Experienced Hypoglycemia Research Articles

Utilization of simulated patients to assess diabetes and asthma counseling practices among community pharmacists in Qatar.

Background Patient counseling is one of the most important services a pharmacist can provide to patients. Studies have shown that counseling provided by pharmacists may prevent medication related problems and improve adherence to medication therapy. Objective To explore counseling practices among community pharmacists using simulated patients and to determine if patient, pharmacist, and pharmacy characteristics influence the counseling provided by community pharmacists. Setting Private community pharmacies within Qatar. Method This is a randomized, cross sectional study where simulated patients visited community pharmacies and presented the pharmacist with a new prescription or requested a refill for either a diabetes or asthma medication. Pharmacists completed a questionnaire at the end of the simulated interaction, which was utilized to determine if patient, pharmacist, or pharmacy characteristics had any influence on the counseling provided to patients. A scoring system was devised to assess the pharmacist's counseling practices. Main outcome measure To evaluate the type of information provided by community pharmacists to the simulated patient regarding diabetes and asthma. Results One hundred and twenty-nine pharmacists were enrolled in the study. Eighty one percent of pharmacists had a score <35%. Medication name (95%), directions (47%), indication (43%), and dose (41%) were the most frequently counseled components by pharmacists during the simulated interaction. Male patients received better counseling compared to the female patients (t=6.177; p<0.0001). Pharmacists with a master of pharmacy degree provided significantly better counseling (f=3.261; p=0.042). Many pharmacists (65%) provided hypoglycemia management to patients, however, 63% referred the patient to the physician when the patient experienced hypoglycemia from inappropriate medication administration. Only 2 (7%) pharmacists correctly counseled the patient on all 8 inhaler administration steps. Majority of pharmacists (50%) educated on the role of the rescue and controller therapy in asthma, however, 33% referred the patient to the physician when the patient inquired about controller therapy use. Conclusion Patient counseling was substandard with the majority of community pharmacists focusing on the name of the medication. Pharmacists rarely assessed patient's medical history or medication use. Disease management and problem solving skills of pharmacists were suboptimal with many referring patients back to the physician.

Effectiveness of MiniMed 640G with SmartGuard® System for prevention of hypoglycemia in pediatric patients with type 1 diabetes mellitus

Introduction/aimsTreatment with the MiniMed 640G-SmartGuard® system (640G-SG, sensor-augmented insulin pump system with low predicted glucose suspension feature) has been shown to decrease risk of hypoglycemia without altering metabolic control in patients with T1DM. The study purpose was to assess the impact of 640G-SG on hipoglycemia frequency and on metabolic control in a pediatric population with T1DM. Patients/methodsA retrospective study on 21 children treated with 640G-SG. HbA1c, mean blood glucose (mg/dL), glucose variation coefficient, frequency of hypoglycemia (<70mg/dL) and hyperglycemia (>180mg/dL), daily capillary blood glucose measurements, ketosis/diabetic ketoacidosis, and severe hypoglycemic episodes were analyzed and compared before and during use of the system. Fasting blood glucose, frequency of sensor use and number and duration of system suspension events were also assessed in the last month of use of the system. ResultsAll patients used the system continuously (5.0±2.1 months), with a median sensor use of 92%. Significant decreases were seen in hypoglycemia frequency (10.4±5.2% to 7.6±3.3%, p=0.044) and number of capillary blood glucose measurements (11.3±2.2 to 8.1±2.1, p<0.001), and there was no increase in hyperglycemia frequency (p=0.65). Mean system suspension time was 3.1±1.2h/day (37.3% of overnight stops). Changes in HbA1c, mean blood glucose, and variation coefficient were not significant. No patient experienced diabetic ketoacidosis or severe hypoglycemia. ConclusionsThe sensor-augmented pump with the predictive low glucose suspension management system, as implemented in the 640G-SG system, can help avoid risk of hypoglycemia without significantly affecting metabolic control or causing diabetic ketoacidosis, and decrease the burden of additional capillary blood glucose measurements in our pediatric cohort.

Efectividad del sistema MiniMed 640G con SmartGuard® para la prevención de hipoglucemia en pacientes pediátricos con diabetes mellitus tipo 1

Introduction/aimsTreatment with the MiniMed 640G-SmartGuard® system (640G-SG, sensor-augmented insulin pump system with low predicted glucose suspension feature) has been shown to decrease risk of hypoglycemia without altering metabolic control in patients with T1DM. The study purpose was to assess the impact of 640G-SG on hipoglycemia frequency and on metabolic control in a pediatric population with T1DM. Patients/methodsA retrospective study on 21 children treated with 640G-SG. HbA1C, mean blood glucose (mg/dl), glucose variation coefficient, frequency of hypoglycemia (<70mg/dl) and hyperglycemia (>180mg/dl), daily capillary blood glucose measurements, ketosis/diabetic ketoacidosis, and severe hypoglycemic episodes were analyzed and compared before and during use of the system. Fasting blood glucose, frequency of sensor use and number and duration of system suspension events were also assessed in the last month of use of the system. ResultsAll patients used the system continuously (5.0±2.1 months), with a median sensor use of 92%. Significant decreases were seen in hypoglycemia frequency (10.4±5.2% to 7.6±3.3%, p=.044) and number of capillary blood glucose measurements (11.3±2,2 to 8.1±2,1, p<.001), and there was no increase in hyperglycemia frequency (p=.65). Mean system suspension time was 3.1±1.2hours/day (37.3% of overnight stops). Changes in HbA1c, mean blood glucose, and variation coefficient were not significant. No patient experienced diabetic ketoacidosis or severe hypoglycemia. ConclusionsThe sensor-augmented pump with the predictive low glucose suspension management system, as implemented in the 640G-SG system, can help avoid risk of hypoglycemia without significantly affecting metabolic control or causing diabetic ketoacidosis, and decrease the burden of additional capillary blood glucose measurements in our pediatric cohort.

Evaluation of Outcomes and Complications in Patients Who Experience Hypoglycemia After Cardiac Surgery

The objective of the study was to elucidate 30-day and long-term outcomes in patients experiencing postoperative hypoglycemia. We conducted a retrospective review of patients who underwent cardiac surgery between September 4, 2007, and April 30, 2011, at Northwestern Memorial Hospital who had intensive treatment of hyperglycemia postoperatively. Of 1,325 patients, 215 experienced a hypoglycemic episode (blood glucose <70 mg/dL) within the first 3 postoperative days. A total of 198 were propensity-score (PS) matched to 363 patients without hypoglycemia. The analysis consisted of a comparison of 30-day cardiac outcomes and long-term mortality between those who experienced a hypoglycemic event and those who did not. Between patients who experienced hypoglycemia compared to those that did not, there were no significant differences in mean glucose values while on insulin drips (119.8 ± 33.5 mg/dL vs. 120.9 ± 30.5 mg/dL; P = .69) or subcutaneous insulin (122.0 ± 38.0 mg/dL vs. 127.2 ± 35.5 mg/dL; P = .11) or postoperative surgical complication rates (30-day mortality: 3.5% vs. 1.7%; complications (any): 40% vs. 42%; 30-day re-admissions: 13% vs. 13%; all cardiac complications: 35% vs. 31%; and all infections: 8% vs. 5%). Over an average of 5.1 ± 2.2 years following index surgery, there was higher all-cause mortality among those PS-matched who had experienced hypoglycemia compared to those who had not (log-rank P = .031), primarily due to those (n = 32) experiencing more than one episode of hypoglycemia. Postoperative hypoglycemia did not negatively impact immediate surgical complication rates but was associated with a significant risk of increased postoperative morbidity and long-term all-cause mortality in patients experiencing multiple episodes of hypoglycemia. BG = blood glucose BMI = body mass index CARD = Cardiovascular Research Database HR = hazard rate PS = propensity score.

Self-reported frequency, severity of, and awareness of hypoglycemia in type 2 diabetes patients in Turkey.

ObjectivesHypoglycemia is a common side effect of insulin therapy in type 1 and type 2 diabetes. Limited data exist on the frequency of hypoglycemic events in type 2 diabetic patients in Turkey. Our study investigated self-reported hypoglycemic events and awareness of hypoglycemia in Turkish patients with type 2 diabetes.MethodsPeople with type 2 diabetes older than 18 years of age were recruited from the two university hospital diabetes clinics. The frequency and severity of hypoglycemia and awareness of hypoglycemia during the preceding year were determinated using questionnaires by the face-to-face interview method.ResultsIn this study of 187 patients with type 2 diabetes, 83.4% had impaired awareness of their hypoglycemia, and 62% reported that they had missed some of the symptoms of hypoglycemia. Of the patients reporting hypoglycemic symptoms and severity level, 84.1% experienced mild hypoglycemia, 60% moderate, and 15.5% severe hypoglycemia in the past year. No significant association was made between hypoglycemia awareness and age, body-mass index (BMI), years of diabetes, dose of insulin, duration of insulin use, number of meals, or amount of snacking. A significant correlation was found between A1c levels and hypoglycemia awareness and severity of hypoglycemia. A significant correlation was found between dose of insulin, amount of snacking, and severity of hypoglycemia. No significant association was made between severity of hypoglycemia and age, BMI, years of diabetes, duration of insulin use, or the number of meals. However, the group with severe hypoglycemia had diabetes longer, and the average daily dose of insulin use was higher than in other groups.ConclusionsAccording to the study results, the percentage of patients with impaired awareness of hypoglycemia is high, and 62% of patients reported that they had missed some of the symptoms of hypoglycemia in type 2 diabetes. In addition, the percentage of severe hypoglycemic events is not low. Impaired awareness of hypoglycemia is a major risk factor for severe hypoglycemic events. Patients should be educated about the danger of hypoglycemia. Education should be improved, and a determined attempt should be made to eradicate the problem.

Severe hypoglycemia, impaired awareness of hypoglycemia, and self-monitoring in adults with type 1 diabetes: Results from Diabetes MILES—Australia

AimsTo assess prevalence of severe hypoglycemia, awareness and symptoms of hypoglycemia, and their associations with self-monitoring of blood glucose. MethodsDiabetes MILES—Australia Study participants completed validated questionnaires and study-specific items. ResultsOf 642 adults with type 1 diabetes, 21% reported ≥1 severe hypoglycemic event in the past six months, and 21% reported impaired awareness of hypoglycemia (IAH). Severe hypoglycemia was increased four-fold for those with IAH compared with intact awareness (1.4±3.9 versus 0.3±1.0). Of those with IAH, 92% perceived autonomic and 88% neuroglycopenic symptoms, albeit at lower glucose thresholds compared to people with intact awareness. Those with IAH were more likely to perceive both symptom types at the same glucose level or to perceive neuroglycopenic symptoms first (all p<0.001). Eighteen percent with IAH treated hypoglycemia only when they perceived symptoms and another 18% only when their capillary glucose was <3.0mmol/L. ConclusionsOne in five adults with type 1 diabetes had IAH or experienced severe hypoglycemia in the past sixmonths. Total loss of hypoglycemia symptoms was rare; most people with IAH retained autonomic symptoms, perceived at relatively low glucose levels. Frequent self-monitoring of blood glucose prompted early recognition and treatment of hypoglycemia, suggesting severe hypoglycemia risk can be minimized.

Fasting with diabetes: a prospective observational study

ObjectivesTo determine the proportion of diabetic patients who develop adverse glycaemic events when fasting regularly.DesignProspective observational study conducted at a tertiary care hospital in South Asia. Five hundred and twenty-three...

Those Salicylate Cases-How Sweet Are They?

Owing to the complex metabolism of salicylates, both hyperglycemia and hypoglycemia have been reported with salicylate poisoning. The aim of this study was to characterize this relationship. Data from the Illinois Poison Center were retrospectively queried over a 5-year period (2008-2012), and patients with a salicylate concentration ≥30 mg/dL were included. Hypoglycemia and hyperglycemia were defined as glucose concentrations <55 and >140 mg/dL, respectively. Of the 160 patients included, most were normoglycemic (81%) and 19% were hyperglycemic. No patient experienced hypoglycemia. Our study indicates that hypoglycemia may be a very rare occurrence in the setting of salicylate poisoning. Clinicians must remain vigilant, regardless of the glucose concentration, when entertaining salicylism as an etiology in appropriate patients.

Dangerous antidiabetic overtreatment of patients with Typ 2 diabetes having experienced severe hypoglycaemia

Aims: Severe hypoglycaemia (SH) may increase cardiovascular and all-cause mortality in patients with long-standing complicated diabetes. We investigated whether in patients with T2DM who had experienced SH individual morbidity and treatment targets had sufficiently been respected.

A review of hypoglycaemia in a South African family practice setting.

BackgroundThe prevalence and incidence of diabetes in South Africa are high and are expected to increase. Mortality and morbidity may be related to hypoglycaemia, and there is limited information on hypoglycaemia from private practice sites. The aim of this study was to assess patients’ education about, knowledge of and response to hypoglycaemia.MethodsThe study site was a general practice, and participants were all patients with diabetes who presented to the practice over a 1-month period. Data were collected using a closed-ended questionnaire and analysed descriptively.FindingsMost respondents were South Africans of Indian origin and were diagnosed with diabetes at a relatively young age. Despite attending a private practice, most had low incomes and low schooling levels. Just under half reported having experienced hypoglycaemia, and there was a strong association between hypoglycaemia and insulin use. Many reported never having received any education around hypoglycaemia.DiscussionThe study highlights the need for early screening for diabetes in this vulnerable population. Hypoglycaemic education should consider low schooling levels even in a private general practice, and further study is required on the quality and frequency of education provided in general practice.

Fear of hypoglycemia, anxiety, and subjective well-being in parents of children and adolescents with type 1 diabetes.

This study explored the association between parental fear of hypoglycemia, anxiety, and subjective well-being in parents of children and adolescents with type 1 diabetes. A total of 120 mothers and 79 fathers participated. Mothers' and fathers' fear of hypoglycemia was significantly associated with anxiety and negative affect as well as with worse glycemic control in child. Paired-samples t-test showed that mothers were more involved in diabetes management and reported more fear and anxiety compared to fathers, but they did not differ in worries about hypoglycemia. The findings suggest screening for fear of hypoglycemia and subjective well-being in all parents regardless of whether their child experienced severe hypoglycemia.

Fasting for Laboratory Tests Poses a High Risk of Hypoglycemia in Patients with Diabetes: A Pilot Prevalence Study in Clinical Practice

Objective: Fasting for lipid profiles is a deeply-rooted tradition that is being revisited. In patients with diabetes, such fasting poses a risk of hypoglycemia, as observed in recent studies and case reports. This iatrogenic, overlooked, form of hypoglycemia has been referred to as Fasting-Evoked En-route Hypoglycemia in Diabetes (FEEHD). The objective of the study is to determine the prevalence of FEEHD in clinical practice. Methods: A two-page survey was administered to adults with diabetes on anti-diabetic medication(s). Patients were asked if they recalled having experienced hypoglycemia while fasting for laboratory tests (FEEHD) during the preceding 12 months. Results: Of 168 patients enrolled, 166 completed the survey, with a mean age of 55.3 (SD: 15.4) years. Seventy-nine (47.6%) were females. Of these 166 patients, 119 (71 %) had type 2 diabetes. Forty-five patients (27.1%) reported having experienced one or more FEEHD events. Notably, only 31.1% of the patients who experienced a FEEHD event informed their provider of the event, and only 40% of FEEHD events reportedly resulted in any subsequent provider-made medication change(s) to prevent future events. Conclusions: This is the first study of FEEHD prevalence in clinical practice, the results of which serve to increase awareness amongst clinicians about the occurrence of FEEHD. We believe that FEEHD appears to be overlooked by clinicians. The prevalence of FEEHD in clinical practice is strikingly high (27.1%). More concerning is the significant underreporting of FEEHD events by patients to their clinicians (31%). We hope this study will trigger further investigation to confirm these preliminary findings and modify practice guidelines.

Long-term Efficacy and Safety of Sitagliptin in Elderly Patients with Type 2 Diabetes Mellitus.

Objective We herein conducted a retrospective study to evaluate the long-term efficacy and safety of sitagliptin treatment in elderly patients with type 2 diabetes mellitus. Methods We analyzed the changes in glycemic control in 112 Japanese type 2 diabetes patients over 65 years of age treated with 50 mg/day sitagliptin. Hemoglobin A1c (HbA1c) levels, liver and kidney functions, and usage of hypoglycemic agents were recorded for 24 months. Results HbA1c levels were significantly decreased, and the significance of HbA1c reduction was maintained during the observation period [from 7.7±1.1% to 7.2±0.7% (p<0.001) at the end of observational period]. The %change in HbA1c levels was significantly and negatively correlated with the baseline HbA1c levels (r=-0.51, p<0.001), but not with age, duration of diabetes, or the estimated glomerular filtration rate (eGFR). No patient experienced severe hypoglycemia episodes, and aspartate transaminase, alanine transaminase, gamma-glutamyl transpeptidase, and the eGFR remained unchanged. The dose of sulfonylurea was finally decreased in 72% of patients treated with sulfonylurea. Conclusion Sitagliptin treatment continually decreases the HbA1c level for 24 months and is useful to reduce the dose of sulfonylurea in elderly patients with type 2 diabetes.

Type II Diabetes Prevalence, Hypoglycemia Episodes, and Hba1C Control In Brazil

Diabetes mellitus type II (DM2), a highly prevalent disease worldwide, negatively impacts public health. However, epidemiology data regarding DM2 are very scarce in Brazil. This study aims to understand DM2 prevalence and control of diabetic symptoms, such as HbA1c levels and hypoglycemia, in Brazil. Data were derived from the 2011 & 2012 Brazil National Health and Wellness Survey, an internet-based general health survey, stratified to be representative of age and gender. Among 24,000 total respondents, 1,026 reported a DM2 diagnosis, further subdivided by HbA1c levels: “controlled,” indicated by HbA1c<7% (n=57); “uncontrolled,” indicated by HbA1c≥7% (n=67); and unknown HbA1c (n=902). Additionally, respondents were categorized by hypoglycemia experience in the past three months: not experienced (n=186), experienced (n=701), and unknown (n=139). The Morisky Medication Adherence Scale-4 was used to categorize respondents with no non-adherent behaviors regarding their diabetes medication as “adherent.” Resultswere weighted to be representative of the adult Brazilian population. One-way ANOVAs and chi-squares were used to examine group differences. In Brazil, projected estimates reveal that 4.0% (n=5,585,272) of the adult population have a DM2 diagnosis. Of those diagnosed, average age was 56.5 years old, 53.2% are female, 54.3% are white, 80.9% have less than a degree, 69.3% make less than R$6,500 annually, 68.4% have public insurance, and 73.5% are overweight or obese. Regarding HbA1c levels, only 4.0% were controlled, 5.4% were uncontrolled, and 90.6% were unknown. Additionally, 17.0% experienced recent hypoglycemia, 69.6% did not, and 13.5% did not know. The majority were taking diabetes medication (86.4%), but only 37.2% were adherent. Although most Brazilian DM2 respondents are currently taking prescription medication, few are adherent to their medication and have adequate knowledge about their symptoms. Considering public health implications of diabetes, awareness, education programs, and pharmaceutical care for DM2 patients may improve adherence to treatment.

Optimal candidates for the switch from glimepiride to sitagliptin to reduce hypoglycemia in patients with type 2 diabetes mellitus.

BackgroundSitagliptin is a novel antidiabetic agent with a low risk for hypoglycemia. We investigated the efficacy and safety of sitagliptin when patients switched from a sulfonylurea to sitagliptin and identified good candidates for the switch.MethodsSixty-one patients with type 2 diabetes switched from glimepiride with metformin to sitagliptin with metformin due to clinical hypoglycemia. Serum glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and 2-hour postprandial plasma glucose (2h-PPG) before and 12 and 24 weeks after the drug switch were checked.ResultsHbA1c and FPG levels did not change 12 or 24 weeks after the switch; however, the 2h-PPG level decreased from 218.0±67.5 mg/dL at baseline to 197.1±69.9 mg/dL at 12 weeks and 192.3±67.4 mg/dL at 24 weeks after switching drugs (P=0.045, P=0.018, respectively). All but one patient no longer experienced hypoglycemia after discontinuing glimepiride. In a multivariate logistic regression analysis, a high homeostasis model assessment of insulin resistance and low baseline HbA1c level were independent predictors of an HbA1c ≤7% after switching to sitagliptin.ConclusionGlycemic control was not aggravated in patients 24 weeks after the drug switch, and symptomatic hypoglycemia decreased significantly. Patients with dominant insulin resistance may be good candidates for switching from a sulfonylurea to sitagliptin to reduce hypoglycemia.

Identifying Risk Factors for Severe Hypoglycemia in Hospitalized Patients with Diabetes

Some of the deleterious effects of hypoglycemia in hospitalized patients include increased rates of mortality and longer length of stay. Our primary objective was to identify the risk factors associated with severe hypoglycemia to identify those patients at highest risk. The medical records of 5,026 patients with diabetes mellitus (DM) admitted in 2010 were reviewed to identify those patients that developed severe hypoglycemia (blood glucose [BG] <40 mg/dL). We performed χ2 tests to assess statistical significance. Adjusted logical regression was used to determine the risk factors for hypoglycemia in the hospital. Out of 5,026 DM patients included in our review, 81 experienced severe hypoglycemia (1.6%). Statistically higher proportions of chronic kidney disease (CKD; 69.1% vs. 46.9%, P<.001), congestive heart failure (CHF; 48.1% vs. 28.5%, P<.001), sepsis (49.4% vs. 12.5%, P<.001), insulin use (45.7% vs. 26.04%, P = .000), type 1 DM (21% vs. 5.1%, P = .000), and cirrhosis (14.8% vs. 7.2%, P = .009) were seen in the severe hypoglycemic group compared to the nonsevere hypoglycemic group. Overall, 84% of patients who experienced an episode of severe hypoglycemia in the hospital (BG <40 mg/dL) had a previous episode of hypoglycemia (BG <70 mg/dL). The odds ratios (ORs) for type 1 DM, sepsis, previous hypoglycemia, and insulin use were 3.43 (95% confidence interval [CI] 1.81, 6.49), 2.64 (95% CI 1.6, 4.35), 46.1 (95% CI 24.76, 85.74), and 1.66 (95% CI 1.02, 2.69), respectively. Prior episodes of hypoglycemia in the hospital, the presence of type 1 DM, insulin use, and sepsis were identified as independent risk factors for the development of severe hypoglycemia in the hospital.

Recurrent Hypoglycemia Following Total Pancreatectomy and Islet Autotransplantation.

Total pancreatectomy and Islet autotransplantation (TP-IAT) is a treatment modality for chronic pancreatitis after therapies have been exhausted. The aim to prevent surgical diabetes in these patients is achieved in approximately one third of cases. In another third, autograft function is insufficient to achieve insulin independence while still improving glucose management. We report a case of an insulin independent islet autograft recipient, experiencing frequent hypoglycemia. The patient developed symptoms of abdominal pain her early thirties, leading to the diagnosis of idiopathic pancreatitis and subsequent Whipple resection of the pancreatic head in 2003 followed by a symptom free interval. Obstruction of the pancreaticojejunostomy necessitated a surgical revision and Roux-en-Y reconstruction of the gastrojeujunostomy in 2008. An episode of acute on chronic pancreatitis and recurring symptoms culminated in the indication of completion pancreatectomy and splenectomy, followed by IAT in 2012. The islet Isolation from the pancreas remnant (29 g) yielded a total Islet equivalents (IEQ) of 267,000 (5650,000 IEQ/kg BW). Islets were infused into the liver via the splenic vein stump under systemic heparinization. Post-operative blood glucose (BG) levels did not exceed 160 mg/dl. Following the discontinuation of protective exogenous insulin therapy 3 months postoperatively, the patient experienced hypoglycemia with increasing frequency and intensity, especially postprandial, following physical exercise and at night. Supportive treatment with a diet of Carbohydrates with low Glycemic index and Acarbose were initiated but failed to prevent hypoglycemia. Extensive workup and metabolic testing revealed a relative lack of glucagon response to hypoglycemia, reduced first phase insulin secretion, impaired Cortisol response to hypoglycemia and impaired postprandial incretin release. In conclusion, we report the rare case of Hypoglycemia complicating the outcome of IAT. Mechanisms of post IAT hypoglycemia remain elusive despite some evidence for impaired Glucagon action. Treatment thus far is limited to glycemic management with continuous glucose monitoring and therapeutic glucose intake.

Examination of Implementation of Intravenous and Subcutaneous Insulin Protocols and Glycemic Control in Heart Transplant Patients

Perioperative glycemic management is particularly challenging in heart transplant (HT) patients who are on high-dose steroids and subject to surgical stress. The objective of the study was to examine the efficacy and safety of perioperative insulin administration in HT patients with and without diabetes. Medical records of 71 HT patients from June 1, 2005 to July 31, 2009 whose hyperglycemia was managed by our Glucose Management Service (GMS) were analyzed for up to 1 year after HT. Their daily blood glucose (BG) averages on intravenous (i.v.) insulin drips and subcutaneous (s.q.) insulin, hypoglycemia rates, reasons for hypoglycemia, and deviations from insulin protocols were analyzed. Daily BG averages between diabetic (DM) and nondiabetic (nonDM) patients were not significantly different while on the drip but were significantly different for first 5 days on s.q. (P<.05). The daily insulin glargine doses were similar. No patients developed severe hypoglycemia (BG ≤40 mg/dL) while on drip, and only 2.8% experienced hypoglycemia on s.q. Among 40 episodes of moderate hypoglycemia while on drip, 15 had nurse deviations from protocol prior to the episode. Posttransition day fasting glucose was at goal (mean 124.7 ± 35.4 mg/dL); however 39.4% (28/71) of patients received a transition insulin glargine dose that was different from the amount indicated by protocol. The likelihood of developing moderate hypoglycemia on s.q. was associated with the glargine dose used at the time of transition (odds ratio [OR] 1.03, P = .034). Inpatient insulin protocols implemented by a GMS are successful in obtaining glycemic control with minimal side effects in patients with and without diabetes, even when they are on a high-dose steroid regimen.

In Silico Optimization of Basal Insulin Infusion Rate during Exercise: Implication for Artificial Pancreas

Several clinical trials have been performed to assess safety and efficacy of closed-loop control. Some included physical activity (PA), with the goal of challenging the control algorithms with a rapid change in insulin sensitivity while reducing the risk of hypoglycemia. However, the question remains as to the necessity to inform the control algorithm on the imminent PA. The aim here is to assess in silico (i) if it is necessary to announce upcoming PA and (ii) if this is the case, what is the safest strategy of basal insulin reduction in the context of the closed-loop control. We modified the University of Virginia/Padova type 1 diabetes simulator to incorporate the effect of PA based on a study in healthy subjects that demonstrated an almost doubling of insulin sensitivity during PA versus rest. Two in silico experiments, including a PA session, have been simulated on the virtual adult population: one in the absence of and one with different degrees of reductions and durations of basal insulin infusion rates. Most in silico subjects experienced hypoglycemia in the absence of basal insulin adjustment. We show that, in the absence of patient-specific information, a safe and effective strategy is to reduce basal insulin by 50% starting 90 min before exercise and by 30% during exercise. Our results suggest that control algorithms could benefit by knowing an upcoming PA. Ideally, the control algorithm should be informed about the patient-specific basal insulin reduction pattern. An alternative strategy that has been proposed here has been deemed safe and effective in in silico experiments.

Effects of Sport-Specific, Intermittent High-Intensity Exercise on Post-Exercise Heart Rate Variability and Glycemia in Young Athletes with Type 1 Diabetes

Type 1 diabetes (T1D) is associated with hypoglycemia and premature autonomic disturbance (using heart rate variability [HRV]) - both which have been implicated in sudden death. This study examined the effect of a single bout of intermittent high-intensity exercise (IHE) on nocturnal HRV in ten hockey players with T1D and ten teammates without T1D. HRV and BG were analyzed from 12am-6am following hockey activity and low activity days. Hockey-type IHE on a cycle ergometer decreased BG by -1.9 ± 2.8 mmol/L, while an actual hockey game increased BG by 1.0 ± 3.2 mmol/L. One participant experienced nocturnal hypoglycemia after a hockey game (lasting 230 min). A significantly better nocturnal HRV profile (QTc, SDNN, pNN50, RMSSD) was observed following the low activity day compared to the days where IHE took place (p<0.05). There was no difference in HRV between T1D and non-T1D participants. This study documented the unique ability of a hockey game to increase BG in youth with T1D. Furthermore, given that decreased HRV is commonly noted in youth with T1D, this study suggests that the onset of autonomic hindrances can be delayed in highly-active individuals.