Hypoglycemia anticipation, awareness and treatment training (HAATT) reduces occurrence of severe hypoglycemia among adults with type 1 diabetes mellitus

Towards standardization of person-reported outcomes (PROs) in pediatric diabetes research: A consensus report

BACKGROUND

Diabetes ranks among the most common chronic conditions in childhood and adolescence. It is unique among chronic conditions, in that clinical outcomes are intimately tied to how the child or adolescent living with diabetes and their parents or carers react to and implement good clinical practice guidance. It is widely recognized that the individual's perspective about the impact of trying to manage the disease together with the burden of self-management should be addressed to achieve optimal health outcomes. Standardized, rigorous assessment of behavioural and mental health outcomes is crucial to aid understanding of person-reported outcomes alongside, and in interaction with, physical health outcomes. Whilst tempting to conceptualize person-reported outcomes as a focus on perceived quality of life, the reality is that health-related quality of life is multi-dimensional and covers indicators of physical or functional health status, psychological well-being and social well- being.

METHODS

In this context, this Consensus Statement has been developed by a collection of experts in diabetes to summarize the central themes and lessons derived in the assessment and use of person-reported outcome measures in relation to children and adolescents and their parents/carers, helping to provide a platform for future standardization of these measures for research studies and routine clinical use.

RESULTS

This consensus statement provides an exploration of person-reported outcomes and how to routinely assess and incorporate into clincial research.

A single-site feasibility randomised controlled trial comparing 'my hypo compass' short pyscho-educational intervention with standard care alone in individuals with type 1 diabetes and impaired awareness of hypoglycaemia

AIMS

The HypoCOMPaSS multi-centre trial achieved improvement in hypoglycaemia awareness and 20-fold reduction in severe hypoglycaemia (SH) in a cohort with long-standing type 1 diabetes (T1D). All participants received 'my hypo compass' (MHC) brief structured psycho-educational intervention in addition to optimisation of insulin delivery/glucose monitoring. In this 24-week, prospective, single-centre feasibility RCT, we piloted MHC as a sole intervention in comparison to standard clinical care alone (CON).

METHODS

Participants with T1D and impaired hypoglycaemia awareness (IAH) (Clarke score ≥4) were recruited. MHC comprised a group/individual 1-2 h face-to-face session followed by a telephone call and second face-to-face session at 4 weeks. Outcome measures at 24 weeks were compared with baseline.

RESULTS

Fifty-two individuals provided consent for screening with 39 fulfilling eligibility criteria. Fifteen withdrew before any study intervention. Twenty-four adults with (mean ± SD) T1D duration 41.0 ± 15.1 years commenced/completed the study (100% visit attendance); 12 randomised to MHC and 12 to CON. All had IAH at baseline and at 24 weeks. Annualised SH rate following MHC was 3.8 ± 19.0 (24 weeks) versus 12.6 ± 3.5 (Baseline) and in CON group 2.0 ± 19.0 (24 weeks) versus 4.6 ± 11.5 (Baseline). 'Immediate Action' for and 'Worry' about hyperglycaemia measured by the Hyperglycaemia Avoidance Scale appeared lower following MHC. Participants attended all study visits and reflected positively on the MHC intervention.

CONCLUSIONS

Feasibility of MHC implementation without additional intervention has been demonstrated. MHC education was associated with positive changes in attitudes and behaviours with the potential to reduce SH risk. MHC provides a validated, simple, well-received programme to fulfil the educational component within RCTs targeting problematic hypoglycaemia and as part of holistic clinical care.

Burden and Coping Strategies of Hypoglycemia in People with Diabetes

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.

Current and future therapies to treat impaired awareness of hypoglycemia

In order to achieve optimal glycemic control, intensive insulin regimes are needed for individuals with Type 1 Diabetes (T1D) and insulin-dependent Type 2 Diabetes (T2D). Unfortunately, intensive glycemic control often results in insulin-induced hypoglycemia. Moreover, recurrent episodes of hypoglycemia result in both the loss of the characteristic warning symptoms associated with hypoglycemia and an attenuated counterregulatory hormone responses. The blunting of warning symptoms is known as impaired awareness of hypoglycemia (IAH). Together, IAH and the loss of the hormonal response is termed hypoglycemia associated autonomic failure (HAAF). IAH is prevalent in up to 25% in people with T1D and up to 10% in people with T2D. IAH and HAAF increase the risk of severe hypoglycemia 6-fold and 25-fold, respectively. To reduce this risk for severe hypoglycemia, multiple different therapeutic approaches are being explored that could improve awareness of hypoglycemia. Current therapies to improve awareness of hypoglycemia include patient education and psychoeducation, the use of novel glycemic control technology, pancreas/islet transplantation, and drug therapy. This review examines both existing therapies and potential therapies that are in pre-clinical testing. Novel treatments that improve awareness of hypoglycemia, via improving the counterregulatory hormone responses or improving hypoglycemic symptom recognition, would also shed light on the possible neurological mechanisms that lead to the development of IAH. To reduce the risk of severe hypoglycemia in people with diabetes, elucidating the mechanism behind IAH, as well as developing targeted therapies is currently an unmet need for those that suffer from IAH.

The Hypoglycemic Fear Syndrome: Understanding and Addressing This Common Clinical Problem in Adults With Diabetes

Although a broad literature on fear of hypoglycemia and its impact on people with type 1 or type 2 diabetes has accumulated over the past three decades, there has been surprisingly little guidance concerning how best to tackle this problem in clinical care. The aim of this article is to begin filling this gap by describing the "hypoglycemic fear syndrome," which we define as hypoglycemic fear that has become so overwhelming that it leads to avoidance behaviors and chronically elevated glucose levels. We begin by presenting several illustrative cases, describing the syndrome and how it is most commonly presented in clinical care, and detailing its most common precipitants. We then offer practical, evidence-based strategies for clinical intervention, based on the literature and our clinical experience.

Hypoglycaemia in type 1 diabetes mellitus: risks and practical prevention strategies

Hypoglycaemia, which occurs when blood levels of glucose fall below what is considered a normal range, is a well-known complication of insulin therapy in individuals with type 1 diabetes mellitus. Despite advances in diabetes mellitus management, hypoglycaemia has continued to affect the majority of these individuals, leading to suboptimal care and decreased quality of life. Multiple epidemiological studies have demonstrated the risks associated with hypoglycaemic events. With this understanding, various advances have been made in therapeutics for diabetes mellitus management. Diabetes mellitus education continues to form the foundation for management and prevention of hypoglycaemia. The advent of newer diabetes mellitus technologies and newer insulins herald improvements in management strategies and hypoglycaemia prevention. Improved understanding of these newer approaches is needed to ensure delivery of safe and effective care to individuals with type 1 diabetes mellitus, leading to reductions in both the short-term and long-term morbidity and mortality associated with hypoglycaemic events.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Continuous Glucose Monitoring and Other Wearable Devices to Assess Hypoglycemia among Older Adult Outpatients with Diabetes Mellitus

BACKGROUND

Hypoglycemia (HG) causes symptoms that can be fatal, and confers risk of dementia. Wearable devices can improve measurement and feedback to patients and clinicians about HG events and risk.

OBJECTIVES

The aim of the study is to determine whether vulnerable older adults could use wearables, and explore HG frequency over 2 weeks.

METHODS

First, 10 participants with diabetes mellitus piloted a continuous glucometer, physical activity monitor, electronic medication bottles, and smartphones facilitating prompts about medications, behaviors, and symptoms. They reviewed graphs of glucose values, and were asked about the monitoring experience. Next, a larger sample (N = 70) wore glucometers and activity monitors, and used the smartphone and bottles, for 2 weeks. Participants provided feedback about the devices. Descriptive statistics summarized demographics, baseline experiences, behaviors, and HG.

RESULTS

In the initial pilot, 10 patients aged 50 to 85 participated. Problems addressed included failure of the glucometer adhesive. Patients sought understanding of graphs, often requiring some assistance with interpretation. Among 70 patients in subsequent testing, 67% were African-American, 59% were women. Nearly one-fourth (23%) indicated that they never check their blood sugars. Previous HG was reported by 67%. In 2 weeks of monitoring, 73% had HG (glucose ≤70 mg/dL), and 42% had serious, clinically significant HG (glucose under 54 mg/dL). Eight patients with HG also had HG by home-based blood glucometry. Nearly a third of daytime prompts were unanswered. In 24% of participants, continuous glucometers became detached.

CONCLUSION

Continuous glucometry occurred for 2 weeks in an older vulnerable population, but devices posed wearability challenges. Most patients experienced HG, often serious in magnitude. This suggests important opportunities to improve wearability and decrease HG frequency among this population.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effectiveness of Therapeutic Patient Education Interventions in Obesity and Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Diabetes mellitus (DM) and obesity account for the highest burden of non-communicable diseases. There is increasing evidence showing therapeutic patient education (TPE) as a clinically and cost-effective solution to improve biomedical and psychosocial outcomes among people with DM and obesity. The present systematic review and meta-analysis present a critical synthesis of the development of TPE interventions for DM and obesity and the efficacy of these interventions across a range of biomedical, psychosocial and psychological outcomes. A total of 54 of these RCTs were identified among patients with obesity and diabetes and were thus qualitatively synthesized. Out of these, 47 were included in the quantitative synthesis. There was substantial heterogeneity in the reporting of these outcomes (I2 = 88.35%, Q = 317.64), with a significant improvement noted in serum HbA1c levels (standardized mean difference (SMD) = 0.272, 95% CI: 0.118 to 0.525, n = 7360) and body weight (SMD = 0.526, 95% CI: 0.205 to 0.846, n = 1082) in the intervention group. The effect sizes were comparable across interventions delivered by different modes and delivery agents. These interventions can be delivered by allied health staff, doctors or electronically as self-help programs, with similar effectiveness (p < 0.001). These interventions should be implemented in healthcare and community settings to improve the health outcomes in patients suffering from obesity and DM.

Fear of hypoglycemia-An underestimated problem

INTRODUCTION

Fear of hypoglycemia (FOH) is a phenomenon that affects people with diabetes experiencing hypoglycemia. On the one hand, FOH is an adaptive mechanism that helps to protect patients from hypoglycemia and its consequences. On the other hand, the non-normative level of FOH causes anxiety and tension, disturbs normal functioning, and makes normoglycemia maintenance difficult.

OBJECTIVE

The main objective of this review was to describe factors influencing FOH and methods of measurement of FOH levels. Moreover, we highlighted the impact of the new technologies used in diabetes therapy on FOH and different therapeutic possibilities helping patients cope with excessive levels of FOH. We also presented clinical cases of patients with high FOH levels met in clinical practice and discussed methods to better diagnose and assist people with this kind of problem.

METHODS

We searched for studies and articles via PubMed using the keywords fear of hypoglycemia, diabetes, and hypoglycemia. From screened documents identified from literature search, 67 articles were included in our review.

RESULTS

We divided results from literature screening into five parts: fear of hypoglycemia and hypoglycemia definition, risk factors for the FOH, methods of measuring levels of FOH, therapies for the FOH, and modern technologies. We also described clinical examples of abnormal fear of hypoglycemia in patients.

CONCLUSION

The review highlights the importance of taking into consideration fear of hypoglycemia phenomenon in diabetic patients in everyday clinical practice.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Impact of Hybrid Closed Loop Therapy on Hypoglycemia Awareness in Individuals with Type 1 Diabetes and Impaired Hypoglycemia Awareness

Objective: This study evaluated the efficacy of using a hybrid closed loop (HCL) system in restoring hypoglycemia awareness in individuals with impaired awareness of hypoglycemia (IAH). Research Design and Methods: Participants with IAH (Gold score ≥4) were recruited into a randomized crossover pilot study. They participated in two 8-week periods using a HCL system (Medtronic 670G™) (intervention) and standard insulin pump therapy (control). Hyperinsulinemic hypoglycemic clamp studies were undertaken at baseline and at the end of each study period for the evaluation of the counter-regulatory hormonal and symptomatic responses to hypoglycemia. Results: Seventeen participants (mean age [standard deviation] 35.8 years [11.2 years]) were included in the study. Peak epinephrine levels (median, interquartile range [IQR]) in response to hypoglycemia were similar postintervention and control periods; 234.7 pmol/L (109.2; 938.9) versus 188.3 pmol/L (133.7; 402.9), P = 0.233. However, both peak adrenergic and neuroglycopenic symptom scores were higher after intervention; 5.0 (4.5; 9.0) versus 4.0 (4.0; 5.5), P = 0.009, and 8.5 (6.0; 15.0) versus 6.5 (6.0; 7.0) P = 0.014, respectively. Self-reported hypoglycemia awareness improved: median (IQR) Gold score was 4.0 (3.0; 5.5) versus 5.5 (4.5; 6.0); intervention versus control, P = 0.033. Time spent <3.9 and <3.0 mmol/L was lower in the intervention group than in control, P = 0.002. Other patient-reported outcomes (hypoglycemia fear and diabetes treatment satisfaction) did not change. Conclusions: A short-term use of a HCL system failed to demonstrate an improvement in counter-regulatory hormonal responses. However, higher hypoglycemia symptom scores during controlled hypoglycemia, better self-reported hypoglycemia awareness, and less time spent in hypoglycemia suggest the potential benefits of a HCL system in people with IAH. Trial Registration: anzctr.org.au Identifier: ACTRN12616000909426.

Detection of low glucose levels in sweat with colorimetric wearable biosensors

Low glucose levels during exercise may lead to hypoglycemia, which can have grave consequences in diabetic athletes. Mobile colorimetric wearable biosensors that measure glucose levels in sweat are ideal for self-monitoring as they can utilize the camera in smartphones for signal reading. However, colorimetric biosensors proposed thus far have higher limit of detection (LOD) than electrochemical devices, which makes them unsuitable for detecting hypoglycemia. In this manuscript we describe colorimetric wearable biosensors that detect glucose in sweat with an LOD of 0.01 mM and a dynamic range up to 0.15 mM. The devices are made of filter paper and incorporate a sweat volume sensor and a color chart for signal correction. The biosensors do not suffer from interferences originated by delayed sample readings, or differences in bending angle and sample pH. When applied to volunteers performing an exercise routine, sweat glucose levels corrected with sweat volume measurements correlated well with blood glucose measurements performed with a commercial device. The devices are lightweight and easily disposable. These features, along with the smartphone-based colorimetric readout, makes them promising as "over-the-counter" tests for measuring glucose levels non-invasively during exercise.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Clinical approaches to treat impaired awareness of hypoglycaemia

Impaired awareness of hypoglycaemia (IAH) affects between 25% and 30% of all people with type 1 diabetes (T1D) and markedly increases risk of severe hypoglycaemia. This greatly feared complication of T1D impairs quality of life and has a recognised morbidity. People with T1D have an increased propensity to hypoglycaemia as a result of fundamental physiological defects in their ability to respond appropriately to a fall in blood glucose levels. With repeated exposure to low glucose, many then develop a condition referred to as IAH, where there is a reduced ability to perceive the onset of hypoglycaemia and take appropriate corrective action. The management of individuals with IAH relies initially on its identification in the clinic through a detailed exploration of the frequency of hypoglycaemia and an assessment of the individual's ability to recognise these episodes. In this review article, we will address the clinical strategies that may help in the management of the patient with IAH once identified, who may or may not also suffer from problematic hypoglycaemia. The initial focus is on how to identify such patients and then on the variety of approaches involving educational programmes and technological approaches that may be taken to minimise hypoglycaemia risk. No single approach can be advocated for all patients, and it is the role of the health care professional to identify the clinical strategy that best enables their patient to achieve this goal.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Use of a Smartphone Application to Reduce Hypoglycemia in Type 1 Diabetes: A Pilot Study

BACKGROUND

Hypoglycemia and hypoglycemia unawareness are common in long-standing type 1 diabetes (T1D). This pilot study examined the real-world use of a smartphone application (app), which receives meter readings and logs hypoglycemic symptoms, causes, and treatments to reduce hypoglycemia.

METHODS

Adults with T1D and recent hypoglycemia synchronized their glucose meter to their smartphone and used the Joslin HypoMap™ app powered by Glooko to track hypoglycemic events. At baseline, and after 6 and 12 weeks of using the app, a blinded continuous glucose monitor (CGM; Dexcom G4) was used for 2 weeks and surveys administered.

RESULTS

Participants (n = 22) at baseline had mean (SD) age 43 (14) years, duration of diabetes 26 (13) years, A1c 8.0% (0.87) and 21/22 had reduced hypoglycemia awareness per Clarke Hypoglycemia Unawareness survey scores; 13 (59%) were "CGM completers" (CGM data available at baseline and follow-up). Most noncompletion related to time required/difficulties using the mobile app. After 6 weeks, 8/13 completers (62% of CGM completers, 36% of total participants) had reduced daytime minutes with glucose <54 mg/dL (mean ↓331 minutes) and 10/13 (77% of CGM completers; 45% of total participants) had reduced time ≤ 70 mg/dL (mean ↓449 minutes). This was not sustained at 12 weeks, at which time half of the completers had less time ("improved"). Five participants reported improved hypoglycemia awareness; 9 stated the app helped them better recognize hypoglycemia.

CONCLUSIONS

Use of this phone app has the potential to help reduce daytime hypoglycemia in a subset of T1D adults with reduce hypoglycemia awareness; larger studies are needed.

Sustained Reduction in Severe Hypoglycemia in Adults With Type 1 Diabetes Complicated by Impaired Awareness of Hypoglycemia: Two-Year Follow-up in the HypoCOMPaSS Randomized Clinical Trial

OBJECTIVE

Severe hypoglycemia is a feared complication of type 1 diabetes; yet, few trials have targeted prevention using optimized self-management (educational, therapeutic, and technological support). We aimed to investigate whether improved awareness and reduced severe hypoglycemia, achieved during an intensive randomized clinical trial (RCT), were sustained after return to routine care.

RESEARCH DESIGN AND METHODS

Ninety-six adults with type 1 diabetes (29 ± 12 years' duration) and impaired awareness of hypoglycemia at five U.K. tertiary referral diabetes centers were recruited into a 24-week 2 × 2 factorial RCT (HypoCOMPaSS). Participants were randomized to pump (continuous subcutaneous insulin infusion [CSII]) or multiple daily injections (MDIs) and real-time continuous glucose monitoring (RT-CGM) or self-monitoring of blood glucose (SMBG), with equal education/attention to all groups. At 24 weeks, participants returned to routine care with follow-up until 24 months, including free choice of MDI/CSII; RT-CGM vs. SMBG comparison continued to 24 months. Primary outcome was mean difference (baseline to 24 months [between groups]) in hypoglycemia awareness.

RESULTS

Improvement in hypoglycemia awareness was sustained (Gold score at baseline 5.1 ± 1.1 vs. 24 months 3.7 ± 1.9; P < 0.0001). Severe hypoglycemia rate was reduced from 8.9 ± 12.8 episodes/person-year over the 12 months prestudy to 0.4 ± 0.8 over 24 months (P < 0.0001). HbA_1c improved (baseline 8.2 ± 3.2% [66 ± 12 mmol/mol] vs. 24 months 7.7 ± 3.1% [61 ± 10 mmol/mol]; P = 0.003). Improvement in treatment satisfaction and reduced fear of hypoglycemia were sustained. There were no significant differences between interventions at 24 months.

CONCLUSIONS

Optimized insulin replacement and glucose monitoring underpinned by hypoglycemia-focused structured education should be provided to all with type 1 diabetes complicated by impaired awareness of hypoglycemia.

The role of structured education in the management of hypoglycaemia

The role of intensive glycaemic control in preventing microvascular disease in diabetes is well established. Iatrogenic hypoglycaemia is, however, a major barrier to effective treatment. Hypoglycaemia is associated with a significant level of morbidity and, despite pharmacological and technological therapeutic advances, reported rates of severe hypoglycaemia in clinical practice have not fallen over the last 20 years. This suggests that human factors are of major relevance and that ensuring the effective self-management of diabetes is an important strategy for the reduction of hypoglycaemic risk. Most of the evidence for the impact of this strategy on hypoglycaemia risk is confined to adults with type 1 diabetes although, in this review, we also cite studies that have specifically addressed this in type 2 diabetes. There are relatively few adequately powered RCTs that have rigorously evaluated the effectiveness of structured education and training programmes on hypoglycaemia; however, the available data suggest a subsequent reduction in severe hypoglycaemia rates of around 50%, a rate reduction that is comparable with that observed following technological interventions. Furthermore, longitudinal observational cohorts support these data, showing similar reductions in rates of hypoglycaemia following structured education. Those who continue to experience recurrent hypoglycaemia and impaired awareness of hypoglycaemia despite education and training in diabetes self-management may benefit from technological interventions and/or interventions that specifically address psychological factors that contribute to hypoglycaemia risk; however, there is urgent need for further research in this area. In the meantime, structured education for effective self-management of diabetes should be part of routine therapy for all those with type 1 diabetes.

Reduced prevalence of impaired awareness of hypoglycemia in a population-based clinic sample of youth with type 1 diabetes

BACKGROUND

Impaired awareness of hypoglycemia (IAH) is associated with an increased risk for severe hypoglycemia (SH). However, reduced rates of SH raise the question as to whether there has been a reduction in IAH. The aim of this study was to determine the change in prevalence of IAH in a population-based cohort of adolescents with Type 1 diabetes (T1D).

METHODS

Children older than 12 years with T1D documented their responses to hypoglycemia based on the modified Clarke questionnaire. The prevalence of IAH was also analyzed in a similar population-based cohort using the same questionnaire in 2002. The clinical details of the participants and the number of SH events in the preceding year were determined from the Western Australian diabetes database.

RESULTS

The questionnaire was administered to 413 children in 2002 and to 444 children in 2015 with similar baseline characteristics. The prevalence of IAH was 33% in 2002 and 21% in 2015 (P < .001). A lower HbA1c, younger age at diagnosis and longer duration of diabetes correlated with IAH in 2002 but not in 2015. There was a significant decline in the rates of SH in 2015 compared with 2002 (P < .001) despite a reduced HbA1c in 2015. IAH increased the risk of SH in both cohorts (52 vs 16 events/100 patient years in 2002 and 8 vs 2 events/100 patient years in 2015).

CONCLUSIONS

Although IAH has reduced, IAH is still prevalent in a substantial minority of adolescents and continues to be associated with an increased risk of SH.

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

Hypoglycemia has been considered as a major barrier to achieving the proper glycemic target in type 2 diabetes mellitus patients. In particular, severe hypoglycemia (SH), which is defined as a hypoglycemic episode requiring the assistance of another person to raise the patient's glucose level, is a serious complication of diabetes because of its possible fatal outcomes. Recently, the recommendations for diabetes care have emphasized a patient-centered approach, considering the individualized patient factors including hypoglycemia. Many studies have been performed which analyzed the risk factors and clinical outcomes for SH. From the studies, researchers recommend that targeting a less stringent glycosylated hemoglobin level and selecting a safer class of drugs for hypoglycemia are appropriate for patients with a high risk of SH. Also, careful clinical attention to prevent hypoglycemia, including intensive education, is necessary to minimize the risk of SH and SH-related fatal outcomes.

Update on strategies limiting iatrogenic hypoglycemia

The prevalence of type 2 diabetes mellitus (T2DM) is increasing all over the world. Targeting good glycemic control is fundamental to avoid the complications of diabetes linked to hyperglycemia. This narrative review is based on material searched for and obtained via PubMed up to April 2015. The search terms we used were: 'hypoglycemia, diabetes, complications' in combination with 'iatrogenic, treatment, symptoms.' Serious complications might occur from an inappropriate treatment of hyperglycemia. The most frequent complication is iatrogenic hypoglycemia that is often associated with autonomic and neuroglycopenic symptoms. Furthermore, hypoglycemia causes acute cardiovascular effects, which may explain some of the typical symptoms: ischemia, QT prolongation, and arrhythmia. With regards to the latter, the night represents a dangerous period because of the major increase in arrhythmias and the prolonged period of hypoglycemia; indeed, sleep has been shown to blunt the sympatho-adrenal response to hypoglycemia. Two main strategies have been implemented to reduce these effects: monitoring blood glucose values and individualized HbA1c goals. Several drugs for the treatment of T2DM are currently available and different combinations have been recommended to achieve individualized glycemic targets, considering age, comorbidities, disease duration, and life expectancy. In conclusion, according to international guidelines, hypoglycemia-avoiding therapy must reach an individualized glycemic goal, which is the lowest HbA1c not causing severe hypoglycemia and preserving awareness of hypoglycemia.

Interventions That Restore Awareness of Hypoglycemia in Adults With Type 1 Diabetes: A Systematic Review and Meta-analysis

OBJECTIVE

Impaired awareness of hypoglycemia (IAH) increases the risk of severe hypoglycemia (SH) sixfold and affects 30% of adults with type 1 diabetes (T1D). This systematic review and meta-analysis looks at the educational, technological, and pharmacological interventions aimed at restoring hypoglycemia awareness (HA) in adults with T1D.

RESEARCH DESIGN AND METHODS

We searched The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, Social Sciences Citation Index, PsycINFO, and CINAHL from inception until 1 October 2014. Included studies described HA status at baseline. Outcome measures were SH rates, change in HA, counterregulatory hormone responses, and glycemic control.

RESULTS

Forty-three studies (18 randomized controlled trials, 25 before-and-after studies) met the inclusion criteria, comprising 27 educational, 11 technological, and 5 pharmacological interventions. Educational interventions included structured diabetes education on flexible insulin therapy, including psychotherapeutic and behavioral techniques. These were able to reduce SH and improve glycemic control, with greater benefit from the latter two techniques in improving IAH. Technological interventions (insulin pump therapy, continuous glucose monitoring, and sensor-augmented pump) reduced SH, improved glycemic control, and restored awareness when used in combination with structured education and frequent contact. Pharmacological studies included four insulin studies and one noninsulin study, but with low background SH prevalence rates.

CONCLUSIONS

This review provides evidence for the effectiveness of a stepped-care approach in the management of patients with IAH, initially with structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioral therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, in those with persisting need.

A qualitative evaluation of DAFNE-HART: A psychoeducational programme to restore hypoglycaemia awareness

AIMS

Impaired awareness of hypoglycaemia (IAH) in people with type 1 diabetes is a dangerous condition that is associated with a six-fold greater risk of severe hypoglycaemia than for people with awareness. A new psychoeducational programme, DAFNE-HART, has been specifically designed to address persistent IAH. The initial pilot showed promising outcomes including fewer hypoglycaemic episodes and improved hypoglycaemia awareness. This aim of this paper is to report the development and qualitative evaluation of DAFNE-HART from participant interviews.

METHODS

DAFNE-HART incorporates diabetes education with two psychological approaches that have demonstrated efficacy in long-term health conditions: motivational interviewing and cognitive behaviour therapy. The course, delivered across two UK locations included both group and individual support over a 6-week period facilitated by DAFNE educators, trained and supervised by a clinical psychologist. Semi-structured interviews were conducted with 19 participants immediately after their courses and the interviews were analysed using grounded theory.

RESULTS

Five main themes emerged which describe the behavioural changes people made to their diabetes management, the development of new attitudes and beliefs, their experiences of regaining hypoglycaemia cues, reactions to the course format and the significance of the relationship with their care provider. Participants provide insights into how the course changed their view of IAH and led to practical changes in minimising hypoglycaemia.

CONCLUSIONS

Integration of psychological techniques into diabetes education can address the cognitive and motivational barriers to restoring awareness and optimal diabetes management. It is suggested that further research is needed to evaluate this programme in a larger sample, over a longer time frame.

Technology to Reduce Hypoglycemia

Hypoglycemia is a major barrier toward achieving glycemic targets and is associated with significant morbidity (both psychological and physical) and mortality. This article reviews technological strategies, from simple to more advanced technologies, which may help prevent or mitigate exposure to hypoglycemia. More efficient insulin delivery systems, bolus advisor calculators, data downloads providing information on glucose trends, continuous glucose monitoring with alarms warning of hypoglycemia, predictive algorithms, and finally closed loop insulin delivery systems are reviewed. The building blocks to correct use and interpretation of this range of available technology require patient education and appropriate patient selection.

Evidence-informed clinical practice recommendations for treatment of type 1 diabetes complicated by problematic hypoglycemia

Problematic hypoglycemia, defined as two or more episodes per year of severe hypoglycemia or as one episode associated with impaired awareness of hypoglycemia, extreme glycemic lability, or major fear and maladaptive behavior, is a challenge, especially for patients with long-standing type 1 diabetes. Individualized therapy for such patients should include a composite target: optimal glucose control without problematic hypoglycemia. Therefore, we propose a tiered, four-stage algorithm based on evidence of efficacy given the limitations of educational, technological, and transplant interventions. All patients with problematic hypoglycemia should undergo structured or hypoglycemia-specific education programs (stage 1). Glycemic and hypoglycemia treatment targets should be individualized and reassessed every 3-6 months. If targets are not met, one diabetes technology-continuous subcutaneous insulin infusion or continuous glucose monitoring-should be added (stage 2). For patients with continued problematic hypoglycemia despite education (stage 1) and one diabetes technology (stage 2), sensor-augmented insulin pumps preferably with an automated low-glucose suspend feature and/or very frequent contact with a specialized hypoglycemia service can reduce hypoglycemia (stage 3). For patients whose problematic hypoglycemia persists, islet or pancreas transplant should be considered (stage 4). This algorithm provides an evidence-informed approach to resolving problematic hypoglycemia; it should be used as a guide, with individual patient circumstances directing suitability and acceptability to ensure the prudent use of technology and scarce transplant resources. Standardized reporting of hypoglycemia outcomes and inclusion of patients with problematic hypoglycemia in studies of new interventions may help to guide future therapeutic strategies.

Home-based diabetes symptom self-management education for Mexican Americans with type 2 diabetes

This pilot study evaluated an innovative diabetes symptom awareness and self-management educational program for Mexican Americans, a fast growing minority population experiencing a diabetes epidemic. Patients with diabetes need assistance interpreting and managing symptoms, which are often annoying and potentially life-threatening. A repeated measures randomized controlled trial was conducted with 72 Mexican Americans aged 25-75 years with type 2 diabetes. Experimental condition participants received eight weekly, in-home, one-on-one educational and behavior modification sessions with a registered nurse focusing on symptom awareness, glucose self-testing and appropriate treatments, followed by eight biweekly support telephone sessions. Wait-listed control condition participants served as comparisons at three time points. Hierarchical linear modeling was used to evaluate the effects of the intervention between- and within groups on psychosocial, behavioral and clinical outcomes. Participants were predominantly female, middle-aged, moderately acculturated and in poor glycemic control. Experimental group participants (n = 39) significantly improved glycemic control, blood pressure, symptoms, knowledge, self-efficacy, empowerment and quality of life. Post intervention focus groups reported satisfaction with the symptom focus. Addressing symptoms led to clinical and psychosocial improvements. Symptoms seem to be an important motivator and a useful prompt to engage patients in diabetes self-management behaviors to relieve symptoms and prevent complications.

Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes

Background

Many adults with type 1 diabetes cannot self-manage their diabetes effectively and die prematurely with diabetic complications as a result of poor glucose control. Following the positive results obtained from a randomised controlled trial (RCT) by the Dose Adjustment For Normal Eating (DAFNE) group, published in 2002, structured training is recommended for all adults with type 1 diabetes in the UK.

Aim

With evidence that blood glucose control is not always improved or sustained, we sought to determine factors explaining why some patients benefit from training more than other patients, identifying barriers to successful self-management, while developing other models to make skills training more accessible and effective.

Findings

We confirmed that glycaemic outcomes are not always improved or sustained when the DAFNE programme is delivered routinely, although improvements in psychosocial outcomes are maintained. DAFNE courses and follow-up support is needed to help participants instil and habituate key self-management practices such as regular diary/record keeping. DAFNE graduates need structured professional support following training. This is currently either unavailable or provided ad hoc without a supporting evidence base. Demographic and psychosocial characteristics had minimal explanatory power in predicting glycaemic control but good explanatory power in predicting diabetes-specific quality of life over the following year. We developed a DAFNE course delivered for 1 day per week over 5 weeks. There were no major differences in outcomes between this and a standard 1-week DAFNE course; in both arms of a RCT, glycaemic control improved by less than in the original DAFNE trial. We piloted a course delivering both the DAFNE programme and pump training. The pilot demonstrated the feasibility of a full multicentre RCT and resulted in us obtaining subsequent Health Technology Assessment programme funding. In collaboration with the National Institute for Health Research (NIHR) Diabetes Research Programme at King’s College Hospital (RG-PG-0606-1142), London, an intervention for patients with hypoglycaemic problems, DAFNE HART (Dose Adjustment for Normal Eating Hypoglycaemia Awareness Restoration Training), improved impaired hypoglycaemia awareness and is worthy of a formal trial. The health economic work developed a new type 1 diabetes model and confirmed that the DAFNE programme is cost-effective compared with no structured education; indeed, it is cost-saving in the majority of our analyses despite limited glycated haemoglobin benefit. Users made important contributions but this could have been maximised by involving them with grant writing, delaying training until the group was established and funding users’ time off work to maximise attendance. Collecting routine clinical data to conduct continuing evaluated roll-out is possible but to do this effectively requires additional administrator support and/or routine electronic data capture.

Conclusions

We propose that, in future work, we should modify the current DAFNE curricula to incorporate emerging understanding of behaviour change principles to instil and habituate key self-management behaviours that include key DAFNE competencies. An assessment of numeracy, critical for insulin dose adjustment, may help to determine whether or not additional input/support is required both before and after training. Models of structured support involving professionals should be developed and evaluated, incorporating technological interventions to help overcome the barriers identified above and enable participants to build effective self-management behaviours into their everyday lives.

Trial registration

ClinicalTrials.gov NCT01069393.

Funding

The NIHR Programme Grants for Applied Research programme.

A psychoeducational program to restore hypoglycemia awareness: the DAFNE-HART pilot study

OBJECTIVE

To develop and pilot a novel intervention addressing motivational and cognitive barriers to avoiding hypoglycemia in people with type 1 diabetes and persistent impaired awareness of hypoglycemia (IAH) despite training in flexible insulin therapy.

RESEARCH DESIGN AND METHODS

A 6-week intervention using motivational interviewing and cognitive behavioral techniques was designed. Diabetes educators were trained and supported in its delivery to 23 people with IAH (Gold score ≥4).

RESULTS

Twelve months postcourse, hypoglycemia awareness had improved (P < 0.001). Median (range) rates of severe hypoglycemia (SH) fell from 3 (0-104) to 0 (0-3) per person per year (P < 0.0001) and moderate from 14 (0-100) to 0 (0-18) per person per 6 weeks (P < 0.001). Worry and behavior around hyperglycemia improved. HbA1c was unchanged.

CONCLUSIONS

A pilot intervention targeting motivation and cognitions around hypoglycemia engaged patients with resistant IAH and recurrent SH and was associated with significant improvement, supporting the hypothesis that these factors underpin problematic hypoglycemia.

Hypoglycemia in patients with type 1 diabetes: epidemiology, pathogenesis, and prevention

Hypoglycemia is uncommon in the general, nondiabetic population but occurs frequently in persons with diabetes treated with insulin or insulin secretagogues. Thus, iatrogenic hypoglycemia explains the majority of cases among persons with type 1 diabetes (T1DM). Since T1DM is characterized by absolute insulin dependence, the current imperfections in insulin replacement therapies often lead to a mismatch between caloric supply and circulating insulin levels, thus increasing the risk for glycemic fluctuations. Hypoglycemia is the limiting factor to excellent glycemic control in insulin-treated subjects. Intensification of glycemic control was associated with a 300 % increase in the rate of hypoglycemia in the Diabetes Control and Complications Trial. Recent measurements using continuous glucose monitoring reveal an alarming rate of daytime and nocturnal episodes of hypoglycemia in patients with T1DM. Etiological factors underlying hypoglycemia in T1DM include predictable triggers (skipped meals, exercise, insulin over dosage) as well as defective counterregulation, a component of hypoglycemia-associated autonomic failure.

Defective counterregulation and hypoglycemia unawareness in diabetes: mechanisms and emerging treatments

For people with diabetes, hypoglycemia remains the limiting factor in achieving glycemic control. This article reviews recent advances in how the brain senses and responds to hypoglycemia. Novel mechanisms by which individuals with insulin-treated diabetes develop hypoglycemia unawareness and impaired counterregulatory responses are outlined. Prevention strategies for reducing the incidence of hypoglycemia are discussed.

Fear of hypoglycaemia in patients with type 1 diabetes: do patients and diabetologists feel the same way?

AIM

This study described and compared the perception of hypoglycaemia in both patients with type 1 diabetes and diabetologists.

METHODS

This was an observational cross-sectional study undertaken in France in 2011. Data for what hypoglycaemia represents and practices related to it were collected using a questionnaire completed by patients with type 1 diabetes (all>12 years of age) and their diabetologists. Agreement between patients and physicians was evaluated by the intraclass correlation coefficient (ICC) and Gwet's coefficient (GC).

RESULTS

A total of 485 patients were enrolled by 118 diabetologists. Half the patients thought that hypoglycaemia was always symptomatic. According to both patients and diabetologists, hypoglycaemia impaired quality of life, caused anxiety and was disturbing, especially at night. Clinical symptoms of hypoglycaemia (sweating, shakiness, anxiety) were linked to patient's age and diabetes duration. Regarding hypoglycaemia frequency, agreement was good for severe hypoglycaemia (GC: 0.61 and 0.72 for diurnal and nocturnal hypoglycaemia, respectively) and poor for mild hypoglycaemia (ICC: 0.44 and 0.40, respectively). Diabetologists correctly evaluated the impact of hypoglycaemia on quality of life, but overestimated the hypoglycaemia-induced burden and anxiety. Counteractive behaviours were frequent: 23% of patients decreased their insulin dose, 20% increased their sugar intake and 12% ate extra snacks. Diabetologists were generally aware of these measures, but not of how often patients used them.

CONCLUSION

Diabetologists and patients do not share enough information about hypoglycaemia. Fear of hypoglycaemia and counteractive behaviours should be looked for by diabetologists. Systematic advice and specially adapted education should also be provided to increase patients' awareness of hypoglycaemia.

Experiences of using blood glucose targets when following an intensive insulin regimen: a qualitative longitudinal investigation involving patients with Type 1 diabetes

AIMS

Use of blood glucose targets is considered essential to help patients with Type 1 diabetes achieve tight glycaemic control following structured education. To foster effective use of blood glucose targets, we explored patients' experiences and views of implementing clinically recommended blood glucose targets after attending a structured education programme promoting intensive insulin treatment.

METHODS

Repeat, in-depth interviews with 30 patients with Type 1 diabetes recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. Data were analysed using an inductive, thematic approach.

RESULTS

Patients found use of blood glucose targets motivational. Targets enabled patients to identify problems with blood glucose control and prompted them to make insulin dose adjustments independently, or with assistance. However, patients tended to adapt or simplify targets over time to: make them more attainable and easy to remember; reduce risk of hypoglycaemia; and, mitigate feelings of failure when attempts to attain clinically defined targets were unsuccessful. Some patients were advised to use elevated targets to counter hypoglycaemia unawareness and required help from health professionals to determine when/if these should be reduced.

CONCLUSIONS

Although blood glucose targets are an important component of diabetes self-management, patients may adapt and personalize them over time, sometimes inadvertently, with a potentially detrimental impact on long-term glycaemic control. Blood glucose targets should be regularly revisited during clinical reviews and revised/new targets agreed to accommodate patients' concerns and difficulties. Other interventions may need to be considered to promote effective use of blood glucose targets.

Poor cognitive function and risk of severe hypoglycemia in type 2 diabetes: post hoc epidemiologic analysis of the ACCORD trial

OBJECTIVE

Self-management of type 2 diabetes including avoidance of hypoglycemia is complex, but the impact of cognition on safe self-management is not well understood. This study aimed to assess the effect of baseline cognitive function and cognitive decline on subsequent risk of severe hypoglycemia and to assess the effect of different glycemic strategies on these relationships.

RESEARCH DESIGN AND METHODS

Prospective cohort analysis of data from the ACCORD trial included 2,956 adults aged ≥55 years with type 2 diabetes and additional cardiovascular risk factors. Cognitive tests (Digit Symbol Substitution Test [DSST], Rey Auditory Verbal Learning Test, Stroop Test, and Mini Mental Status Examination) were conducted at baseline and 20 months. Study outcomes were incident confirmed severe hypoglycemia requiring medical assistance (HMA) and hypoglycemia requiring any assistance (HAA).

RESULTS

After a median 3.25-year follow-up, a 5-point-poorer baseline score on the DSST was predictive of a first episode of HMA (hazard ratio 1.13 [95% CI 1.08-1.18]). Analyses of the other cognitive tests and of HAA were consistent with the DSST results. Cognitive decline over 20 months increased the risk of subsequent hypoglycemia to a greater extent in those with lower baseline cognitive function (P(interaction) = 0.037). Randomization to an intensive versus standard glycemic strategy had no impact on the relationship between cognitive function and the risk of severe hypoglycemia.

CONCLUSIONS

Poor cognitive function increases the risk of severe hypoglycemia in patients with type 2 diabetes. Clinicians should consider cognitive function in assessing and guiding their patients regarding safe diabetes self-management regardless of their glycemic targets.

Patient experience of hypoglycaemia unawareness in Type 1 diabetes: are patients appropriately concerned?

OBJECTIVE

Risk of severe hypoglycaemia is increased by absence of subjective awareness of hypoglycaemia and reduced by avoidance of minor hypoglycaemia. For many, problems persist despite educational strategies that work for others. We explored psychological factors that might inhibit the efforts of an individual in hypoglycaemia avoidance.

METHODS

People with Type 1 diabetes and hypoglycaemia unawareness gave semi-structured interviews exploring their perceptions and experiences of their condition. Identified factors were grouped into categories and analysed to establish links and form a grounded theory in a constant comparative analysis. A questionnaire was devised from the qualitative analysis to identify patients with problematic beliefs about their hypoglycaemia.

RESULTS

Saturation (no new themes emerging) was reached with 17 patients. Responses fell into two groups: high concern and low concern regarding hypoglycaemia unawareness. Those in the first group described severe hypoglycaemia as aversive and wanted to regain awareness. The second group included three patients in whom unawareness was not associated with severe hypoglycaemia, nevertheless unhelpful attitudes which inhibited hypoglycaemia avoidance were expressed. Responses from this group fell into categories: (1) normalizing the presence of unawareness; (2) underestimating its consequences; (3) wanting to avoiding the 'sick role'; and (4) overestimating the consequences of hyperglycaemia.

CONCLUSIONS

A qualitative analysis of patient interviews identified deficits in education, technology and motivation in hypoglycaemia unawareness. Interventions can therefore be tailored to target underlying problems that prevent individual patients from regaining awareness. A brief assessment tool was devised to categorize patients' hypoglycaemia unawareness accordingly. Psychological interventions should be developed to address the problems of 'low concern' regarding hypoglycaemia unawareness.

Medically minimising the impact of hypoglycaemia in type 2 diabetes: a review

INTRODUCTION

Some therapies for type 2 diabetes (T2DM) are limited by hypoglycaemia, and this underestimated side effect carries an associated morbidity and financial burden. Large trials that have examined strict glycaemic control and cardiovascular outcomes in T2DM have highlighted the potential harm of exposure to hypoglycaemia in people with coronary heart disease.

AREAS COVERED

The responses to, and the morbidity associated with, hypoglycaemia in T2DM are discussed with identification of people most at risk of severe hypoglycaemia. The evidence base for non-pharmacological strategies and the risks of hypoglycaemia associated with various treatment modalities are examined. This review provides the clinician with a rational approach to the selection of different anti-diabetes drugs to minimize the risk of hypoglycaemia.

EXPERT OPINION

When managing T2DM, insulin and insulin secretagogues should be used judiciously and glycaemic targets individualized to avoid hypoglycaemia. Incretin mimetics present a lower risk of hypoglycaemia with similar efficacy as traditional agents in treating hyperglycaemia. The potential relationship between hypoglycaemia and precipitation of acute cardiovascular events is a highly topical area of research and may help determine what glycaemic targets are appropriate in people with T2DM.

Hypoglycemia in type 1 diabetes mellitus

Iatrogenic hypoglycemia, typically the result of the interplay of therapeutic hyperinsulinemia and compromised defenses resulting in hypoglycemia-associated autonomic failure (HAAF) in diabetes, is a problem for people with type 1 diabetes mellitus (T1DM). It causes recurrent morbidity is sometimes fatal, leads to recurrent hypoglycemia, and precludes euglycemia over a lifetime of T1DM. Risk factors include those that result in relative or absolute insulin excess and those indicative of HAAF in diabetes. Elimination of hypoglycemia from the lives of people with T1DM will likely be accomplished by new treatment methods that provide plasma glucose-regulated insulin replacement or secretion.

Sustained efficacy of continuous subcutaneous insulin infusion in type 1 diabetes subjects with recurrent non-severe and severe hypoglycemia and hypoglycemia unawareness: a pilot study

BACKGROUND

This study evaluated the effect of CSII on hypoglycemia awareness and on glucose profile in type 1 diabetes (T1D) subjects with repeated non-severe or severe hypoglycemia (NS or SH, respectively).

METHODS

We included subjects (1) older than 18 years, (2) with T1D duration of >5 years, (3) on multiple doses of insulin, and (4) without micro- or macrovascular complications and more than four NS events per week (in the last 8 weeks) and more than two SH events (in the last 2 years). NS/SH episodes and hypoglycemia awareness were evaluated. A 72-h continuous glucose monitoring (CGM) was performed before continuous subcutaneous insulin infusion (CSII). A hypoglycemia-induced test was used to evaluate each patient's symptoms in euglycemia/hypoglycemia. Quality of life (QoL) was also evaluated. After 6, 12, and 24 months, all the subjects were reevaluated.

RESULTS

Twenty subjects were included (34.0 +/- 7.5 years old, 12 women, A1c 6.7 +/- 1.1%, 16.2 +/- 6.6 years of diabetes' duration). At baseline, 19 out of 20 subjects displayed hypoglycemia unawareness, which diminished significantly during the follow-up (3 out of 20). NH episodes per week diminished from 5.40 +/- 2.09 at baseline to 2.75 +/- 1.74 at the end of the follow-up (P < 0.001). SH episodes fell from 1.25 +/- 0.44 per subject-year to 0.05 +/- 0.22 after 24 months (P < 0.001). Hemoglobin A1c remained unaltered. With CGM, the percentage of values within 70-180 mg/dL increased (53.2 +/- 11.0% to 60.3 +/- 17.1%, P = 0.13), and the percentage of values <70 mg/dL decreased (13.7 +/- 9.4% to 9.1 +/- 5.2%, P = 0.07), after 24 months. Mean amplitude of glycemic excursions diminished after 24 months of CSII (136 +/- 28 mg/dL to 115 +/- 19 mg/dL; P < 0.02). An improvement in all the aspects of QoL was observed. The basal alteration in symptom response to an induced hypoglycemia improved after 24 months of initiating CSII leading to a response indistiguishable from that observed in a control group of subjects with T1D without repeated NH and SH.

CONCLUSIONS

CSII prevents hypoglycemic episodes, improves hypoglycemia awareness, and ameliorates glycemic profile in T1D subjects with repeated NS/SH. Its use is also associated with an improvement in diabetes QoL.

A simple and promising tool to improve self-monitoring of blood glucose in patients with diabetes

AIM

To examine patient formation of implementation plans, a volitional strategy, and its influence on self-monitoring of blood glucose (SMBG).

METHODS

A randomized experimental-control design over a 2-week time period was used. The study population was diabetes patients with HbA1c >7% and requiring insulin therapy. Patients were recruited from a southeastern Michigan healthcare system. A self-administered intervention was designed to assist patients to formulate plans to perform SMBG. The primary outcome measure was SMBG rates. Three control groups were used to control for testing effects. Hypotheses were tested using ANOVA at a significance level of 0.05. SMBG was measured using a 2-week diary and two recall measures.

RESULTS

There were 402 patients with diabetes recruited for the study. Analyses indicated that making implementation plans increased SMBG rates as assessed by a diary and two recall measures. The patients in the experimental group checked their blood sugar up to 7.77 times more than the control groups (sig<0.05) over a 2-week time period as measured by the diary.

CONCLUSIONS

Patient behavior can be impacted by using an implementation planning tool. This technique can help improve patient self-monitoring behavior.

Hypoglycaemia: an overview

Hypoglycaemia is a frequent side-effect of treatment with insulin and sulfonylureas for people with diabetes, threatening potentially serious morbidity and preventing optimal glycaemic control. Fear of hypoglycaemia and development of syndromes such as impaired awareness and counterregulatory deficiency provide additional hazards for intensification of treatment. Rapid lowering of HbA1c may be potentially dangerous in type 2 diabetes because of the adverse cardiovascular effects induced by hypoglycaemia. Hypoglycaemia can disrupt many everyday activities such as driving, work performance and recreational pursuits. Measures to reduce the risk of hypoglycaemia are labour-intensive and require substantial resources.

Blood glucose awareness training delivered over the internet

OBJECTIVE

Blood glucose awareness training (BGAT), a psycho-educational intervention, trains individuals with type 1 diabetes to 1) detect/interpret internal cues to better detect extreme blood glucose levels, e.g., neurogenic and neuroglycopenic symptoms; and 2) interpret external cues to detect current and anticipate future extreme blood glucose levels, e.g., insulin timing/dose and recent self-monitoring of blood glucose results. Although outcome studies using BGAT are significant, limitations include the requirement of eight weekly meetings and limited professionals trained to deliver BGAT.

RESEARCH DESIGN AND METHODS

Due to the limitations mentioned above, BGAT was converted for web-based delivery. The internet allows BGAT delivery to be dynamic, engaging, convenient, and personalized. Efficacy was evaluated using a 2 (BGAThome, n = 20, vs. control, n = 20) x 2 (pre/post) design.

RESULTS

BGAThome was judged as useful and easy to use, was completed by 94% of the participants, and resulted in significant clinical improvements (P < 0.05).

CONCLUSIONS

The internet may be an efficient and effective means of delivering diabetes interventions like BGAT.

Impact of therapeutic advances on hypoglycaemia in type 2 diabetes

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

Averting iatrogenic hypoglycemia through glucose prediction in clinical practice: progress towards a new procedure in diabetes

BACKGROUND

Hypoglycemia is a risk factor common to all insulin therapy. The hypothesis is that efforts to reduce or prevent this adverse side effect may fail because providers generally lack the resources to predict not only future blood glucose levels but also future risks of hypoglycemia. This lack has been remedied. A controlled study was undertaken to test the hypothesis.

METHODS

Twenty-two insulin dependent subjects suffering more than one (1) episode/week of hypoglycemia with similar insulin regimens, similar diabetes education and similar self-management training participated in this study. For all subjects, a remote monitoring resource (registry and database) was used to capture daily SMBG and afford a return path for provider interventions and decision support. Identical telemedical methods were used which differed only for the provider either by the presence (prediction group) or by the absence (control group) of an on-screen, visual display of predicted glycemia and predicted risks of hypoglycemia. The study lasted 2 months.

RESULTS

Over an average of 41 days from baseline to follow up and while using the glycemic prediction resource, providers intervened more effectively in the prediction group reducing rates of hypoglycemia nine-fold (P<0.0001) and insulin therapy by just -9 U/day (P<0.01). Mean pre-meal glycemia was not compromised. Over 61 days from baseline to final follow up but without glycemic predictions in the control group, providers' interventions were less effective and resulted in no net changes in rates of hypoglycemia, daily insulin therapy, or mean pre-meal glycemia.

CONCLUSIONS

Given knowledge of future glycemia and future risks of hypoglycemia, providers in clinical practice can now avert iatrogenic hypoglycemia in less than 2 months. A shared diabetes data center furnishing remote data capture and decision support is fundamental to the implementation of this as a new clinical procedure in diabetes.

Management of diabetes-related hypoglycemia

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