Endocrinology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Basma Haris
- Department of Pediatric Endocrinology, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Department of Pediatric Endocrinology, Sidra Medicine, Doha, Qatar
- Correspondence: Khalid Hussain, Sidra Medicine, OPC, C6-340, PO Box 26999, Al Luqta Street, Education City North Campus, Doha, Qatar, Tel +974-4003-7608, Email
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9
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Abraham MB, Karges B, Dovc K, Naranjo D, Arbelaez AM, Mbogo J, Javelikar G, Jones TW, Mahmud FH. ISPAD Clinical Practice Consensus Guidelines 2022: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1322-1340. [PMID: 36537534 PMCID: PMC10107518 DOI: 10.1111/pedi.13443] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Discipline of Pediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Diana Naranjo
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Ana Maria Arbelaez
- Division of Endocrinology and Diabetes, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joyce Mbogo
- Department of Pediatric and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Ganesh Javelikar
- Department of Endocrinology and Diabetes, Max Super Speciality Hospital, New Delhi, India
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Discipline of Pediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Farid H Mahmud
- Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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10
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Monzani A, Savastio S, Manzo A, Scalogna A, Pozzi E, Sainaghi PP, Della Corte F, Rabbone I. Not only for caregivers: intranasal glucagon for severe hypoglycaemia in a simulation study. Acta Diabetol 2022; 59:1479-1484. [PMID: 35951133 DOI: 10.1007/s00592-022-01952-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/27/2022] [Indexed: 11/01/2022]
Abstract
AIMS To evaluate: (i) the propensity of paediatrics and emergency medicine residents to select different therapeutic options and (ii) the speed and administration success in a high-fidelity simulation of severe hypoglycaemia in a child with type 1 diabetes (T1DM). METHODS In this single-centre high-fidelity simulation study, 51 paediatrics or emergency medicine residents were exposed to a scenario of severe hypoglycaemia in a T1DM child attending an ambulatory setting, before and after a training on the preparation and administration of both injectable and IN glucagon. Time for drug delivery and its effectiveness were collected. RESULTS Before training, 45.1% of participants chose to administer injectable glucagon, 43.1% intravenous glucose solution, 5.9% intranasal (IN) glucagon, and 5.9% took no action. Administration was successful in 74% of injectable glucagon, 33.3% intravenous glucose solution, and 22.7% IN glucagon. After training, 58.8% of participants chose IN and 41.2% injectable glucagon, with 100% of successful administrations for IN glucagon and 90.5% for injectable glucagon. Time to successful administration was shorter for IN than injectable glucagon (23 ± 10 vs. 38 ± 7 s, p < 0.0001). CONCLUSIONS IN glucagon is an easy and effective option for severe hypoglycaemia treatment, with an almost zero possibility of failure provided that adequate training is imparted.
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Affiliation(s)
- A Monzani
- Division of Paediatrics, Department of Health Sciences, University of Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - S Savastio
- Division of Paediatrics, Department of Health Sciences, University of Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - A Manzo
- Division of Paediatrics, Department of Health Sciences, University of Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - A Scalogna
- SIMNOVA Interdepartmental Centre for Innovative Learning and Simulation in Medicine and Allied Health Professions, University of Piemonte Orientale, via Lanino 1, 28100, Novara, Italy
| | - E Pozzi
- Division of Paediatrics, Department of Health Sciences, University of Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - P P Sainaghi
- Department of Translational Medicine, University of Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - F Della Corte
- SIMNOVA Interdepartmental Centre for Innovative Learning and Simulation in Medicine and Allied Health Professions, University of Piemonte Orientale, via Lanino 1, 28100, Novara, Italy
- Department of Translational Medicine, University of Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy
| | - I Rabbone
- Division of Paediatrics, Department of Health Sciences, University of Piemonte Orientale, via Solaroli 17, 28100, Novara, Italy.
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11
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Regulation of feeding and therapeutic application of bioactive peptides. Pharmacol Ther 2022; 239:108187. [DOI: 10.1016/j.pharmthera.2022.108187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/25/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022]
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12
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Grant JS, Talley MH. Glucagon Nasal Powder: Treating Hypoglycemia in Individuals With Diabetes Mellitus. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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13
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Lu B, GhavamiNejad A, Liu JF, Li J, Mirzaie S, Giacca A, Wu XY. "Smart" Composite Microneedle Patch Stabilizes Glucagon and Prevents Nocturnal Hypoglycemia: Experimental Studies and Molecular Dynamics Simulation. ACS APPLIED MATERIALS & INTERFACES 2022; 14:20576-20590. [PMID: 35471922 DOI: 10.1021/acsami.1c24955] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Hypoglycemia is a major complication associated with insulin therapy in people with diabetes that could cause life-threatening conditions if untreated. Glucagon, a counter-acting hormone, is thus administered for rescue of severe hypoglycemia. However, due to the instability of glucagon, only limited medications are available for emergency use, which are unsuitable for patients with hypoglycemia unawareness or with the inability to self-administer, especially during sleep (namely, nocturnal hypoglycemia). To prevent unattended and extended hypoglycemia, we designed a "smart" composite microneedle (cMN) patch capable of stabilizing glucagon, sensing hypoglycemia, and delivering glucagon automatically on demand. In this design, native glucagon was encapsulated in glucose-responsive microgels containing a glucagon-stabilizing component rationally selected by molecular dynamics (MD) simulation. A cMN patch was then prepared by incorporating the glucagon microgels with poly(methyl vinyl ether-alt-maleic anhydride) (PMVE-MAH) and poly(ethylene glycol) (PEG) followed by thermal cross-linking. The rationally designed zwitterionic polymer-based microgels preserved the native structure of glucagon and prevented heat-induced fibrillation evidenced by RP-HPLC, circular dichroism, and transmission electron microscopy. MD simulations suggested that the polymeric microgels stabilized glucagon by inhibition of oligomer formation via peptide-polymer noncovalent interactions. The polymer formed multiple hydrogen bonds with the polar and charged amino acid residues of the glucagon molecule, shielding the peptide surface from aggregation. In vivo efficacy studies using streptozotocin-induced type 1 diabetic (T1D) rats demonstrated that the glucagon-loaded cMN patch could prevent hypoglycemia induced by insulin overdose during a 12 h period. The results suggest that this new glucagon "smart" patch may be a promising system for improving the quality of life of those suffering from nocturnal hypoglycemia and hypoglycemia unawareness.
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Affiliation(s)
- Brian Lu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
| | - Amin GhavamiNejad
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
| | - Jackie Fule Liu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
| | - Jason Li
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
| | - Sako Mirzaie
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
| | - Adria Giacca
- Departments of Physiology and Medicine, Institute and Medical Science and Banting and Best Diabetes Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Xiao Yu Wu
- Advanced Pharmaceutics and Drug Delivery Laboratory, Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario M5S 3M2, Canada
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14
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Seibold J, Ramshorn-Zimmer A, Ebert T, Tönjes A. Diabetologische Notfälle im Krankenhaus. DIABETOLOGE 2022. [DOI: 10.1007/s11428-022-00875-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Porcellati F, Di Mauro S, Mazzieri A, Scamporrino A, Filippello A, De Fano M, Fanelli CG, Purrello F, Malaguarnera R, Piro S. Glucagon as a Therapeutic Approach to Severe Hypoglycemia: After 100 Years, Is It Still the Antidote of Insulin? Biomolecules 2021; 11:biom11091281. [PMID: 34572493 PMCID: PMC8464883 DOI: 10.3390/biom11091281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022] Open
Abstract
Hypoglycemia represents a dark and tormented side of diabetes mellitus therapy. Patients treated with insulin or drug inducing hypoglycemia, consider hypoglycemia as a harmful element, which leads to their resistance and lack of acceptance of the pathology and relative therapies. Severe hypoglycemia, in itself, is a risk for patients and relatives. The possibility to have novel strategies and scientific knowledge concerning hypoglycemia could represent an enormous benefit. Novel available glucagon formulations, even now, allow clinicians to deal with hypoglycemia differently with respect to past years. Novel scientific evidence leads to advances concerning physiopathological mechanisms that regulated glycemic homeostasis. In this review, we will try to show some of the important aspects of this field.
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Affiliation(s)
- Francesca Porcellati
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Stefania Di Mauro
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Alessio Mazzieri
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Alessandra Scamporrino
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Agnese Filippello
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Michelantonio De Fano
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Carmine Giuseppe Fanelli
- Department of Medicine and Surgery, Perugia University School of Medicine, Via Gambuli 1, 06126 Perugia, Italy; (F.P.); (A.M.); (M.D.F.); (C.G.F.)
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
| | - Roberta Malaguarnera
- Faculty of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy
- Correspondence: ; Tel.: +39-0935-536577
| | - Salvatore Piro
- Department of Clinical and Experimental Medicine, Internal Medicine, Garibaldi-Nesima Hospital, University of Catania, 95122 Catania, Italy; (S.D.M.); (A.S.); (A.F.); (F.P.); (S.P.)
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16
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Rabbone I, Missineo A, Zanetta S, Salzano G, Schiaffini R, Scaramuzza AE, Lombardo F. Parent and patient knowledge of nasal glucagon use and efficacy in a large cohort of Italian children and adolescents with type 1 diabetes. Diabetes Obes Metab 2021; 23:2004-2005. [PMID: 33830640 DOI: 10.1111/dom.14398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 01/05/2023]
Affiliation(s)
- Ivana Rabbone
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Anna Missineo
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Sara Zanetta
- Division of Pediatrics, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Giuseppina Salzano
- Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
| | - Riccardo Schiaffini
- Diabetes Unit, Department of Pediatrics, Bambin Gesù Children's Hospital, Rome, Italy
| | | | - Fortunato Lombardo
- Department of Human Pathology in Adult and Developmental Age, University of Messina, Messina, Italy
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17
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Holstein DJF, Holstein JD, Fischer D, Mende M, Frier BM, Holstein A. Out-of-Hospital Management of Diabetic Emergencies in Germany: Structural and Process Quality. Exp Clin Endocrinol Diabetes 2021; 130:454-461. [PMID: 34284506 DOI: 10.1055/a-1523-7562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIMS To collect and analyse representative data of structural and process quality in the management of diabetic emergencies in Germany in 2020. METHODS A standardised questionnaire comprising detailed items concerning clinically relevant parameters on the structural and process quality of out-of-hospital management of diabetic emergencies was sent nationwide to medical directors of emergency medical service districts (EMSDs). Results were compared with those from a similar study conducted in 2001. RESULTS The return rate of the questionnaires represented 126 EMSDs, serving a total population of > 40.1 million. Only 4% of ambulances carried glucagon (6% in 2001). In 2020, blood glucose determination increased significantly to 71% of all emergency interventions and to 29% of suspected cardiac emergencies (24% and 15%, respectively, in 2001). In 100% of EMSDs severe hypoglycaemia (SH) was treated by paramedics by administering intravenous dextrose before the arrival of a doctor compared to 63% in 2001. The potential value of nasal glucagon was acknowledged by 43% of responders. In selected patients, treatment of SH was conducted without hospital admission in 78% of EMDs (60% in 2001). Fifty-three percent of medical directors acknowledged the need for further training in diabetic emergencies (47% in 2001). Cooperation for medical education between emergency teams and a diabetes centre was reported by 14% (41% in 2001). CONCLUSION Structural and process quality of the management of diabetic emergencies in Germany has improved considerably since 2001. Persisting deficiencies could be improved by providing better medical equipment in ambulances and ongoing education to the entire emergency teams.
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Affiliation(s)
- David J F Holstein
- Integrated Research and Treatment Center Adiposity Diseases, University of Leipzig, Germany
| | - Judith D Holstein
- Division of Nephrology and Internal Intensive Care Medicine, Charite' University Medicine Berlin, Germany
| | - Daniel Fischer
- Department of Emergency Medicine, Lippe-Detmold Hospital, Germany
| | - Meinhard Mende
- Clinical Trial Centre and Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Germany
| | - Brian M Frier
- The Queen's Medical Research Institute, University of Edinburgh, Scotland, UK
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18
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Kahn PA, Liu S, McCoy R, Gabbay RA, Lipska K. Glucagon use by U.S. adults with type 1 and type 2 diabetes. J Diabetes Complications 2021; 35:107882. [PMID: 33593689 PMCID: PMC8054027 DOI: 10.1016/j.jdiacomp.2021.107882] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/18/2021] [Accepted: 01/29/2021] [Indexed: 11/27/2022]
Abstract
The American Diabetes Association recommends that all patients at risk for hypoglycemia be prescribed glucagon. Despite this recommendation, there is evidence that prescription rates are lower than expected for patients with type 1 and type 2 diabetes. This study investigated prescription patterns for glucagon among de-identified administrative claims from OptumLabs® Data Warehouse for prescriptions between January 1, 2014 and December 31, 2014 among pharmacologically treated type 1 and 2 diabetes patients. We find that glucagon was rarely filled by patients with type 1 and type 2 diabetes, including fewer than 5% of patients with prior hypoglycemia requiring emergency healthcare utilization. Among patients with type 1 diabetes, glucagon fills were unpredictable and not targeted to highest risk patients.
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Affiliation(s)
- Peter A Kahn
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Shuling Liu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, United States of America
| | - Rozalina McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America; Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America; OptumLabs, Cambridge, MA
| | - Robert A Gabbay
- Harvard Medical School, Joslin Diabetes Center, Boston, MA, United States of America
| | - Kasia Lipska
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, United States of America; Department of Internal Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, CT, United States of America.
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