Glucose Responses to Aerobic Exercise Are Influenced by Glucose Levels before the Exercise and Menstrual Cycle Phase in Adults with Type 1 Diabetes on Multiple Daily Insulin Injections.

Insulin Pumps

Real-World Diabetes Technology: Overcoming Barriers and Disparities.

BackgroundInsulin therapy is required to prevent diabetic ketoacidosis and to optimise blood glucose levels in order to to minimise vascular complications in all Children and Young People with Type 1...

Quality of life in Danish children and adolescents with type 1 diabetes treated with continuous subcutaneous insulin infusion or multiple daily injections

Exercise training reduces cardiovascular disease risk, partly due to arterial blood pressure (BP) lowering at rest and during fixed-load exercise. However, it is unclear whether exercise training can reduce BP at rest and during exercise in adults with well-healed burn injuries. Therefore, the purpose of this investigation was to test the hypothesis that 6 mo of unsupervised exercise training reduces BP at rest and during lower-body cycle ergometry in adults with well-healed burn injuries. Thirty-nine adults (28 with well-healed burn injuries and 11 controls) completed 6 mo of unsupervised, progressive exercise training including endurance, resistance, and high-intensity interval components. Before and after exercise training, we measured BP at rest, during fixed-load submaximal exercise (50 and 75 W), during fixed-intensity submaximal exercise (40% and 70% of V̇o2peak), and during maximal exercise on a lower-body cycle ergometer. We compared cardiovascular variables using two-way ANOVA (group × pre/postexercise training [repeated factor]). Adults with well-healed burn injuries had higher diastolic BP at rest (P = 0.04), which was unchanged by exercise training (P = 0.26). Exercise training reduced systolic, mean, and diastolic BP during fixed-load cycling exercise at 75 W in adults with well-healed burn injuries (P ≤ 0.03 for all), but not controls (P ≥ 0.67 for all). Exercise training also reduced mean and diastolic BP during exercise at 40% (P ≤ 0.02 for both), but not at 70% (P ≥ 0.18 for both), of V̇o2peak. These data suggest that a 6-mo unsupervised exercise training program lowers BP during moderate, but not vigorous, aerobic exercise in adults with well-healed burn injuries.NEW & NOTEWORTHY Adults with well-healed burn injuries have greater cardiovascular disease morbidity and all-cause mortality compared with nonburn-injured adults. We found that exercise training reduced blood pressure (BP) during fixed-load cycling at 75 W and during moderate, but not vigorous, intensity cycling exercise in adults with well-healed burn injuries. These data suggest that 6 mo of unsupervised exercise training provides some degree of cardioprotection by reducing BP responses during submaximal exercise in well-healed burn-injured adults.

Achieving optimal glycemic targets is the main therapeutic goal in patients with type 2 diabetes (T2D) mellitus. HbA1c is the reference biomarker for monitoring glycemic control; however, in specific conditions affecting erythrocyte turnover or in patients on multiple daily injection (MDI) insulin regimens, the determination of glycated albumin (GA) may be preferable. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors represent a novel class of antidiabetic drugs that lower plasma glucose concentrations quickly, with insulin-independent mechanisms. Herein, we explored the role of GA in predicting the short-term response to SGLT-2 inhibitors as add-on to MDI insulin. Sixteen patients with long-standing, poorly controlled T2D on MDI insulin starting an SGLT-2 inhibitor were subjected to plasma GA and HbA1c measurements at 30 days intervals for up to 3 months in order to examine the temporal changes of these glycemic biomarkers. At the end of the study, grossly coincident with the life span of erythrocytes, a significant decrease in median HbA1c was observed, (from 8.7 [range: 8.2-9.3%] at baseline to 7.2 [range: 7.0-7.9%]), with the advantage of less insulin dose requirements. However, significant, and incremental reductions in median GA determinations could be already evident after 30 days (-3.5 [range: -7.5, -2.5%]) and 60 days (-6.4 [range: -10.5, -4.7%]) from the start of SGLT-2 inhibitor treatment and persisted for up to 3 months (-8.6 [range: -12.1, 6.1%]). The decrements of HbA1c observed at the 3-month visit were highly correlated with the concurrent absolute reductions of plasma GA (ρ=0.550, P=0.027), whereas a borderline significance could be demonstrated with reference to reductions in plasma GA at 30 and 60 days. Although limited by the small number of participants, these preliminary findings suggest that GA, rather than HbA1c, could represent a useful and reliable biomarker in T2D to monitor the early glucose-lowering effects of antidiabetic drugs with rapid onset of action, such as SGLT-2 inhibitors and MDI insulin.

More than 35 million Americans live with type 2 diabetes (T2D), resulting in the need for newer strategies and technologies to manage the disease. Insulin pump therapy (IPT) has historically been reserved for type 1 diabetes, although emerging data demonstrates improved glucose outcomes for patients with T2D using IPT. To measure the change in HgbA1c in patients with T2D after changing therapy from multiple daily injections (MDI) to continuous subcutaneous insulin infusion through IPT. A retrospective comparison study was conducted by reviewing the electronic medical record of patients with T2D, older than 18 years, who had been on multiple daily insulin injections for at least 1 year, followed by IPT for at least 1 year. One hundred seventy-one patients met the inclusion criteria. There was a statistically significant reduction in mean HgbA1c from 9.6% to 7.6%. Insulin pump therapy may result in lower HgbA1c levels for T2D not at goal on MDI. Patients on multiple daily insulin injections who are not at goal should be considered for IPT.

The Official Journal of ATTD Advanced Technologies & Treatments for Diabetes Conference 22‐25 February 2023 I Berlin & Online

Adults with Down‐Syndrome seem to be protected from early aging‐associated increases in arterial stiffness and to present blunted responses to maximal aerobic exercise in comparison to age‐matched controls, possibly underlying diminished vascular reserve. However, whether these arterial stiffness responses apply to adults with intellectual and developmental disabilities (IDD) in general remains unknown. We compared central and peripheral arterial stiffness response patterns between persons with and without IDD of different age groups following maximal aerobic exercise. We hypothesized that adults with IDD would show an attenuated arterial stiffness response to maximal aerobic exercise in comparison to young and middle‐aged adults without IDD. Thirty young adults with (n=15, age= 30 ± 7 years) and without (n=15, age= 27 ± 7 years) IDD, and 15 middle‐aged adults (age= 51 ± 4 years) without IDD performed a bout of maximal aerobic exercise. Central and peripheral arterial stiffness were measured at rest and following maximal aerobic exercise using applanation tonometry estimates of carotid‐femoral (cfPWV), carotid‐distal (cdPWV), and carotid‐radial (crPWV) pulse wave velocity, respectively. cfPWV was unchanged following maximal aerobic exercise in young adults with and without IDD (figure) but increased in middle‐aged adults (d= 0.85; 95% CI: 0.27 to 1.42 m.s‐1, p= 0.005), whereas cdPWV was reduced (d= ‐0.77; 95% CI: ‐1.06 to ‐0.48 m.s‐1, p< 0.001) and crPWV unchanged in all three groups, independent of changes in mean arterial pressure. Overall group differences suggest that young adults with (d= ‐1.78; 95% CI: ‐3.20 to ‐0.37 m.s‐1, p= 0.009) and without(d= ‐1.84; 95% CI: ‐3.26 to ‐0.43 m.s‐1, p= 0.007) IDD had lower cfPWV than middle‐aged adults. We found no evidence of early vascular aging and or a diminished vascular reserve following maximal aerobic exercise in adults with IDD.

Although guidelines advocate similar CGM targets for insulin-treated persons with type 1 and type 2 diabetes, it is unclear how these persons differ with respect to hypoglycaemia, glucose variability and other CGM metrics in clinical practice. Methods; We used data from two multicenter randomized controlled trials (GOLD and MDI-Liraglutide) where 161 persons with type 1 diabetes and 124 persons with type 2 diabetes treated with multiple daily injections were included and monitored with masked CGM. Persons from both cohorts had similar mean glucose levels, 10.9 mmol/l (196 mg/dL) in persons with type 1 diabetes and 10.8 mmol/l (194 mg/dL) in persons with type 2 diabetes. Time in hypoglycemia (<3.9 mmol/l (70 mg/dL) was 5.1% and 1.0 % for persons with type 1 and type 2 diabetes, respectively (p<0.001). Corresponding estimates for the standard deviations of mean glucose levels were 4.4 mmol/l (79 mg/dL) vs 3.0 (54 mg/dL) (p<0.001), for CV 41% vs 28% (p<0.001) and for time in range 38.2% vs 45.3%, respectively (p=0.004). Mean C-peptide levels were 0.05 nmol/l and 0.67 nmol/l (p<0.001) for persons with type 1 and type 2 diabetes, respectively. Persons with type 1 diabetes compared to persons with type 2 diabetes treated with multiple daily injections spend considerably more time in hypoglycemia, have higher glucose variability, and less "Time in range". This needs to be taken into account in daily clinical care and in recommended targets for CGM metrics.

Background: Advanced hybrid closed-loop (AHCL) automated insulin delivery systems are the most effective therapy in terms of assisting people with type 1 diabetes (T1D) to achieve glycemic targets; however, the cost can represent a barrier to uptake. In this study, a cost-utility analysis of the MiniMed™ 780G AHCL system (MM780G) versus intermittently scanned continuous glucose monitoring (is-CGM) plus multiple daily insulin injections (MDI) in people with T1D not achieving glycemic goals was performed across six European countries. Methods: Clinical input data were sourced from the ADAPT trial. Assuming a baseline HbA1c of 9.04%, HbA1c reductions of 1.54% for AHCL and 0.2% for is-CGM+MDI were modeled. The analyses were performed from a payer perspective over a time horizon of 40 years and an annual discount rate of 3% was applied. Results: Across all countries, the use of AHCL was projected to result in an incremental gain in quality-adjusted life expectancy of >2 quality-adjusted life years (QALYs) versus is-CGM+MDI. Lifetime direct costs were higher with AHCL resulting in incremental cost-utility ratios for AHCL versus is-CGM+MDI ranging from EUR 11,765 per QALY gained in Austria to EUR 43,963 per QALY gained in Italy. Conclusions: For people with T1D managed with is-CGM+MDI not achieving glycemic targets, initiation of the MM780G system was projected to improve long-term clinical outcomes; however, due to differences in health care costs between countries, the health economic outcomes differed. In all included countries, AHCL is likely to be cost-effective relative to is-CGM+MDI for people not achieving glycemic goals with is-CGM+MDI. The ADAPT trial is registered with ClinicalTrials.gov, NCT04235504.

Background:A prolonged QT interval plays a causal role in fatal arrhythmia and is known to be a risk factor for sudden cardiac death. Although diabetic patients with microvascular complications tend to have a longer QT interval, the therapeutic effect of diabetes on the QT interval remains unclear. Here, we assessed the changes in QT interval in patients with type 2 diabetes (T2D) who received multiple daily insulin injections.Materials and methods:Patients with T2D (n = 34) who were admitted to our hospital and initiated multiple daily insulin injections for glycemic control were enrolled in this study. Clinical measurements, including electrocardiogram, were taken on admission and discharge. The QT interval was measured manually in lead II on the electrocardiogram, and corrected QT interval (QTc) was calculated using Bazett’s formula. The change in QTc (ΔQTc) during hospitalization (median, 15 days) and clinical parameters affecting ΔQTc were investigated.Results:QTc was shortened from 439 ± 24 to 427 ± 26 ms during hospitalization (p < 0.0001). ΔQTc was positively correlated with the changes in fasting plasma glucose (ΔFPG, r = 0.55, p = 0.0008) and glycated albumin (r = 0.38, p = 0.026) following insulin therapy, but not with the final dose of insulin (r = −0.20, p = 0.26). The multiple regression analyses revealed that ΔFPG was independently associated with ΔQTc.Conclusions:Multiple daily insulin injections can ameliorate QT interval by lowering the blood glucose levels in T2D, suggesting that glycemic control is important for preventing patients with T2D from sudden cardiac death.

Recent meta-analyses in the published medical literature have found improved glycaemic control with continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) of insulin for patients with diabetes mellitus. In Australia, CSII is predominantly used in type 1 diabetes mellitus (T1DM) patient populations. OBJECTIVE/INTERVENTION: To project long-term costs and outcomes of CSII (Novorapid or Humalog) compared with MDI (NPH insulin plus Novorapid or Humalog) in adult and adolescent T1DM patients in Australia. The study was a modelling analysis utilising a lifetime horizon in adult and adolescent specialty care T1DM patient populations from Australia. Published Australian diabetes complication costs (adjusted to Australian dollars [$A], year 2006 values), treatment costs and discount rates of 5.0% per annum were applied to costs and clinical outcomes. A lifetime horizon was taken, considering only direct medical costs and excluding indirect and non-medical costs. The validated CORE diabetes model employs standard Markov/Monte Carlo simulation techniques. It was used to simulate diabetes progression in Australian adult (mean age 43 years, duration of diabetes 17 years, mean glycosylated haemoglobin [HbA(1c)] 8.2%) and adolescent (mean age 17 years, duration of diabetes 6 years, mean HbA(1c) 8.9%) patients with baseline characteristics taken predominantly from Australian National Diabetes Information Audit and Benchmarking (ANDIAB) in Australia. The main outcome measures were incremental costs and effectiveness of CSII compared with MDI in Australian adult and adolescent patients with T1DM. Mean direct lifetime costs were $A34,642 higher with CSII treatment than with MDI for adult patients and $A41,779 higher for adolescent patients. Treatment with CSII was associated with an improvement in life expectancy of 0.393 years for adults compared with MDI and 0.537 years for adolescents. The corresponding gains in QALYs were 0.467 QALYs and 0.560 QALYs for adults and adolescents, respectively. This produced incremental cost effectiveness ratios (ICERs) of $A88,220 and $A77,851 per life-year gained for CSII compared with MDI for adult and adolescent T1DM patients, respectively, in Australia. These data also produced corresponding ICERs of $A74,147 per QALY and $A74,661/QALY for adult and adolescent T1DM patients, respectively. Sensitivity analyses suggested that our base-case assumptions were mostly robust with improvements in ICERs for reduction in hypoglycaemic events with CSII treatment and worse ICERs for lower HbA(1c) changes associated with CSII treatment compared with MDI. Our analysis suggests that CSII is associated with ICERs in the range of $A53,022-259,646 per QALY gained, with most ICERs representing good value for money in Australia under the majority of scenarios explored.

Pharmacotherapy in Type 1 Diabetes

The goal of the study was to determine whether continuous subcutaneous insulin infusion (CSII) differs from a multiple daily injection (MDI) regimen based on neutral protamine hagedorn (NPH) as basal insulin with respect to glycaemic control and quality of life in people with Type 1 diabetes. The 5-Nations trial was a randomized, controlled, crossover trial conducted in 11 European centres. Two hundred and seventy-two patients were treated with CSII or MDI during a 2-month run-in period followed by a 6-month treatment period, respectively. The quality of glycaemic control was assessed by HbA(1c), blood glucose values, and the frequency of hypoglycaemic events. For the evaluation of the quality of life, three different self-report questionnaires have been assessed. CSII treatment resulted in lower HbA(1c) (7.45 vs. 7.67%, P < 0.001), mean blood glucose level (8.6 vs. 9.4 mmol/l, P < 0.001) and less fluctuation in blood glucose levels than MDI (+/- 3.9 vs. +/- 4.3 mmol/l, P < 0.001). There was a marked reduction in the frequency of hypoglycaemic events using CSII compared with MDI, with an incidence ratio of 1.12 [95% confidence interval (CI): 1.08-1.17] and 2.61 (95% CI: 1.59-4.29) for mild and severe hypoglycaemia, respectively. The overall score of the diabetes quality of life questionnaire was higher for CSII (P < 0.001), and an improvement in pump users' perception of mental health was detected when using the SF-12 questionnaire (P < 0.05). CSII usage offers significant benefits over NPH-based MDI for individuals with Type 1 diabetes, with improvement in all significant metabolic parameters as well as in patients' quality of life. Additional studies are needed to compare CSII with glargine- and detemir-based MDI.