Defining and reporting hypoglycemia in diabetes: a report from the American Diabetes Association Workgroup on Hypoglycemia

Improved glycaemic control in people with type 2 diabetes initiating or switching to IDegAsp in a real-world setting in China

AIMS

To investigate glycaemic control in Chinese adults with type 2 diabetes (T2D) initiating, or switching to insulin degludec/insulin aspart (IDegAsp), a co-formulation of basal, and bolus insulin, in a real-world setting.

MATERIALS AND METHODS

A 20-week, prospective, single-arm, open-label, non-interventional study was conducted in Chinese adults with T2D initiating, or switching to IDegAsp after anti-hyperglycaemic treatment with oral antidiabetic drugs (OADs), other insulins, or glucagon-like peptide-1 receptor agonists. The primary endpoint was a change in HbA1c from baseline to end of the study; the secondary endpoints included a change in fasting plasma glucose and Diabetes Treatment Satisfaction Questionnaire (DTSQ) score.

RESULTS

Significant reductions were observed in mean HbA1c and fasting plasma glucose, among both the overall population (N = 878; -1.27%-points [95% CI: -1.36; -1.19]; p < 0.0001, and -1.61 mmol/L [95% CI: -1.81; -1.41]; p < 0.0001, respectively), and in subgroups switching from OADs only, or basal, or premix insulins ± OADs. The mean total DTSQ score increased from 26.4 (baseline) to 31.6 (end-of-study). No significant, or unexpected tolerability, or safety issues were observed. Significant reductions were observed in incidence rates of non-severe (rate ratio 0.37 [95% CI: 0.24; 0.59]; p < 0.0001) and nocturnal non-severe (rate ratio 0.45 [95% CI: 0.21; 0.94]; p = 0.0326) hypoglycaemic episodes.

CONCLUSIONS

In a broad, real-world Chinese population of adults with T2D, initiating or switching to IDegAsp was associated with improved glycaemic control and lower rates of hypoglycaemia. The use of IDegAsp could be an effective treatment option for those with suboptimal glycaemic control or therapeutic inertia.

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.

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.

Direct costs of severe hypoglycemia events in individuals with diabetes mellitus: a perspective from the Colombian health system - a single-center study

BACKGROUND AND AIMS

Diabetes mellitus is one of the more prevalent chronic diseases globally, and healthcare expenditures for diabetes care are on the rise. Intensive diabetes treatment has been associated with reducing the risk of chronic complications. However, hypoglycemia, the most common adverse effect, poses a significant risk to individuals' lives and is linked to high costs for healthcare systems.

METHODS

We conducted a retrospective cross-sectional study to determine direct costs by identifying emergency room visits due to hypoglycemia events using diagnostic codes during January 2017 to June 2019. Direct costs were calculated using billed data from the payer and information on outpatient treatment regimens. Differences in median costs were estimated based on length of stay and type of outpatient treatment.

RESULTS

Data from 101 patients and the same number of events were included. Women represented (62.4%) of the patients, the median age was 70 (IQR 59.5-80). Blood glucose levels at admission ranged from 12 mg/dL to 67 mg/dL. Most patients were on insulin for outpatient treatment. The median cost of care per hypoglycemia episode was US $345.35 (IQR US $202-727.8), and the cost per episode was higher in patients treated with regimens that included sulfonylureas.

CONCLUSIONS

The management of patients admitted to the emergency department with a diagnosis of hypoglycemia places a significant burden on the Colombian healthcare system, primarily due to the associated hospitalization costs. Patients treated with regimens that included sulfonylureas incurred higher costs per episode. Prevention, patient education, and individualized treatment approaches could help alleviate the burden of hypoglycemia on both patients and the healthcare system.

Engaging Patients in Discussions About Medication Deprescribing

BACKGROUND

Deprescribing, intentional medication discontinuation or dose reduction, can reduce potentially inappropriate medication use and medication-related harms. Engaging patients in deprescribing discussions may increase likelihood of deprescribing and promote shared decision-making.

OBJECTIVE

To examine the impact of patient-directed educational brochures on patient engagement and deprescribing discussions with primary care providers (PCPs).

DESIGN

We mailed medication-specific brochures 2 weeks prior to each patient's PCP appointment (4/12/2021-10/7/2022), followed by a mailed survey 2 weeks after scheduled PCP visits.

PARTICIPANTS

Patients from three Veterans Affairs facilities with scheduled PCP appointments eligible for one of three medication-based cohorts (proton pump inhibitor, gabapentin, diabetes-hypoglycemia risk).

MAIN MEASURES

Our primary outcome was patient-reported deprescribing discussions with their PCP (yes/no). Descriptive statistics characterized engagement with and reactions to the brochure. Multivariable logistic regression models determined associations of patient characteristics, attitudes, and brochure-engagement with reported deprescribing discussions.

KEY RESULTS

Adjusting only for patient characteristics, discussions were less likely if respondents were Black (vs. White: OR 0.47, 95% CI 0.29-0.78) and more likely with higher education level (e.g., advanced degree vs. high school or less: OR 2.39, 95% CI 1.53-3.73), and adequate health literacy (OR 1.84, 95% CI 1.16-2.92). After further adjusting for general deprescribing attitudes and brochure engagement, discussions were more likely if respondents completed brochure activities (vs. did not read brochures: OR 2.23, 95% CI 1.39-3.59), contacted their PCPs prior to their visits (OR 2.47, 95% CI 1.34, 4.58), or discussed the brochure with family/friends (OR 1.72, 95% CI 1.22-2.41) or a healthcare provider (OR 3.18, 95% CI 2.08-4.85).

CONCLUSIONS

Patient characteristics and brochure engagement were associated with deprescribing discussions. Patient-centered deprescribing brochures can foster patient engagement and inclusion of patient perspectives into deprescribing decisions. Future studies should explore implementation strategies that promote greater deprescribing reach and adoption among patients with lower health literacy.

Fasting vs. no fasting prior to catheterization laboratory procedures: the SCOFF trial

BACKGROUND AND AIMS

Current guidelines recommend 6 h of solid food and 2 h of clear liquid fasting for patients undergoing cardiac procedures with conscious sedation. There are no data to support this practice, and previous single-centre studies support the safety of removing fasting requirements. The objective of this study was to determine the non-inferiority of a no-fasting strategy to fasting prior to cardiac catheterization procedures which require conscious sedation.

METHODS

This is a multicentre, investigator-initiated, non-inferiority, randomized trial conducted in Australia with a prospective open-label, blinded endpoint design. Patients referred for coronary angiography, percutaneous coronary intervention, or cardiac implantable electronic device (CIED)-related procedures were enrolled. Patients were randomized 1:1 to fasting as normal (6 h solid food and 2 h clear liquid) or no-fasting requirements (encouraged to have regular meals but not mandated to do so). Recruitment occurred from 2022 to 2023. The primary outcome was a composite of aspiration pneumonia, hypotension, hyperglycaemia, and hypoglycaemia assessed with a Bayesian approach. Secondary outcomes included patient satisfaction score, new ventilation requirement (non-invasive and invasive), new intensive care unit admission, 30-day readmission, 30-day mortality, 30-day pneumonia.

RESULTS

A total of 716 patients were randomized with 358 in each group. Those in the fasting arm had significantly longer solid food fasting (13.2 vs. 3.0 h, Bayes factor >100, indicating extreme evidence of difference) and clear liquid fasting times (7.0 vs. 2.4 h, Bayes factor >100). The primary composite outcome occurred in 19.1% of patients in the fasting arm and 12.0% of patients in the no-fasting arm. The estimate of the mean posterior difference in proportions with credibility interval (CI) in the primary composite outcome was -5.2% (95% CI -9.6 to -.9), favouring no fasting. This result confirms the non-inferiority (posterior probability >99.5%) and superiority (posterior probability 99.1%) of no fasting for the primary composite outcome. The no-fasting arm had improved patient satisfaction scores with a posterior mean difference of 4.02 points (95% CI 3.36-4.67, Bayes factor >100). Secondary outcome events were observed to be similar.

CONCLUSIONS

In patients undergoing cardiac catheterization and CIED-related procedures, no fasting was non-inferior and superior to fasting for the primary composite outcome of aspiration pneumonia, hypotension, hyperglycaemia, and hypoglycaemia. Patient satisfaction scores were significantly better with no fasting. This supports removing fasting requirements for patients undergoing cardiac catheterization laboratory procedures that require conscious sedation.

The effectiveness and safety of linagliptin within elderly type 2 diabetes mellitus: a meta-analysis and systematic review

INTRODUCTION

Linagliptin is a convenient and effective drug approved for glycemic management in type 2 diabetes mellitus (T2DM). However, the effectiveness and safety evidence of linagliptin remains unclear with the increasing prevalence of T2DM in elderly patients. The aim of this study was to evaluate the effectiveness and safety of linagliptin within T2DM cases who aged ≥60 years.

EVIDENCE ACQUISITION

The researchers pooled 4903 cases aged ≥60 years with T2DM from 5 published randomized clinical trials obtained from multiple databases. The safety was evaluated by the incidence and severity of adverse events which mainly focused on hypoglycemia. The major effectiveness end point was the change of glycated hemoglobin (HbA1c). Then the researchers made the qualitative and quantitative assessments of the investigation.

EVIDENCE SYNTHESIS

The level of HbA1c and fasting plasma glucose was significantly reduced by linagliptin (WMD=-0.63%, 95% CI: -0.81, -0.44; P<0.00001; Z=6.70) and (WMD=-15.58 mg/dL, 95% CI: -22.34, -8.82; P<0.00001; Z=4.52) relative to that in the placebo cohort. The incidences of overall (OR=1.01, 95% CI: 0.82, 1.25; P=0.91) and severe negative events (OR=0.88, 95% CI: 0.61, 1.25; P=0.46) were not significant increased in linagliptin cohorts compared to the placebo cohorts. There is insignificant difference in hypoglycemia between linagliptin and placebo cohorts for the 24 weeks' study (OR=1.12, 95% CI: 0.85, 1.48; P=0.41). Severe hypoglycemia had slightly descended incidence, whereas insignificant difference was shown in the linagliptin cohorts in contrast to placebo cohorts (OR=0.95, 95% CI: 0.68, 1.32, P=0.76).

CONCLUSIONS

Linagliptin is an effective drug with excellent safety for elderly T2DM.

Chen K, Cherñavvsky D, Clements M, Cote GL, Dhatariya KK, Drincic A, Ejskjaer N, Espinoza J, Fabris C, Fleming GA, Gabbay MAL, Galindo RJ, Gómez-Medina AM, Heinemann L, Hermanns N, Hoang T, Hussain S, Jacobs PG, Jendle J, Joshi SR, Koliwad SK, Lal RA, Leiter LA, Lind M, Mader JK, Maran A, Masharani U, Mathioudakis N, McShane M, Mehta C, Moon SJ, Nichols JH, O’Neal DN, Pasquel FJ, Peters AL, Pfützner A, Pop-Busui R, Ranjitkar P, Rhee CM, Sacks DB, Schmidt S, Schwaighofer SM, Sheng B, Simonson GD, Sode K, Spanakis EK, Spartano NL, Umpierrez GE, Vareth M, Vesper HW, Wang J, Wright E, Wu AH, Yeshiwas S, Zilbermint M, Kohn MA. The Diabetes Technology Society Error Grid and Trend Accuracy Matrix for Glucose Monitors

INTRODUCTION

An error grid compares measured versus reference glucose concentrations to assign clinical risk values to observed errors. Widely used error grids for blood glucose monitors (BGMs) have limited value because they do not also reflect clinical accuracy of continuous glucose monitors (CGMs).

METHODS

Diabetes Technology Society (DTS) convened 89 international experts in glucose monitoring to (1) smooth the borders of the Surveillance Error Grid (SEG) zones and create a user-friendly tool-the DTS Error Grid; (2) define five risk zones of clinical point accuracy (A-E) to be identical for BGMs and CGMs; (3) determine a relationship between DTS Error Grid percent in Zone A and mean absolute relative difference (MARD) from analyzing 22 BGM and nine CGM accuracy studies; and (4) create trend risk categories (1-5) for CGM trend accuracy.

RESULTS

The DTS Error Grid for point accuracy contains five risk zones (A-E) with straight-line borders that can be applied to both BGM and CGM accuracy data. In a data set combining point accuracy data from 18 BGMs, 2.6% of total data pairs equally moved from Zones A to B and vice versa (SEG compared with DTS Error Grid). For every 1% increase in percent data in Zone A, the MARD decreased by approximately 0.33%. We also created a DTS Trend Accuracy Matrix with five trend risk categories (1-5) for CGM-reported trend indicators compared with reference trends calculated from reference glucose.

CONCLUSION

The DTS Error Grid combines contemporary clinician input regarding clinical point accuracy for BGMs and CGMs. The DTS Trend Accuracy Matrix assesses accuracy of CGM trend indicators.

Food Insecurity and Hypoglycemia among Older Patients with Type 2 Diabetes Treated with Insulin or Sulfonylureas: The Diabetes & Aging Study

BACKGROUND

Severe hypoglycemia is a serious adverse drug event associated with hypoglycemia-prone medications; older patients with diabetes are particularly at high risk. Economic food insecurity (food insecurity due to financial limitations) is a known risk factor for hypoglycemia; however, less is known about physical food insecurity (due to difficulty cooking or shopping for food), which may increase with age, and its association with hypoglycemia.

OBJECTIVE

Study associations between food insecurity and severe hypoglycemia.

DESIGN

Survey based cross-sectional study.

PARTICIPANTS

Survey responses were collected in 2019 from 1,164 older (≥ 65 years) patients with type 2 diabetes treated with insulin or sulfonylureas.

MAIN MEASURES

Risk ratios (RR) for economic and physical food insecurity associated with self-reported severe hypoglycemia (low blood glucose requiring assistance) adjusted for age, financial strain, HbA1c, Charlson comorbidity score and frailty. Self-reported reasons for hypoglycemia endorsed by respondents.

KEY RESULTS

Food insecurity was reported by 12.3% of the respondents; of whom 38.4% reported economic food insecurity only, 21.1% physical food insecurity only and 40.5% both. Economic food insecurity and physical food insecurity were strongly associated with severe hypoglycemia (RR = 4.3; p = 0.02 and RR = 4.4; p = 0.002, respectively). Missed meals ("skipped meals, not eating enough or waiting too long to eat") was the dominant reason (77.5%) given for hypoglycemia.

CONCLUSIONS

Hypoglycemia prevention efforts among older patients with diabetes using hypoglycemia-prone medications should address food insecurity. Standard food insecurity questions, which are used to identify economic food insecurity, will fail to identify patients who have physical food insecurity only.

Efficacy and safety of insulin glargine 300 U/mL in people with type 2 diabetes in China: The INITIATION study

AIM

To evaluate the efficacy and safety of insulin glargine 300 U/mL (Gla-300) in people with suboptimally controlled type 2 diabetes (T2D) in China.

METHODS

INITIATION (NCT05002933) was a prospective, interventional, multicentre, single-arm, phase IV study conducted in China. Individuals with suboptimally controlled T2D who were insulin naïve or switching from another basal insulin (insulin experienced) were included. The primary endpoint was the change in HbA1c from baseline to week 24. Safety assessments included hypoglycaemia and adverse events (AEs).

RESULTS

In total, 568 participants were enrolled and 562 initiated Gla-300 treatment (189 in the insulin-naïve subgroup; 373 in the insulin-experienced subgroup). At week 24, the mean ± standard error (SE) change in HbA1c from baseline was -0.91% ± 0.05% (-9.9 ± 0.5 mmol/mol; P < .0001). Significant HbA1c reductions were also observed in the insulin-naïve (mean ± SE change: -1.38% ± 0.09% [-15.1 ± 1.0 mmol/mol]) and insulin-experienced (-0.68% ± 0.05% [-7.4 ± 0.5 mmol/mol]) subgroups (both P < .0001). During the 24-week treatment period, the incidence of confirmed hypoglycaemia (plasma glucose ≤ 3.9 mmol/L) was 39.7% for all hypoglycaemia and 13.3% for nocturnal hypoglycaemia; the incidence of severe hypoglycaemia was low (0.5%). Overall, treatment-emergent AEs (TEAEs) were reported in 126 participants (22.4%), with no serious treatment-related TEAEs.

CONCLUSIONS

Gla-300 was effective in improving glycaemic control and had a relatively low risk of hypoglycaemia in people with suboptimally controlled T2D who were insulin naïve or switching from another basal insulin in China.

Enhancing severe hypoglycemia prediction in type 2 diabetes mellitus through multi-view co-training machine learning model for imbalanced dataset

Patients with type 2 diabetes mellitus (T2DM) who have severe hypoglycemia (SH) poses a considerable risk of long-term death, especially among the elderly, demanding urgent medical attention. Accurate prediction of SH remains challenging due to its multifaced nature, contributed from factors such as medications, lifestyle choices, and metabolic measurements. In this study, we propose a systematic approach to improve the robustness and accuracy of SH predictions using machine learning models, guided by clinical feature selection. Our focus is on developing long-term SH prediction models using both semi-supervised learning and supervised learning algorithms. Using the action to control cardiovascular risk in diabetes trial, which includes electronic health records for over 10,000 individuals, we focus on studying adults with T2DM. Our results indicate that the application of a multi-view co-training method, incorporating the random forest algorithm, improves the specificity of SH prediction, while the same setup with Naive Bayes replacing random forest demonstrates better sensitivity. Our framework also provides interpretability of machine learning models by identifying key predictors for hypoglycemia, including fasting plasma glucose, hemoglobin A1c, general diabetes education, and NPH or L insulins. The integration of data routinely available in electronic health records significantly enhances our model's capability to predict SH events, showcasing its potential to transform clinical practice by facilitating early interventions and optimizing patient management. By enhancing prediction accuracy and identifying crucial predictive features, our study contributes to advancing the understanding and management of hypoglycemia in this population.

Latent Autoimmune Diabetes in Adults Following Bariatric Surgery-Induced Hypoglycemia in a 36-Year-Old Woman

Post-bariatric surgery hypoglycemia, also recognized as late dumping syndrome or postprandial hyperinsulinemic hypoglycemia, is a complex condition often driven by multifactorial roots, including postoperative anatomical changes, altered gut hormone responses, metabolic shifts, and other hidden conditions, necessitating a multidisciplinary approach for appropriate evaluation and treatment. We present the case of a 36-year-old female nurse who experienced recurrent hypoglycemia following gastric sleeve surgery. Despite significant weight loss and dietary adjustments, she continued to struggle with unstable blood glucose levels. A comprehensive dysglycemia evaluation revealed the presence of an autoimmune disorder consistent with the criteria for latent autoimmune diabetes in adults (LADA), as defined by "The Immunology of Diabetes Society" (IDS). This new diagnosis added complexity to her clinical management, leading us to reassess her treatment strategy. As a result, her treatment plan was modified to include the initiation of insulin and the introduction of the newly FDA-approved teplizumab, which may help delay the progression of autoimmune diabetes. This case underscores the importance of systematic hypoglycemia evaluations in bariatric surgery patients to optimize clinical outcomes. Managing hypoglycemia in these patients requires a collaborative effort involving endocrinologists, surgeons, and nutritionists to ensure the best outcomes and improve the patient's quality of life.

Association of Postoperative Hypoglycemia With Mortality After Elective Craniotomy

BACKGROUND AND OBJECTIVES

Hypoglycemia is a known risk of intensive postoperative glucose control in neurosurgical patients. However, the impact of postoperative hypoglycemia after craniotomy remains unexplored. This study aimed to determine the association between postoperative hypoglycemia and mortality in patients undergoing elective craniotomy.

METHODS

This study involved adult patients who underwent elective craniotomy at the West China Hospital, Sichuan University, between January 2011 and March 2021. We defined moderate hypoglycemia as blood glucose levels below 3.9 mmol/L (70 mg/dL) and severe hypoglycemia as blood glucose levels below 2.2 mmol/L (40 mg/dL). The primary outcome was postoperative 90-day mortality.

RESULTS

This study involved 15 040 patients undergoing an elective craniotomy. Overall, 504 (3.4%) patients experienced moderate hypoglycemia, whereas 125 (0.8%) patients experienced severe hypoglycemia. Multivariable analysis revealed that both moderate hypoglycemia (adjusted odds ratio [aOR] 1.86, 95% CI 1.24-2.78) and severe (aOR 2.94, 95% CI 1.46-5.92) hypoglycemia were associated with increased 90-day mortality compared with patients without hypoglycemia. Moreover, patients with moderate (aOR 2.78, 95% CI 2.28-3.39) or severe (aOR 16.70, 95% CI 10.63-26.23) hypoglycemia demonstrated a significantly higher OR for major morbidity after adjustment, compared with those without hypoglycemia. Patients experiencing moderate (aOR 3.20, 95% CI 2.65-3.88) or severe (aOR 14.03, 95% CI 8.78-22.43) hypoglycemia had significantly longer hospital stays than those without hypoglycemia. The risk of mortality and morbidity showed a tendency to increase with the number of hypoglycemia episodes in patients undergoing elective craniotomy (P for trend = .01, <.001).

CONCLUSION

Among patients undergoing an elective craniotomy, moderate hypoglycemia and severe hypoglycemia are associated with increased mortality, major morbidity, and prolonged hospital stays. In addition, the risk of mortality and major morbidity increases with the number of hypoglycemia episodes.

Differential associations of risk factors with severe and non-severe hypoglycaemia: the Hypoglycaemia Assessment Tool prospective observational study in people with insulin-treated type 1 diabetes and type 2 diabetes

AIM

To assess the differential association of risk factors with severe and non-severe hypoglycaemia.

MATERIALS AND METHODS

The Hypoglycaemia Assessment Tool study evaluated the risk of hypoglycaemia over a 4-week period in patients with type 1 diabetes (T1D) and type 2 diabetes (T2D) on insulin in 24 countries. Negative binomial regressions were applied to examine the associations of several risk factors with severe and non-severe hypoglycaemia.

RESULTS

The median age was 41 years in 5949 patients with T1D and 62 years in 12 914 patients with T2D. The 4-week rates of non-severe hypoglycaemic were 5.57 and 1.40 episodes per person in T1D and T2D, respectively; the corresponding rates for severe hypoglycaemia were 0.94 and 0.30. The excess risk was 42% higher for severe than non-severe hypoglycaemia in females versus males with T2D; 27% higher in patients with T2D with versus without a continuous glucose monitoring (CGM); and 47% lower in patients with T1D with versus without an insulin pump. The excess risk also differed across geographical areas and was marginally lower for severe than non-severe hypoglycaemia for higher values of HbA1c in patients with T2D. Associations with severity of hypoglycaemia were not different for age, diabetes and insulin therapy duration, previous hypoglycaemic episodes and insulin regimen.

CONCLUSIONS

The risk of severe versus non-severe hypoglycaemia differs in patients with T1D and T2D; sex, the use of a CGM and insulin pump, and geographical areas were differently associated with one type of hypoglycaemia than the other.

Efficacy of 10%,25% and 50% dextrose in the treatment of hypoglycemia in the emergency department - A randomized controlled study

INTRODUCTION

Documented symptomatic hypoglycemia is defined as "event during which typical symptoms of hypoglycemia are accompanied by measured blood glucose of ≤70 mg/dL. Most of the studies and recommendations for the unconscious hypoglycemic adult advocate the use of 25 g of glucose as 50 mL of 50% dextrose solution intravenous or 1 mg of intramuscular glucagon.

OBJECTIVE

To compare the efficacy and safety of 5 g boluses of 10%, 25% and 50% dextrose in the treatment of hypoglycemic patients presenting to our emergency department.

METHODS

This was a randomized controlled single blinded study. Hypoglycemic patients in altered mental status were randomized into three treatment arms to be administered 10%, 25% or 50% dextrose. 5 g aliquots of intravenous 10%,25% or 50% dextrose were administered over 1 min. Time taken to achieve a Glasgow Coma Scale (GCS) of 15 and median total doses (g) were the primary outcomes.

RESULTS

Data of 204 patients were analysed in the study. There was no difference in the median time to achieve a GCS of 15 in all three treatment arms (6 min). Total median dose administered in the 10% and 25% groups was lower than 50% (10 g vs 15 g). Proportion of patients who received the maximum dose of 25 g was higher in the 50% group as compared to 10% and 25% groups (12%, 3%, 4%).

CONCLUSION

There was no difference in 10% dextrose and 25% dextrose as compared to 50% dextrose in achieving the baseline mental status (or GCS 15) in the treatment of hypoglycemia in the ED.

Assessing Carbohydrate Counting Accuracy: Current Limitations and Future Directions

Diabetes mellitus is a prevalent chronic autoimmune disease with a high impact on global health, affecting millions of adults and resulting in significant morbidity and mortality. Achieving optimal blood glucose levels is crucial for diabetes management to prevent acute and long-term complications. Carbohydrate counting (CC) is widely used by patients with type 1 diabetes to adjust prandial insulin bolus doses based on estimated carbohydrate content, contributing to better glycemic control and improved quality of life. However, accurately estimating the carbohydrate content of meals remains challenging for patients, leading to errors in bolus insulin dosing. This review explores the current limitations and challenges in CC accuracy and emphasizes the importance of personalized educational programs to enhance patients' abilities in carbohydrate estimation. Existing tools for assessing patient learning outcomes in CC are discussed, highlighting the need for individualized approaches tailored to each patient's needs. A comprehensive review of the relevant literature was conducted to identify educational programs and assessment tools dedicated to training diabetes patients on carbohydrate counting. The research aims to provide insights into the benefits and limitations of existing tools and identifies future research directions to advance personalized CC training approaches. By adopting a personalized approach to CC education and assessment, healthcare professionals can empower patients to achieve better glycemic control and improve diabetes management. Moreover, this review identifies potential avenues for future research, paving the way for advancements in personalized CC training and assessment approaches and further enhancing diabetes management strategies.

Frequency of hypoglycaemia with basal insulin treatments in adults with type 1 diabetes treated with basal-bolus insulin regimens in treat-to-target trials: A narrative review

AIM

To summarise, in a narrative review, published data on hypoglycaemia occurrence with basal insulin therapy in adults with type 1 diabetes treated with basal-bolus insulin regimens in treat-to-target randomised controlled trials.

METHODS

Data were included from 21 eligible trials, which mainly used self-measured blood glucose or plasma glucose to detect hypoglycaemia.

RESULTS

All-day self-measured blood glucose or plasma glucose level 2 (glucose threshold of 3.1 or 3.0 mmol/L) and level 3 (severe, requiring assistance) hypoglycaemic events were reported, respectively, by a range of 69.0%-97.5% and 0%-13.4% adults when receiving basal-bolus insulin therapy, with rates of 10.6-68.1 and 0.0-0.4 events per patient-year of exposure, respectively. Hypoglycaemia rates measured using continuous glucose monitoring (three studies) were numerically, yet consistently, higher than with either other method, except when limiting to symptomatic events. Nocturnal hypoglycaemia rates were generally less than 30% of the equivalent all-day rates.

CONCLUSIONS

Differences across the studies in design (e.g., titration targets) and participant characteristics hindered comparison of hypoglycaemia rates by insulin formulation. Consequently, few trends were identified by insulin formulation, study methodology or individuals' characteristics, suggesting that further research is required to identify treatment strategies that facilitate development of individualised recommendations to lower hypoglycaemia risk. These findings are useful to understand hypoglycaemia risk with available basal insulin therapies when used in a multiple daily injection regimen, as well as to provide context for the results of ongoing and future clinical trials, including those for two once-weekly basal insulins, insulin icodec and basal insulin Fc.

Weight Loss Surgery Increases Kidney Transplant Rates in Patients With Renal Failure and Obesity

OBJECTIVE

To describe the outcomes of kidney transplant (KT) candidates with obesity undergoing sleeve gastrectomy (SG) to meet the criteria for KT.

METHODS

Retrospective analysis was conducted of electronic medical records of KT candidates with obesity (body mass index >35 kg/m2) who underwent SG in our institution. Weight loss, adverse health events, and the listing and transplant rates were abstracted and compared with the nonsurgical cohort.

RESULTS

The SG was performed in 54 patients; 50 patients did not have surgery. Baseline demographic characteristics were comparable at the time of evaluation. Mean body mass index ± SD of the SG group was 41.7±3.6 kg/m2 at baseline (vs 41.5±4.3 kg/m2 for nonsurgical controls); at 2 and 12 months after SG, it was 36.4±4.1 kg/m2 and 32.6±4.0 kg/m2 (P<.01 for both). In the median follow-up time of 15.5 months (interquartile range, 6.4 to 23.9 months), SG was followed by active listing (37/54 people), and 20 of 54 received KT during a median follow-up time of 20.9 months (interquartile range, 14.7 to 28.3 months) after SG. In contrast, 14 of 50 patients in the nonsurgical cohort were listed, and 5 received a KT (P<.01). Three patients (5.6%) experienced surgical complications. There was no difference in overall hospitalization rates and adverse health outcomes, but the SG cohort experienced a higher risk of clinically significant functional decline.

CONCLUSION

In KT candidates with obesity, SG appears to be effective, with 37% of patients undergoing KT during the next 18 months (P<.01). Further research is needed to confirm and to improve the safety and efficacy of SG for patients with obesity seeking a KT.

Risk factors and metabolomics of mild cognitive impairment in type 2 diabetes mellitus

Objective: This study aimed to explore the risk factors, metabolic characteristics, and potential biomarkers of mild cognitive impairment in type 2 diabetes mellitus (T2DM-MCI) and to provide potential evidence for the diagnosis, prevention, and treatment of mild cognitive impairment (MCI) in patients with type 2 diabetes mellitus (T2DM). Methods: A total of 103 patients with T2DM were recruited from the Endocrinology Department of The Second Affiliated Hospital of Dalian Medical University for inclusion in the study. The Montreal Cognitive Assessment (MoCA) was utilized to evaluate the cognitive functioning of all patients. Among them, 50 patients were categorized into the T2DM-MCI group (MoCA score < 26 points), while 53 subjects were classified into the T2DM without cognitive impairment (T2DM-NCI) group (MoCA score ≥ 26 points). Serum samples were collected from the subjects, and metabolomics profiling data were generated by Ultra-high performance liquid chromatography-mass spectrometry (UHPLC-MS). These groups were analyzed to investigate the differences in expression of small molecule metabolites, metabolic pathways, and potential specific biomarkers. Results: Comparison between the T2DM-MCI group and T2DM-NCI group revealed significant differences in years of education, history of insulin application, insulin resistance index, insulin-like growth factor-binding protein-3 (IGFBP-3), and creatinine levels. Further binary logistic regression analysis of the variables indicated that low educational level and low serum IGFBP-3 were independent risk factor for T2DM-MCI. Metabolomics analysis revealed that differential expression of 10 metabolites between the T2DM-MCI group and T2DM-NCI group (p < 0.05 and FDR<0.05, VIP>1.5). Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment pathway analysis revealed that fatty acid degradation was the most significant pathway. Receiver operating characteristic (ROC) analysis shows that lysophosphatidylcholine (LPC) 18:0 exhibited greater diagnostic efficiency. Conclusion: This study revealed that a shorter duration of education and lower serum IGFBP-3 levels are independent risk factors for T2DM-MCI. Serum metabolites were found to be altered in both T2DM-MCI and T2DM-NCI groups. T2DM patients with or without MCI can be distinguished by LPC 18:0. Abnormal lipid metabolism plays a significant role in the development of MCI in T2DM patients.

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.

Comparator Data Characteristics and Testing Procedures for the Clinical Performance Evaluation of Continuous Glucose Monitoring Systems

Comparing the performance of different continuous glucose monitoring (CGM) systems is challenging due to the lack of comprehensive guidelines for clinical study design. In particular, the absence of concise requirements for the distribution of comparator (reference) blood glucose (BG) concentrations and their rate of change (RoC) that are used to evaluate CGM performance, impairs comparability. For this article, several experts in the field of CGM performance testing have collaborated to propose characteristics of the distribution of comparator measurements that should be collected during CGM performance testing. Specifically, it is proposed that at least 7.5% of comparator BG concentrations are <70 mg/dL (3.9 mmol/L) and >300 mg/dL (16.7 mmol/L), respectively, and that at least 7.5% of BG-RoC combinations indicate fast BG changes with impending hypo- or hyperglycemia, respectively. These proposed characteristics of the comparator data can facilitate the harmonization of testing conditions across different studies and CGM systems and ensure that the most relevant scenarios representing real-life situations are established during performance testing. In addition, a study protocol and testing procedure for the manipulation of glucose levels are suggested that enable the collection of comparator data with these characteristics. This work is an important step toward establishing a future standard for the performance evaluation of CGM systems.

Reporting hypoglycaemia as a hospital-acquired complication: assessing biochemical and clinical validity

BACKGROUND AND AIMS

Given treatment-related hypoglycaemia in hospitals can lead to adverse outcomes, the Australian Commission on Safety and Quality in Health Care has included hypoglycaemia as a reportable hospital-acquired complication (HAC) with financial disincentives. However, the designation of a hypoglycaemia HAC relies on clinical coding without a defined glucose threshold or clinical context. We assessed the biochemical validity and clinical relevance of a hypoglycaemia HAC.

METHODS

We performed a retrospective review on patients discharged from the Northern Health hospitals between March and August 2021 who were designated as experiencing a hypoglycaemia HAC. We assessed cases for biochemical validity (glucose <4.0 mmol), clinical context and whether they were treatment-related (treatment with insulin or sulphonylurea). We then compared this cohort with a hospital-wide glucometric survey based on a point-prevalence study to determine the proportion of individuals with hypoglycaemic events that were designated as hypoglycaemia HAC.

RESULTS

Two hundred fifty-six admissions were coded as hypoglycaemia HAC. Eleven (4%) did not have a biochemically valid episode. Of the valid cases, 34 (14%) were not treated with any glucose-lowering medication and 11 (4%) were treated with noninsulin, nonsulphonylurea glucose-lowering medication. Two hundred admissions (78%) were considered treatment-related HAC. Of 139 individuals with diabetes identified in the hospital-wide point-prevalence study, 25 (18%) had biochemical evidence for hypoglycaemia: 22 were treatment-related, of which 68% were not coded as HAC.

CONCLUSION

Given safety and cost implications, the designation of hypoglycaemia HAC requires a standardised definition incorporating a biochemical threshold and clinical context. We propose a clinically relevant definition of hypoglycaemia HAC to promote safe diabetes care.

Continuous glucose monitoring in people with diabetes and end-stage kidney disease-review of association studies and Evidence-Based discussion

Diabetic nephropathy is currently the leading cause of end-stage kidney disease. The present methods of assessing diabetes control, such as glycated hemoglobin or self-monitoring of blood glucose, have limitations. Over the past decade, the field of continuous glucose monitoring has been greatly improved and expanded. This review examines the use of continuous glucose monitoring in people with end-stage kidney disease treated with hemodialysis (HD), peritoneal dialysis (PD), or kidney transplantation. We assessed the use of both real-time continuous glucose monitoring and flash glucose monitoring technology in terms of hypoglycemia detection, glycemic variability, and efficacy, defined as an improvement in clinical outcomes and diabetes control. Overall, the use of continuous glucose monitoring in individuals with end-stage kidney disease may improve glycemic control and detection of hypoglycemia. However, most of the published studies were observational with no control group. Moreover, not all studies used the same assessment parameters. There are very few studies involving subjects on peritoneal dialysis. The small number of studies with limited numbers of participants, short follow-up period, and small number of manufacturers of continuous glucose monitoring systems are limitations of the review. More studies need to be performed to obtain more reliable results.

Continuous glucose monitoring in older adults with diabetes: Data from the diabetes prospective follow-up (DPV) registry

AIMS

To analyse predictors for continuous glucose monitoring (CGM) use in people with diabetes aged ≥60 years using insulin therapy and to assess the rates of CGM use during recent years (2019-2021).

RESEARCH DESIGN AND METHODS

Prospective study including 6849 individuals with diabetes and insulin therapy (type 2 diabetes: n = 5320; type 1 diabetes: n = 1529) aged ≥60 years. Data from 129 treatment centres were retrieved from the Diabetes Prospective Follow-up Registry (DPV) in March 2023.

RESULTS

Sensor use in individuals aged ≥60 years has increased in type 1 (2019: 28%, 2020: 39%, 2021: 45%) and type 2 diabetes (2019: 10%, 2020: 16%, 2021: 18%). Predictors for sensor use in older individuals with type 1 diabetes are younger age and CSII use (p < 0.001). Predictors in older individuals with type 2 diabetes are younger age, longer diabetes duration, higher BMI and CSII use (p < 0.001).

CONCLUSIONS

CGM has become more common in older adults with diabetes and will presumably increase further. Age is a predictor for sensor use in older adults with diabetes. Age-related physical barriers and insufficient usability of devices, lack of interest in technologies, but possibly also effects of prejudice on the grounds of age may contribute to this finding.

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.

Hypoglycemia Unawareness-A Review on Pathophysiology and Clinical Implications

Hypoglycemia is a particular problem in people with diabetes while it can also occur in other clinical circumstances. Hypoglycemia unawareness describes a condition in which autonomic and neuroglycopenic symptoms of hypoglycemia decrease and hence are hardly perceivable. A failure to recognize hypoglycemia in time can lead to unconsciousness, seizure, and even death. The risk factors include intensive glycemic control, prior episodes of severe hypoglycemia, long duration of diabetes, alcohol consumption, exercise, renal failure, and sepsis. The pathophysiological mechanisms are manifold, but mainly concern altered brain glucose sensing, cerebral adaptations, and an impaired hormonal counterregulation with an attenuated release of glucagon, epinephrine, growth hormone, and other hormones, as well as impaired autonomous and neuroglycopenic symptoms. Physiologically, this counterregulatory response causes blood glucose levels to rise. The impaired hormonal counterregulatory response to recurrent hypoglycemia can lead to a vicious cycle of frequent and poorly recognized hypoglycemic episodes. There is a shift in glycemic threshold to trigger hormonal counterregulation, resulting in hypoglycemia-associated autonomic failure and leading to the clinical syndrome of hypoglycemia unawareness. This clinical syndrome represents a particularly great challenge in diabetes treatment and, thus, prevention of hypoglycemia is crucial in diabetes management. This mini-review provides an overview of hypoglycemia and the associated severe complication of impaired hypoglycemia awareness and its symptoms, pathophysiology, risk factors, consequences, as well as therapeutic strategies.

Insulin independence following islet transplantation improves long-term metabolic outcomes

AIMS

Pancreatic islet allotransplantation is an effective therapy for type 1 diabetes mellitus, restoring glycaemic control and hypoglycaemic awareness in patients with recurrent severe hypoglycaemia. Insulin independence following transplant is being increasingly reported; however, this is not a primary endpoint in the UK. Having surpassed 10 years of islet transplantation in Scotland, we aimed to evaluate the impact of insulin independence following transplant on metabolic outcomes and graft survival.

METHODS

We conducted a retrospective analysis on data collected prospectively between 2011 and 2022. Patients who underwent islet transplantation in Scotland up to the 31st January 2020 were included. Primary endpoint was graft survival (stimulated C-peptide >50 pmol/L). Secondary endpoints included GOLD score, HbA1c, C-peptide and insulin requirement. Outcomes were compared between patients who achieved insulin independence at any point following transplant versus those who did not.

RESULTS

60 patients were included. 74.5% experienced >50 severe hypoglycaemic episodes in the year preceding transplant. There was a 55.0% decrease in insulin requirement following transplant and 30.0% achieved insulin independence. Mean graft survival time was 9.0 years (95% CI 7.2-10.9) in patients who achieved insulin independence versus 4.4 years (95% CI 3.4-5.3) in patients who did not. Insulin independence was associated with significantly improved graft function, glycaemic control and hypoglycaemic awareness at 1 year.

CONCLUSIONS

This is the largest UK single-centre study on islet transplant to date. Our findings demonstrate significantly improved outcomes in patients who achieved insulin independence following islet transplantation.

Machine learning-based prediction of risk factors for abnormal glycemic control in diabetic cancer patients receiving nutrition support: a case-control study

PURPOSE

To date, risk factors affecting abnormal glycemic control have not been investigated. This study aimed to analyze risk factors for hypoglycemia or hyperglycemia in diabetic cancer patients receiving nutritional support by using machine learning methods.

METHODS

This retrospective two-center study was performed using medical records. Odds ratios and adjusted odds ratios were estimated from univariate and multivariate analyses, respectively. Machine learning algorithms, including five-fold cross-validated multivariate logistic regression, elastic net, and random forest, were developed to predict risk factors for hypoglycemia and hyperglycemia.

RESULTS

Data from 127 patients were analyzed. The use of sulfonylurea (SU) and blood urea nitrogen (BUN) level > 20 mg/dL increased hypoglycemia by 6.3-fold (95% CI 1.30-30.47) and 5.0-fold (95% CI 1.06-23.46), respectively. In contrast, patients who received an actual energy intake/total energy expenditure (TEE) ≥ 120% and used dipeptidyl peptidase-4 (DPP-4) inhibitors had a higher risk of hyperglycemia by 19.3- (95% CI 1.46-254.78) and 3.3-fold (95% CI 1.23-8.61), respectively. An initial blood glucose level ≥ 182.5 mg/dL also increased the risk of hyperglycemia by 15.3-fold. AUROC values for all machine learning methods indicated acceptable and excellent performance for hypoglycemia and hyperglycemia.

CONCLUSION

The use of SU and BUN level > 20 mg/dL increased the risk of hypoglycemia, whereas an initial blood glucose level ≥ 182.5 mg/dL, a supplied actual energy intake/ TEE ≥ 120%, and the use of DPP-4 inhibitors increased the risk of hyperglycemia.

Safety and care of no fasting prior to catheterization laboratory procedures: a non-inferiority randomized control trial protocol (SCOFF trial)

Aims

Cardiac catheterization procedures are typically performed with local anaesthetic and proceduralist guided sedation. Various fasting regimens are routinely implemented prior to these procedures, noting the absence of prospective evidence, aiming to reduce aspiration risk. However, there are additional risks from fasting including patient discomfort, intravascular volume depletion, stimulus for neuro-cardiogenic syncope, glycaemic outcomes, and unnecessary fasting for delayed/cancelled procedures.

Methods and results

This is an investigator-initiated, multicentre, randomized trial with a prospective, open-label, blinded endpoint (PROBE) assessment based in New South Wales, Australia. Patients will be randomized 1:1 to fasting (6 h solid food and 2 h clear liquids) or to no fasting requirements. The primary outcome will be a composite of hypotension, hyperglycaemia, hypoglycaemia, and aspiration pneumonia. Secondary outcomes will include patient satisfaction, contrast-induced nephropathy, new intensive care admission, new non-invasive or invasive ventilation requirement post procedure, and 30-day mortality and readmission.

Conclusions

This is a pragmatic and clinically relevant randomised trial designed to compare fasting verse no fasting prior to cardiac catheterisation procedures. Routine fasting may not reduce peri-procedural adverse events in this setting.

Characterisation and clinical outcomes in children and adolescents with diabetes according to newly defined subgroups: a cohort study from the DPV registry

Background

Personalised therapy has emerged as a possibly more efficient approach taking disease heterogeneity into account. The aim of this study was to determine whether recently described subgroups of childhood diabetes have prognostic association with diabetes-specific complications and, therefore, might be a basis for personalised therapies.

Methods

We applied a previously developed subgroup classification to pediatric patients (diabetes onset <18 years) from the prospective Diabetes Patient Follow-up (DPV) registry with documented data between January 1, 2000 and March 31, 2022, from diabetes centers in Germany, Austria, Switzerland, and Luxembourg. The classification required information on islet autoantibody status, age, haemoglobin A1c (HbA1c), and body-mass index (BMI-SDS) at disease manifestation, as well as follow up data after 2 and after 4 years, which was available in 22,719 patients. Patients without documented data on these parameters were excluded from the analysis. The cumulative risk of severe hypoglycemia, diabetic ketoacidosis (DKA), retinopathy, and nephropathy were analysed by Kaplan-Meier analyses over a median follow-up of 6.8 years (IQR 4.8-9.6).

Findings

Patients were classified into 10 subgroups (P1-P7 islet autoantibody-positive, n = 19,811; N1-N3 islet autoantibody-negative, n = 2908). The groups varied markedly with respect to specific acute and chronic complications. Severe hypoglycemia was a characteristic feature in young islet autoantibody-positive subgroups P1, P3, P4 (10-year risk 46, 46 and 47%) and the islet autoantibody-negative groups N1, N2 (43 and 46%). Nephropathy was identified in patient groups P2 and P5 (10-year risk 16%), which had features of moderate disease such as preserved C-peptide, low HbA1c, and very low frequency of DKA at diabetes onset. Group P7, which was defined by a high BMI, was associated with poor metabolic control, DKA, and retinopathy. In contrast, islet autoantibody-negative patients with high BMI (N3) had a low risk for all four complications.

Interpretation

Subgrouping of childhood diabetes at diabetes onset provided prognostic value for the development of acute and chronic diabetes-specific complications.

Funding

The DPV initiative is supported by The German Ministry of Education and Research (BMBF) within the German Center for Diabetes Research, the diabetes surveillance of the Robert Koch Institute, the German Diabetes Association (DDG) and INNODIA.

Risk factors of severe hypoglycemia among patients with type 2 diabetes mellitus in outpatient clinic of tertiary hospital in Indonesia

This study aimed to describe risk factors of severe hypoglycemia in type 2 diabetes mellitus (T2DM) patients in a tertiary care hospital in Indonesia. This study was a retrospective cohort study in the Endocrinology Outpatient Clinic of Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia. All subjects more than 18 years old who had been visiting the clinic for at least a year were included. Subjects were interviewed whether they had any severe hypoglycemia events within the past year, while data on risk factor variables of severe hypoglycemia was taken from medical records one year before data collection. We recruited 291 subjects, among whom 25.4% suffered at least one episode of severe hypoglycemia within one year. History of severe hypoglycemia (OR 5.864, p ≤ 0.001), eGFR less than 60 mL/min/1.73m2 (OR 1.976, p = 0.028), and insulin use (OR 2.257, p = 0.021) were associated with increased risk of severe hypoglycemia. In conclusion, history of previous severe hypoglycemia, eGFR less than 60 mL/min/1.73m2, and insulin use were associated with severe hypoglycemia.

Ethnicity/race, parent educational attainment, and obesity associated with prediabetes in children

BACKGROUND/OBJECTIVES

Obesity and other predictors of type 2 diabetes disproportionally affect Hispanic and Black children in the US compared to non-Hispanic White (NHW) children. Yet, the prevalence of prediabetes in children remains unestablished, and guidelines for screening young children are lacking. This study examined the relationships between demographic factors and prediabetes in vulnerable youth in central Texas.

SUBJECTS/METHODS

This is a cross-sectional analysis of baseline data from 976 3rd-5th graders (7-12 years) who participated in TX Sprouts, a school-based gardening, nutrition, and cooking trial in 16 elementary schools serving mainly children from minority backgrounds and lower-income households. Measures collected included age, sex, ethnicity, free/reduced-priced school lunch (FRL) status, parent educational attainment (questionnaires), BMI from height (stadiometer) and weight (TANITA scale), and prediabetes status from fasting plasma glucose (FPG) and HbA1c. Regressions examined cross-sectional associations between demographics and FPG, HbA1c, and prediabetes.

RESULTS

Children were 47% male, 67% Hispanic, and 10% Black, with a mean age of 9.3 years; 71% received FRL, 50% had overweight/obesity, and 26% had prediabetes. Prediabetes rates were 2.8 and 4.8 times higher in Hispanic and Black children compared to NHW children, respectively (p ≤ 0.001), and 1.5 times higher in children with obesity versus normal BMI (p = 0.02). Children of parents with only an 8th-grade education, some high school education, or a high school degree had 3.1, 2.7, and 2.2 times higher odds of having prediabetes compared to children of college graduates, respectively (p ≤ 0.004). Analyses with FPG and HbA1c yielded similar results.

CONCLUSION

These findings suggest a potential need for earlier screening, more comprehensive testing guidelines, and prevention programs tailored toward minority children, children with obesity, and children of parents with low educational attainment. Future research should explore this finding in a larger, nationally representative sample.

Incidence and predictors of mortality in children with diabetic ketoacidosis in the comprehensive specialized referral hospitals of West Amhara Region, Northwest Ethiopia: a retrospective follow-up study

Background

Diabetic ketoacidosis is one of the major life-threatening conditions associated with acute metabolic complications. It remains a major public health problem in developing countries such as Ethiopia.

Objective

To assess the incidence and prediction of mortality in children with diabetic ketoacidosis in West Amhara Region Comprehensive Specialized Referral Hospitals, Northwest Ethiopia, in 2022.

Methods

An institution-based retrospective follow-up study was conducted among 423 study participants with a confirmed diagnosis of diabetic ketoacidosis from 01/01/2017 to 31/12/2021. Data were entered, coded, cleaned, and checked using Epi-Data version 4.6 and exported to Stata version 14 for data analysis.

Results

A total of 401 child records were included in the final analysis and were followed for 3781 days during the study period. The overall mortality of children with diabetic ketoacidosis was 10.6 per 1000 person-days observed (95% CI: 7.8-14.4) during the entire follow-up period. Hypoglycemia (AHR=4.6; 95% CI: 2.13-10.1), rural residence (AHR=2.9; 95% CI=1.01-8.11), age younger than five (AHR=4.4; 95% CI=1.4-13.7) or between five and 10 (AHR=3.1; 95% CI=1.1-8.8), and female gender (AHR=2.6; 95% CI=1.1-5.8) were significant predictors of mortality.

Conclusions

The incidence rate of mortality in children with diabetic ketoacidosis was relatively high. Age, rural residence, female gender, and hypoglycemia were significantly predictive of mortality. Community education or mass campaigns about the signs and symptoms of diabetic ketoacidosis may reduce the mortality rate in children.

Translation and Validation Study of the Hypoglycemia Fear Survey in a Greek Population of Children and Adolescents with Type 1 Diabetes Mellitus and their Parents

The present study attempted to translate and culturally adapt an established research instrument, the Hypoglycemia Fear Survey (HFS) questionnaire, to the Greek population and evaluate its validity and internal consistency so that it can be used for the assessment of hypoglycemia fear in Greek children and adolescents with T1DM and their parents. One hundred Greek children and adolescents with T1DM, 54 males, 6-18 years old, and one of their parents participated in this validation study. The participants completed the translated Greek HFS, which includes one version for children (CHFS) and one for parents (PHFS). Exploratory Factor Analysis (EFA) was used to assess construct validity. Internal consistency was assessed using Cronbach's alpha, and convergent validity was established by estimating the correlation coefficients between the scores of the HFS scales/subscales and the different constructs of the Pediatric Quality of Life Inventory. The CHFS and PHFS exhibited adequate internal consistency for the total score and the Worry subscale, but lower consistency for the Behavior subscale. High test-retest reliability was also shown. We conclude that the Greek version of the HFS is a valid and reliable instrument to assess the fear of hypoglycemia in Greek children and adolescents with T1DM and their parents.

Cognitive Outcome After Islet Transplantation

Severe or repeated hypoglycemia events may favor memory complaints in type 1 diabetes (T1D). Pancreatic islet transplantation (IT) is an alternative option to exogenous insulin therapy in case of labile T1D, implying a maintenance immunosuppression regimen based on sirolimus or mycophenolate, associated with tacrolimus, that may also have neurological toxicity. The objective of this study was to compare a cognitive rating scale Mini-Mental State Examination (MMSE) between T1D patients with or without IT and to identify parameters influencing MMSE.

Methods

This retrospective cross-sectional study compared MMSE and cognitive function tests between islet-transplanted T1D patients and nontransplanted T1D controls who were transplant candidates. Patients were excluded if they refused.

Results

Forty-three T1D patients were included: 9 T1D patients before IT and 34 islet-transplanted patients (14 treated with mycophenolate and 20 treated with sirolimus). Neither MMSE score (P = 0.70) nor higher cognitive function differed between islet versus non-islet-transplanted patients, whatever the type of immunosuppression. In the whole population (N = 43), MMSE score was negatively correlated to glycated hemoglobin (r = -0.30; P = 0.048) and the time spent in hypoglycemia on the continuous glucose monitoring (r = -0.32; P = 0.041). MMSE score was not correlated to fasting C-peptide level, time spent in hyperglycemia, average blood glucose, time under immunosuppression, duration of diabetes, or beta-score (success score of IT).

Conclusions

This first study evaluating cognitive disorders in islet-transplanted T1D patients argues for the importance of glucose balance on cognitive function rather than of immunosuppressive treatment, with a favorable effect of glucose balance improvement on MMSE score after IT.

Total Pancreatectomy With Islet Autotransplantation as an Alternative to High-risk Pancreatojejunostomy After Pancreaticoduodenectomy: A Prospective Randomized Trial

OBJECTIVE

To compare pancreaticoduodenectomy (PD) and total pancreatectomy (TP) with islet autotransplantation (IAT) in patients at high risk of postoperative pancreatic fistula (POPF).

BACKGROUND

Criteria to predict the risk of POPF occurrence after PD are available. However, even when a high risk of POPF is predicted, TP is not currently accepted as an alternative to PD, because of its severe consequences on glycaemic control. Combining IAT with TP may mitigate such consequences.

METHODS

Randomized, open-label, controlled, bicentric trial (NCT01346098). Candidates for PD at high-risk pancreatic anastomosis (ie, soft pancreas and duct diameter ≤3 mm) were randomly assigned (1:1) to undergo either PD or TP-IAT. The primary endpoint was the incidence of complications within 90 days after surgery.

RESULTS

Between 2010 and 2019, 61 patients were assigned to PD (n=31) or TP-IAT (n=30). In the intention-to-treat analysis, morbidity rate was 90·3% after PD and 60% after TP-IAT ( P =0.008). According to complications' severity, PD was associated with an increased risk of grade ≥2 [odds ratio (OR)=7.64 (95% CI: 1.35-43.3), P =0.022], while the OR for grade ≥3 complications was 2.82 (95% CI: 0.86-9.24, P =0.086). After TP-IAT, the postoperative stay was shorter [median: 10.5 vs 16.0 days; P <0.001). No differences were observed in disease-free survival, site of recurrence, disease-specific survival, and overall survival. TP-IAT was associated with a higher risk of diabetes [hazard ratio=9.1 (95% CI: 3.76-21.9), P <0.0001], but most patients maintained good metabolic control and showed sustained C-peptide production over time.

CONCLUSIONS

TP-IAT may become the standard treatment in candidates for PD, when a high risk of POPF is predicted.

Impact of severe hypoglycaemia requiring hospitalization on mortality in people with type 1 diabetes: A national retrospective observational cohort study

AIMS

To assess if the risk of all-cause mortality increases in people with type 1 diabetes (T1D) with increasing number of severe hypoglycaemia episodes requiring hospitalization.

MATERIALS AND METHODS

We conducted a national retrospective observational cohort study in people with T1D (diagnosed between 2000 and 2018). Clinical, comorbidity and demographic variables were assessed for impact on mortality for people with no, one, two and three or more episodes of severe hypoglycaemia requiring hospitalization. The time to death (all-cause mortality) from the timepoint of the last episode of severe hypoglycaemia was modelled using a parametric survival model.

RESULTS

A total of 8224 people had a T1D diagnosis in Wales during the study period. The mortality rate (95% confidence interval [CI]) was 6.9 (6.1-7.8) deaths/ 1000 person-years (crude) and 15.31 (13.3-17.63) deaths/ 1000 person-years (age-adjusted) for those with no occurrence of severe hypoglycaemia requiring hospitalization. For those with one episode of severe hypoglycaemia requiring hospitalization the mortality rate (95% CI) was 24.9 (21.0-29.6; crude) and 53.8 (44.6-64.7) deaths/ 1000 person-years (age-adjusted), for those with two episodes of severe hypoglycaemia requiring hospitalization it was 28.0 (23.1-34.0; crude) and 72.8 (59.2-89.5) deaths/ 1000 person-years (age-adjusted), and for those with three or more episodes of severe hypoglycaemia requiring hospitalization it was 33.5 (30.0-37.3; crude) and 86.3 (71.7-103.9) deaths/ 1000 person years (age-adjusted; P < 0.001). A parametric survival model showed that having two episodes of severe hypoglycaemia requiring hospitalization was the strongest predictor for time to death (accelerated failure time coefficient 0.073 [95% CI 0.009-0.565]), followed by having one episode of severe hypoglycaemia requiring hospitalization (0.126 [0.036-0.438]) and age at most recent episode of severe hypoglycaemia requiring hospitalization (0.917 [0.885-0.951]).

CONCLUSIONS

The strongest predictor for time to death was having two or more episodes of severe hypoglycaemia requiring hospitalization.

Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery

Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.

Development of an artificial intelligence system to identify hypoglycaemia via ECG in adults with type 1 diabetes: protocol for data collection under controlled and free-living conditions

INTRODUCTION

Hypoglycaemia is a harmful potential complication in people with type 1 diabetes mellitus (T1DM) and can be exacerbated in patients receiving treatment, such as insulin therapies, by the very interventions aiming to achieve optimal blood glucose levels. Symptoms can vary greatly, including, but not limited to, trembling, palpitations, sweating, dry mouth, confusion, seizures, coma, brain damage or even death if untreated. A pilot study with healthy (euglycaemic) participants previously demonstrated that hypoglycaemia can be detected non-invasively with artificial intelligence (AI) using physiological signals obtained from wearable sensors. This protocol provides a methodological description of an observational study for obtaining physiological data from people with T1DM. The aim of this work is to further improve the previously developed AI model and validate its performance for glycaemic event detection in people with T1DM. Such a model could be suitable for integrating into a continuous, non-invasive, glucose monitoring system, contributing towards improving surveillance and management of blood glucose for people with diabetes.

METHODS AND ANALYSIS

This observational study aims to recruit 30 patients with T1DM from a diabetes outpatient clinic at the University Hospital Coventry and Warwickshire for a two-phase study. The first phase involves attending an inpatient protocol for up to 36 hours in a calorimetry room under controlled conditions, followed by a phase of free-living, for up to 3 days, in which participants will go about their normal daily activities unrestricted. Throughout the study, the participants will wear wearable sensors to measure and record physiological signals (eg, ECG and continuous glucose monitor). Data collected will be used to develop and validate an AI model using state-of-the-art deep learning methods.

ETHICS AND DISSEMINATION

This study has received ethical approval from National Research Ethics Service (ref: 17/NW/0277). The findings will be disseminated via peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT05461144.

Network meta-analysis of glucose-lowering drug treatment regimens with the potential risk of hypoglycemia in patients with type 2 diabetes mellitus in terms of glycemic control and severe hypoglycemia

Insulin and its secretagogues are essential for some patients with type 2 diabetes (T2D) to maintain good glycemic control (GC), but severe hypoglycemia (SH) is a concern. This network meta-analysis aimed to find optimal glucose-lowering drug treatment regimens in terms of GC and SH in T2D patients. MEDLINE and EMBASE were used to identify trials that compared two or more treatments including insulins and/or sulfonylurea or glinides and that examined both GC and SH. Treatment hierarchy was expressed as the surface under the cumulative ranking curve (SUCRA) probabilities. We identified 137 eligible trials comprising 42 treatments. The use of insulins and non-insulin glucose-lowering agents except for sulfonylurea or glinide had a higher SUCRA than insulins only for hemoglobin A1c (A1C) (p = 0.01) changes and achievement of A1C < 7.0% (p = 0.02) or A1C ≤ 6.5% (p = 0.002). The use of sulfonylurea or glinide and other non-insulin glucose-lowering agents resulted in a lower SUCRA for SH than insulins only when trials were analyzed for A1C change (p = 0.06) and achievement of A1C < 7.0% (p = 0.004) or A1C ≤ 6.5% (p = 0.004). Cluster analysis indicated that premixed insulin plus glucagon-like peptide-1 receptor agonist (Mix-ins + GLP1) belonged to the high-efficacy category for GC and glinide plus thiazolidinedione (glinide + TZD) belonged to the relatively high-efficacy category for GC among several high-safety categories regarding SH. In T2D patients, clinicians should consider appropriate combinations of non-insulin glucose-lowering agents (especially glinide + TZD) for reducing SH risk before switching to insulin therapies. If switching, they should be willing to add non-insulin glucose-lowering agents (especially, Mix-ins + GLP1) to insulins to further improve GC.

The use of isCGM leads to marked reduction in severe hypoglycemia requiring emergency medical service or hospital admission and diabetic ketoacidosis in adult type 1 diabetes patients

AIMS

To determine the effect of the use of intermittently scanned continuous glucose monitoring (isCGM) on acute diabetes-related complications in adult type 1 diabetes patients.

METHODS

Six hundred and forty-two adult type 1 diabetes patients with isCGM were identified from electronic health records in Siun sote region in Eastern Finland. A retrospective real-world analysis was conducted combining hospital admission and prehospital emergency service data to compare incidences of hypoglycemia requiring emergency medical support (EMS) involvement or hospital admission and diabetic ketoacidosis (DKA) before and after the start of isCGM. Data were collected from January 2015 to April 2020. Primary outcome was the rate of hypoglycemia requiring EMS involvement or hospital admission and DKA events. HbA1c was recorded at the start of isCGM and was compared with the last known HbA1c during the use of isCGM. The isCGM used in the study did not contain alarm functions.

RESULTS

Altogether 220 hypoglycemic events were identified during the study period. Incidence rate of hypoglycemic events decreased after the start of isCGM (72 events, incidence rate 50 events/1000 person-years) compared with the time before the start (148 events, incidence rate 76 events/1000 person-years) (p = 0.043). The incidence rate of DKA decreased after the start of isCGM compared with time before isCGM use (4 and 15 events/1000 person-years, respectively; p = 0.002). The change in mean HbA1c was - 0.28% (- 3.1 mmol/mol) between baseline and the last HbA1c measurement (p < 0.001).

CONCLUSIONS

In addition to lowering HbA1c in type 1 diabetes patients, isCGM is also effective in preventing acute diabetes-related complications such as hypoglycemia requiring EMS involvement or hospital admission and DKA.

Steroid supplementation before minor oral surgical procedures in patients taking long-term glucocorticoids: A triple-blinded, randomized, placebo-controlled trial

BACKGROUND

Patients undergoing long-term glucocorticoid therapy are administered additional glucocorticoids before minor dental procedures, although this is not supported by evidence. The authors designed this study to validate the hypothesis that routine blanket glucocorticoid supplementation is unnecessary during minor oral surgical procedures under local anesthesia.

METHODS

The authors recruited 270 patients into 3 groups (1:1:1 allocation) from the dental outpatient department. Primary outcomes were changes in hemodynamic parameters and frequency of adverse events among the 3 groups. The secondary outcome was the association of preprocedural stress and procedural pain with periprocedural adverse events in the long-term glucocorticoid therapy group (groups I and II).

RESULTS

No clinically relevant changes in hemodynamic parameters among the 3 groups were found. The authors also found low periprocedural adverse events in all 3 groups combined (n = 1), so they did not explore the secondary outcomes further.

CONCLUSIONS

Among patients undergoing long-term glucocorticoid therapy for indications other than primary adrenal insufficiency, elective minor oral surgical procedures can be performed safely with only their daily dose of glucocorticoid when their medical conditions are optimized. Routine additional glucocorticoid supplementation appears unnecessary. The results of the study also revealed opportunities for value addition by means of integrating oral health care with medical follow-up for patients with multiple co-occurring medical conditions.

PRACTICAL IMPLICATIONS

Routine blanket glucocorticoid supplementation among patients taking a long-term glucocorticoid for indications other than primary adrenal insufficiency appears unnecessary before minor oral surgical procedures under local anesthesia. This clinical trial was registered at Clinical Trial Registry-India. The registration number is CTRI/2017/02/007779.

Glucose Counterregulation: Clinical Consequences of Impaired Sympathetic Responses in Diabetic Dogs and Cats

Insulin induced hypoglycemia (IIH) is common in veterinary patients and limits the clinician's ability to obtain adequate glycemic control with insulin therapy. Not all diabetic dogs and cats with IIH exhibit clinical signs and hypoglycemia might be missed by routine blood glucose curve monitoring. In diabetic patients, counterregulatory responses to hypoglycemia are impaired (lack of decrease in insulin levels, lack of increase in glucagon, and attenuation of the parasympathetic and sympathoadrenal autonomic nervous systems) and have been documented in people and in dogs but not yet in cats. Antecedent hypoglycemic episodes increase the patient's risk for future severe hypoglycemia.

Dextrose Administration and Resuscitation Outcomes in Patients with Blood Sugar Less Than 150 mg/dL during Cardiopulmonary Resuscitation: An Observational Data Analysis

Low blood sugar is commonly found during cardiopulmonary resuscitation (CPR). However, current guidelines do not mention the importance of glucose testing and acute management for hypoglycemia during CPR. We intended to investigate the association between dextrose administration and resuscitation outcomes in patients with blood sugar less than 150 mg/dL during cardiac arrest in the emergency department (ED). We conducted a retrospective cohort study at a tertiary hospital between 2017 and 2020, including patients with intra-arrest blood glucose <150 mg/dL. Logistic regression with inverse probability treatment weighting (IPTW) was used. The primary outcome was the return of spontaneous circulation (ROSC). Secondary outcomes included survival to hospital admission and hospital discharge and favorable neurological outcomes at discharge. A total of 865 patients received CPR at the ED during the study period. Of these, 229 with low blood sugar were included (60 in the treatment group and 169 in the non-treatment group). The mean age was 59.5 ± 21.4 years. After IPTW, dextrose administration during CPR was not associated with ROSC (adjusted OR [aOR] 1.44, 95% CI 0.30−0.69), survival to hospital admission (aOR 1.27, 95% CI 0.54−3.00), survival to hospital discharge (aOR 0.68, 95% CI 0.20−2.29), and favorable neurological status (aOR 2.21, 95% CI 0.23−21.42). Our findings suggested that dextrose administration during CPR at the ED might not lead to better or worse resuscitation outcomes. Owing to the design limitations and residual confounding factors, strong recommendations for dextrose administration could not be formulated. Further evidence is needed from prospective trials to confirm the efficacy of dextrose during CPR.

Prediction Models for Prognosis of Hypoglycemia in Patients with Diabetes: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically summarize the reported prediction models for hypoglycemia in patients with diabetes, compare their performance, and evaluate their applicability in clinical practice.

METHODS

We selected studies according to the PRISMA, appraised studies according to the Prediction model Risk of Bias Assessment Tool (PROBAST), and extracted and synthesized the data according to the CHARMS. The databases of PubMed, Web of Science, Embase, and Cochrane Library were searched from inception to 31 October 2021 using a systematic review approach to capture all eligible studies developing and/or validating a prognostic prediction model for hypoglycemia in patients with diabetes. The risk bias and clinical applicability were assessed using the PROBAST. The meta-analysis of the performance of the prediction models were also conducted. The protocol of this study was recorded in PROSPERO (CRD42022309852).

RESULTS

Sixteen studies with 22 models met the eligible criteria. The predictors with the high frequency of occurrence among all models were age, HbA1c, history of hypoglycemia, and insulin use. A meta-analysis of C-statistic was performed for 21 prediction models, and the summary C-statistic and its 95% confidence interval and prediction interval were 0.7699 (0.7299-0.8098), 0.7699 (0.5862-0.9536), respectively. Heterogeneity exists between different hypoglycemia prediction models (τ² was 0.00734≠0).

CONCLUSIONS

The existing predictive models are not recommended for widespread clinical use. A high-quality hypoglycemia screening tool should be developed in future studies.

Managing Severe Hypoglycaemia in Patients with Diabetes: Current Challenges and Emerging Therapies

Hypoglycaemia is common in patients with diabetes mellitus and is a limiting factor for achieving adequate glycaemic control. In the vast majority of cases, hypoglycaemia develops due to the imbalance between food intake and insulin injections. As recurrent hypoglycaemia leads to significant morbidity and mortality, the recognition and immediate treatment of hypoglycaemia in diabetic patients is thus important. In the last 20 years, the introduction of improved insulin analogues, insulin pump therapy, continuous glucose monitoring (CGM), and sensor-augmented pump therapy have all made significant improvements in helping to reduce and prevent hypoglycaemia. In terms of treatment, the American Diabetes Association recommends oral glucose as the first-line treatment option for all conscious patients with hypoglycaemia. The second line of treatment (or first line in unconscious patients) is the use of glucagon. Novel formulations of glucagon include the nasal form, the Gvoke HypoPen which is a ready-to-deliver auto-injector packaged formulation and finally a glucagon analogue, Dasiglucagon. The Dasiglucagon formulation has recently been approved for the treatment of severe hypoglycaemia. It is a ready-to-use, similar to endogenous glucagon and its potency is also the same as native glucagon. It does not require reconstitution before injection and therefore ensures better compliance. Thus, significant improvements including development of newer insulin analogues, insulin pump therapy, continuous glucose monitoring (CGM), sensor-augmented pump therapy and novel formulations of glucagon have all contributed to reducing and preventing hypoglycaemia in diabetic individuals. However, considerable challenges remain as not all patients have access to diabetes technologies and to the newer glucagon formulations to help reduce and prevent hypoglycaemia.

Comparison of gliclazide vs linagliptin on hypoglycemia and cardiovascular events in type 2 diabetes mellitus: A systematic review

BACKGROUND

Cardiovascular outcome trials have demonstrated cardiovascular safety of glimepiride (a sulfonylureas) against dipeptidyl peptidase-4 inhibitor linagliptin. Gliclazide (another newer sulfonylureas) has shown similar glycemic efficacy and 50% decreased risk of hypoglycemia compared to glimepiride.

AIM

Considering the absence of cardiovascular outcome trials for gliclazide, we decided to conduct a systematic review of the literature to assess the car-diovascular (CV) safety by assessing the risk for major adverse CV events and hypoglycemia risk of gliclazide vs linagliptin in patients with type 2 diabetes (T2D).

METHODS

This systematic review followed the current Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to analyze all the clinical studies published from 2008 that compared the two drugs in patients with T2D with no risk of CV disease (CVD). We included only evidence designated high quality by the Oxford Center for Evidence-based Medicine-Levels of Evidence.

RESULTS

Eight clinical studies were included in the narrative descriptive analysis (gliclazide: 5 and linagliptin: 3). The CV safety of gliclazide in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation trial and of linagliptin in the Cardiovascular and Renal Microvascular Outcome Study With Linagliptin (CARMELINA) and CARdiovascular Outcome study of LINAgliptin vs glimepiride in patients with T2D (CAROLINA) trials were excluded from the comparative analysis as these trials demonstrated CV and hypoglycemia benefits in patients at high risk of CVD. However, since these are landmark trials, they were discussed in brief to show the CV benefits and low hypoglycemia risk of gliclazide and linagliptin. We did not find any study comparing gliclazide with linagliptin. Hence, direct comparison of their major adverse CV events and hypoglycemia risk could not be carried out. However, the literature meeting the inclusion criteria showed that both drugs were effective in achieving the desired glycemic control and had low major adverse CV events and hypoglycemia risk in adult patients with no history of CVD.

CONCLUSION

Gliclazide can be considered an effective and safe glucose-lowering drug in T2D patients with no established CVD but at high risk of CVD due to their T2D status. Future randomized controlled trials comparing gliclazide with linagliptin or dipeptidyl peptidase-4 inhibitors can confirm these findings.

Pathophysiology and management of hypoglycemia in diabetes

In the century since the discovery of insulin, diabetes has changed from an early death sentence to a manageable chronic disease. This change in longevity and duration of diabetes coupled with significant advances in therapeutic options for patients has fundamentally changed the landscape of diabetes management, particularly in patients with type 1 diabetes mellitus. However, hypoglycemia remains a major barrier to achieving optimal glycemic control. Current understanding of the mechanisms of hypoglycemia has expanded to include not only counter-regulatory hormonal responses but also direct changes in brain glucose, fuel sensing, and utilization, as well as changes in neural networks that modulate behavior, mood, and cognition. Different strategies to prevent and treat hypoglycemia have been developed, including educational strategies, new insulin formulations, delivery devices, novel technologies, and pharmacologic targets. This review article will discuss current literature contributing to our understanding of the myriad of factors that lead to the development of clinically meaningful hypoglycemia and review established and novel therapies for the prevention and treatment of hypoglycemia.