Insulin Dose Adjustment Research Articles

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes.

Optimal glycaemic control before and during pregnancy improves both maternal and fetal outcomes. This article summarizes the recently published guidelines on the management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units produced by the Joint British Diabetes Societies for Inpatient Care and available in full at www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. Hyperglycaemia following steroid administration can be managed by variable rate intravenous insulin infusion (VRIII) or continuous subcutaneous insulin infusion (CSII) in women who are willing and able to safely self-manage insulin dose adjustment. All women with diabetes should have capillary blood glucose (CBG) measured hourly once they are in established labour. Those who are found to be higher than 7mmol/l on two consecutive occasions should be started on VRIII. If general anaesthesia is used, CBG should be monitored every 30min in the theatre. Both the VRIII and CSII rate should be reduced by at least 50% once the placenta is delivered. The insulin dose needed after delivery in insulin-treated Type 2 and Type 1 diabetes is usually 25% less than the doses needed at the end of first trimester. Additional snacks may be needed after delivery especially if breastfeeding. Stop all anti-diabetes medications after delivery in gestational diabetes. Continue to monitor CBG before and 1h after meals for up to 24h after delivery to pick up any pre-existing diabetes or new-onset diabetes in pregnancy. Women with Type 2 diabetes on oral treatment can continue to take metformin after birth.

Benefits of Use of Professional CGM in Low Socioeconomic Population

Introduction: Self-monitoring blood glucose (BG) using a glucometer is the standard of care for patients with diabetes. However, up to 67% of patients fail to routinely monitor BG, which is one of the major challenges to optimize glycemic management. With an emergence of technology, continuous glucose monitoring devices (CGM) are now used by many patients for guiding therapeutic changes. However, such technology is not always available in low socioeconomic areas. Objective: To examine the ability of professional CGM for guiding therapeutic changes in a population with limited access to technology to improve glycemic control as measured by A1c, patient glucometer data, hypoglycemia events, and total daily insulin requirements before and after the testing period. Method: Professional CGM (Freestyle Libre Pro) was placed for 10-14 days in 19 patients age ≥ 18 years (mean age 47.6 years +/-19.6 SD, 58.42% female) with T1DM or T2DM on insulin therapy. CGM data was downloaded after the testing period, glucose results were retrospectively reviewed with the patient, and insulin dose adjustments were made. Results: 66% of patients showed improvement in A1c with a median decrease of 0.8%. Mean A1c pre 9.2 and post 8.77 with the p value=0.13 Fewer hypoglycemic episodes and higher total daily use of insulin are noted in the post-CGM period. 7 episodes of severe hypoglycemic before and none following CGM use. There was an increase in the mean dose of insulin from 51.79 units to 56.93 units, p=0.14 post CGM. Statistically significant decrease in episodes of hyperglycemia Post CGM (Pre 11.66 to Post 4.18, p=0.03). Conclusion: Professional CGM is useful for improving glycemic control in a low socioeconomic population with limited access to current technology. Despite a relatively small sample size, our study showed that there was an improvement in HbA1c and the decrease in the number of episodes of hyperglycemia and hypoglycemia after CGM placement. Disclosure S. Hashmi: None. S. Mon: None.

Comparison of Different Self-Adjustment Regimens of Basal Insulin in Outpatients with T2DM

Self-adjustment of basal insulin dose were proved to be effective and widely used in clinical practice. However, no study compares the efficacy and safety of different self-adjustment regimens of basal insulin in T2DM. T2DM with inadequate glucose control on OADs who were to start basal insulin from our outpatient clinics were enrolled and randomized to two groups. Patients in Group A were guided to adjust insulin dose 2-6U weekly; those in Group B adjusted insulin dose 2-3U every 3 days. Dose titration was based on self-monitored blood glucose (SMBG) to achieve a target FBG of 6.1mmol/L. The titration regimen is shown in Table. A total of 648 patients aged 53.9 years old finished the 12-week visits. The baseline characteristics were even between groups. The FBG achieving rates were similar between Group A (75.7%) and Group B (74.4%). Compared with baseline, FBG and HbA1c decreased in both groups (FBG:10.7mmol/L vs. 6.6mmol/L in Group A, 10.8mmol/L vs. 6.5mmol/L in Group B; HbA1c:9.3% vs. 6.9% in group A, 9.5% vs. 6.8% in Group B, respectively, All P<0.001). The reduction of FBG (-4.1mmol/L vs. -4.2mmol/L) and HbA1c (-2.4% vs. -2.7%) were similar between groups, so as the hypoglycemic incidences (17.9% vs. 20.1%). The frequency of SMBG was higher in Group B (5.21 times/week vs. 4.69 times/week, p=0.02). In conclusion, both self-adjustment regimens in this study are effective and safe in T2DM.Table. Insulin Titration Protocol.Fasting blood glucose(mmol/L)Dose adjustment (U)Group AGroup B<4.4-2U-2∼3U4.4-6.1No changeNo change6.2-7.8+2U+2∼3U7.9-9.9+4U+2∼3U>10.0+6U+2∼3U Disclosure X. Hu: None. X. Yang: None. W. Xu: None. H.R. Deng: None. X. Guo: None. B. Yao: None. L. Zeng: None. J. Weng: None.

Use of Continuous Glucose Monitoring Data for Defining Glucose Control in Insulin-Treated Patients

Glycated haemoglobin (HbA1c) and self-monitoring of blood glucose (SMBG) are usually used to define glucose control in diabetic patients, but in many cases they are insufficient to present overall control. Continuous Glucose Monitoring (CGM) is used for adjustment of insulin doses but derived data could help to define glucose control. We assess the use of CGM data for defining control in subgroup of patients treated with insulin. We studied 75 diabetic patients (43 men, 32 women; age 55.23±8.99 years, disease duration 12.84±7.02 years) - 33 with type 2 diabetes on pre-mixed insulin, 21 with type 2 on multiple insulin injection (MII), 21 with type 1 on MMI. Patients did multiple daily blood glucose measurements of fasting and prandial blood glucose for three month period. HbA1c was measured and CGM by using iProTM for seven days was performed at the end of this period. Based on HbA1c assessment 36.36% of patients on premixed insulin, 19.05% of type 2 patients on MII and 9.52% of type 1 patients on MII were with good control. After estimation of results from SMBG these percentage were respectively 28.14%, 12.11%, 4.51%. CGM defined 27.27% of patients on premixed insulin, 23.80% of type 2 patients on MII and 2.38% of type 1 patients on MII as well controlled. In addition CGM gave information about insulin excursion - they were with no significant difference in the three groups (17.09±7.01, p=0.231). CGM was more informative than SMBG in presenting hypoglycemic episode (p=0.01) including night hypoglycemia and especially their duration (p=0.001). No difference was found in different groups with no dependence on type of diabetes or insulin regimen. Nevertheless of short observed period CGM data could give much information about overall glucose control that is comparable to three month blood glucose measurement and are better than other methods in estimating hypoglycemic episodes. Performing of CGM should be included in recommendations for assessment of glucose control. Disclosure T. Totomirova: None. I. Daskalova: None. M. Arnaudova: None.

Effect of Remote Glucose Monitoring Utilizing Computerized Insulin Dose Adjustment Algorithms on A1C Levels—A Preliminary Report

Adjusting insulin doses is very challenging for primary care physicians because of infrequent office visits and time constraints at the visit. For patients, frequent office visits are a barrier. We have used FDA-approved, computerized insulin dose adjustment algorithms and remote glucose monitoring to circumvent both of these issues. Diabetic patients in a safety net clinic who took insulin for at least 6 months with A1C levels ?8.0% were enrolled in a study in which an iHealth glucose meter was attached to a smartphone containing an app downloaded from the Web that transmitted the glucose values to a secure, HIPAA-approved server. There the values were analyzed by the algorithms and a report with recommendations for dose changes was generated and sent to a clinic nurse practitioner every 2-3 weeks who could accept or modify the recommendations. A clinic staff individual contacted the patient with the insulin dose changes. Twenty-eight diabetic patients (one type 1) have reached 3 months. Their mean age (± SD) was 55.9 ± 8.6 years, 15 were females and 13 were males. There were 20 Latinos, 4 African-Americans, 3 Caucasians, and 1 Asian. Their insulin regimens were: basal alone - 11, basal/bolus - 14 and self-mixed/split - 3. Non-insulin drugs were not changed. Their baseline A1C levels (± SD) of 10.0% ± 1.2 decreased by 1.9% ± 0.9 to 8.1% ± 1.1 after 3 months. Their total insulin dose increased by 24%. There were no episodes of severe hypoglycemia (requiring 2nd party assistance) nor emergency room visits for hypoglycemia. Conclusion: Remote glucose monitoring utilizing computerized insulin dose adjustment algorithms to analyze glucose values and generating recommendations for dose changes at more frequent intervals markedly improved A1C levels in poorly controlled diabetic patients in the absence of office visits. Disclosure M.B. Davidson: Employee; Self; Insulin Algorithms, Inc. J. Davidson: Employee; Self; Insulin Algorithms.

Adults with T1D Report Half-Unit Pen Prevents Hyperglycemia and Hypoglycemia with Less Worry and Anxiety

People with type 1 diabetes (PWD) that strive for lower glucose targets are in need of more precise dosing and may require smaller insulin dose adjustments. Most currently available pens deliver insulin in one unit (U) increments, and few deliver half (0.5) U. There is a need to better understand who is using half unit pens (HUP) and their potential benefit for patients in the real world. This study aims to characterize PWD who have used (current/former=EVER users) HUP vs. those PWD that have never used HUP (NEVER users). This research also identified the main factors driving benefit from PWD perspective. An observational, cross-sectional survey was completed through T1D Exchange’s online patient community, myGlu.org. Chi square test, Fisher’s exact test, and t-tests were used for analyses. A total of 278 PWD (156 EVER, 122 NEVER users) over the age of 18 were recruited for the study (mean age: 42±13 years old, gender: 55% male, mean BMI (kg/m2): 26.0 ±3.8, and mean A1c (%): 6.3± 0.9), EVER users had diabetes a shorter duration (p<.001). NEVER users were more likely to use an insulin pump (p<.001). EVER users self-reported a significantly lower upper fasting glucose target compared to NEVER users (p<.001), and a lower overall post-prandial glucose target (p<.001). NEVER users were more likely to start to treat low blood sugar at lower readings (p<.001), and they were more confident in avoiding severe hypoglycemia (p<.001). Based on PWD experience, the greatest benefits of using HUP were prevention of hypo and hyperglycemia events and less worry and anxiety. HUP is an option for PWD that wish to maintain tighter management of their diabetes, avoiding hypo and hyperglycemic events while decreasing their level of worry and anxiety about their disease. It is important for PWD and health care providers to understand the benefits of this insulin delivery device to appreciate options for making diabetes management easier. Disclosure C. Piras de Oliveira: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. B. Mitchell: Stock/Shareholder; Spouse/Partner; Eli Lilly and Company. L. Fan: Employee; Self; Eli Lilly and Company. C. Garey: None. B. Liao: Employee; Self; Eli Lilly and Company. J. Bispham: None. N. Vint: Employee; Self; Eli Lilly and Company. M. Perez-Nieves: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. A.H. McAuliffe-Fogarty: Advisory Panel; Self; Novo Nordisk Inc..

Evaluation of a New Protocol of Insulin Dose Adjustment in a Low-Resource Setting

Glycemic control (GC) is difficult to achieve in settings where only NPH, R and pre-mixed insulins are available, test strips are scarce, and food insecurity is common. We evaluated the impact of a sliding-scale based insulin adjustment protocol in Haiti. Thirty youth aged 11-28 years with T1D treated with 70/30 Mixtard were randomized to remain on 70/30 (G70, n=15) or switch to self-mixed NPH+R (GNR, n=15). Carbohydrate (CHO) ratio and insulin sensitivity factor were calculated based on total daily insulin dose (TDD), and translated into sliding scales with either insulin correction dose (ICD) only (G70), or the sum of a 60 g CHO meal dose and ICD (GNR). Self-monitored blood glucose (SMBG) and insulin were administered before AM and PM meals. All had bi-monthly visits for 12 weeks. In G70 vs. GNR, age (19.3±4.5 vs. 19.2±5.4 years), sex (40 vs. 53% m), normal BMI (87 vs. 80%), diabetes duration (5.3±4.2 vs. 5.3±4.5 years), and baseline A1c (9.8±2.1 vs. 10.8±2.9%, p=0.27) did not differ. A1c declined to 8.0±1.3% (-1.8%, p<0.006) vs. 8.9±1.2% (-1.9%, p<0.02), p=0.83, without severe acute complication. Skipped meals per week (3.7±2.9 vs. 4.1±3.3), missed SMBG (3.5±3.4 vs. 7.4±7.6%, p=0.07), and increase of TDD (7.7±7.8 vs. 6.6±9.6 units) were similar. Use of sliding scales adjusted for SMBG and meals omission, and frequent clinic visits significantly improved GC in youth with T1D in a low-resource setting, regardless of pre- or self-mixed insulin. Disclosure E. Jean Baptiste: None. P. Larco: None. M. Charles Larco: None. J.E. von Oettingen: None. E. Dubois: None. R. Paul: None. E. Fleury-Milfort: None. R. Charles: None. G.D. Ogle: None.

Insulin Titration Algorithms Incorporated into a Patient Glucose Diary Result in Significant Improvements in Glucose Profiles and A1C

A 44-week, multinational RCT compared efficacy, safety, and subject preference for bolus insulin initiation using a wearable bolus insulin delivery patch (Patch, Calibra Medical) vs. an insulin pen (Pen, NovoLog FlexPen®) in 278 T2D subjects on basal insulin (0.52 U/kg) (A1C: mean ± SD, 8.7% ± 1.0, BMI: 32.6 kg/m2, duration: 15 y), using insulin titration algorithms incorporated into a patient diary. At randomization, basal insulin dose was divided 1:1, basal:bolus. Subjects used SMBG patterns weekly to adjust insulin doses. The diary also included algorithms for adjusting bolus insulin at each meal if SMBG was above or below target and if meal size was larger or smaller than usual. At 44 weeks there was significant (p<.0001) improvement in A1C with both Patch (mean ± SD 7.0% ± 0.1) and Pen (7.0% ± 0.1). In addition, 7-point SMBG profiles improved dramatically from baseline to Week 44, showing improved fasting glucose and near-normal post-meal values using this set of algorithms (Fig). Total insulin doses increased (Patch: 1.33 U/kg; Pen: 1.38 U/kg), with a basal:bolus ratio of 40:60 in both groups. There was a low incidence of adverse events and hypoglycemia with no difference between groups. In summary, by making weekly insulin adjustments based on simple algorithms embedded in a patient glucose diary, T2D subjects can significantly improve A1C values and 7-point glucose profiles. Disclosure M.L. Johnson: Research Support; Self; Calibra Medical, Medtronic, Sanofi, Novo Nordisk Inc., Abbott, POPS! Diabetes Care, National Institute of Diabetes and Digestive and Kidney Diseases, Dexcom, Inc., Hygieia, JDRF. D.M. Dreon: Employee; Self; Calibra Medical. B.L. Levy: Employee; Self; LifeScan, Inc. R.M. Bergenstal: Research Support; Self; Johnson & Johnson Services, Inc.. Consultant; Self; Johnson & Johnson Services, Inc.. Research Support; Self; Abbott. Advisory Panel; Self; Abbott. Research Support; Self; Becton, Dickinson and Company. Consultant; Self; Becton, Dickinson and Company. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., AstraZeneca, Takeda Pharmaceuticals U.S.A., Inc., Dexcom, Inc.. Stock/Shareholder; Self; Merck & Co., Inc.. Research Support; Self; Eli Lilly and Company, Sanofi. Advisory Panel; Self; Sanofi, Roche Pharma. Research Support; Self; Novo Nordisk Inc.. Advisory Panel; Self; Novo Nordisk Inc.. Research Support; Self; Medtronic. Consultant; Self; Medtronic. Research Support; Self; Hygieia. Advisory Panel; Self; Hygieia, Glooko, Inc.. Research Support; Self; JAEB Center For Health Research, JDRF, National Institute of Diabetes and Digestive and Kidney Diseases.

Intervention of the Flash Glucose Sensing Technology on Glycemic Control and Treatment Satisfaction in Patients with Type 2 Diabetes Treated Intensively by Insulin—A Randomized Controlled Trial

Objective: To determine the satisfaction from treatment and effectiveness of flash glucose monitoring system (FGM) in patients with type 2 diabetes. Design and Methods: 101 individuals with type 2 diabetes on multiple daily insulin injection (MDI) therapy for ≥1 year (mean duration 21.81±7.65 years) and HbA1c 7.4-10.2% (57-88 mmol/mol) were randomized to the intervention (n=53) or the standard care group (n=48). Those in the intervention group were instructed to use FGM and once a week 7-points BG assessment to confirm any a symptomatic hypoglycemia. The control group continued the routine BG measurement as before the study and add once a week 7-points BG measurement at constant day. For 12 weeks, both groups were instructed to adjust insulin dose in the frequent face-to-face and telephone visits. Satisfaction from treatment, quality of life, comfort using FGM, HbA1c and hypoglycemia events were evaluated. Results: The mean age was 66.75 ± 7.55; 64.35% were male. Total treatment satisfaction increased in the intervention group (p=0.053). At the 12 week of the study, subjects in the intervention group found treatment significantly more flexible (p=0.019), convenient (p=0.052), and would recommend it more to their counterparts (p=0.023). The mean HbA1c was 8.51 ± 0.81%. After 10 weeks, HbA1c changes were -0.82% in the intervention group and -0.29% in the control (p=0.0013). 67.9% subjects from the intervention study and 27.1% from the control group reduced HbA1c ≥0.5% HbA1c (p<0.001); and 39.6% subjects from the intervention and 16.7% from the control group reduced HbA1c≥1.0% (p=0.0076) without increasing frequency of hypoglycemia. Conclusion: FGM potentially produces a modification of behavior/life style and improves treatment satisfaction. It improves glycemic control in subjects with type 2 diabetes treated by MDI without increased frequency of hypoglycemia. Disclosure M. Yaron: None. E. Roitman: Speaker's Bureau; Self; Merck Sharp & Dohme Corp., Novo Nordisk A/S, Sanofi. Advisory Panel; Self; Sanofi. Speaker's Bureau; Self; AstraZeneca. Advisory Panel; Self; AstraZeneca. Speaker's Bureau; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Consultant; Self; GlucoMe. Stock/Shareholder; Self; GlucoMe. G. Aharon-Hananel: None. Z. Landau: None. T. Ganz: None. M. Karp: None. M. Ish-Shalom: None. J. Singer: None. J. Wainstein: None. I. Raz: Advisory Panel; Self; AstraZeneca. Consultant; Self; AstraZeneca. Speaker's Bureau; Self; AstraZeneca. Advisory Panel; Self; Boehringer Ingelheim GmbH. Speaker's Bureau; Self; Boehringer Ingelheim GmbH. Advisory Panel; Self; Eli Lilly and Company. Speaker's Bureau; Self; Eli Lilly and Company. Stock/Shareholder; Self; DarioHealth. Advisory Panel; Self; Merck Sharp & Dohme Corp., Novo Nordisk Inc.. Speaker's Bureau; Self; Novo Nordisk Inc.. Advisory Panel; Self; Orgenesis Inc., Pfizer Inc., Sanofi R&D, SmartZyme Biopharma. Consultant; Self; Bristol-Myers Squibb Company. Speaker's Bureau; Self; Bristol-Myers Squibb Company, Johnson & Johnson Diabetes Institute, LLC., Merck Sharp & Dohme Corp., Novartis Pharma K.K., Sanofi-Aventis. Consultant; Self; FuturRx Ltd, Insuline Medical,Camereyes Ltd, Exscopia, Medial EarlySign Ltd. Stock/Shareholder; Self; Glucome Ltd, InsuLine Medical Ltd.. Consultant; Self; Dermal Biomics Inc. Stock/Shareholder; Self; Orgenesis Inc.. Speaker's Bureau; Self; Teva Pharmaceutical Industries Ltd.. Advisory Panel; Self; Concenter BioPharma/Silkim Ltd, Camereyes Ltd. Stock/Shareholder; Self; CameraEyes Ltd. Advisory Panel; Self; Breath of Life PharmaLtd, Panaxia.

A novel approach to basal-bolus insulin initiation in adults with newly diagnosed type 1 diabetes: an observational cohort study of a service redesign

Aims: The National Institute for Health and Care Excellence (NICE) recommendation for insulin in newly diagnosed type 1 diabetes is a ‘basal-bolus’ regimen of prandial insulin with twice-daily basal insulin initiated at diagnosis. We developed an insulin initiation programme that embraces the contribution of endogenous insulin to glycaemic control in adults newly diagnosed with type 1 diabetes. Our aim was to embed carbohydrate counting skills and dose adjustment very early on to mitigate against the decline in glycaemic control that is commonly seen post honeymoon.Methods: We designed a novel insulin initiation programme that focused initially on prandial insulin replacement using the lowest possible dose of basal insulin. The approach also facilitates carbohydrate counting and bolus insulin dose adjustment behaviours from diagnosis.Results: Prior to implementing the new programme, the mean HbA1c at 12 months was 64 mmol/mol (8.0%) (95% CI 60 to 69 (7.6% to 8.4%)). This reduced to 55 mmol/mol (7.1%) (95% CI 51 to 58 (6.9% to 7.4%)), p<0.001 with the new programme. The improved HbA1c persisted to 3 years of follow-up (p<0.001). There were no episodes of diabetic ketoacidosis or severe hypoglycaemia associated with this novel approach.Conclusions: We suggest that using minimal basal insulin and focusing on prandial bolus insulin replacement in adults newly diagnosed with type 1 diabetes is safe, more physiological and may be better able to achieve lasting glycaemic control than the currently proposed national guidelines. This approach will need to be tested formally in an adequately designed randomised controlled clinical trial.

Performance of a 2-step insulin infusion protocol with adjustment of insulin doses for Asians in the medical intensive care unit following cardiothoracic surgery

Most previous insulin infusion protocols are titrated for Westerners and are not simple to follow. In this study, we tested the efficacy and safety of our simple insulin infusion protocol utilizing lower insulin doses for Asians. A total of 152 patients with type 2 diabetes undergoing cardiothoracic surgery were included. After surgery, blood glucose (BG) was initially managed according to our algorithm protocol, and subsequently by the post-algorithm protocol. Insulin infusion rates in the algorithm protocol were titrated in two steps according to (1) current BG levels and (2) the difference between current and previous BG levels. In the post-algorithm protocol, insulin lispro was injected subcutaneously in addition to intravenous insulin infusion according to BG levels. The efficacy was assessed as achievement rates of two target BG ranges (140-199 and 80-199mg/dL), and safety was assessed as hypoglycemia (< 70mg/dL) and protocol error rates. With the use of the algorithm protocol, 58.7% of 1749 BG measurements achieved a range of 140-199mg/dL, and 95.9% achieved levels within the 80-199mg/dL range. Hypoglycemia and protocol error rates were 0.47 and 0.51%, respectively. With the post-algorithm protocol, 48.7 and 98.3% of 898 BG measurements achieved each target range. Hypoglycemia and protocol error rates were 0.78 and 0.22%, respectively. Severe hypoglycemia (< 40mg/dL) was not observed. Our insulin infusion protocol seems to be efficacious, safe, and widely feasible for Asian patients because of its simplicity and lower insulin dose.

The impact of cognitive impairment in dementia on self-care domains in diabetes: A systematic search and narrative review.

Self-management is integral to effective chronic disease management. Cognitive impairments (CogImp) associated with dementia have not previously been reviewed in diabetes mellitus (DM) self-care. The aims of this study are to know (1) whether CogImp associated with dementia impact self-care and (2) whether specific CogImp affects key DM self-care processes. A systematic literature search with a narrative review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This review examined studies published from January, 2000 to February, 2016 describing the relationship between cognition and DM self-care domains in community dwelling older adults with dementia/CogImp. Eight studies met inclusion criteria. Decrements in all self-care domains were associated with CogImp. Problem solving was related to reduced disease knowledge (OR 0.87, 95% CI=0.49-1.55), resulting in poorer glycemic control. Decision-making impairments manifested as difficulties in adjusting insulin doses, leading to more hospital admissions. People without CogImp were better able to find/utilize resources by adhering to recommended management (OR 1.03, 95% CI=1.02-1.05). A lack of interaction with health care providers was demonstrated through reduced receipt of important routine investigation including eye examinations (ARR=0.85, 95% CI=0.85-0.86), HbA1c testing (ARR=0.96, 95% CI=0.96-0.97), and LDL-C testing (ARR=0.91, 95% CI=0.901-0.914). People without CogImp had better clinic attendance (OR 2.17, 95% CI=1.30-3.70). Action taking deficits were apparent through less self-testing of blood sugar levels (20.2% vs 24.4%, P=0.1) resulting in poorer glycemic control, self-care, and more frequent micro/macrovascular complications. Persons with diabetes and CogImp, particularly in domains of learning, memory and executive function, were significantly impaired in all self-care tasks.

Glycemic impact of intensified self monitoring of blood glucose in insulin treated subjects with type 2 diabetes mellitus

Objective:The aim of this study was to evaluate if intensified self-monitoring of blood glucose (SMBG) improves glycemic control in insulin-treated subjects with type 2 diabetes mellitus (T2DM). Methods:Ninety-six adults with stable but poorly controlled [glycated hemoglobin (HbA1c) level &gt;7.5%] T2DM receiving twice-daily biphasic insulin were randomly assigned to either of the two groups: intensive monitors (IM) that performed SMBG at least twice daily or conventional monitors (CM) that performed SMBG at their discretionary frequency for 12 weeks. Demographic, clinical, and glycemic indices, including fasting blood glucose (FBG), postprandial glucose (PPG), and HbA1c, were compared at baseline and week 12. Results:A total of 71 subjects (25 IM and 46 CM) completed the study. Both groups had similar HbA1c at baseline. From baseline to week 12, the IM group had higher mean daily test strip usage (P &lt;0.001), engaged in more frequent insulin dose adjustments (P &lt;0.001), and attained greater daily insulin dosage (P = 0.002). All glycemic indices including FBG, PPG, and HbA1c improved significantly from baseline to week 12 in the IM but not in the CM group. HbA1c level declined by −1.2 ±0.4% in the IM group (P = 0.002). There was no difference in the frequency of hypoglycemia in both groups. The monthly cost of intensified SMBG was nearly four times that of conventional monitoring (P &lt;0.001). Conclusion:Both short- and long-term glycemic control significantly improved by intensified SMBG in stable but poorly controlled insulin-treated adults with T2DM. Intensified SMBG enabled better self-titration of insulin and probably other self-care practices. This benefit, however, occurred at the expense of costs that may be difficult to sustain in resource-poor countries.

Insulin therapy for type 2 diabetes \u2013 are we there yet? The d-Nav\xae story

Insulin replacement therapy is mostly used by patients with type 2 diabetes who become insulin deficient and have failed other therapeutic options. They comprise about a quarter of those with diabetes, endures the majority of the complications and consumes the majority of the resources. Adequate insulin replacement therapy can prevent complications and reduce expenses, as long as therapy goals are achieved and maintained. Sadly, these therapy goals are seldom achieved and outcomes have not improved for decades despite advances in pharmacotherapy and technology.There is a growing recognition that the low success rate of insulin therapy results from intra-individual and inter-individual variations in insulin requirements. Total insulin requirements per day vary considerably between patients and constantly change without achieving a steady state. Thus, the key element in effective insulin therapy is unremitting and frequent dosage adjustments that can overcome those dynamics. In practice, insulin adjustments are done sporadically during outpatient clinic. Due to time constraints, providers are not able to deliver appropriate insulin dosage optimization.The d-Nav® Insulin Guidance Service has been developed to provide appropriate insulinization in insulin users without increasing the burden on healthcare systems. It relies on dedicated clinicians and a spectrum of technological solutions. Patients are provided with a handheld device called d-Nav® which advises them what dose of insulin to administer during each injection and automatically adjust insulin dosage when needed. The d-Nav care specialists periodically follow-up with users through telephone calls and in-person consultations to bestow user confidence, correct usage errors, triage, and identify uncharacteristic clinical courses.The following review provide details about the service and its clinical outcomes.

Adjunctive therapy for glucose control in patients with type 1 diabetes.

Type 1 diabetes mellitus (T1DM) is characterized by relative or absolute insulin deficiency. Despite treatment with insulin therapy, glycemic goals are not always met, and insulin therapy is sometimes limited by adverse effects, including hypoglycemia and weight gain. Several adjunctive therapies have been evaluated in combination with insulin in patients with T1DM to improve glycemic control while minimizing adverse effects. Pramlintide, an amylin analog, can improve glycemic control, primarily through lowering postprandial blood glucose levels. Patients may experience weight loss and an increased risk of hypoglycemia and require additional mealtime injections. Metformin provides an inexpensive, oral treatment option and may reduce blood glucose, especially in overweight or obese patients with minimal risk of hypoglycemia. Metformin may be more effective in patients with impaired insulin sensitivity. Glucagon-like peptide-1 receptor agonists reduce primarily postprandial blood glucose and insulin dose and promote weight loss. They are expensive, cause transient nausea, may increase risk of hypoglycemia and require additional injections. Sodium–glucose transport-2 inhibitors improve glycemic control, promote weight loss and have low risk of hypoglycemia with appropriate insulin adjustment; however, these agents may increase the risk of diabetic ketoacidosis in patients with T1DM. Patient-specific characteristics should be considered when selecting adjunctive therapy for patients with T1DM. Close monitoring, insulin dose adjustments and patient education are all important to ensure safe and effective use of these agents.

Cost-effectiveness of insulin pumps compared with multiple daily injections both provided with structured education for adults with type 1 diabetes: a health economic analysis of the Relative Effectiveness of Pumps over Structured Education (REPOSE) randomised controlled trial

ObjectivesTo assess the long-term cost-effectiveness of insulin pumps and Dose Adjustment for Normal Eating (pumps+DAFNE) compared with multiple daily insulin injections and DAFNE (MDI+DAFNE) for adults with type 1 diabetes...

Type 1 Diabetes in Children and Adolescents.

Type 1 Diabetes in Children and Adolescents.

Continuous Glucose Monitoring in Pregnant Women With Type 1 Diabetes (CONCEPTT): A Multicenter International Randomised Controlled Trial

(Abstracted from Lancet 2017;390:2347–2359) It is established that optimal maternal glycemic control throughout pregnancy is associated with a decrease in adverse fetal outcomes. A proper glycemic index can be difficult to control in women with type 1 diabetes during pregnancy because of the complexity of insulin dose adjustment, gestational changes in insulin sensitivity, and day-to-day changes to insulin absorption in late pregnancy. Nationwide UK data show the rates of severe hypoglycemia, particularly in early pregnancy, are 5 times higher among pregnant women than nonpregnant and that only 40% of women with type 1 diabetes achieve target glycated hemoglobin (HbA1c) after 24 weeks of gestation. Continuous glucose monitoring (CGM) provides real-time quantitative information on the direction and rate of change of glucose levels.

Flash forward: a review of flash glucose monitoring.

The FreeStyle Libre flash glucose monitor became available on prescription (subject to local health authority approval) in all four nations of the UK from November 2017, a watershed moment in the history of diabetes care. Calibration free, the FreeStyle Libre is a disc worn on the arm for 14 days which is designed largely to replace the recommended 4-10 painful finger-stick blood glucose tests required each day for the self-management of diabetes. This review discusses clinical data from randomized and observational studies, considers device accuracy metrics and deliberates its popularity and the potential challenges that this new device brings to diabetes care in the UK. In randomized trials, FreeStyle Libre use is associated with a reduction in hypoglycaemia and, in observational studies, improvements in HbA1c levels. User satisfaction is high and adverse events are low. Accuracy of the FreeStyle Libre is comparable to currently available real-time continuous glucose monitors in adults, children and during pregnancy; the cost of the FreeStyle Libre is lower. Glucose data can be visualized in multiple devices and platforms, and summarized in an ambulatory glucose profile to aid pattern recognition and insulin dose adjustment. There is a need for appropriate education, of both users and healthcare professionals, to harness the full benefits. Further randomized studies to assess the long-term impact on HbA1c , particularly in those with high baseline HbA1c and in specific age groups, such as adolescents and young adults, are warranted. The potential impact on complications, is yet to be realized.

Update on insulin treatment of dogs and cats with non-complicated diabetes mellitus

Diabetes mellitus is a common endocrine disease of dogs and cats. Treatment is mainly based on insulin administration and dietary modifications. The aim of this review is to provide updated information on insulin treatment of dogs and cats with non-complicated diabetes mellitus. During the last years, there has been significant progress in the management of this disease, thanks to the use of long-acting insulin preparations that do not cause pronounced fluctuations of blood glucose concentrations (insulin glargin and detemir) and because of the widespread use of home glucose monitoring by the owners of diabetic pets. Home glucose monitoring is based on capillary blood sampling from the ear pinnae or the foot pad and measurement of blood glucose concentration with a portable blood glucose meter. This can be done periodically (e.g. every week) to replace the traditional in-clinic blood glucose curve; in this case, blood glucose concentration is measured just before the morning insulin administration and then every 1-2 hours until the next dose (usually for 12 hours). Furthermore, especially for the cat, home glucose monitoring can be performed 3-5 times per day, on a daily basis, in order to safely adjust insulin dose and achieve tight control of hyperglycemia (i.e. blood glucose concentration between 50 and 200 mg dl-1 throughout the day). The combination of dietary management, of insulin glargine or detemir administration and of the tight control of hyperglycemia has substantially increased the proportion of cats that enter into temporal or permanent diabetic remission and can be further managed without insulin. Another important achievement is the use of continuous glucose monitoring systems to monitor interstitial fluid glucose concentrations. These devices can be used in the clinic and at home and they can measure glucose concentration every 5 minutes for up to 72 consecutive hours, thus facilitating optimal adjustment of insulin treatment.