Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society

Personalized machine learning models for noninvasive hypoglycemia detection in people with type 1 diabetes using a smartwatch: Insights into feature importance during waking and sleeping times

Hypoglycemia is a major challenge for people with diabetes. Therefore, glycemic monitoring is an important aspect of diabetes management. However, current methods such as finger pricking and continuous glucose monitoring systems (CGMS) are invasive, and hypoglycemia has still been shown to occur despite advancements in CGMS. Consequently, a growing body of research has been directed toward noninvasive hypoglycemia detection, relying on data from medical devices and wearables that can record physiological changes elicited by hypoglycemia. Consumer-grade wearables such as smartwatches remain an attractive yet underexplored candidate for such applications. Therefore, we explored the potential of a consumer-grade wearable for hypoglycemia prediction and investigated differing feature importance during waking and sleeping times. Smartwatch data from 18 adults with type 1 diabetes was collected, preprocessed, and imputed. Machine learning (ML) models were built using a tree-based ensemble algorithm to detect hypoglycemic events registered by CGMS. Models were built in a personalized manner using the same participant's data for training and testing, with separate modeling for daytime and nighttime. The relative importance of input features on model decisions was analyzed using SHAP (SHapley Additive exPlanations). Seventeen personalized models were built with an average area under the receiver operating characteristic curve (AUROC) score of 0.74 ± 0.08. Average specificity and sensitivity were 0.76 ± 0.18 and 0.71 ± 0.15, respectively. Time-of-day, activity, and cardiac features showed comparable importance in daytime models (29.9%, 28.5%, and 24%, respectively), while in nighttime models, cardiac features demonstrated the highest importance (42.2%) followed by time-of-day features (37.5%) and respiratory features (15.2%). In summary, we demonstrate the potential of consumer-grade wearables in noninvasive hypoglycemia detection. By additionally considering different physiological states (waking and sleeping) during modeling, our results offer further insights into differences in relative feature importance influencing the model's decision, guiding future research in this area.

High-Dose Semaglutide (Up to 16 mg) in People With Type 2 Diabetes and Overweight or Obesity: A Randomized, Placebo-Controlled, Phase 2 Trial

OBJECTIVE

Studies have demonstrated dose-dependent efficacy of glucagon-like peptide 1 receptor agonists for glycemic control and body weight. The aim of this trial was to characterize the dose-dependent effects of semaglutide (up to 16 mg/week) in people with type 2 diabetes and overweight or obesity.

RESEARCH DESIGN AND METHODS

In this parallel-group, participant- and investigator-blinded, phase 2 trial, 245 individuals with type 2 diabetes and BMI ≥27 kg/m2 on metformin were randomized to weekly semaglutide (2, 8, or 16 mg s.c.) or placebo for 40 weeks. Doses were escalated every 4 weeks, followed by a maintenance period. Dose modifications were not allowed. Primary and secondary efficacy end points included change from baseline to week 40 in HbA1c and body weight, respectively.

RESULTS

Estimated treatment difference between 16 and 2 mg was -0.3 percentage points (%-points) (95% CI -0.7 to 0.2; P = 0.245) for HbA1c change and -3.4 kg (-6.0 to -0.8; P = 0.011) for weight change for the treatment policy estimand and -0.5%-points (-1.0 to -0.1; P = 0.015) and -4.5 kg (-7.6 to -1.4; P = 0.004), respectively, for the hypothetical estimand. Dose-response modeling confirmed these findings. Treatment-emergent adverse events (AEs) and treatment discontinuations due to AEs, primarily gastrointestinal, were more frequent in the semaglutide 8 and 16 mg groups than in the 2 mg group. No severe hypoglycemic episodes were reported.

CONCLUSIONS

Higher semaglutide doses for type 2 diabetes and overweight or obesity provide modest additional glucose-lowering effect, with additional weight loss, at the expense of more AEs and treatment discontinuations. A study for evaluating high-dose semaglutide in obesity is currently underway.

Challenges in detecting and predicting adverse drug events via distributed analysis of electronic health record data from German university hospitals

The Medical Informatics Initiative Germany (MII) aims to facilitate the interoperability and exchange of electronic health record data from all German university hospitals. The MII use case "POLyphamacy, drug interActions and Risks" (POLAR_MI) was designed to retrospectively detect medication-related risks in adult inpatients. As part of POLAR_MI, we aimed to build predictive models for specific adverse events. Here, using the two adverse events gastrointestinal bleeding and drug-related hypoglycaemia as examples, we present our initial investigation to determine whether these adverse events and their associations with potential risk factors can be detected. We applied a two-step distributed analysis approach to electronic health record data from 2018 to 2021. This approach consisted of a local statistical data analysis at ten participating centres, followed by a mixed-effects meta-analysis. For each adverse event, two multivariable logistic regression models were constructed: (1) including only demographics, diagnoses and medications, and (2) extended by laboratory values. As numerically stable estimations of both models were not possible at each centre, we constructed different centre subgroups for meta-analyses. We received prevalence estimates of around 1.2% for GI bleeding and around 3.0% for drug-related hypoglycaemia. Although unavailability of laboratory values was a common reason hindering model estimation, multivariable regression models were obtained for both adverse events from several centres. Regarding our original intention to build predictive models, the median area under the receiver operating characteristic curve was above 0.70 for all multivariable regression models, indicating feasibility. In conclusion, plausible estimates for prevalence and regression modelling odds ratios were received when using a distributed analysis approach on inpatient treatment data from diverse German university hospitals. Our results suggest that the development of predictive models in a distributed setting is possible if the research question is adapted to the infrastructure and the available data.

Construction and validation of a risk prediction model for hypoglycemia in patients with gestational diabetes mellitus

OBJECTIVE

We explored the prevalence and determinants of hypoglycemia in patients with gestational diabetes mellitus (GDM), and we developed and validated a nomogram prediction model.

METHODS

We extracted data from the clinical records of 475 patients with GDM attending the tertiary class A specialized hospital in Zhuhai City between December 2021 and June 2023 for a modeling group, and we used data of another cohort of 204 GDM cases for a validation group. We conducted a logistic regression analysis to identify factors associated with hypoglycemia in patients with GDM and generated a risk prediction model presented as a nomogram. The model was validated using data from the patients in the validation group.

RESULTS

The prevalence of hypoglycemia in the study population was 25.5%. Our risk prediction model incorporated four predictors, including a fasting oral glucose tolerance test (OGTT) value, the number of fetuses, the presence or absence of intrahepatic cholestasis of pregnancy (ICP), and the blood glucose level self-monitoring frequency. The area under the receiver operating characteristic (ROC) curve was 0.786 for the modeling set and 0.742 for the validation set. The Brier score was 0.155, and the calibration slope was 0.750, demonstrating satisfactory clinical usefulness of the model. Moreover, a decision curve analysis further supported our model's clinical relevance.

CONCLUSION

The prevalence of hypoglycemia in patients with GDM is considerable. Our nomogram prediction model demonstrated good performance for identifying high-risk individuals. The model could serve as a valuable tool for screening and managing hypoglycemia among patients with GDM.

Improving Sleep Quality to Enhance Athletic Activity-The Role of Nutrition and Supplementation: A Mini-Short Review

Sleep is a fundamental part of life for all living beings. The propensity to fall asleep is regulated by a circadian rhythm, which controls the secretion of the hormone melatonin. Melatonin secretion is linked to the light and dark phases of the day/night cycle. Getting proper sleep is an essential part of a healthy lifestyle. Scientific evidence shows that sleeping less than 7 h per night, or as little as 2 h per night, is a cardiovascular, metabolic, and cerebral risk factor. In addition, the role of sleep is fundamental for the recovery phase for athletes. Nutrition, supplementation, and exercise can greatly support the quality and quantity of sleep. They can have positive effects on sleep through specific physiological and biochemical responses. The objective of this short review is to critically investigate the possible sleep benefits of nutrition, exercise, and supplementation and to discuss further directions for research in this area.

Dietary glycemic and insulin indices in association with sleep quality and duration in patients undergoing angiography

BACKGROUND AND AIMS

Research examining the relationship between glycemic and insulin indices and sleep quality and duration is scarce and has yielded contradictory results. This study evaluated the relationship between dietary glycemic and insulin indices and the quality and quantity of sleep among adults referred for angiography.

METHODS

The present cross-sectional study was conducted on 653 participants referred for angiography at Afshar Hospital, Yazd, central Iran. Sleep parameters were evaluated through the Pittsburgh Sleep Quality Index (PSQI). Dietary intakes were assessed using a validated food frequency questionnaire (FFQ). Binary logistic regression was employed to determine the association between dietary glycemic and insulin indices and sleep quality and quantity among patients with cardiovascular risk factors.

RESULTS

After adjusting for factors including age, sex, energy intake, marital status, education level, occupation, economic condition, body mass index, smoking status, drug addiction, physical activity, depression score, syntax score, diabetes status, and caffeine intake, analyses revealed a significant positive association between the dietary insulin index (DII) and sleep disorders (OR = 2.42; 95%CI: 1.20-4.87, Ptrend = 0.003). Additionally, the dietary glycemic index (DGI) was positively associated with sleep latency (OR = 1.81; 95%CI: 1.06-3.10, Ptrend = 0.04). No significant relationship was observed between dietary glycemic or insulin load and overall sleep quality or its components.

CONCLUSION

In conclusion, greater DII might be associated with the odds of sleep disorders. Also, higher DGI was linked to the likelihood of sleep latency among adults undergoing angiography. Further prospective studies are necessary to corroborate our results.

Analysis of patient characteristics and safety of insulin glargine U300 use in 21 359 patients with type-2 diabetes and chronic kidney disease: DPV registry study

AIMS

Managing type-2 diabetes (T2D) in chronic kidney disease (CKD) patients requires consideration of kidney function, and many drugs have not been investigated thoroughly. Clinical studies have demonstrated Glargine U300 (Gla-300) supports achievement of adequate glycemic control at low hypoglycemia risk.

MATERIALS AND METHOD

This cross-sectional study analysed routine data of 21 359 T2D patients with CKD (1786 using Gla-300; 19 568 without any insulin) from the prospective Diabetes-Patienten-Verlaufsdokumentation (DPV) registry to evaluate patient characteristics and safety of Gla-300 use across different CKD stages.

RESULTS

Patients on Gla-300 had T2D onset at an earlier age (median age 55.1 vs. 62.3 years), longer diabetes duration (17.3 vs. 11.3 years), higher body weight (91.3 vs. 83.9 kg) and HbA1c levels (7.3% vs. 6.7%) than non-insulin patients (all p < 0.001). Gla-300 usage increased from CKD stage 1-4 (median dose 44 vs. 55 units) with higher baseline HbA1c levels (7.2% vs. 7.4%). Although severe hypoglycemia rates were low, a slight increase (0.01%/PY vs. 0.04%/PY) was observed with decreasing estimated glomerular filtration rate levels. Compared to others, stage 5 CKD patients had a distinct profile with lower HbA1c levels (6.9%), body weight (90 kg) and higher Gla-300 usage (50 units). Metformin, SGLT-2 inhibitors and GLP-1 RA were common concomitant drugs with diminished usage in advanced CKD stages, while Gla-300 was common at all stages.

CONCLUSION

Despite variations in patient profiles, Gla-300 is widely used across all CKD stages, particularly in advanced stages with a low rate of severe hypoglycemia, suggesting its safe administration in CKD patients.

Diabetic neuropathy: cutting-edge research and future directions

Diabetic neuropathy (DN) is a prevalent and debilitating complication of diabetes mellitus, significantly impacting patient quality of life and contributing to morbidity and mortality. Affecting approximately 50% of patients with diabetes, DN is predominantly characterized by distal symmetric polyneuropathy, leading to sensory loss, pain, and motor dysfunction, often resulting in diabetic foot ulcers and lower-limb amputations. The pathogenesis of DN is multifaceted, involving hyperglycemia, dyslipidemia, oxidative stress, mitochondrial dysfunction, and inflammation, which collectively damage peripheral nerves. Despite extensive research, disease-modifying treatments remain elusive, with current management primarily focusing on symptom control. This review explores the complex mechanisms underlying DN and highlights recent advances in diagnostic and therapeutic strategies. Emerging insights into the molecular and cellular pathways have unveiled potential targets for intervention, including neuroprotective agents, gene and stem cell therapies, and innovative pharmacological approaches. Additionally, novel diagnostic tools, such as corneal confocal microscopy and biomarker-based tests, have improved early detection and intervention. Lifestyle modifications and multidisciplinary care strategies can enhance patient outcomes. While significant progress has been made, further research is required to develop therapies that can effectively halt or reverse disease progression, ultimately improving the lives of individuals with DN. This review provides a comprehensive overview of current understanding and future directions in DN research and management.

Impact of real-time glucose monitoring using FreeStyle Libre 3 on glycaemia in type 2 diabetes managed with basal insulin plus SGLT2 inhibitor and/or GLP-1 agonist: the FreeDM2 randomised controlled trial protocol

INTRODUCTION

Effective management of type 2 diabetes mellitus (T2DM) consists of lifestyle modification and therapy optimisation. While glycaemic monitoring can be used as a tool to guide these changes, this can be challenging with self-monitoring of blood glucose (SMBG). The FreeStyle Libre 3 (FSL3) is a real-time continuous glucose monitoring (CGM) system designed to replace SMBG. The evidence for the benefit of CGM in people with T2DM on non-intensive insulin regimens is limited. This study aims primarily to assess the glycaemic impact of FSL3 in people with suboptimally controlled T2DM treated with basal-only insulin regimens plus sodium-glucose cotransporter-2 (SGLT-2) inhibitor and/or glucagon-like peptide (GLP)-1 agonist.

METHODS AND ANALYSIS

This is an open-label, multicentre, parallel design, randomised (2:1) controlled trial. Recruitment has been offered across 24 clinical centres in the UK and nationally through self-referral. Adults with T2DM treated with basal-only insulin regimens plus SGLT-2 inhibitor and/or GLP-1 agonist and with screening HbA1c from ≥59 mmol/mol to ≤97 mmol/mol are included. Eligible participants will be randomised to either FSL3 (intervention) for 32 weeks or continuation of SMBG (control). The study is split into two phases, each of 16 weeks duration: phase 1 consisting of self-management with basal-insulin self-titration and phase 2 where additional therapies may be initiated. Control group participants may subsequently enter an optional extension phase to receive FSL3. The primary endpoint is the difference between treatment groups in mean change from baseline in HbA1c at 16 weeks. Secondary outcomes include HbA1c at 32 weeks, CGM-based metrics, therapy changes, physical activity levels and psychosocial measures. An economic evaluation for costs and patient outcomes will be undertaken.

ETHICS AND DISSEMINATION

The study was approved by the Health Research Authority, Health and Care Research Wales and the West Midlands-Edgbaston Research Ethics Committee (reference: 23/WM/0092). Study results will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05944432.

SECONDARY IDENTIFYING NUMBER

Identifier assigned by the sponsor: ADC-UK-PMS-22057.

PROTOCOL VERSION

Revision D. Dated, 13 December 2024.

Evaluating the impact of severe hypoglycaemia definition wording on severe hypoglycaemia history assessment

AIM

Several wordings of the definition of severe hypoglycaemia (SH) exist. This study aims to evaluate how different SH definition wordings affect SH history assessment.

METHODS

In this cross-sectional study, surveys were emailed to registrants of the T1D Exchange, a U.S. national type 1 diabetes patient registry. Participants' demographic information was collected. Six-month SH history was evaluated with questionnaires including SH definition wordings from either (1) professional societies, (2) a diabetes community website, or (3) a hypoglycaemia research questionnaire. Analyses included the McNemar test, pairwise Wilcoxon signed-rank test, logistic regression analysis, Kappa statistics, and Spearman correlation.

RESULTS

A total of 1580 valid responses were obtained from participants (52% female; mean ± SD age: 46 ± 15 years; 95% White; mean ± SD diabetes duration: 25 ± 16 years). Questionnaires with four different SH definition wordings yielded significant variations in the prevalence of SH (i.e., having developed at least one episode of SH) and the number of SH episodes: the ADA/ENDO 2013 definition wording yielded the highest results on both metrics, whereas HypoA-Q and ADA 2023 yielded the lowest. Among participants reporting at least one SH episode, the number of episodes identified with the different SH definition wordings was poorly correlated (Rs: 0.09-0.37; p < 0.001). Race, education level, and household income were associated with higher odds of discrepancies in SH history (p < 0.05).

CONCLUSION

This U.S. national survey with individuals living with type 1 diabetes demonstrated significant discrepancies in SH history when assessed with different SH definition wordings. Race and socioeconomic status were associated with these discrepancies.

Prevalence and factors of fear of hypoglycemia among Chinese older adults with type 2 diabetes mellitus: A cross-sectional study

The fear of hypoglycemia (FOH) in older adults with type 2 diabetes mellitus (T2DM) has seriously affected their glycemic control and quality of life. This was a cross-sectional study to identify the disease-related characteristics, psychological and social factors of FOH in older persons with T2DM, and to explore the relationship between these factors. A total of 332 older Chinese adults diagnosed with T2DM completed the survey. Results: The mean FOH score was 33.14 ± 11.273, which was associated with age, education, frequency of hypoglycemic episodes and types of hypoglycemia. Social support and psychological resilience were negatively correlated with FOH, and the association between social support and FOH in the participants was partially mediated by psychological resilience. Conclusions: Our study highlight that medical staff should pay more attention to the mental health status of older adults with T2DM, improving mental resilience and strengthening social support can help reduce their FOH level, and thereby help them control blood glucose scientifically and improve their quality of life.

Self-reported hypoglycemia and associated factors among patients living with T1D s at University of Gondar Comprehensive Specialized Hospital, Northwest, Ethiopia: a cross-sectional study

Background

Hypoglycemia is a major public health problem that negatively influences blood glucose control in the treatment of type 1 diabetes. It has more severe clinical and economic effects in patients living with T1D patients. However, real-world clinical evidence of reported hypoglycemia is limited. Thus, the purpose of the study was to determine the prevalence of self-reported hypoglycemia and its associated factors among patients living with T1Dat the University of Gondar Comprehensive Specialized Hospital (UOGCSH).

Methods

A prospective hospital-based cross-sectional study was conducted among patients living with T1D attending the ambulatory clinic of UOGCSH from November 1, 2021, to April 30, 2022. To select the study participants, a convenient sampling technique was used. Multivariable binary logistic regression was used to identify predictors of self-reported hypoglycemia. A P-value < 0.05 was considered statistically significant and reported as a 95% Confidence Interval (CI).

Results

A total of 216 patients living with T1D (mean age: 50.91 ± 18.98 years) were included. The mean duration of DM diagnosis and insulin use were 9.41 ± 8.00 and 7.10 ± 6.00 years, respectively. Self-reported hypoglycemia was prevalent among 86.6% (95% CI: 82.1-91.0) of the study participants, with 69% experiencing non-severe and 31% experiencing severe hypoglycemia. More than half of the patients, 122 (56.5%), reported experiencing four or more (≥ 4) episodes of hypoglycemia. Knowledge of insulin self-administration, specifically a low level of knowledge (AOR=4.87; 95% CI: 1.55-15.26), was significantly associated with self-reported hypoglycemia. The majority of patients living with T1D, 155 (71.8%), had impaired awareness of hypoglycemia.

Conclusion

Self-reported hypoglycemia was considerably high among Patients living with T1D. Knowledge of insulin self-administration, specifically at a low level, was associated with an increased risk of reported hypoglycemia. Thus, continued health education of Patients living with T1D regarding insulin self-administration and awareness of hypoglycemia symptoms is necessary to prevent further complications.

Health-Economic Modelling of Improved Behavior in Insulin Injection Technique in Belgium

BACKGROUND

Adequate insulin injection technique (IIT) is crucial to optimize the efficacy of diabetes therapy. Widespread non-practice of injection-site rotation and frequent reuse of insulin pen needles (PN) promote high rates of lipohypertrophy (LH) among people living with diabetes (PwD). LH is associated with increased insulin requirement and suboptimal insulin absorption leading to worsened glycemic control and increased risk for hypoglycemia. Avoiding out-of-the-pocket patient costs of PN could reduce PN reuse, thereby limiting its contribution to LH occurrence.

OBJECTIVES

A model was developed to compute the impact of a behavior shift in reuse on clinical and economic outcomes for type 1 and insulin-treated type 2 diabetes populations in Belgium.

METHODS

Patient populations were characterized by treatment-specific characteristics and grouped by their frequency of PN replacement. The intervention was modelled to cause a change in reuse frequency, with the effects propagating downstream of the model. Model and input parameters were based on literature research and expert opinions from a Delphi panel, since available data was found to be limited, incomplete or inconsistent and assumptions were needed.

RESULTS

Using the current situation as comparator, this analysis showed a reduction of healthcare expenditures following an improvement in IIT. Considering a 5-year time horizon, this study yields potential savings of 52.6 million euros (28.1-77.9 million euros) when 55% of PwD improve PN reuse behavior.

CONCLUSION

Our model shows that even in an era of technological advances and established diabetes care, lack of adherence to correct IIT has an important impact on economic and health outcomes of PwD in Belgium.

The Effect of 50% Dextrose on Serum Glucose Levels in Adult Hypoglycemic Patients: A Prospective Observational Study

OBJECTIVE

This study aimed to observe changes in serum glucose levels following the administration of 50 mL of 50% dextrose solution (D50) in hypoglycemic patients. Specifically, we seek to determine the prevalence of rebound hyperglycemia episodes, the peak effect, and the duration of action of a single dose of 50 mL D50.

METHOD

This prospective observational study was conducted at four emergency departments (two tertiary care hospitals and two secondary care hospitals) in Oman over a three-year period, from May 1, 2019, to April 30, 2022. Adult patients (>12 years old) presenting with documented hypoglycemia (serum glucose level ≤3.9 mmol/L) were included. All patients underwent bedside serum glucose measurements at predetermined time intervals following the administration of D50. Data were analyzed using the Epidata program (Buenos Aires, Argentina). The mean serum glucose level at each time interval was calculated, along with the prevalence of rebound hyperglycemia. The independent sample t-test, one-way ANOVA, and Pearson's chi-squared test were used for statistical analysis.

RESULTS

A total of 102 patients (53 females and 48 males) were included in this study. The majority of patients were diabetic (N = 87), while 15 (14.7%) were non-diabetic. Rebound hyperglycemia was predominantly observed within five minutes of administering 50 mL of D50, with a mean serum glucose level of 12.2 mmol/L and a maximum reading of 22.6 mmol/L. Rebound hyperglycemia occurred more frequently in the non-diabetic group (73.3%) compared to the diabetic group (56.3%). Six patients (5.7%) required a second dose of 50 mL D50, all of whom were diabetic.

CONCLUSION

A single dose of 50 mL D50 effectively restores and maintains the desired serum glucose level in non-diabetic hypoglycemic adult patients for up to 60 minutes. However, diabetic patients may require additional doses or continuous dextrose-containing fluids if they do not begin oral feeding. Using a lower concentration of dextrose-containing fluids may help mitigate the phenomenon of rebound hyperglycemia.

Glucagon-like peptide-1 and impaired counterregulatory responses to hypoglycemia in type 1 diabetes

This letter comments on a study by Jin et al, published recently in the World Journal of Diabetes. Hypoglycemia is a significant complication of diabetes, with primary defense mechanisms involving the stimulation of glucagon secretion in α-cells and the inhibition of insulin secretion in pancreatic β-cells, which are often compromised in type 1 diabetes mellitus (T1DM) and advanced type 2 diabetes mellitus. Recurrent hypoglycemia predisposes the development of impaired hypoglycemia awareness, a condition underpinned by complex pathophysiological processes, encompassing central nervous system adaptations and several hormonal interactions, including a potential role for glucagon-like peptide-1 (GLP-1) in paracrine and endocrine vias. Experimental evidence indicates that GLP-1 may impair hypoglycemic counterregulation by disrupting the sympathoadrenal system and promoting somatostatin release in pancreatic δ-cells, which inhibits glucagon secretion from neighboring α-cells. However, current trials evaluating GLP-1 receptor agonists (GLP-1 RAs) in T1DM patients have shown promising benefits in reducing insulin requirements and body weight, without increasing the risk of hypoglycemia. Further research is essential to elucidate the specific roles of GLP-1 and GLP-1 RAs in modulating glucagon secretion and the sympathetic-adrenal reflex, and their impact on hypoglycemia unawareness in T1DM patients.

Effectiveness of ertugliflozin during Ramadan fasting in patients with type 2 diabetes mellitus: a real-world study (ErtuRamadan study)

Background

Management of type 2 diabetes mellitus (T2DM) during Ramadan fasting presents unique challenges due to prolonged fasting periods, irregular meal schedules, and altered medication timing, potentially impacting glycemic control. Ertugliflozin, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, has been shown to improve glycemic control in T2DM effectively. However, the effectiveness of ertugliflozin during Ramadan fasting, a period with unique glycemic challenges, has not been studied extensively.

Methods

This study was a multicenter, real-life experience study involving 1373 adult patients with known T2DM for at least one year, an HbA1c level of less than 10%, and who intended to fast during Ramadan. Participants were divided into two groups: the Ertu group (n=703), consisting of patients who had been on a stable dose of ertugliflozin for at least three months before Ramadan, and the non-Ertu group (n=670), which included patients receiving other oral antihyperglycemic drugs (OADs) except ertugliflozin. Patients attended a baseline visit one month before the first day of Ramadan and a follow-up visit within one month after the last day of Ramadan. Both visits included history taking, physical examinations, and laboratory tests. The primary endpoints were changes in HbA1c levels, body weight, body mass index (BMI), and the incidence of hypoglycemia during Ramadan fasting.

Results

The mean age of the study participants was 50.37 ± 11.14 (SD) years, with 40.6% male and 58.7% female. Patients receiving ertugliflozin showed significant reduction in HbA1C (-0.65 ± 0.67% vs. -0.22 ± 0.64%, p<0.001), body weight (-1.24 ± 2.58 kg vs. -0.36 ± 3.41 kg, p<0.001), and BMI (-0.48 ± 1.03 kg/m² vs. -0.11 ± 1.33 kg/m², p<0.001) compared to the non-Ertu group. Hypoglycemia was reported in 0.3% of the ertugliflozin group and 0.7% of the other group, with comparable adverse events (p=.23; ≥0.05), indicating a favorable safety profile for ertugliflozin during fasting.

Conclusion

This study demonstrates that ertugliflozin is effective and safe for patients with T2DM during Ramadan fasting.

Characterising impaired awareness of hypoglycaemia and associated risks through HypoA-Q: findings from a T1D Exchange cohort

AIMS/HYPOTHESIS

We aimed to: (1) externally validate the five-item Hypoglycaemia Awareness Questionnaire (HypoA-Q) impaired awareness subscale (HypoA-Q IA); (2) examine how impaired awareness of hypoglycaemia (IAH) relates to the risk of severe hypoglycaemia and level 2 hypoglycaemia; and (3) identify factors associated with IAH.

METHODS

Nationwide survey of T1D Exchange registrants was conducted to collect data on demographics, 6 month severe-hypoglycaemia history, hypoglycaemia awareness status (via HypoA-Q IA, the Gold instrument and the Clarke instrument) and continuous glucose monitor (CGM) measures. The Clarke hypoglycaemia awareness factor (Clarke-HAF) was calculated to exclude severe-hypoglycaemia history items. Analyses included Cronbach's α, Spearman correlations and logistic regression.

RESULTS

Valid survey responses were collected from N=1580 adults with type 1 diabetes (median age, 44 years; 52% female participants; median HbA1c, 48 mmol/mol [6.5%]). Of these, 94% of participants were using CGMs and 69% were using hybrid closed-loop (HCL) systems; 30% had at least one severe-hypoglycaemia episode in the past 6 months. The HypoA-Q IA had satisfactory internal reliability (α=0.79) and construct validity. Higher HypoA-Q IA scores were independently associated with greater risk of severe hypoglycaemia (p<0.001), performing comparably to the Gold instrument and the Clarke-HAF instrument. HypoA-Q IA-determined IAH was independently associated with 88% higher odds of developing severe hypoglycaemia (p<0.001) and twofold higher odds for spending ≥1% of time in level 2 hypoglycaemia (p=0.011). Higher age and longer diabetes duration were associated with higher IAH risk (p<0.001). CGM and HCL use was associated with lower IAH risk (p<0.001).

CONCLUSIONS/INTERPRETATION

The HypoA-Q IA is a brief, valid and reliable tool for assessing IAH in today's technology-oriented era. IAH was independently associated with severe hypoglycaemia and level 2 hypoglycaemia in a cohort with high prevalence of advanced diabetes technology use and HbA1c within the recommended range. CGM and HCL use was related to lower IAH risk.

Pharmacotherapy of type 1 diabetes - part 1: yesterday

INTRODUCTION

Type 1 diabetes is a unique autoimmune attack on the β cell of the pancreatic islet resulting in progressive destruction of these cells and as a result the ability of the body to maintain insulin production. The consequences of insulin deficiency are very severe, and the disease was fatal prior to the ability to extract insulin from animal pancreas in 1921. We review progress in the treatment of childhood type 1 diabetes over the past 100 years.

AREAS COVERED

We used PubMed and standard search engines to search for the evolution of diagnosis and treatment of type 1 diabetes.

EXPERT OPINION

Insulin replacement proved lifesaving for children afflicted with type 1 diabetes. However, it was observed that these children suffered from microvascular and large vessel disease. The Diabetes Control and Complications Trial (DCCT) with its extension Epidemiology of Diabetes Interventions and Complications Trial (EDIC) proved that control of blood glucose as close to normal as possible could prevent these diabetes-related conditions. Many formuations of insulin with varying onset and duration of action have been developed; yet normalization of glucose levels is difficult due to hypoglycemic events. There is continued progress toward that goal.

Risk of hypoglycaemia among people with type 2 diabetes not treated with insulin: A retrospective analysis of Medicare Advantage beneficiaries

AIMS

In 2022, the Centers for Medicare & Medicaid Services released proposed changes to Medicare's continuous glucose monitoring (CGM) coverage policy, making individuals with a history of problematic hypoglycaemia eligible for CGM coverage, irrespective of insulin use. This study estimated the burden of hypoglycaemia in Medicare Advantage beneficiaries with noninsulin-treated type 2 diabetes (T2D).

MATERIALS AND METHODS

We retrospectively analysed US healthcare claims data using Optum's deidentified Clinformatics® database. Noninsulin-treated beneficiaries were identified in the 16 years from January 2007 to March 2023. Hypoglycaemia-related encounters (HREs) were those accompanied by a hypoglycaemia-specific ICD-9/10 diagnosis code in any position on the claim or the first or second position. HREs following the first claim related to T2D were reported by setting (ambulatory or inpatient/emergency department [ED]).

RESULTS

HREs were identified in 689,853 (21.4%) of 3,229,695 noninsulin-treated Medicare Advantage beneficiaries, of whom 82.9% (n = 571,581) had ≥1 HRE in an ambulatory location and 26.8% (n = 184,833) in an ED/inpatient location. Use of sulfonylurea (odds ratio [OR]: 4.33 confidence interval [CI: 4.27-4.38]), evidence of end-stage kidney disease (OR: 2.87 [CI: 2.79-2.94]), hypertension (OR: 3.09 [CI: 3.04-3.15]) and retinopathy (OR: 2.94 [CI: 2.82-3.07]) were the strongest predictors of an HRE (p < 0.001).

CONCLUSIONS

These findings show that HREs are prevalent in noninsulin-treated diabetes and identify a large number of patients who may benefit from CGM. Because >80% of HREs occur in the ambulatory setting and >70% occur in patients not taking sulfonylureas, primary care providers should be aware of the latest eligibility criteria for Medicare's coverage of CGM and not restrict this technology to their sulfonylurea-treated patients.

Cardiovascular, Metabolic, and Safety Outcomes with Semaglutide by Baseline Age: Post Hoc Analysis of SUSTAIN 6 and PIONEER 6

INTRODUCTION

The high risk of cardiovascular events in people with type 2 diabetes increases with age. The cardiovascular effects of once-weekly subcutaneous and once-daily oral semaglutide versus placebo in people with type 2 diabetes at high cardiovascular risk were investigated in the SUSTAIN 6 and PIONEER 6 cardiovascular outcomes trials, respectively. It is unknown whether the effects of semaglutide are age dependent.

METHODS

This post hoc analysis evaluated cardiovascular, metabolic, and safety outcomes with semaglutide versus placebo in age subgroups (≤ 60; > 60 to ≤ 65; > 65 to ≤ 70; and > 70 years) pooled from SUSTAIN 6 and PIONEER 6. Major adverse cardiovascular events (composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke), changes from baseline in glycated hemoglobin A1c (HbA1c) and body weight, and adverse events were analyzed.

RESULTS

Semaglutide reduced major adverse cardiovascular events and its components versus placebo across age subgroups (most hazard ratios < 1.0; pinteraction > 0.05). The treatment difference in HbA1c reduction was greater in those aged ≤ 60 years than in older subgroups (pinteraction = 0.01). Reductions in body weight with semaglutide versus placebo were consistent across age subgroups (pinteraction = 0.124). Serious adverse events or severe hypoglycemic episodes did not differ between semaglutide and placebo across age subgroups.

CONCLUSION

Semaglutide consistently reduced major adverse cardiovascular events and body weight versus placebo across age subgroups; its safety profile did not differ with age. These results suggest that relaxing HbA1c targets based solely on age may not always be required for people with type 2 diabetes.

TRIAL REGISTRATION

SUSTAIN 6 (NCT01720446) and PIONEER 6 (NCT02692716) are registered at ClinicalTrials.gov.

Experiences of adolescents and young adults with type 1 diabetes and chronically elevated glucose levels following the transition from multiple daily injections to advanced hybrid closed-loop: A qualitative study

AIM

To understand experiences of using second-generation advanced hybrid closed-loop (AHCL) therapy in adolescents and young adults with chronically elevated glucose levels who were previously using multiple daily injections (MDI) therapy.

METHOD

Semi-structured interviews with participants aged 13-25 years, on AHCL therapy for 3 months as part of a single-arm prospective study. Key inclusions: HbA1c ≥69 mmol/mol (8.5%); diabetes duration ≥1 year; and using MDI therapy prior to the study. Qualitative content analysis was used to identify themes and subthemes.

RESULTS

Interviews were conducted among 14 participants with mean age 19.4 ± 4.3 years and mean baseline HbA1c 90 ± 25 mmol/mol (10.4 ± 4.5%). Three themes were identified: (1) substantially improved glucose levels improved perceptions of overall health; (2) features of AHCL aid in adoption and ongoing self-management; and (3) burden of care was reduced through automation of insulin delivery. Overall, there were positive impacts on physical, mental and social well-being. Participants were willing to overlook minor frustrations with AHCL because of the vast benefits that they had experienced. Four participants reported transient pseudo-hypoglycaemia: symptoms of hypoglycaemia when objectively measured glucose was in the clinically recommended range (3.9-10 mmol/L, 70-180 mg/dL).

CONCLUSION

Transition to AHCL therapy positively impacted diabetes management in adolescents and youth with chronically elevated glucose levels. It appears to create a window of opportunity in which youth may re-engage with diabetes management. Pseudo-hypoglycaemia can occur during the transition to AHCL. This could be a barrier to AHCL uptake and is likely to require individualised support.

Interoceptive Awareness Is Associated With Impaired Awareness of Hypoglycemia in Adults With Type 1 Diabetes

OBJECTIVE

To assess the association between impaired awareness of hypoglycemia (IAH) and interoceptive awareness in type 1 diabetes.

RESEARCH DESIGN AND METHODS

A total of 154 adults with type 1 diabetes completed IAH surveys and the Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2). Logistic regression was performed for assessment of associations between IAH and MAIA-2, accounting for covariates.

RESULTS

Significant relationships were observed between IAH and two MAIA-2 scales. Each 1-point increase on the Not-Worrying subscale was associated with 87% increased odds of IAH (odds ratio 1.87, CI 1.01-3.46) and on the Attention Regulation subscale was associated with 72% decreased odds of IAH (0.28, 0.12-0.66). Compared with scoring >90th percentile for Attention Regulation, scoring <10th percentile and scoring in the 10th-90th percentiles were associated with 71-fold (71.26, 3.42-1482.10) and 12-fold (12.73, 1.19-135.57) increased odds of IAH, respectively.

CONCLUSIONS

Less worry about and reduced ability to sustain and control attention to body sensations were associated with significantly increased odds of IAH.

Sensor-derived glycaemic metrics in pregnant women with type 1 diabetes randomised to faster acting insulin aspart or insulin aspart-A secondary analysis of the CopenFast trial

AIMS

We compared sensor-derived glycaemic metrics in pregnant women with type 1 diabetes (T1D) randomised to faster acting insulin aspart (faster aspart) or insulin aspart (IAsp).

METHODS

A pre-planned secondary analysis of the CopenFast trial included women with T1D using intermittently scanned continuous glucose monitoring (isCGM) during pregnancy. Glycaemic metrics, including time in range (TIRp, 3.5-7.8 mmol/L) and time below range in pregnancy (TBRp, <3.5 mmol/L), were evaluated in the intervals: from randomisation (median 9.5 weeks, interquartile range 9.0-11.0) to 21 weeks, from 22 to 33 weeks and from 34 to 37 weeks.

RESULTS

In total, 113 (91%) of 124 women using isCGM in the original trial were included. At randomisation, glycaemic metrics were comparable in both groups. Women randomised to faster aspart achieved higher TIRp from 22 to 33 weeks (estimated treatment difference 5.1% [95% confidence interval 0.3; 9.7], p = 0.04) and mean TIRp >70% from randomisation to 21 weeks onwards, while this was achieved after 34 weeks in women randomised to IAsp. TBRp remained stable around 4% throughout pregnancy in both groups. One (2%) versus 5 (9%) experienced ≥1 severe hypoglycaemic event (odds ratio 0.93 [-0.2; -0.01], p = 0.04). Infant birthweight standard deviation score was lower in the faster aspart group (estimated treatment difference -0.5 [-0.9; -0.03], p = 0.04); however, this attenuated when adjusting for parity (p = 0.10).

CONCLUSIONS

Women using faster aspart achieved more TIRp and experienced less severe hypoglycaemia compared to women using IAsp. Infant birthweight was lower and thereby more appropriate in the faster aspart group; however, this attenuated when adjusting for parity.

Effectiveness and safety of insulin glargine 300 U/mL in insulin-naïve individuals according to diabetes duration: Results from the REALI European pooled data analysis

AIM

To evaluate the effectiveness and safety of insulin glargine 300 U/mL (Gla-300) initiation according to diabetes duration (DD).

MATERIALS AND METHODS

We analysed patient-level data from 2381 insulin-naïve individuals with type 2 diabetes (T2D), of whom 2349 (98.7%) were treated with Gla-300 for 24 weeks. Of the 2381 participants, 1048 (44.0%) had a DD of less than 8 years and 1333 (56.0%) had a DD of 8 years or longer. We further analysed the subgroups of participants having a DD of less than 4 years (N = 450), 4-8 years (N = 598), 8-12 years (N = 627) and 12 years or longer (N = 706).

RESULTS

Mean ± standard deviation age was 60.2 ± 9.0 years in participants with a DD less than 8 years and 64.2 ± 8.8 years in those with a DD of 8 years or longer. At 24 weeks of Gla-300 therapy, HbA1c improved with a least-squares (LS) mean change from baseline of -1.88% (95% confidence interval [CI], -1.95 to -1.80) and -1.71% (95% CI, -1.77 to -1.65), respectively, resulting in a LS mean difference between groups of 0.17% (95% CI, 0.07 to 0.26; P = .0005). In the subgroup analysis, LS mean HbA1c reduction from baseline to week 24 was highest in participants with a DD of less than 4 years and lowest in participants with a DD of 12 years or longer. Overall, incidences of symptomatic and severe hypoglycaemia were low, irrespective of DD, without body weight changes.

CONCLUSIONS

Gla-300 was effective and safe in insulin-naïve individuals with T2D, regardless of DD. Improvement in HbA1c was greater when Gla-300 was initiated in participants with a DD of less than 4 years, although the difference between the groups was modest.

American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Balapattabi K, Beverly EA, Early B, Bruemmer D, Echouffo-Tcheugui JB, Ekhlaspour L, Garg R, Khunti K, Lal R, Lingvay I, Matfin G, Pandya N, Pekas EJ, Pilla SJ, Polsky S, Segal AR, Seley JJ, Selvin E, Stanton RC, Bannuru RR. 6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes-2025

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, an interprofessional 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.

Recurrent events modeling based on a reflected Brownian motion with application to hypoglycemia

Patients with type 2 diabetes need to closely monitor blood sugar levels as their routine diabetes self-management. Although many treatment agents aim to tightly control blood sugar, hypoglycemia often stands as an adverse event. In practice, patients can observe hypoglycemic events more easily than hyperglycemic events due to the perception of neurogenic symptoms. We propose to model each patient's observed hypoglycemic event as a lower boundary crossing event for a reflected Brownian motion with an upper reflection barrier. The lower boundary is set by clinical standards. To capture patient heterogeneity and within-patient dependence, covariates and a patient level frailty are incorporated into the volatility and the upper reflection barrier. This framework provides quantification for the underlying glucose level variability, patients heterogeneity, and risk factors' impact on glucose. We make inferences based on a Bayesian framework using Markov chain Monte Carlo. Two model comparison criteria, the deviance information criterion and the logarithm of the pseudo-marginal likelihood, are used for model selection. The methodology is validated in simulation studies. In analyzing a dataset from the diabetic patients in the DURABLE trial, our model provides adequate fit, generates data similar to the observed data, and offers insights that could be missed by other models.

The double life of glucose metabolism: brain health, glycemic homeostasis, and your patients with type 2 diabetes

The maintenance of cognitive function is essential for quality of life and health outcomes in later years. Cognitive impairment, however, remains an undervalued long-term complication of type 2 diabetes by patients and providers alike. The burden of sustained hyperglycemia includes not only cognitive deficits but also the onset and progression of dementia-related conditions, including Alzheimer's disease (AD). Recent research has shown that the brain maintains an independent glucose "microsystem"-evolved to ensure the availability of fuel for brain neurons without interruption by transient hypoglycemia. When this milieu is perturbed, brain hyperglycemia, brain glucotoxicity, and brain insulin resistance can ensue and interfere with insulin signaling, a key pathway to cognitive function and neuronal integrity. This newly understood brain homeostatic system operates semi-autonomously from the systemic glucoregulatory apparatus. Large-scale clinical studies have shown that systemic dysglycemia is also strongly associated with poorer cognitive outcomes, which can be mitigated through appropriate clinical management of plasma glucose levels. Moreover, these studies demonstrated that glucose-lowering agents are not equally effective at preventing cognitive dysfunction. Glucagon-like peptide-1 (GLP-1) receptor analogs and sodium glucose cotransporter 2 inhibitors (SGLT2is) appear to afford the greatest protection; metformin and dipeptidyl peptidase 4 inhibitors (DPP-4is) also significantly improved cognitive outcomes. Sulfonylureas (SUs) and exogenous insulin, on the other hand, do not provide the same protection and may actually worsen cognitive outcomes. In the creation of a treatment plan, comorbid cognitive conditions should be considered. These efficacious treatments create a new gold standard of managing hyperglycemia-one which is consistent with the "complication-centric prescribing" mandates issued in type 2 diabetes treatment guidelines. The increasing longevity enjoyed by our populace places the onus on clinical care to play the "long game" in using targeted treatments for glucose control in patients with, or at risk for, cognitive decline to maintain cognitive wellness later in life. This article reviews critical emerging data for scientists and trialists and translates new enhancements in patient care for practitioners.

Evaluating the precision and reliability of real-time continuous glucose monitoring systems in ambulatory settings: a systematic review

Background

Continuous glucose monitoring (CGM) with minimally invasive devices plays a key role in the assessment of daily diabetes management by detecting and alerting to potentially dangerous trends in glucose levels, improving quality of life, and treatment adherence. However, there is still uncertainty as to whether CGMs are accurate enough to replace self-monitoring of blood glucose, especially in detecting episodes of hypoglycemia.

Objectives

Evaluate clinical, numerical accuracy, sensitivity, and specificity of the CGM devices commercially available when compared to the reference standard of arterial or venous blood glucose.

Data sources and methods

We searched the Cochrane Library, PubMed, EMBASE, and LILACS databases. The quality was assessed with the Quality Assessment Diagnostic Accuracy Studies (QUADAS-2) tool. Clinical and numerical accuracy data were extracted. Sensitivity and specificity were calculated using Review Manager software. Heterogeneity was assessed by visual examination of forest plot and summary receiver operating characteristic curves.

Results

Twenty-two studies with a total of 2294 patients were included. The average mean absolute relative difference for overall diagnostic accuracy was 9.4%. None of the devices evaluated with ISO 15197:2013 criteria achieved values ⩾95% of measurements in the stipulated ranges in hypoglycemia (±15 mg/dL), but two devices did achieve it in hyperglycemia (±15%; Dexcom G6 and G7). Most of the devices evaluated with consensus error grids reached values above 99% in zones A and B only in overall accuracy and hyperglycemia. For hypoglycemia, the average sensitivity was 85.7% and specificity 95.33%, and for hyperglycemia was 97.45% and 96% respectively.

Conclusion

Currently available CGM devices have adequate accuracy for euglycemia and hyperglycemia; however, it is still inadequate for hypoglycemia, although it has improved over time.

Trial registration

Prospero registration ID CRD42023399767.

Glucose Control During Labour and Delivery in Type 1 Diabetes - An Update on Current Evidence

PURPOSE OF REVIEW

To provide an update on diabetes management during labour and delivery in women with type 1 diabetes with focus on appropriate insulin administration, carbohydrate supply and use of diabetes technology to support safe delivery and neonatal well-being.

RECENT FINDINGS

During active labour and elective cesarean section capillary blood glucose monitoring or continuous glucose monitoring at least hourly is recommended. Infusion with isotonic (5%) glucose can be given with adjustable infusion rate to address maternal carbohydrate requirements and to prevent maternal hypoglycemia. Subcutaneous insulin administration with multiple injections or insulin pump therapy is considered at least as safe and efficient as intravenous administration to obtain tight glycemic targets. Automated insulin delivery via insulin pump can be continued during labour and delivery. Diabetes management during labour and delivery involves intensive glucose monitoring, adequate insulin administration and carbohydrate administration to support safe delivery and neonatal well-being.

Real-Life Effectiveness of iGlarLixi (Insulin Glargine 100 U/ml and Lixisenatide) in People with Type 2 Diabetes (T2D) According to Baseline HbA1c and BMI

INTRODUCTION

This study aimed to evaluate the effect of baseline body mass index (BMI) and glycated hemoglobin (HbA1c) on the effectiveness and safety of initiating iGlarLixi (insulin glargine 100 U/ml and lixisenatide) in people with type 2 diabetes (T2D) in routine clinical practice.

METHODS

We pooled patient-level data from 1406 people with inadequately controlled T2D, initiating a 24-week iGlarLixi treatment. Analysis sets were based on baseline BMI and HbA1c. In the BMI set, 894 (64%) people had a BMI ≥ 30 kg/m2 and 510 (36%) a BMI < 30 kg/m2; in the HbA1c set, 615 (44%) people had an HbA1c  >9%, 491 (35%) between 8 and 9%, and 298 (21%) < 8%.

RESULTS

After initiating iGlarLixi, HbA1c decreased in all participants, with the greatest least-squares mean reduction at 2.15% from baseline to week 24 in those with baseline HbA1c > 9% (using a mixed model for repeated measures). Overall, mean ± standard deviation body weight decreased by 1.9 ± 4.8 kg, with the most prominent loss of 2.6 ± 4.9 kg recorded in people presenting with obesity. Reported hypoglycemia rates were low across all groups.

CONCLUSIONS

Initiation of iGlarLixi in people with uncontrolled T2D is effective and safe in clinical practice, across different baseline HbA1c and BMI categories.

Comparing quality of life in traditional face-to-face visits with a hybrid approach of telemedicine with in-person follow-ups in recent users of advanced closed-loop systems: a randomized controlled clinical trial in patients with type 1 diabetes

Background

Our objective was to assess the effect of a hybrid telemedicine approach, in conjunction with face-to-face follow-up, on the quality of life in recent users of an advanced hybrid closed-loop (AHCL) system.

Methods

A 1-year open randomized (1:1) clinical trial (ClinicalTrials.gov ID NCT04900636). Participants with type 1 diabetes (T1D) recent users of an AHCL system (Minimed® 780G) for at least 2-6 months, and ⩾18 years old were eligible. The primary outcome was the change in quality of life measured by the Type 1 Diabetes Life (ViDa1) Questionnaire from baseline to 12 months of hybrid telemedicine plus face-to-face follow-up compared to standard clinical practice. Additionally, impacts on A1c levels, glucose metrics, advert events, and safety outcomes were assessed.

Results

Between January and December 2021, 46 participants were randomly assigned in a 1:1 ratio to either the hybrid telemedicine group (n = 23) or the control group (n = 23); 45 participants completed the study, with only 1 from the control group withdrawing before visit 3. At baseline, mean age was 37 ± 15 years and A1c was 6.9 ± 0.5%. After 12 months, no statistically significant differences in ViDa1 scores between groups were observed. Despite reducing in-person visits in the hybrid follow-up arm, there were no increases in adverse events. Overall, A1c levels significantly decreased from 6.9 ± 0.5% at baseline to 6.7 ± 0.5% after 12 months (P = 0.006) without differences between treatment arms, accompanied by reductions in glycemic variability and time below the target range.

Conclusion

Our study suggests that there were no significant differences in ViDa1 scores between the two groups at the end of the follow-up. However, among adult patients with T1D who recently adopted an AHCL system, satisfactory glycemic control can be attained through a hybrid follow-up approach, reducing face-to-face visits, without increasing technical complications.

Pharmacist consult to prevent hypoglycemia in adult inpatients with renal dysfunction

PURPOSE

The objective of this study was to evaluate the impact of a pharmacist consult service on rates of hypoglycemia in adult inpatients with renal dysfunction receiving antidiabetic medications.

METHODS

This was a single-center, institutional review board-approved, quasi-experimental, 2-phase prospective study. Adult inpatients admitted within 48 to 96 hours of hospitalization with a creatine clearance of less than 30 mL/min or estimated glomerular filtration rate of less than 30 mL/min/1.73 m2 and an active antidiabetic medication order were included. Patients located in a critical care unit or with a previous or planned transplantation were excluded. Each phase was conducted over 4 months. The primary endpoint was the change in the incidence of hypoglycemic episodes (blood glucose [BG] of <70 mg/dL) per 100 patient days when comparing the cohorts. Secondary endpoints included the incidence of recurrent and severe (BG of <40 mg/dL) episodes of hypoglycemia per 100 patient days, occurrence of a BG concentration of higher than 300 mg/dL, and length of stay.

RESULTS

Overall, 150 patients were included in the retrospective preimplementation phase and 172 were included in the prospective postimplementation phase. In the postimplementation group, there was a significant decrease in the rate of hypoglycemia per 100 patient days when compared to the retrospective group (5.8 vs 9.0; incidence rate ratio, 1.55; 95% confidence interval, 1.2-2.0; P < 0.05). There was no difference in secondary endpoints between the groups.

CONCLUSION

The implementation of a pharmacy consult service resulted in lower rates of hypoglycemic events, which supports pharmacist involvement to prevent hypoglycemia in this at-risk population. Additional studies involving pharmacists working under collaborative practice agreements may reinforce the results.

Nocturnal hypoglycemia is associated with next day cognitive performance in adults with type 1 diabetes: Pilot data from the GluCog study

OBJECTIVE

 Individuals with type 1 diabetes (T1D) have increased risk for cognitive dysfunction and high rates of sleep disturbance. Despite associations between glycemia and cognitive performance using cross-sectional and experimental methods few studies have evaluated this relationship in a naturalistic setting, or the impact of nocturnal versus daytime hypoglycemia. Ecological Momentary Assessment (EMA) may provide insight into the dynamic associations between cognition, affective, and physiological states. The current study couples EMA data with continuous glucose monitoring (CGM) to examine the within-person impact of nocturnal glycemia on next day cognitive performance in adults with T1D. Due to high rates of sleep disturbance and emotional distress in people with T1D, the potential impacts of sleep characteristics and negative affect were also evaluated.

METHODS

 This pilot study utilized EMA in 18 adults with T1D to examine the impact of glycemic excursions, measured using CGM, on cognitive performance, measured via mobile cognitive assessment using the TestMyBrain platform. Multilevel modeling was used to test the within-person effects of nocturnal hypoglycemia and hyperglycemia on next day cognition.

RESULTS

 Results indicated that increases in nocturnal hypoglycemia were associated with slower next day processing speed. This association was not significantly attenuated by negative affect, sleepiness, or sleep quality.

CONCLUSIONS

 These results, while preliminary due to small sample size, showcase the power of intensive longitudinal designs using ambulatory cognitive assessment to uncover novel determinants of cognitive fluctuation in real world settings, an approach that may be utilized in other populations. Findings suggest reducing nocturnal hypoglycemia may improve cognition in adults with T1D.

Screening for Hypoglycaemia Risk and Medication Changes in Diabetes Patients Using Pharmacy Dispensing Data

Background: To improve hypoglycaemia management in primary care, more insight is needed into the opportunities to screen for hypoglycaemia risk and subsequent treatment modification using routinely available data. Our primary aim was to assess the number of diabetes patients with an estimated high risk of hypoglycaemia and describe the treatment changes in these patients using pharmacy dispensing data. Additionally, our aim was to investigate patient characteristics associated with such treatment changes. Methods: A drug utilisation cohort study with a 1-year follow-up using the IADB.nl pharmacy database was conducted. Patients aged 35 years or older who received at least two glucose-lowering medication dispensings in 2019 were included. Hypoglycaemia risk was determined using a validated algorithm based on patient demographics and dispensing data. The hypoglycaemia risk score ranged between 0 and 1. The anniversary method was used to evaluate treatment changes after 1 year. Factors associated with treatment changes were assessed by multinomial logistic regression. Results: Around one-quarter (26.9%) of the 36,628 included patients had a hypoglycaemia score of 0.6 or more. After a 1-year follow-up, the majority of these patients (88.9%) experienced no diabetes treatment changes. De-intensification was observed for 8.8% and intensification for 2.3%. Having a high-risk score, being female, and being younger in age were associated with de-intensification. Conclusions: A substantial number of primary care patients using glucose-lowering medications appear at risk of hypoglycaemia, whereas few of them undergo medication de-intensification. Pharmacy dispensing data can be helpful in screening for diabetes patients in whom a review of treatment is indicated.

Investigation of Glucose Metabolism by Continuous Glucose Monitoring and Validation of Dipeptidyl Peptidase 4 Inhibitor Use in Patients with Myotonic Dystrophy Type 1

Objectives: We characterized blood glucose fluctuations in patients with myotonic dystrophy type 1 (DM1). After confirming the incretin secretion capacity of patients with DM1, we intended to clarify whether dipeptidyl peptidase 4 (DPP-4) inhibitor administration was appropriate in cases of DM1 with diabetes mellitus. Methods: A 48 h continuous glucose monitoring (CGM) was performed in 29 Japanese patients with DM1. An oral glucose tolerance test (OGTT) was performed in patients with DM1 and five disease controls, and levels of blood glucose, insulin, and incretin (glucagon-like peptide-1 and gastric inhibitory polypeptide) were measured. DPP-4 inhibitors were administered to patients with diabetes mellitus complicated by DM1, and the CGM results were compared. Results: The CGM showed distinct patterns of blood glucose variability among patients classified by an OGTT pattern with significant differences in glucose parameters such as time above 140 mg/dL and mean amplitude of glycemic excursions between the groups. High sensor glucose values were observed in a certain number of patients who were classified as having normal or impaired glucose tolerance by the OGTT. The CGM confirmed the presence of low glucose levels in several patients. Incretin secretion, the target of DPP-4 inhibitors, was preserved in patients with DM1. DPP-4 inhibitor treatment resulted in lower glucose levels and improved insulin secretion in some patients. Conclusions: This is the first CGM study for DM1 patients. The CGM identified potential early abnormalities in glucose metabolism in DM1. In the future, it will be crucial to explore effective methods for harnessing CGM and assessing it quantitatively in DM1.

Ustekinumab for type 1 diabetes in adolescents: a multicenter, double-blind, randomized phase 2 trial

Immunotherapy targeting the autoimmune process in type 1 diabetes (T1D) can delay the loss of β-cells but needs to have minimal adverse effects to be an adjunct to insulin in the management of T1D. Ustekinumab binds to the shared p40 subunit of interleukin (IL)-12 and IL-23, targeting development of T helper 1 cells and T helper 17 cells (TH1 and TH17 cells) implicated in the pathogenesis of T1D. We conducted a double-blind, randomized controlled trial of ustekinumab in 72 adolescents aged 12-18 years with recent-onset T1D. Treatment was well tolerated with no increase in adverse events. At 12 months, β-cell function, measured by stimulated C-peptide, was 49% higher in the intervention group (P = 0.02), meeting the prespecified primary outcome. Preservation of C-peptide correlated with the reduction of T helper cells co-secreting IL-17A and interferon-γ (TH17.1 cells, P = 0.04) and, in particular, with the reduction in a subset of TH17.1 cells co-expressing IL-2 and granulocyte-macrophage colony-stimulating factor (IL-2+ GM-CSF+ TH17.1 cells, P = 0.04). A significant fall in β-cell-targeted (proinsulin-specific) IL-17A-secreting T cells was also seen (P = 0.0003). Although exploratory, our data suggest a role for an activated subset of TH17.1 cells in T1D that can be targeted with minimal adverse effects to reduce C-peptide loss, which requires confirmation in a larger study. (International Standard Randomised Controlled Trial Number Registry: ISRCTN 14274380).

Effectiveness of the flash glucose monitoring system in preventing severe hypoglycemic episodes and in improving glucose metrics and quality of life in subjects with type 1 diabetes at high risk of acute diabetes complications

AIMS

To assess the effectiveness of the intermittent-scanned continuous glucose monitoring (isCGM) system in preventing severe hypoglycemic episodes and in improving glucose parameters and quality of life.

METHODS

Four hundred T1D individuals were enrolled in a prospective real-word study with an intermittently scanned continuous glucose monitoring device during the 12-months follow-up. The primary endpoint was the incidence of severe hypoglycemic events.

RESULTS

82% of subjects were naïve to the use of the device (group A) and 18% were already wearing the system (group B). The cumulative incidence of severe hypoglycemia (SH) at 12 months was 12.06 per 100 person-year (95% CI: 8.35-16.85) in group A and 10.14 (95% CI: 4.08-20.90) in group B without inter-group differences. In group A there was a significant decrease in SH at 12 months compared to 3 months period (p = 0.005). Time in glucose range significantly increased in both groups accompanied with a significant decrease in glucose variability. HbA1c showed a progressive significant time-dependent decrease in group A. The use of the device significantly improved the perceived quality of life.

CONCLUSION

This study confirmed the effectiveness of the isCGM in reducing hypoglycemic risk without glucose deterioration, with potential benefits on adverse outcomes in T1D individuals.

TRIAL REGISTRATION

ClinicalTrials.gov registration no. NCT04060732.

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.

Nutritional Status, Dietary Intake, and Nutrition-Related Interventions Among Older Adults With Type 1 Diabetes: A Systematic Review and Call for More Evidence Toward Clinical Guidelines

There is an emerging population of older adults (≥65 years) living with type 1 diabetes. Optimizing health through nutrition during this life stage is challenged by multiple and ongoing changes in diabetes management, comorbidities, and lifestyle factors. There is a need to understand nutritional status, dietary intake, and nutrition-related interventions that may maximize well-being throughout the life span in type 1 diabetes, in addition to nutrition recommendations from clinical guidelines and consensus reports. Three reviewers used Cochrane guidelines to screen original research (January 1993-2023) and guidelines (2012-2023) in two databases (MEDLINE and CENTRAL) to characterize nutrition evidence in this population. We found limited original research explicitly focused on nutrition and diet in adults ≥65 years of age with type 1 diabetes (six experimental studies, five observational studies) and meta-analyses/reviews (one scoping review), since in the majority of analyses individuals ≥65 years of age were combined with those age ≥18 years, with diverse diabetes durations, and also individuals with type 1 and type 2 diabetes were combined. Further, existing clinical guidelines (n = 10) lacked specificity and evidence to guide clinical practice and self-management behaviors in this population. From a scientific perspective, little is known about nutrition and diet among older adults with type 1 diabetes, including baseline nutrition status, dietary intake and eating behaviors, and the impact of nutrition interventions on key clinical and patient-oriented outcomes. This likely reflects the population's recent emergence and unique considerations. Addressing these gaps is foundational to developing evidence-based nutrition practices and guidelines for older adults living with type 1 diabetes.

Glycaemic outcomes in people living with diabetes under 65 and over 65 years old using an intermittently scanned continuous glucose monitoring system

Objective

Intermittently scanned continuous glucose monitoring (isCGM) has revolutionised the care of people with diabetes but its uptake and benefits in older adults are not well known. We examined the impact of isCGM (Freestyle Libre, FSL) on glycaemic outcomes in younger (⩽65 years) and older adults (>65 years) with diabetes.

Design and methods

In total, 2260 adult patients registered on the Libreview account at University Hospitals Birmingham NHS Foundation Trust, UK, were included. Inclusion criteria: all patients with type 1 and type 2 diabetes aged >18 years, use of isCGM >6 months, scanning at least 6 times/day. Demographics, diabetes history and glycaemic outcomes (time in range (TIR), time above range and time below range (TBR), estimated HbA1c, HbA1c at start and at end of study) were collected by accessing electronic patient records and Libreview. Outcomes were compared between age groups ⩽65 or >65 years old.

Results

Most patients were of Caucasian ethnicity (⩽65 years 68%, >65 years 73%) and had type 1 diabetes. Mean duration of diabetes was 19.5 years (range 0-65 years) and 34.5 years (range 0-79 years) for ⩽65 and >65 years, respectively. Only a quarter of those ⩽65 years achieved (219/943; 23.2%) their age specific TIR target compared to 69% (78/113) of those >65 years cohort, while 70.1% (663/946) of ⩽65 years and 40.7% (46/113) of >65 years achieved their age-specific TBR target. When the less strict ⩽65 years TBR target was applied, 75% (85/113) of >65 years cohort achieved this.

Conclusion

FSL use was associated with improved glycaemic outcomes across all age groups. Individualised targets may be needed to improve TBR in those aged >65 years.

Out of Sight, Out of Mind: A Call to Action for the Treatment of Hypoglycemia

Hypoglycemia will inevitably occur. Being prepared and implementing a treatment plan should help to restore euglycemia and resolve hypoglycemia symptoms. The plan comprises fast-acting carbohydrates and, importantly, ready-to-use glucagon for self-administration when carbohydrates are not working or for third-party administration when the affected person is unwilling or unable to swallow (e.g., unconscious or in a coma).

Severe hypoglycemia in a diabetic patient with pituitary apoplexy: a case report

INTRODUCTION

Hypoglycemia is a common occurrence in diabetic patients. But unlike non diabetic patients, its causes are frequently related to drugs they are receiving to control blood glucose. But this may not always be the case. Here we report a type 2 diabetic patient with severe hypoglycemia owing to acute hypopituitarism secondary to pituitary apoplexy.

CASE PRESENTATION

A 45 year old male diabetic patient from Ethiopia taking 2 mg of oral glimepiride daily who presented with change in mentation of 30 minutes and blood glucose recording of 38 mg/dl upon arrival to the emergency room. Brain magnetic resonance imaging showed pituitary macroadenoma with hemorrhage suggestive of pituitary apoplexy. Blood work up showed low adrenocorticotropic hormone, cortisol, and serum sodium levels. Subsequently transsphenoidal hypophysectomy was done.

CONCLUSION

The occurrence of hypoglycemia in a diabetic patient taking sulphonylurea monotherapy is common. But when it is severe enough to cause altered mentation, patients should be approached differently. In the presence of clinical clues suggesting cortisol deficiency, hypopituitarism can be a possible cause.

Population pharmacokinetics and pharmacodynamics of nasal glucagon in patients with type 1 or 2 diabetes

The objective was to characterize the pharmacokinetics (PK) and pharmacodynamics (PD) of glucagon after injectable or nasal administration and confirm the appropriate therapeutic dose of nasal glucagon (NG) for adult patients. Six clinical studies with PK and five clinical studies with PD (glucose) data were included in the analysis. Doses ranging from 0.5 to 6 mg NG, and 0.5 to 1 mg injectable glucagon were studied. A total of 6284 glucagon and 7130 glucose concentrations from 265 individuals (patients and healthy participants) were available. Population PK/PD modeling was performed using NONMEM. Glucagon exposure and glucose response were simulated for patients administered various doses of NG to confirm the optimal dose. Glucagon PK was well-described with a single compartment disposition with first-order absorption and elimination processes. Bioavailability of NG relative to injectable glucagon was 16%. Exposure-response modeling revealed that lower baseline glucose was associated with higher maximum drug effect. The carry-over effect from prior insulin administration was incorporated into the model through a time-dependent increase in elimination rate of glucose. Simulations showed that more than 99% of hypoglycemic adult patients would experience treatment success, defined as an increase in blood glucose to ≥70 mg/dL or an increase of ≥20 mg/dL from nadir within 30 min after administration of NG 3 mg. The population PK/PD model adequately described the PK and PD profiles of glucagon after nasal administration. Modeling and simulations confirmed that NG 3 mg is the most appropriate dose for rescue treatment during hypoglycemia emergencies.

Comparative Efficacy and Safety of Glucagon-like Peptide-1 Receptor Agonists in Children and Adolescents with Obesity or Overweight: A Systematic Review and Network Meta-Analysis

Four glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been used in children and adolescents with obesity or overweight. This network meta-analysis was conducted to compare the efficacy and safety of these regimens. Embase, PubMed, and Scopus were searched on March 2023 and updated in June 2024 for eligible randomized controlled trials (RCTs). The primary efficacy outcomes were mean difference in actual body weight, BMI (body mass index), BMI z score, and waist circumference. Safety outcomes included nausea, vomiting, diarrhea, abdominal pain, injection-site reaction, and hypoglycemia. Eleven RCTs with 953 participants were eligible. Semaglutide exhibited greater effects in reducing weight, BMI, and BMI z score versus the placebo. Semaglutide was associated with greater weight loss and BMI z score reduction in comparison with exenatide, liraglutide, and dulaglutide. Semaglutide also significantly decreased BMI than exenatide. None of the four GLP-1 RAs were associated with higher risks of diarrhea, headache, and abdominal pain versus the placebo. Liraglutide was more likely to cause nausea, vomiting, hypoglycemia, and injection-site reactions than the placebo. Liraglutide also had higher odds of causing injection-site reactions than other GLP-1 RAs. Semaglutide appeared to be the most effective and safe option among four GLP-1 RAs in children and adolescents with obesity or overweight.

Risk factors for hypoglycaemia in non-critical hospitalised diabetic patients

OBJECTIVE

To determine the risk factors for hypoglycaemia in patients with diabetes on general hospital wards based on a systematic review of the literature since 2013 and meta-analysis.

METHODS

Systematic review of the literature focused on the conceptual and methodological aspects of the PRISMA Declaration. The search carried out in Pub Med, Web of Science, Medline, Scielo, Lilacs, OVID, grey literature and Google Academic focused on risk factors for hypoglycaemia in patients with diabetes on general hospital wards. The CASPe (Critical Appraisal Skills Programme Spanish) tool was applied for quality control.

RESULTS

From 805 references, 70 potentially eligible articles were identified for review of abstracts and full text. Finally, according to inclusion and exclusion criteria, seven studies with 554,601 patients of Asian, European and North American ethnicity were selected. A meta-analysis performed using the random effects model found an association between the presence of hypoglycaemia and: the use of insulin (OR 2.89 [95% CI: 1.8-4.5]); the use of long-acting insulin (OR 2.27 [95% CI: 1.8-2.8]) or fast-acting insulin (OR 1.4 [95% CI: 1.18-1.85]); nasogastric tube feeding (OR 1.75 [95% CI: 1.33-2.3]); chronic kidney disease (OR 1.65 [95% CI: 1.14-2.38]); congestive heart failure (OR 1.36 [95% CI: 1.10-1.68]); and elevated levels of glycosylated haemoglobin (OR 1.59 [95% CI: 1.32-1.91]).

CONCLUSION

The factors associated with the risk of hypoglycaemia in non-critically ill hospitalised patients with type 2 diabetes were: use of any insulin; nasogastric tube feeding; elevated glycosylated haemoglobin levels; history of congestive heart failure; and chronic kidney disease.

Hypoglycemia and Mortality Risk in Incident Hemodialysis Patients

OBJECTIVE

Hypoglycemia is a frequent occurrence in chronic kidney disease patients due to alterations in glucose and insulin metabolism. However, there are sparse data examining the predictors and clinical implications of hypoglycemia including mortality risk among incident hemodialysis patients.

DESIGN AND METHODS

Among 58,304 incident hemodialysis patients receiving care from a large national dialysis organization over 2007-2011, we examined clinical characteristics associated with risk of hypoglycemia, defined as a blood glucose concentration <70 mg/dL, in the first year of dialysis using expanded case-mix + laboratory logistic regression models. We then examined the association between hypoglycemia during the first year of dialysis with all-cause mortality using expanded case-mix + laboratory Cox models.

RESULTS

In the first year of dialysis, hypoglycemia was observed among 16.8% of diabetic and 6.9% of nondiabetic incident hemodialysis patients. In adjusted logistic regression models, clinical characteristics associated with hypoglycemia included younger age, female sex, African-American race, presence of a central venous catheter, lower residual renal function, and longer dialysis session length. In the overall cohort, patients who experienced hypoglycemia had a higher risk of all-cause mortality risk (reference: absence of hypoglycemia): adjusted hazard ratio (95% confidence interval) 1.08 (1.04, 1.13). In stratified analyses, hypoglycemia was also associated with higher mortality risk in the diabetic and nondiabetic subgroups: adjusted hazard ratios (95% confidence interval's) 1.08 (1.04-1.13), and 1.17 (0.94-1.45), respectively.

CONCLUSIONS

Hypoglycemia was a frequent occurrence among both diabetic and nondiabetic hemodialysis patients and was associated with a higher mortality risk. Further studies are needed to identify approaches that reduce hypoglycemia risk in the hemodialysis population.

Preventing severe hypoglycemia in adults with type 2 diabetes (PHT2): Design, delivery and evaluation framework for a randomized controlled trial

BACKGROUND

Severe hypoglycemia is a common and feared complication of medications used to lower blood glucose levels in individuals with diabetes. Psychoeducational interventions can prevent severe hypoglycemia in individuals with type 1 diabetes (T1D). We aim to determine the effectiveness of this approach among adults with type 2 diabetes (T2D) at elevated risk for severe hypoglycemia.

METHODS

Preventing Hypoglycemia in Type 2 diabetes (PHT2) is a two-arm, parallel, randomized controlled trial. Participants are eligible if they are adults with T2D receiving care at an integrated group practice in Washington state and have experienced one or more episodes of severe hypoglycemia in the prior 12 months or have impaired awareness of hypoglycemia (Gold score ≥ 4). Participants are randomized to proactive nurse care management with or without my hypo compass, an evidence-based, psychoeducational intervention combining group and individual self-management training. For this study, my hypo compass was adapted to be suitable for adults with T2D and from an in-person to a virtual intervention over videoconference and telephone. The primary outcome is any self-reported severe hypoglycemia in the 12 months following the start of the intervention. Secondary outcomes include biochemical measures of hypoglycemia, self-reported hypoglycemia awareness, fear of hypoglycemia, and emergency department visits and hospitalizations for severe hypoglycemia. The study includes a process evaluation to assess implementation fidelity and clarify the causal pathway.

CONCLUSION

The PHT2 trial will compare the effectiveness of two approaches for reducing severe hypoglycemia in adults with T2D.

TRIAL REGISTRATION

clinicaltrials.gov, # NCT04863872.

Clinical Warburg Effect in a Patient With Mantle Cell Lymphoma: A Case Report

The clinical Warburg effect is a rare occurrence in cancer biology where tumor cells primarily utilize glycolysis for energy production, leading to significant hypoglycemia and lactate formation. This presentation is associated with a poor prognosis for the patient. In this context, we describe the case of a 53-year-old woman with stage IV mantle cell lymphoma who developed the clinical Warburg effect with solely arrhythmia and without neurological symptoms. She received prompt treatment for glucose stabilization and underwent inpatient chemotherapy. This case underscores the importance of early intervention to reduce tumor burden and highlights the effectiveness of hemodialysis in stabilizing metabolic acidosis. Further investigation into this approach is warranted.

Safety and Efficacy of Switching SAR341402 Insulin Aspart and Originator Insulin Aspart vs Continuous Use of Originator Insulin Aspart in Adults With Type 1 Diabetes: The GEMELLI X Trial

BACKGROUND

SAR341402 insulin aspart (SAR-Asp) is a rapid-acting insulin analog developed as an interchangeable biosimilar to the marketed insulin aspart reference product (NovoLog; NN-Asp). GEMELLI X was a randomized controlled trial to assess outcomes with a biosimilar in line with the US Food and Drug Administration requirements for designation as an interchangeable biosimilar. This report assessed whether multiple switches between SAR-Asp and NN-Asp lead to equivalent safety and efficacy compared with continuous use of NN-Asp in adults with type 1 diabetes (T1D) treated with multiple daily injections, using once-daily insulin glargine U100 (Lantus) as the basal insulin.

METHODS

This open-label randomized (1:1), parallel-group, phase 3 trial compared four × four weeks of alternating use of individually titrated SAR-Asp and NN-Asp (NN-Asp for first four weeks, SAR-Asp in last four weeks; switching group) vs 16 weeks of continuous use of NN-Asp (nonswitching group). End points included pharmacokinetics, immunogenicity, adverse events, hypoglycemia, insulin dose, and change in efficacy parameters.

RESULTS

Of the 210 patients randomized, 200 (95.5%) completed the trial. Patients assigned to switching group (n = 104) and nonswitching group (n = 106) showed similar safety and tolerability, including anti-insulin aspart antibody responses, adverse events, and hypoglycemia. At week 16, there was no relevant difference between switching vs nonswitching groups in the change from baseline in glycated hemoglobin (least square [LS] mean difference = 0.05% [95% confidence interval [CI] = -0.13, 0.22]; 0.50 mmol/mol [-1.40, 2.39]), fasting plasma glucose (LS mean difference = 0.23 mmol/L [95% CI = -1.08, 1.53]; 4.12 mg/dL [-19.38, 27.62]), and changes in insulin dosages.

CONCLUSIONS

Alternating doses of SAR-Asp and NN-Asp compared with continuous use of NN-Asp showed similar safety, immunogenicity, and clinical efficacy in adults with T1D. This study supports interchangeability between SAR-Asp and NN-Asp in T1D management.