Hypoglycemia In Adult Patients Research Articles

Effectiveness of a flash glucose monitoring systems implementation program through a group and telematic educational intervention in adults with type 1 diabetes

ObjectivesVerifying the clinical effectiveness and the impact on quality-of-life parameters, fear of hypoglycaemia and satisfaction with the treatment obtained with a flash glucose monitoring (MFG) devices implantation program that includes a telematic and group educational intervention in adults with type 1 diabetes. Patients and methodsProspective quasi-experimental study, carried out during the COVID-19 pandemic period with a 9-month follow-up at the Virgen Macarena University Hospital, Sevilla. ResultsEighty-eight participants were included (men: 46.6%; mean age (years) 38.08, SD: 9.38); years of DM1 evolution: 18.4 (SD: 10.49); treatment with multiple doses insulin (MDI) 70.5% vs 29.5% subcutaneous insulin infusion therapy (CSII)). Baseline HbA1c was 7.74% (1.08). After the intervention, the global decrease in HbA1c was −0.45% (95% CI [−0.6, −0.25], P < 0.01), increasing to −1.08% in the group that started with HbA1c ≥ 8% (P < 0.01). A mean decrease in the Fear of Hypoglycemia 15 (FH15) test score of −6.5 points was observed (P < 0.01). In the global score of the Spanish version of Diabetes Quality Of Life (DQOL-s) test, the decrease was −8.44 points (P < 0.01). In Diabetes Treatment Satisfaction Questionnaire test (DTQ-s), global score increased in + 4 points (P < 0.01). ConclusionsThe incorporation of an educational program in group and telematic format within the development of MFG devices implantation strategies is an effective option, with associated benefits in quality of life and fear of hypoglycemia in adult patients with DM1. This option can be implemented in usual clinical practice.

Predicting Risk of Hypoglycemia in Patients With Type 2 Diabetes by Electronic Health Record-Based Machine Learning: Development and Validation.

BackgroundHypoglycemia is a common adverse event in the treatment of diabetes. To efficiently cope with hypoglycemia, effective hypoglycemia prediction models need to be developed.ObjectiveThe aim of this study was to develop and validate machine learning models to predict the risk of hypoglycemia in adult patients with type 2 diabetes.MethodsWe used the electronic health records of all adult patients with type 2 diabetes admitted to West China Hospital between November 2019 and December 2021. The prediction model was developed based on XGBoost and natural language processing. F1 score, area under the receiver operating characteristic curve (AUC), and decision curve analysis (DCA) were used as the main criteria to evaluate model performance.ResultsWe included 29,843 patients with type 2 diabetes, of whom 2804 patients (9.4%) developed hypoglycemia. In this study, the embedding machine learning model (XGBoost3) showed the best performance among all the models. The AUC and the accuracy of XGBoost are 0.82 and 0.93, respectively. The XGboost3 was also superior to other models in DCA.ConclusionsThe Paragraph Vector–Distributed Memory model can effectively extract features and improve the performance of the XGBoost model, which can then effectively predict hypoglycemia in patients with type 2 diabetes.

Prevalence of Post–Glucose Challenge Hypoglycemia in Adult Patients With Cystic Fibrosis and Relevance to the Risk of Cystic Fibrosis–Related Diabetes

ObjectivesThe clinical relevance of fasting and postprandial hypoglycemia in patients with cystic fibrosis (CF) is poorly characterized. Our aim in this study was to characterize the prevalence of hypoglycemia in adult patients during oral glucose tolerance test (OGTT) screening and determine its impact on the risk of developing CF-related diabetes (CFRD). MethodsWe analyzed 2 cohorts of pancreatic insufficient patients with CF exposed to comparable treatment recommendations in France (Lyon CF cohort [DIAMUCO]) and Canada (Montréal CF cohort [MCFC]). Patients were classified into 3 groups based on hypoglycemia absence or presence as well as its severity at baseline. We defined the groups as follows: level 2 hypoglycemia (L2H; plasma glucose [PG]<3.0 mmol/L), level 1 hypoglycemia (L1H; PG 3.0 to <4.0 mmol/L) and no hypoglycemia (NH) during an OGTT. ResultsA total of 153 MCFC and 114 DIAMUCO subjects were included in the study. In total, 22% of the patients experienced hypoglycemia, with 5% having it on 2 or more OGTTs. The L1H and L2H groups tended to have a lower 2-hour glucose and higher early-phase insulin secretion (insulin area under the curve at 0 to 30 minutes) compared with NH patients. In both cohorts, a greater proportion of men and patients with normal glucose tolerance had hypoglycemia. Over a 5-year period, there were no cases of CFRD in the L2H group, whereas 4 subjects in the L1H group and 36 in the NH group developed CFRD. ConclusionsPatients with hypoglycemia were at lower risk of developing CFRD, but at higher risk of early-phase insulin secretion and unsuppressed insulin secretion. This could potentially lead to further hypoglycemia after the 2-hour OGTT, suggesting high clinical relevance.

Efectividad de un programa de implantación de sistemas de monitorización flash de glucosa a través de una intervención educativa grupal y telemática en adultos con diabetes tipo 1

ObjectivesVerifying the clinical effectiveness and the impact on quality-of-life parameters, fear of hypoglycaemia and satisfaction with the treatment obtained with a flash glucose monitoring (MFG) devices implantation program that includes a telematic and group educational intervention in adults with type 1 diabetes. Patients and methodsProspective quasi-experimental study, carried out during the COVID-19 pandemic period with a 9-month follow-up at the Virgen Macarena University Hospital, Sevilla. ResultsEighty-eight participants were included (men: 46.6%; mean age (years) 38.08, SD: 9.38); years of DM1 evolution: 18.4 (SD: 10.49); treatment with multiple doses insulin (MDI) 70.5% vs 29.5% subcutaneous insulin infusion therapy (CSII)). Baseline HbA1c was 7.74% (1.08). After the intervention, the global decrease in HbA1c was −0.45% (95% CI [−0.6, −0.25], P<.01), increasing to −1.08% in the group that started with HbA1c≥8% (P<.01). A mean decrease in the Fear of Hypoglycemia 15 (FH15) test score of −6.5 points was observed (P<.01). In the global score of the spanish version of Diabetes Quality Of Life (DQOL-s) test, the decrease was −8.44 points (P<.01). In Diabetes Treatment Satisfaction Questionnaire test (DTQ-s), global score increased in +4 points (P<.01). ConclusionsThe incorporation of an educational program in group and telematic format within the development of MFG devices implantation strategies is an effective option, with associated benefits in quality of life and fear of hypoglycemia in adult patients with DM1. This option can be implemented in usual clinical practice.

Prevalence of Post-Glucose Challenge Hypoglycemia in Adult Patients with Cystic Fibrosis and Relevance to the Risk of Cystic Fibrosis–Related Diabetes

The clinical relevance of fasting and post-prandial hypoglycemia in patients with cystic fibrosis (CF) is poorly characterized. Our aim was to characterize the prevalence of hypoglycemia in adult patients during oral glucose tolerance test (OGTT) screening and determine its impact on the risk of developing CF-related diabetes (CFRD).

Beyond Glycated Hemoglobin: Harnessing Data From Sensor-Based Technology to Improve Glucose Variability, Time in Range and Hypoglycemia in Adult Patients With Type 1 Diabetes

Glycated hemoglobin (A1C) has traditionally been the “gold standard” for monitoring patients with type 1 diabetes (T1D), but it may not be the best indicator of glycemic control for individual patients due to a number of limitations. It is well known that A1C may not accurately reflect glycemic control in patients with conditions, such as hemoglobinopathy and anemia. However, even in the absence of these conditions, a given A1C level can be associated with a wide range of mean glucose concentration due to individual variations in red blood cell lifespan and glycation rates (1).

Development and validation of a risk prediction model for severe hypoglycemia in adult patients with type 2 diabetes: a nationwide population-based cohort study.

PurposeThere is a scarcity of long-term prediction models for severe hypoglycemia (SH) in subjects with type 2 diabetes mellitus (T2DM). In this study, a model was developed and validated to predict the risk of SH in adult patients with T2DM.Patients and methodsBaseline and follow-up data from patients with T2DM who received health evaluations from January 1, 2009, to December 31, 2010 (n=1,676,885) were analyzed as development (n=1,173,820) and validation (n=503,065) cohorts using the National Health Insurance Database (DB) in Korea. New SH episodes were identified using ICD-10 codes. A Cox proportional hazards regression model and Cox model coefficients were used to derive a risk scoring system, and 14 predictive variables were selected. A risk score nomogram based on the risk prediction model was created to estimate the 1-year risk of SH.ResultsIn the development cohort, a total of 5,325 (0.45%) patients experienced SH episodes during the follow-up period. After multivariable adjustment, older age, female sex, current smoker, drinking, low body mass index, lack of exercise, previous SH events, insulin or multiple oral hypoglycemic agent use, presence of hypertension or chronic kidney disease, longer duration of diabetes, low or high glucose level, and high Charlson Comorbidity Index score were found to be significant risk factors for the development of SH and were incorporated into the risk model. The concordance indices were 0.871 (95% confidence interval, 0.863–0.881) in development cohort and 0.866 (95% CI, 0.856–0.879) in the validation cohort. The calibration plot showed a nearly 45° line, which indicates that this model predicts well an absolute SH event.ConclusionThis 14-variable prediction model for SH events may be a useful tool to identify high-risk patients and guide prevention of SH in adult patients with T2DM.

The Economic Burden of Insulin-Related Hypoglycemia in Adults with Diabetes: An Analysis from the Perspective of the Italian Healthcare System.

IntroductionThe aim of this analysis was to estimate the cost of insulin-related hypoglycemia in adult patients with diabetes in Italy using the Local Impact of Hypoglycemia Tool (LIHT), and to explore the effect of different hypoglycemia rates on budget impact.MethodsDirect costs and healthcare resource utilization were estimated for severe and non-severe hypoglycemic episodes in Italy and applied to the population of adults with type 1 diabetes (T1DM) and type 2 diabetes (T2DM) and their corresponding hypoglycemia episode rates (0.49 severe and 53.3 non-severe episodes per year for T1DM, and 0.09 severe and 9.3 non-severe episodes per year for T2DM). Uncertainty around model inputs was explored through sensitivity and scenario analyses.ResultsThe direct cost of insulin-related hypoglycemia in Italy is estimated at €144.7 million per year, with €65 million attributable to severe episodes and €79.6 million due to non-severe episodes. The total cost of hypoglycemia is approximately 1.7-fold higher for T2DM (€91.7 million) than for T1DM (€53 million). The cost of a hypoglycemic episode ranges from €4.59 for a non-severe event where additional self-monitoring of blood glucose (SMBG) testing is the only cost incurred, to €5790.59 for a severe event that also requires an ambulance, A&E, hospitalization, and a visit to a diabetes specialist. A reduction in hypoglycemia event rates could result in substantial cost savings; for example, a 20% reduction in severe and non-severe hypoglycemia rates could result in a saving of €47,769 per general population of 100,000 people.ConclusionsThe LIHT highlights the substantial economic burden of insulin-related hypoglycemia in Italy, particularly with regards to non-severe hypoglycemia, an aspect of hypoglycemia that is often overlooked. This analysis may aid healthcare decision-making by allowing the costs of insulin therapies or diabetes self-management programs to be balanced with the savings provided by reductions in hypoglycemia.FundingNovo Nordisk, UK.Electronic supplementary materialThe online version of this article (10.1007/s13300-018-0418-0) contains supplementary material, which is available to authorized users.

Reporting Severe Hypoglycemia in Type 1 Diabetes: Facts and Pitfalls.

To describe potential factors influencing reporting of severe hypoglycemia in adult patients with type 1 diabetes and to analyze their effect on reported rates of severe hypoglycemia. Reported rates of severe hypoglycemia defined as need for third party assistance vary between 0.3-3.0 events per patient-year in unselected cohorts, corresponding to a yearly prevalence range of 10-53%. When defined as need for parenteral therapy with glucose or glucagon or need for admission to an emergency unit or hospitalization, incidence and prevalence rates of severe hypoglycemia are 0.02-0.5 events per patient-year and 1-29%, respectively. When subjects with recurrent severe hypoglycemia in the past or suffering from impaired hypoglycemia awareness are excluded from participation in studies, lower rates are reported. Studies applying anonymous reporting or reporting by partners report higher rates of severe hypoglycemia. There is a large variation between studies reporting incidence and prevalence of severe hypoglycemia in patients with type 1 diabetes, mainly explained by definition of severity, methods of reporting, and patient selection. These findings call for consensus about hypoglycemia definition and reporting in future research.

Treatment of Hypoglycemia in Adult Patients with Type 1 Diabetes: An Observational Study

1) To characterize the nutritional treatment of hypoglycemia in adult patients with type 1 diabetes mellitus and 2) to compare the characteristics of participants who follow the recommendations with the characteristics of those who do not. A total of 121 adults with type 1 diabetes were included in this cross-sectional analysis. Participants completed a food record and a glycemia and insulin doses logbook to collect data on mild to moderate hypoglycemic events (glycemia <4.0 mmol/L or 4.0 to 5.0 mmol/L with symptoms) and their treatments over a 2-day period. Participants were identified as overcorrecting if they consumed, within 15 minutes after the episode, >20g of carbohydrates for correction. Self-administered questionnaires about fear of hypoglycemia were completed, and cardiometabolic profile variables were measured (glycated hemoglobin, blood pressure, lipid profile and body mass indexes). Of the 121 participants, 94 (78%) reported at least 1 hypoglycemic event, for a total of 271 events (2.2±2.1 episodes per patient). Of these events, 64% were treated within 15 minutes, and they were treated primarily with fruit juice or sweet beverages (39%) or mixed snacks (29%). Average carbohydrate intake for treatment was 32±24 grams. Of the participants, 73% overtreated their episodes. They were significantly younger and had greater fear of hypoglycemia than those who treated the episodes adequately. No difference was observed for cardiometabolic variables. The majority of patients in our cohort overtreated their hypoglycemic episodes. These results suggest that hypoglycemia-correction education needs to be reinforced.

Variability in the Treatment of Prehospital Hypoglycemia: A Structured Review of EMS Protocols in the United States

Background: In many industries, limiting variability in process has been associated with a reduction in errors. Hypoglycemia is a common prehospital diabetic emergency for which most EMS systems have a treatment protocol. Objective: To examine the treatment variability for prehospital hypoglycemia within EMS protocols in the U.S. Methods: EMS protocols were reviewed in a structured fashion from 2 sources: the website www.emsprotocols.org and through manual identification from the 50 largest populated cities in the U.S. Data was abstracted by trained investigators regarding the concentration of glucose recommended for the parenteral reversal of hypoglycemia, clinical treatment thresholds, dose recommendations, follow-up care, and non-transport policies. Descriptive statistics were used to summarize the findings. We also reviewed these EMS protocols for the protocol's effective date, the presence of a specific hypoglycemia patient non-transport policy, the use of dilutions of hypertonic dextrose for pediatric patients, glucagon use, and CBG or GCS for patient follow-up. Results: Protocols were retrieved from 185 EMS agencies of a variety of sizes across the U.S. Seventy percent specified only D50 for the treatment of hypoglycemia in adult patients, 8% only D10, and 22% either D10 or D50. Most protocols (85%), which used D50, specified concentration dilutions for pediatric patients. The most frequently specified initial dose of glucose was 25 g of glucose for adults (73–78%), 0.5 g/kg for pediatric (70%), and 0.5 g/kg for neonates (45%). The median blood glucose level threshold for treatment was 60 mg/dl for patients of all ages, but the mean treatment threshold levels for adults, pediatric patients and neonates were statistically different (p < 0.0001). Nearly all protocols (97%) allowed for the use of glucagon in the absence of vascular access. Patient follow up with a repeat CBG was recommended in 32%, both CBG and GCS in 31%, GCS only in 4%, and no follow-up was specified in 33% of the protocols. A specific policy permitting the non-transport of select patients whose hypoglycemia had been corrected was noted in slightly less than half (49%) of the protocols. Conclusions: In the U.S., EMS protocols for the treatment of hypoglycemia vary significantly. Further studies are warranted to determine the factors underlying this variability and effects on patient outcomes.

Predictors of glycemic control and diabetes-related costs among type 2 diabetes patients initiating therapy with liraglutide in the United States

Objective:Liraglutide has been shown to significantly improve glycemic control and reduce body weight while minimizing the risk of hypoglycemia in adult patients with type 2 diabetes (T2D). This study aimed to identify characteristics that predict clinical and economic outcomes associated with liraglutide therapy in clinical practice in the US.Methods:Using the Truven Health MarketScan Laboratory Database, glycemic control (A1C <7%) and diabetes-related costs were evaluated in T2D patients initiating liraglutide between January 1, 2010 and June 30, 2012. Patients were required to have ≥1 post-index claim for liraglutide and A1C values at baseline and 6 months follow-up. All valid values of baseline A1C were included. Patients previously treated with GLP-1 receptor agonist(s) or insulin, or with evidence of type 1 diabetes, pregnancy, or gestational diabetes during the study period were excluded. Multivariable regression models were used to identify predictors of glycemic control and diabetes-related costs.Results:Of 417 patients newly treated with liraglutide, 54.0% achieved glycemic control (A1C <7%) during follow-up. Factors associated with increased odds of glycemic control during follow-up were: being female, POS/EPO health plan type, baseline A1C, early liraglutide initiation (0–1 prior oral anti diabetics [OADs] vs ≥2), adherence to liraglutide (defined as the proportion of days covered [PDC]), and diabetic retinopathy. Being female, earlier liraglutide initiation (0–1 prior OADs), and higher patient share of liraglutide costs were associated with significantly lower diabetes-related costs during follow-up. Factors associated with significantly higher post-index diabetes-related costs were: higher baseline A1C, baseline use of sulfonylureas, and diabetic retinopathy.Conclusions:Within this commercially-insured population of T2D patients treated with liraglutide, gender, baseline A1C, early liraglutide initiation (0–1 prior OADs), diabetic retinopathy, better adherence, and patient share of liraglutide costs were associated with increased odds of achieving glycemic control and the odds of having higher or lower diabetes-related costs.

Vildagliptin: the evidence for its place in the treatment of type 2 diabetes mellitus

Vildagliptin: the evidence for its place in the treatment of type 2 diabetes mellitus Louise Profit, Paul Chrisp, Carole NadinCore Medical Publishing, Knutsford, UKIntroduction: Type 2 diabetes is increasing in prevalence worldwide and is a leading cause of morbidity and mortality, mainly due to the development of complications. Vildagliptin is an inhibitor of dipeptidyl peptidase 4 (DPP-4), a new class of oral antidiabetic agents.Aims: To evaluate the role of vildagliptin in the management of type 2 diabetes.Evidence review: Clear evidence shows that vildagliptin improves glycemic control (measured by glycosylated hemoglobin and blood glucose levels) more than placebo in adults with type 2 diabetes, either as monotherapy or in combination with metformin. Vildagliptin is as effective as pioglitazone and rosiglitazone, and slightly less effective than metformin, although better tolerated. Further glycemic control is achieved when adding vildagliptin to metformin, pioglitazone, or glimepride. There is evidence that vildagliptin improves beta-cell function and insulin sensitivity. Vildagliptin does not appear to be associated with weight gain or with a higher risk of hypoglycemia than placebo or other commonly used oral antidiabetic agents. Economic evidence is currently lacking.Place in therapy: Vildagliptin improves glycemic control with little if any weight gain or hypoglycemia in adult patients with type 2 diabetes when given alone or in combination with metformin, thiazolidinediones, or sulfonylureas. Since many diabetic patients require combination therapy, the complementary mechanism of action of vildagliptin and other commonly prescribed antidiabetic drugs represents an important new therapeutic option in diabetes management.Key words: dipeptidyl peptidase IV (dipeptidyl peptidase 4) inhibition, glycemic control, LAF 237, type 2 diabetes, vildagliptin