Medical resource use, disturbance of daily life and burden of hypoglycemia in insulin-treated patients with diabetes: results from a European online survey

Adverse Health Outcomes Associated with Hypoglycemia Following Bariatric Surgery

Introduction: Hypoglycemia is prevalent among patients postbariatric surgery, but its clinical implications remain unclear. The purpose of this study was to examine the longitudinal associations of hypoglycemia (i.e., occurrence in the past 3 months, frequency in the past 7 days, number of severe episodes in the past 3 months, and symptoms) with depressive symptoms, quality of life (QoL), work productivity, and weight loss over an 84-month follow-up period after bariatric surgery. Methods: This secondary analysis used data from the Longitudinal Assessment of Bariatric Surgery-2 study. Hypoglycemia, depressive symptoms, QoL, and work productivity were self-reported. Weight was primarily based on objective measures. Linear mixed modeling with time-lagged techniques was used for analysis, adjusting for potential covariates such as age and gender. Results: Across the 84-month follow-up, 20%-30% of participants (N = 552) reported experiencing hypoglycemia in the past 3 months. Hypoglycemia occurrence was positively associated with depressive symptoms [β = 2.4; 95% confidence interval (CI): 1.7, 3.0] and negatively associated with physical (β = -4.2; 95% CI: -5.1, -3.3) and mental QoL (β = -3.4; 95% CI: -4.4, -2.4). These associations became stronger with increased frequency of hypoglycemia, a higher number of severe episodes, and the presence of symptoms. Additionally, hypoglycemia occurrence was associated with several domains of work productivity, including presenteeism (β = 5.8; 95% CI: 3.4, 8.2), work productivity loss (β = 5.6; 95% CI: 2.6, 8.6), and activity impairment (β = 8.8; 95% CI: 6.0, 11.6), with the strength of these associations increasing with greater hypoglycemic frequency. Conclusions: This study highlights the critical role of hypoglycemia in patients' physical and psychosocial well-being postbariatric surgery. Future studies employing more rigorous measures of hypoglycemia and expanded outcomes (e.g. cognitive function) are needed to fully understand its clinical relevance.

Insulin therapy in type 2 diabetes: Insights into clinical efficacy, patient-reported outcomes, and adherence challenges

Insulin therapy plays a crucial role in the management of type 2 diabetes as the disease progresses. Over the past century, insulin formulations have undergone significant modifications and bioengineering, resulting in a diverse range of available insulin products. These products show distinct pharmacokinetic and pharmacodynamic profiles. Consequently, various insulin regimens have em-erged for the management of type 2 diabetes, including premixed formulations and combinations of basal and bolus insulins. The utilization of different insulin regimens yields disparate clinical outcomes, adverse events, and, notably, patient-reported outcomes (PROs). PROs provide valuable insights from the patient's perspective, serving as a valuable mine of information for enhancing healthcare and informing clinical decisions. Adherence to insulin therapy, a critical patient-reported outcome, significantly affects clinical outcomes and is influenced by multiple factors. This review provides insights into the clinical effectiveness of various insulin preparations, PROs, and factors impacting insulin therapy adherence, with the aim of enhancing healthcare practices and informing clinical decisions for individuals with type 2 diabetes.

Severe Hypoglycemia and the Use of Glucagon Rescue Agents: An Observational Survey in Adults With Type 1 Diabetes

Severe hypoglycemia (SH) is the most frequent and potentially serious complication affecting individuals with type 1 diabetes and can have major clinical and psychosocial consequences. Glucagon is the only approved treatment for SH that can be administered by non-health care professionals (HCPs); however, reports on the experiences and emotions of people with type 1 diabetes associated with SH and glucagon rescue use are limited. This survey study demonstrated that an increasing number of individuals with type 1 diabetes have current and filled prescriptions for glucagon and have been educated about glucagon rescue use by an HCP. Despite this positive trend, challenges with SH remain, including a high level of health care resource utilization, considerable out-of-pocket expenses for glucagon kits, a high prevalence of hypoglycemia unawareness, and a negative emotional impact on individuals with diabetes. Nocturnal and exercise-related hypoglycemia were concerns for most survey participants.

Real-World Studies Support Use of Continuous Glucose Monitoring in Type 1 and Type 2 Diabetes Independently of Treatment Regimen

Numerous randomized controlled trials (RCTs) have demonstrated the glycemic benefits of continuous glucose monitoring (CGM) in management of type 1 diabetes (T1D) and type 2 diabetes. Although RCTs remain the gold standard clinical study design, findings from these trials do not necessarily reflect the effectiveness of CGM or reveal the feasibility and wider applications for use in broader real-life settings. This review evaluates recent real-world evidence (RWE) demonstrating the value of CGM to improve clinical outcomes, such as avoidance of severe hypoglycemic and hyperglycemic crises, and improved measures of psychological health and quality of life. Additionally, this review considers recent RWE for the role of CGM to enhance health care resource utilization, including prediction of T1D and applications in gestational diabetes, chronic kidney disease, and monitoring during surgery.

Continuous Glucose Monitoring (CGM) Is a Tool, Not a Reward: Unjustified Insurance Coverage Criteria Limit Access to CGM

Recent studies have demonstrated the clinical utility of continuous glucose monitoring (CGM) use in type 2 diabetes (T2D) patients who are treated with intensive insulin management. Large retrospective database analyses of T2D patients treated with less-intensive therapies have also shown that CGM use was associated with significant reductions in hemoglobin A1c levels and health resource utilization, including diabetes-related hospitalizations and emergency room care. Despite the growing body of evidence supporting CGM use in the broader T2D population, current eligibility criteria required by public and many private insurers are denying millions of individuals with T2D access to this valuable technology. In this article, we discuss an evidence-based rationale for modifying current eligibility requirements for CGM coverage.

The impact of hypoglycaemia on quality of life outcomes among adults with type 1 diabetes: A systematic review

Hypoglycaemia is a common barrier to optimal glycaemic management and often feared among adults with type 1 diabetes. The aim of this systematic review was to summarize current evidence regarding the impact of hypoglycaemia on quality of life (QoL) and related outcomes. Electronic searches of MEDLINE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials were conducted. Peer-reviewed empirical studies investigating the relationship between hypoglycaemia and QoL were eligible for inclusion. Thirty studies met the inclusion criteria. Extracted data was summarized in a narrative synthesis according to Synthesis Without Meta-Analysis guidelines. None of the studies examined the impact of hypoglycaemia on general QoL. There was no association between hypoglycaemia and diabetes-specific QoL in four of the 30 studies. Severe hypoglycaemia was associated with greater fear of hypoglycaemia and diabetes distress, and lower general emotional well-being, but not with depression, anxiety, or health status. Self-treated hypoglycaemia was associated with greater fear of hypoglycaemia. With the exception of fear of hypoglycaemia, this review shows mixed associations between hypoglycaemia and psychological outcomes. Further research is needed to investigate the impact of hypoglycaemia on other domains of QoL.

Human factors studies of a prefilled syringe with stable liquid glucagon in a simulated severe hypoglycemia rescue situation

Background: Two human factors studies evaluated whether a stable liquid formulation of glucagon in a prefilled syringe (G-PFS) could be safely and effectively administered and evaluated the effectiveness of the product label guide and instructions-for-use (IFU). Research design and methods: In a formative study, 11 participants received orientation with the G-PFS instructional materials and performed a single unaided rescue attempt. In the validation study, 75 adult and adolescent participants received training or familiarized themselves with the G-PFS IFU, Label Guide, and device. All participants returned 1 week later to perform a single unaided rescue attempt of a simulated person with diabetes suffering from an emergency severe hypoglycemic event. Results: The formative study resulted in a 100% success rate across all rescue dose attempts. The validation study resulted in 74/75 (99%) of participants successfully using the G-PFS to administer the full glucagon rescue dose, and validated that intended users could learn from, comprehend, and recall the G-PFS instructions to successfully use the product. Conclusion: The G-PFS provides a familiar, easy-to-use alternative to currently marketed lyophilized glucagon kits for treating severe hypoglycemia. The G-PFS IFU and Label Guide enable even untrained users to successfully administer a full rescue dose of stable liquid glucagon.

Estimating the Impact of Diabetes Mellitus on Worker Productivity Using Self-Report, Electronic Health Record and Human Resource Data

OBJECTIVE

We assessed the relationship between diabetes mellitus (DM) and measures of worker productivity, direct health care costs, and costs associated with lost productivity (LP) among health care industry workers across two integrated health care systems.

METHODS

We used data from the Value Based Benefit Design Health and Wellness Study Phase II (VBD), a prospective study of employees surveyed across health systems. Survey and health care utilization data were linked to estimate LP and health care utilization costs.

RESULTS

Mean marginal lost productive time per week was 0.56 hours higher for respondents with DM. Mean adjusted monthly total health care utilization costs were $467 higher for respondents with DM.

CONCLUSION

The impact of DM is reflected in higher rates of LP and higher indirect costs for employers related to LP and higher health care resource use.

Chitosan oligosaccharide (GO2KA1) improves postprandial glycemic response in subjects with impaired glucose tolerance and impaired fasting glucose and in healthy subjects: a crossover, randomized controlled trial

BACKGROUND

The antidiabetic and hypoglycemic effects of chitosan have been reported in previous studies. We have previously shown that chitosan oligosaccharide reduces postprandial blood glucose levels in vivo. We conducted a short-term crossover study to support the results of the previous study.

METHODS

The study was a randomized, double-blind, controlled crossover trial completed at one clinical research site. Subjects with impaired glucose tolerance and impaired fasting glucose and healthy subjects were randomly assigned to consume one of two different experimental test capsules that differed in only the sample source (GO2KA1 vs placebo), and all subjects were instructed to consume the 75 g sucrose within 15 min. After a 7-day interval, the subjects consumed the other capsules that were not consumed on the first day. We assessed blood glucose levels using a 2-h oral sucrose tolerance test. The study was registered at clinicaltrials.gov (NCT03650023).

RESULTS

The test group showed significantly lower blood glucose levels at 60 min (p = 0.010) and postprandial blood glucose areas under the curve (p = 0.012). The change in blood glucose levels at 60 min was significantly lower in the test group than in the placebo group (p = 0.017).

CONCLUSIONS

Based on the results of this study, the consumption of chitosan oligosaccharide (GO2KA1) supplements with a meal can effectively reduce postprandial blood glucose levels, which is relevant to the prevention of diabetes.

Human Factors Usability and Validation Studies of a Glucagon Autoinjector in a Simulated Severe Hypoglycemia Rescue Situation

Background: A room-temperature stable, soluble liquid glucagon formulation loaded into a prefilled, single-use, two-step autoinjector is under development for severe hypoglycemia rescue. We report a human factors validation program evaluating the glucagon autoinjector (GAI) (Gvoke HypoPen™; Xeris Pharmaceuticals, Inc., Chicago, IL) versus marketed glucagon emergency kits (GEKs) for managing severe hypoglycemia. Methods: A simulated-use human factors usability study was conducted with the GAI versus marketed GEKs in 16 participants, including adult caregivers and first responders, experienced with glucagon administration. A summative human factors validation study of the GAI was conducted with 75 volunteers. Participants were (1) trained on the device and procedure or (2) given time to individually read the instructions and familiarize themselves with the device. Participants returned a week later to perform an unaided rescue attempt that simulated rescue of patients with diabetes suffering a hypoglycemia emergency. Participant actions were recorded for critical rescue tasks and use errors. Results: In the usability study, 88% (14) successfully administered a rescue injection using the GAI versus 31% (5) using GEKs (P < 0.05). Mean total rescue time of use was 47.9 s with the GAI versus 109.0 s with GEKs (P < 0.05). In the validation study, 98.7% successfully administered the rescue injection using the GAI. Overall, there were no patterns of differences between trained versus untrained participants, between caregivers versus first responders or between adults versus adolescents. Conclusion: The GAI and instructional materials can be correctly, safely, and effectively used by intended user, which support continued development of the GAI as an alternative to GEKs.

Cost-Effectiveness of Insulin Degludec vs. Insulin Glargine U100 in Type 1 and Type 2 Diabetes Mellitus in a UK Setting

BACKGROUND

Understanding which therapeutic innovations in diabetes represent the best value requires rigorous economic evaluation. Data from randomised controlled trials and observational studies indicate that insulin degludec has a hypoglycemia advantage versus insulin glargine 100 units/mL (glargine U100), the most widely prescribed basal insulin analogue in the UK. This analysis was done to more rigorously assess cost-effectiveness in a UK setting.

METHODS

Data from two double-blinded, randomised, two-period crossover trials in type 1 (SWITCH 1) and type 2 (SWITCH 2) diabetes mellitus were used to assess the cost-effectiveness of degludec vs. glargine U100 with an economic model. Cost-effectiveness was analysed over a 1-year time horizon based on the different rates of hypoglycaemia and actual doses of insulin used, rather than glycaemic control due to the treat-to-target trial design.

RESULTS

In type 1 diabetes mellitus, degludec was highly cost-effective compared with glargine U100, with an incremental cost-effectiveness ratio of £984 (increased costs of only £23/year and improvement in participant health of 0.0232 quality-adjusted life-years (QALYs)). In type 2 diabetes mellitus, it was estimated that quality of life was improved (0.0065 QALYs gain) with degludec compared with glargine U100 at an increased annual cost of £117 (incremental cost-effectiveness ratio, £17,939). One-way sensitivity analyses showed that the results were robust to changes in parameters in both type 1 and type 2 diabetes mellitus.

CONCLUSIONS

The rigorous design of the SWITCH trials, coupled with a representative patient population and a definition of hypoglycaemia that is relevant for real-world patients, makes the results of these trials highly generalisable. The within-trial analysis has the added value of being able to include doses and event rates directly from the trials. This short-term economic analysis estimated that IDeg would be cost-effective relative to IGlar U100 in both type 1 and type 2 diabetes mellitus in the UK.

TRIAL REGISTRATION

SWITCH 1 (NCT02034513); SWITCH 2 (NCT02030600).

FUNDING

Novo Nordisk, Søborg, Denmark.

Recurrent hospitalizations for severe hypoglycemia and hyperglycemia among U.S. adults with diabetes

AIMS

Examine 30-day readmissions for recurrent hypoglycemia and hyperglycemia in a national cohort of adults with diabetes.

METHODS

Retrospective analysis of data from OptumLabs Data Warehouse for all adults with diabetes hospitalized January 1, 2009 to December 31, 2014 with a principal diagnosis of hypoglycemia or hyperglycemia. We examined the rates and risk factors of 30-day readmissions for hypoglycemia and hyperglycemia.

RESULTS

After 6419 index hypoglycemia hospitalizations, 1.2% were readmitted for recurrent hypoglycemia, 0.2% for hyperglycemia, and 8.6% for other causes. Multimorbidity was the strongest predictor of recurrent hypoglycemia. After 6872 index hyperglycemia hospitalizations, 4.0% were readmitted for recurrent hyperglycemia, 0.4% for hypoglycemia, and 5.4% for other causes. Recurrent hyperglycemia was less likely in older patients (OR 0.6, 95% CI 0.5-0.9 for 45-64 vs. <45 years) and with the addition of a new glucose-lowering medication at index discharge (OR 0.40; 95% CI 0.2-0.7). New hypoglycemia readmissions were most likely among patients ≥75 years (OR 13.3, 95% CI 2.4-73.4, vs. <45 years).

CONCLUSIONS

Patients hospitalized for hyperglycemia are often readmitted for recurrent hyperglycemia, while patients hospitalized for hypoglycemia are generally readmitted for unrelated causes. Early recognition of high risk patients may identify opportunities to improve post-discharge management and reduce these events.

Impact of hypoglycemic episodes on health-related quality of life of type-2 diabetes mellitus patients: development and validation of a specific QoLHYPO© questionnaire

Background

Hypoglycemia is a limiting factor to achieving optimal glycemic control in patients with type-2 diabetes mellitus (T2DM), increasing risk of death and complications, reducing health-related quality of life (HRQoL) and work productivity and increasing healthcare costs.

The study’s primary objective was to develop and validate a specific questionnaire to assess the impact of hypoglycemia on the HRQoL of T2DM patients (QoLHYPO^© questionnaire).

Methods

A two-phase multicenter prospective, longitudinal, observational, epidemiologic study of consecutively enrolled patients, not involving any drug, was conducted: In phase 1 (questionnaire development), patients who had given their written informed consent, who were at least 30 years of age, had been diagnosed with T2DM at least 5 years prior, had an HbA1c test in the previous 3 months, and a hypoglycemic episode in the previous 6 months were included. To validate the questionnaire and assess reliability and responsiveness, phase 2 included two cohorts of patients. Patients in the reliability cohort would likely have stable clinical course during the 3 weeks following inclusion in the study and patients in the responsiveness cohort would likely experience changes in their clinical course in the 3 months after enrollment.

Results

Phase 1 included 168 patients: 10 attended semi-structured interviews, 18 for face validity, and 140 for the pilot test (Rasch analysis). Phase 2 included 227 patients: 142 in the reliability cohort and 85 in the responsiveness cohort.

Of the 37 items initially included in Phase 1, 11 (floor/ceiling effect analysis) and 13 (Rasch analysis) were discarded. The final version of the questionnaire consisted of 13 items.

Phase 2 results showed the questionnaire was unidimensional and able to accurately assess HRQoL. Intra-observer reproducibility (ICC = 0.920) and internal consistency (Cronbach’s alpha: visit 1 = 0.912; visit 2 = 0.901) were high, showing high reliability. Internal responsiveness was moderate (standardized effect size 0.5-0.8) and external responsiveness was lower (AUC > 0.5; not statistically significant). Minimal clinically important difference (MCID) was estimated to be 3.2 points.

Conclusions

The QoLHYPO^© questionnaire is a tool that can be used in routine clinical practice to assess the impact of hypoglycemia on the HRQoL of T2DM patients.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0875-1) contains supplementary material, which is available to authorized users.

The economic impact of insulin-related hypoglycemia in Denmark: an analysis using the Local Impact of Hypoglycemia Tool

AIMS

To estimate the direct cost of hypoglycemia in insulin-treated adults with type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in Denmark.

MATERIALS AND METHODS

The Local Impact of Hypoglycemia Tool (LIHT) was used to estimate the costs associated with insulin-related hypoglycemia. Average utilization of healthcare resources, including the costs of pre-hospitalization, hospital admission, healthcare professional contact and follow-up, glucose/glucagon, and extra SMBG tests to monitor blood glucose following an episode, was used to calculate an average cost per severe and per non-severe hypoglycemic episode. The cost per episode was then applied to the rates of severe and non-severe hypoglycemia in people with T1DM and T2DM in Denmark.

RESULTS

The direct cost of insulin-related hypoglycemia in Denmark is DKK 96.2 million per year, which equates to EUR 12.9 million. For people with T1DM prone to severe hypoglycemia (defined as having ≥2 severe episodes in the past year), the cost per person per year increases by DKK 4,155 compared with the T1DM population average, and for people with T2DM prone to non-severe hypoglycemia (defined as having ≥1 non-severe episode in the last 4 weeks), the cost increases by DKK 647 per person per year compared with the T2DM population average.

CONCLUSIONS

The LIHT highlights the substantial economic burden of insulin-related hypoglycemia in Denmark, and provides a means to estimate the savings that could be made by lowering hypoglycemia rates. For example, the costs associated with using a new insulin or introducing a patient education program could be offset with the cost saving from reducing hypoglycemia.

Cost-effectiveness of switching to insulin degludec from other basal insulins: evidence from Swedish real-world data

OBJECTIVES

Health economic analysis from a healthcare and societal point of view was conducted to assess the cost-effectiveness of insulin degludec (IDeg) after switching from other basal insulins in people with type 1 diabetes.

MATERIAL AND METHODS

This was a prospective, open-label, single arm, observational follow-up from August 2013 to October 2015 of 476 consecutive patients at Danderyd Hospital (Stockholm, Sweden) who switched to IDeg from other basal insulins (99% basal insulin analogs). The IMS CORE Diabetes Model (CDM) was used to predict the cost-effectiveness of life-long treatment with IDeg vs. other basal insulins, based on a Swedish setting.

RESULTS

Mean (SD) duration of follow-up was 21.7 (6.0) weeks. Mean HbA_1c decreased by 2.7 mmol/mol, mean basal insulin dose decreased by 13.1% (p < .0001), and mean bolus insulin dose decreased by 7.5% (p < .0001) after switching. Frequencies of non-severe daytime hypoglycemia and non-severe nocturnal hypoglycemia decreased by 12% (p = .0127) and 53% (p < .0001) respectively and severe hypoglycemia was reduced by 62% (p = .0225). The CDM predicted a gain in life expectancy of 0.33 years, a discounted gain in quality-adjusted life-years (QALYs) of 0.54, and lower estimated direct lifetime healthcare costs of SEK 22,757 for patients switching to IDeg. The incremental cost-effectiveness ratio (ICER) showed IDeg as dominant (i.e. higher effectiveness with a lower cost). Sensitivity analyses confirmed the results.

CONCLUSION

Based on this prospective, real-world, follow-up and using the CDM, it was estimated that switching to IDeg from other basal insulins translated into QALY gains including improved life expectancy and health-related quality of life, as well as dominant ICER, meaning cost-savings for the healthcare system. However, the study is limited by its observational design. Extrapolation into the future is only estimated since the actual treatment effect cannot be projected with certainty.

Healthcare resource use, direct and indirect costs of hypoglycemia in type 1 and type 2 diabetes, and nationwide projections. Results of the HYPOS-1 study

BACKGROUND AND AIMS

To obtain an accurate picture of the total costs of hypoglycemia, including the indirect costs and comparing the differences between type 1 (T1DM) and type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

HYPOS-1 was a multicenter, retrospective cohort study which analyzed the data of 2229 consecutive patients seen at 18 diabetes clinics. Data on healthcare resource use and indirect costs by diabetes type were collected via a questionnaire. The domains of inpatient admission and hospital stay, work days lost, and third-party assistance were also explored. Resource utilization was reported as estimated incidence rates (IRs) of hypoglycemic episodes per 100 person-years and estimated costs as IRs per person-years. For every 100 patients with T1DM, 9 emergency room (ER) visits and 6 emergency medical service calls for hypoglycemia were required per year; for every 100 patients with T2DM, 3 ER visits and 1 inpatient admission were required, with over 3 nights spent in hospital. Hypoglycemia led to 58 work days per 100 person-years lost by the patient or a family member in T1DM versus 19 in T2DM. The costs in T1DM totaled €90.99 per person-year and €62.04 in T2DM. Direct and indirect costs making up the total differed by type of diabetes (60% indirect costs in T1DM versus 43% in T2DM). The total cost associated with hypoglycemia in Italy is estimated to be €107 million per year.

CONCLUSIONS

Indirect costs meaningfully contribute to the total costs associated with hypoglycemia. As compared with T1DM, T2DM requires fewer ER visits and incurs lower indirect costs but more frequent hospital use.

The Effect of Canagliflozin, a Sodium Glucose Cotransporter 2 Inhibitor, on Glycemic End Points Assessed by Continuous Glucose Monitoring and Patient-Reported Outcomes Among People With Type 1 Diabetes

OBJECTIVE

To assess the effects of canagliflozin, a sodium glucose cotransporter 2 inhibitor, on glycemic parameters and measures of glucose variability assessed by a 9-point self-monitoring blood glucose (SMBG) and continuous glucose monitoring (CGM) profiles, and patient-reported outcomes as an add-on to insulin among participants with type 1 diabetes.

RESEARCH DESIGN AND METHODS

In this randomized, double-blind study, 351 participants received canagliflozin 100 or 300 mg or placebo for 18 weeks. Change from baseline in daily mean glucose and SD was measured using a 9-point SMBG profile. In a subset of 89 participants who underwent CGM, the change from baseline in mean glucose, measures of glycemic variability (SD, coefficient of variation, and mean amplitude of glycemic excursions), and time spent in glycemic ranges were assessed. Change in treatment satisfaction was evaluated using the Diabetes Treatment Satisfaction Questionnaire (n = 328).

RESULTS

At week 18, reductions in daily mean glucose and SD measured using the 9-point SMBG profile were seen with canagliflozin 100 and 300 mg versus placebo. Reductions in mean glucose (-1.2, -0.7, and 0.6 mmol/L) and measures of glycemic variability assessed by CGM, such as changes in glucose SD (-0.3, -0.7, and 0.1 mmol/L), were also seen with canagliflozin 100 and 300 mg versus placebo, respectively. Canagliflozin 100 and 300 mg were associated with increases in time spent within target (glucose >3.9 to ≤10.0 mmol/L) compared with placebo (11.6%, 10.1%, and -3.5%, respectively) and commensurate reductions in time spent above the target level (glucose >10.0 mmol/L; -12.7%,-7.6%, and 5.7%, respectively). Participants showed greater improvement in treatment satisfaction with canagliflozin versus placebo; reductions in insulin dose, SD of glucose, and body weight contributed to the relationship between canagliflozin and satisfaction change.

CONCLUSIONS

Canagliflozin improved indices of glycemic variability and was associated with improvement in treatment satisfaction versus placebo over 18 weeks among participants with type 1 diabetes. Although these data from this study demonstrate the potential benefits of canagliflozin in people with type 1 diabetes, canagliflozin is not approved for the treatment of type 1 diabetes and should not currently be used in people with type 1 diabetes.

Hypoglycemia and diabetes: increased need for awareness

Hypoglycemia is an abnormally low plasma glucose concentration that may expose individuals to potential harm. It is associated with treatment of type 1 diabetes and type 2 diabetes. Diabetes-related hypoglycemia may result in various complications, reduced quality of life, and increased costs. Hypoglycemia, therefore, impacts patient management and must be considered by primary healthcare practitioners at the forefront of diabetes care. This paper reviews the impact of hypoglycemia on patients and healthcare practitioners in the clinical setting. Recognizing hypoglycemia and its risk factors and identifying high-risk patients can assist with prevention and management. Prevention rather than treatment of hypoglycemia is preferable by individualizing glycemic goals, considering hypoglycemia risk factors, and continuing professional support. Education of patients and healthcare practitioners is also a key factor in hypoglycemia prevention. Although several newer-generation therapies and treatment strategies for type 2 diabetes have a lower risk of hypoglycemia than established agents, long-term safety data are currently lacking. Thus, choice of therapy is important, with hypoglycemic risk varying according to drug selection.

Self-Treated Hypoglycemia in Type 2 Diabetes Mellitus: Results from the Second Wave of an International Cross-Sectional Survey

INTRODUCTION

The aim of this study was to assess the total frequency of self-treated hypoglycemia in type 2 diabetes mellitus patients using regimens including basal insulin analogs, and to describe the psychological impact and behavioral response to these events from the perspective of patients and prescribers (i.e., hospital specialists and primary care physicians).

METHODS

The global attitude of patients and physicians 2 (GAPP2) survey was an online multinational, cross-sectional survey of patients with type 2 diabetes mellitus treated with basal insulin analogs, with or without bolus insulin. Prescribers directly involved in the care of these patients were also surveyed. Here, we report the results of the second wave of the GAPP2 survey, in which the primary variable of interest was self-treated hypoglycemia.

RESULTS

A total of 855 patients and 1003 prescribers, from 7 countries, completed the survey. Overall, 28% of patients had experienced self-treated hypoglycemia during the previous 30 days, with two-thirds of events occurring during the day and one-third of events occurring nocturnally. Prescribers reported discussing events with 55% of patients over this period. Patients worried about self-treated hypoglycemia in a range of situations, and prescribers under-estimated this worry. Many patients who had experienced self-treated hypoglycemia in the last 30 days reported missing (19%), mistiming (7%), or reducing (7%) their basal insulin dose as a result.

CONCLUSION

Self-treated hypoglycemia was relatively common in patients using basal insulin analogs, with or without bolus insulin. Whilst the frequency of hypoglycemia was greater during the daytime than at night, patients worried more about nocturnal events and this level of worry was under-estimated by physicians. Additional advice and support may be needed for both patients and prescribers, to reduce the frequency and impact of self-treated hypoglycemia.

FUNDING

Novo Nordisk.

Hypoglycemia and Medical Expenses in Patients with Type 2 Diabetes Mellitus: An Analysis Based on the Korea National Diabetes Program Cohort

Background and Aims

Hypoglycemia is one of the most important adverse events in individuals with type 2 diabetes mellitus (T2DM). However, hypoglycemia-related events are usually overlooked and have been documented less in clinical practice.

Materials and Methods

We evaluated the incidence, clinical characteristics, and medical expenses of hypoglycemia related events in T2DM patients based on the Korea National Diabetes Program (KNDP), which is the largest multi-center, prospective cohort in Korea (n = 4,350). For accurate outcomes, the KNDP data were merged with claims data from the Health Insurance Review and Assessment Service (HIRA) of Korea.

Results

During a median follow-up period of 3.23 years (95% CI: 3.14, 3.19), 88 subjects (2.02%) were newly diagnosed with hypoglycemia, and the incidence of hypoglycemia was 6.44 cases per 1,000 person-years (PY). Individuals with hypoglycemia were significantly older (59.7±10.7 vs. 53.3±10.4 years, p < 0.001), had more hospital visits (121.94±126.88 days/PY, p < 0.001), had a longer hospital stays (16.13±29.21 days/PY, p < 0.001), and incurred greater medical costs ($2,447.56±4,056.38 vs. $1,336.37±3,403.39 /PY, p < 0.001) than subjects without hypoglycemia.

Conclusion

Hypoglycemia-related events were infrequently identified among the medical records of T2DM subjects. However, they were associated significantly with poor clinical outcomes, and thus, hypoglycemia could have a substantial burden on the Korean national healthcare system.

Drug-related risk of severe hypoglycaemia in observational studies: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) leads to multiple complications, including severe hypoglycaemia events (SHEs). SHEs can impact a patient's quality of life and compliance and may directly result in additional costs to the health care system. The aim of this review was to evaluate the risk of severe hypoglycaemia in patients with type 1 (T1) and 2 (T2) DM as observed in everyday clinical practice for various drug regimens.

METHODS

We conducted a systematic review of observational (retrospective or prospective) studies in the MEDLINE, Embase, and Cochrane Library databases that covered at least 100 children or adults with T1/T2 DM. In T1 DM, basal-bolus/pre-mix insulin (human or analogue) and insulin pump were reviewed, and in T2 DM, basal-bolus/pre-mix insulin (human or analogue), oral antidiabetic drugs supported with basal insulin (human or analogue), sulfonylureas in monotherapy, and combined oral treatment were reviewed. In order to estimate SHE rates, we extracted data on the time horizon of the study, number of patients, number of SHEs, and number of patients experiencing at least one SHE. We used a random effects model to estimate the annual SHE rate. We considered the risk for other antidiabetic medications in T2 DM to be negligible and the results of our main review yielded no observational data for premixes in T1 DM so they were assessed based on relative rates taken from additional systematic reviews. The study, being a desk research, did not involve any human subjects (including human material or human data) and no ethical committee approval was asked for. For the same reason there was no need to collect informed consent for participation in the study.

RESULTS

We identified 76 observational studies encompassing 707,722.30 patient-years. The estimated annual SHE rate varied from 0.168 (95 % CI 0.123-0.237) for insulin pump up to 1.628 for biphasic human insulin in T1 DM patients, and from 0.0035 for oral antidiabetic drugs up to 0.554 (95 % CI 0.157-7.534) for basal-bolus with human insulin in T2 DM patients.

CONCLUSIONS

Our review indicates that SHE rates differ between patients depending on treatment regimen. However, SHEs are also driven by other factors. Proper modelling techniques are needed to use various types of information in published studies.

Recognizing and minimizing hypoglycemia: The need for individualized care

Hypoglycemia is a condition known to disrupt many everyday activities and is associated with increased risks of hospitalization, falls, motor vehicle accidents and mortality. Many patients with diabetes have an increased risk of hypoglycemia due to interventions targeting glycemic control. In these patients, hypoglycemia and fear of hypoglycemia may further reduce adherence to glucose-lowering regimens, contributing to the further aggravation of diabetes-related complications. Avoiding hypoglycemia should be one of the principal goals of any treatment strategies employing agents that can induce hypoglycemia in order to prevent the occurrence of associated symptoms and consequences. The education of patients and their families is an important feature of individualized management strategies in order to prevent, mitigate and treat hypoglycemic episodes. Patients with diabetes need to be made aware of how to recognize the signs of hypoglycemia and of the simple, highly effective steps that they can take to self-manage hypoglycemic episodes. Clinicians should be familiar with the risk factors for hypoglycemia, especially the profiles of the different classes of glucose-lowering medications such as the sulfonylureas and insulin. This article aims to review the risk factors for hypoglycemia and its implications for patients and healthcare systems, and provide practical advice for minimizing the risk of hypoglycemia and its consequences.

Economic resources consumption structure in severe hypoglycemia episodes: a systematic review and meta-analysis

Diabetes mellitus (DM) is associated with severe hypoglycemia events (SHEs) that vary in severity and resource consumption. Here we perform a systematic review in Medline of studies evaluating SHE-related health resource use. Eligible studies investigated patients with DM and included ≥10 SHEs. We also assessed studies identified in another systematic review, and through references from the included studies. We identified 14 relevant studies and used data from 11 (encompassing 6075 patients). Study results were interpreted to fit our definitions, which sometimes required assumptions. SHE type structure was synthesized using Bayesian modeling. Estimating Type 1 & 2 DM separately revealed only small differences; therefore, we used joint results. Of the analyzed SHEs, 9.97% were hospital-treated, 22.3% medical professional-treated, and 67.73% family-treated. These meta-analysis results help in understanding the structure of resource consumption following SHE and can be used in economic studies.

Glycemic Variability and Diabetes Complications: Does It Matter? Simply Put, There Are Better Glycemic Markers!

There is no argument that improving mean levels of glycemic control as judged by assays for glycated hemoglobin (HbA(1c)) reduces the risks of microvascular complications and cardiovascular disease events in patients with type 1 and type 2 diabetes. However, observations in some trials have suggested that targeting HbA(1c) to suggested targets may not always result in improved outcomes for people with long-standing type 2 diabetes. The reasons why the glycemic control strategies that primarily use HbA(1c) in these studies did not have predicted outcomes are not clear. Thus, controversy remains as to whether there are glycemic metrics beyond HbA(1c) that can be defined as effective measures that can be used in addition to HbA(1c) to help in assessing the risk of an individual developing diabetes complications. In this regard, the concept of "glycemic variability" (GV) is one metric that has attracted a lot of attention. GV can be simply defined as the degree to which a patient's blood glucose level fluctuates between high (peaks) and low (nadir) levels. The best and most precise way to assess GV is also one that is still debated. Thus, while there is universal agreement that HbA(1c) is the current gold standard for the primary clinical target, there is no consensus as to whether other proposed glycemic metrics hold promise to provide additional clinical data or whether there should be additional targets beyond HbA(1c). Therefore, given the current controversy, we provide a Point-Counterpoint debate on this issue. In the preceding point narrative, Dr. Hirsch provides his argument that fluctuations in blood glucose as assessed by GV metrics are deleterious and control of GV should be a primary treatment target. In the counterpoint narrative below, Dr. Bergenstal argues that there are better markers to assess the risk of diabetes than GV and provides his consideration of other concepts.

Sotagliflozin, a Dual SGLT1 and SGLT2 Inhibitor, as Adjunct Therapy to Insulin in Type 1 Diabetes

OBJECTIVE

To assess the safety and efficacy of dual sodium-glucose cotransporter (SGLT) 1 and SGLT2 inhibition with sotagliflozin as adjunct therapy to insulin in type 1 diabetes.

RESEARCH DESIGN AND METHODS

We treated 33 patients with sotagliflozin, an oral dual SGLT1 and SGLT2 inhibitor, or placebo in a randomized, double-blind trial assessing safety, insulin dose, glycemic control, and other metabolic parameters over 29 days of treatment.

RESULTS

In the sotagliflozin-treated group, the percent reduction from baseline in the primary end point of bolus insulin dose was 32.1% (P = 0.007), accompanied by lower mean daily glucose measured by continuous glucose monitoring (CGM) of 148.8 mg/dL (8.3 mmol/L) (P = 0.010) and a reduction of 0.55% (5.9 mmol/mol) (P = 0.002) in HbA1c compared with the placebo group that showed 6.4% reduction in bolus insulin dose, a mean daily glucose of 170.3 mg/dL (9.5 mmol/L), and a decrease of 0.06% (0.65 mmol/mol) in HbA1c. The percentage of time in target glucose range 70-180 mg/dL (3.9-10.0 mmol/L) increased from baseline with sotagliflozin compared with placebo, to 68.2% vs. 54.0% (P = 0.003), while the percentage of time in hyperglycemic range >180 mg/dL (10.0 mmol/L) decreased from baseline, to 25.0% vs. 40.2% (P = 0.002), for sotagliflozin and placebo, respectively. Body weight decreased (1.7 kg) with sotagliflozin compared with a 0.5 kg gain (P = 0.005) in the placebo group.

CONCLUSIONS

As adjunct to insulin, dual SGLT1 and SGLT2 inhibition with sotagliflozin improved glycemic control and the CGM profile with bolus insulin dose reduction, weight loss, and no increased hypoglycemia in type 1 diabetes.

Health-economic analysis of real-time continuous glucose monitoring in people with Type 1 diabetes

AIM

To evaluate the clinical benefits and cost-effectiveness of the sensor-augmented pump compared with self-monitoring of plasma glucose plus continuous subcutaneous insulin infusion in people with Type 1 diabetes.

METHODS

The CORE Diabetes Model was used to simulate disease progression in a cohort of people with baseline characteristics taken from a published meta-analysis. Direct and indirect costs for 2010-2011 were calculated from a societal payer perspective, with cost-effectiveness calculated over the patient's lifetime. Discount rates of 3% per annum were applied to the costs and the clinical outcomes.

RESULTS

Use of the sensor-augmented pump was associated with an increase in mean discounted, quality-adjusted life expectancy of 0.76 quality-adjusted life years compared with continuous subcutaneous insulin infusion (13.05 ± 0.12 quality-adjusted life years vs 12.29 ± 0.12 quality-adjusted life years, respectively). Undiscounted life expectancy increased by 1.03 years for the sensor-augmented pump compared with continuous subcutaneous insulin infusion. In addition, the onset of complications was delayed (by a mean of 1.15 years) with use of the sensor-augmented pump. This analysis resulted in an incremental cost-effectiveness ratio of 367,571 SEK per quality-adjusted life year gained with the sensor-augmented pump. The additional treatment costs related to the use of the sensor-augmented pump were partially offset by the savings attributable to the reduction in diabetes-related complications and the lower frequency of self-monitoring of plasma glucose.

CONCLUSIONS

Analysis using the CORE Diabetes Model showed that improvements in glycaemic control associated with sensor-augmented pump use led to a reduced incidence of diabetes-related complications and a longer life expectancy. Use of the sensor-augmented pump was associated with an incremental cost-effectiveness ratio of 367,571 SEK per quality-adjusted life year gained, which is likely to represent good value for money in the treatment of Type 1 diabetes in Sweden.

Fear of hypoglycemia and its determinants in insulin-treated patients with type 2 diabetes mellitus

The aim of the present study was to investigate the prevalence of fear of hypoglycemia, in association with severe hypoglycemia and social factors, in insulin-treated patients with type 2 diabetes mellitus. A questionnaire survey on hypoglycemia and patient–physician communication was carried out in 355 patients with insulin-treated type 2 diabetes mellitus patients at 16 hospitals and clinics. A fear of hypoglycemia was reported by 27.7% of patients. A stepwise logistic regression analysis found that severe hypoglycemia during the past 1 year was a significant determinant of fear of hypoglycemia (odds ratio 2.16, 95% confidence interval 1.06–4.41; P = 0.034), and age (odds ratio 1.02, 95% confidence interval 1.00–1.05, P = 0.038) and living alone (odds ratio 1.93, 95% confidence interval 1.00–3.73, P < 0.05) were significantly higher in patients with fear of hypoglycemia than in those without it.

Association between hypoglycemia and fall-related events in type 2 diabetes mellitus: analysis of a U.S. commercial database

BACKGROUND

Hypoglycemia is a major barrier to achieving optimal glycemic control and managing diabetes successfully in patients with diabetes. Falls are the most significant consequences caused by hypoglycemia episodes. Both hypoglycemia and falls lead to substantial economic burden on the health care system in the United States.

OBJECTIVE

To examine the association of hypoglycemia with fall-related outcomes in elderly patients with type 2 diabetes mellitus (T2DM).

METHODS

Records were obtained for T2DM patients (N = 1,147,937) from January 1, 2008, to December 31, 2011. The nonhypoglycemia patients were randomly matched 1:1 by age and gender to the hypoglycemia patients. Fall-related events (composite of fall-related outcomes) were defined using ICD-9-CM codes. Conditional logistic regression models were used to compare the fall-related events within 30 days, 90 days, 180 days, and 365 days between the 2 cohorts.

RESULTS

A total of 21,613 hypoglycemia patients were matched with 21,613 nonhypoglycemic patients. Patients with hypoglycemia had higher fall-related events within 30 days, 90 days, 180 days, and 365 days (P  less than  0.001 for all frequency differences). Conditional logistic regression analyses showed an elevated risk for fall-related events over 365 days (aOR = 1.95, 95% CI = 1.70-2.24). Subgroup analysis showed elevated risk for patients aged less than  75 years and ≥ 75 years. Elevated risks were also seen for individual fall-related outcomes of fractures, head injuries, long-term care placement, and hospital admissions.

CONCLUSIONS

The risk of fall-related events over 365 days increased 2-fold among elderly patients with diabetes who experienced hypoglycemia.

U300, a novel long-acting insulin formulation

INTRODUCTION

Insulin glargine (100 U/ml; U100) was the first long-acting basal insulin analog to be introduced into clinical practice and it remains the most widely used. Although U100 is an effective and safe treatment, research is ongoing to optimize the time-action profile. The focus of this review is insulin glargine [rDNA origin] injection 300 U/ml (U300), a novel formulation that contains a higher concentration of insulin than U100.

AREAS COVERED

The clinical efficacy and safety of U300 in patients with type 1 and type 2 diabetes mellitus are discussed, with an emphasis on recently released data from the Phase III EDITION clinical trials.

EXPERT OPINION

The higher concentration of insulin in U300 results in a distinct pharmacokinetic and pharmacodynamic profile. U300 has a longer duration of action than U100 and plasma insulin exposure is less variable. Both insulin formulations exhibit a similar efficacy and safety profile, but importantly, U300 is associated with less body weight gain and a lower incidence of hypoglycaemic events.

Challenges associated with insulin therapy in type 2 diabetes mellitus

Despite advances in treatment for type 2 diabetes in recent decades, many patients are failing to achieve adequate glycemic control. Poor glycemic control has been shown to have a detrimental effect on patients' health and well-being, and to have significant negative financial implications for both patients and healthcare systems. Insulin therapy has been proven to significantly reduce glycated hemoglobin levels; however, both patients and physicians can be reluctant to initiate insulin therapy. Research shows that both patient and provider factors contribute to a delay in initiation of insulin therapy. This review discusses the most common barriers contributing to this delay with potential solutions to overcome them.

The psychosocial and financial impact of non-severe hypoglycemic events on people with diabetes: two international surveys

OBJECTIVES

To understand the impact of nocturnal and daytime non-severe hypoglycemic events on healthcare systems, work productivity and quality of life in people with type 1 or type 2 diabetes.

METHODS

People with diabetes who experienced a non-severe hypoglycemic event in the 4 weeks prior to the survey were eligible to participate in a nocturnal and/or daytime hypoglycemia survey. Surveys were conducted in Argentina, Australia, Brazil, Israel, Mexico and South Africa.

RESULTS

In total, 300 respondents were included in nocturnal/daytime hypoglycemia surveys (50/participating country/survey). All respondents with type 1 diabetes and 68%/62% (nocturnal/daytime) with type 2 diabetes were on insulin treatment. After an event, 25%/30% (nocturnal/daytime) of respondents decreased their insulin dose and 39%/36% (nocturnal/daytime) contacted a healthcare professional. In the week after an event, respondents performed an average of 5.6/6.4 (nocturnal/daytime) additional blood glucose tests. Almost half of the respondents (44%) reported that the event had a high impact on the quality of their sleep. Among nocturnal survey respondents working for pay, 29% went to work late, 16% left work early and 12% reported missing one or more full work days due to the surveyed event. In addition, 50%/39% (nocturnal/daytime) indicated that the event had a high impact on their fear of future hypoglycemia.

CONCLUSIONS

The findings suggest that nocturnal and daytime non-severe hypoglycemic events have a large financial and psychosocial impact. Diabetes management that minimizes hypoglycemia while maintaining good glycemic control may positively impact upon the psychological wellbeing of people with diabetes, as well as reducing healthcare costs and increasing work productivity.

The effects of chitosan oligosaccharide (GO2KA1) supplementation on glucose control in subjects with prediabetes

We aimed to evaluate the effect of chitosan oligosaccharide (GO2KA1) supplementation on glucose control in subjects with prediabetes. This study was a randomized, double-blind, placebo-controlled clinical trial. Subjects with prediabetes were randomly assigned to the GO2KA1 intervention group or the placebo group for 12 weeks. We assessed the serum levels of glucose, insulin, and C-peptide by a 2 hour value in the 75 g oral glucose tolerance test (OGTT), HbA1c, pro-inflammatory cytokines, and plasma adiponectin at baseline and after the 12 week intervention. The treatment group showed a significant decrease in the serum glucose level at 30 min (p = 0.013) and at 60 min (p = 0.028). The change of the serum glucose level at 60 min was significant in the treatment group compared with the placebo group (p = 0.030). Also, the plasma level of HbA1c (p = 0.023) and the pro-inflammatory cytokines (IL-6 and TNF-α) were reduced and plasma adiponectin was increased in the GO2KA1 intervention group after the 12 week treatment. However, the placebo group did not show any significant changes in these biomarkers. In subjects with prediabetes, 12 week supplement with GO2KA1 may help control postprandial glucose compared with control.

Evidence-based practice use of incretin-based therapy in the natural history of diabetes

The incretin class of anti-hyperglycemic agents, including glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-inhibitors, is an important addition to the therapeutic armamentarium for the management of appropriate patients with type 2 diabetes mellitus as an adjunct to diet and exercise and/or with the agents metformin, sulfonylureas, thiazolidinediones, or any combination thereof. More recently, US Food and Drug Administration (FDA)-approved indications for incretins were expanded to include use with basal insulin. This review article takes an evidence-based practice approach in discussing the importance of aggressive treatment for diabetes, the principles of incretin physiology and pathophysiology, use of glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, and patient types and contexts where incretin therapy has been found beneficial, from metabolic syndrome to overt diabetes.

Continuous subcutaneous delivery of exenatide via ITCA 650 leads to sustained glycemic control and weight loss for 48 weeks in metformin-treated subjects with type 2 diabetes

AIMS

Evaluate the efficacy and tolerability of ITCA 650 in subjects with type 2 diabetes treated for up to 48 weeks.

METHODS

This was a 24-week extension to a randomized, 24-week, open-label, phase 2 study in subjects with type 2 diabetes inadequately controlled with metformin. Subjects received ITCA 650 mg (20, 40, 60 or 80 μg/day). Mean changes for HbA1c, weight, and fasting plasma glucose (FPG) were evaluated.

RESULTS

Mean changes in HbA1c from baseline to week 48 ranged from -0.85% to -1.51%. At week 48, ≥64% of subjects with an HbA1c ≤7% at week 24 maintained an HbA1c ≤7%. The incidence of adverse events (AEs) was dose-related and ranged from 13.3% with 20 μg/day to 37.5% with 80 μg/day. Most AEs were mild and transient; the incidence of nausea declined from 12.9% to 9.5% over the 24-week extension. One subject on ITCA 650 80 μg/day experienced mild intermittent vomiting. Three (3.5%) subjects experienced severe AEs, but none were considered related to study drug.

CONCLUSION

Significant changes in HbA1c, body weight, and FPG attained with ITCA 650 were maintained to 48 weeks. The incidence of AEs was lower in the 24-week extension than in the initial 24-week treatment phase.

Understanding the economic, daily functioning, and diabetes management burden of non-severe nocturnal hypoglycemic events in Canada: differences between type 1 and type 2

OBJECTIVE

To examine the daily functioning, diabetes management, and economic burden of non-severe nocturnal hypoglycemic events (NSNHEs) in Canada and differences in impacts by diabetes type.

RESEARCH DESIGN AND METHODS

A 20-min web-based survey, with items derived from the literature, expert and patient interviews, assessing the impact of NSNHEs, was administered to patients with self-reported diabetes aged ≥18 having an NSNHE in the past month.

RESULTS

Two thousand, two hundred and seventy-nine Canadian persons with diabetes were screened with 200 respondents meeting criteria and included in the analysis sample. Out of 87 working respondents, 15 reported on average 3.5 h of lost work (absenteeism). The reduction in work productivity (presenteeism) reported was comparable to the impact of arthritis. Other functional impacts included sleep and daily activities. Additionally, respondents' increased their usual blood sugar monitoring practice, on average, 4.2 (SD = 7.5) extra tests were conducted in the week following the event and reduced their insulin over the following 4.8 days. Increased healthcare utilization was also reported. Increased costs as a result of NSNHE for lost work productivity, increased diabetes management, and resource utilization was CAD 70.67 per person per year in this sample. Limitations of the study include the biases which are associated with a web-based survey and self-reported data.

CONCLUSIONS

NSNHEs have serious consequences for patients and diabetes management practices. Greater attention to treatments which reduce NSNHEs can have a major impact on improving functioning while reducing the economic burden of diabetes.