Lower Glucose Target Research Articles

Technology advances in diabetes pregnancy: right technology, right person, right time.

This review outlines some of the extraordinary recent advances in diabetes technology, which are transforming the management of type 1 diabetes before, during and after pregnancy. It highlights recent improvements associated with use of continuous glucose monitoring (CGM) but acknowledges that neither CGM nor insulin pump therapy are adequate for achieving the pregnancy glucose targets. Furthermore, even hybrid closed-loop (HCL) systems that are clinically effective outside of pregnancy may not confer additional benefits throughout pregnancy. To date, there is only one HCL system, the CamAPS FX, with a strong evidence base for use during pregnancy, suggesting that the pregnancy benefits are HCL system specific. This is in stark contrast to HCL system use outside of pregnancy, where benefits are HCL category specific. The CamAPS FX HCL system has a rapidly adaptive algorithm and lower glucose targets with benefits across all maternal glucose categories, meaning that it is applicable for all women with type 1 diabetes, before and during pregnancy. For women of reproductive years living with type 2 diabetes, the relative merits of using non-insulin pharmacotherapies vs diabetes technology (dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors) are unknown. Despite the urgent unmet need and potential benefits, studies of pharmacotherapy and technology use are extremely limited in pregnant women with type 2 diabetes.

200-OR: Effects of Glucose Target on the Performance of a Bihormonal Bionic Pancreas

We performed a non-blinded, random-order, cross-over study in 20 volunteers with type 1 diabetes comparing glycemic regulation by the bihormonal bionic pancreas (BHBP) at three glucose targets (130, 115, and 100 mg/dl). Subjects went about their daily routines during each 3-day test period. In the BHBP arms, lower glucose targets (130 to 115 to 100 mg/dl) were associated with correspondingly lower mean CGM glucose levels (156±12 to 146±14 to 135±14 mg/dl, p<0.005 for each comparison). There was no corresponding difference in percent time <60 mg/dl (0.6±1.0 % to 0.9±1.2% to 0.8±1.1%, p≥0.22 for each comparison). However, there was a corresponding significant increase in glucagon total daily dose (2.2±1.2 to 5.3±2.3 to 8.3±3.0 µg/kg/day, p≤0.001 for each comparison). Mean daily nausea scores reported on a 10 cm visual analog scale were low and not significantly different between BHBP arms (0.5, 0.8 and 1.1 cm for the 130, 115, and 100 mg/dl glucose targets, respectively, p>0.05 for each comparison). There were no significant differences between the different BHBP arms in average hypoglycemia symptoms per day, average hypoglycemia interventions per day, or average grams of oral carbohydrates taken by subjects to prevent or treat hypoglycemia. The 100 mg/dl glucose target had a higher satisfaction score when compared to the 115 and 130 mg/dl glucose targets (4.3 versus 4.15 and 4.18, respectively; p<0.005 for both comparisons). There was no significant difference in satisfaction score between the 115 and 130 mg/dl glucose targets. The results of the present study show that for the BHBP, the lowest glucose target in this comparison was associated with better glycemic control, no statistically significant increase in side effects, and greater user satisfaction than higher glucose targets. Disclosure M. Tuffaha: None. C.A. Balliro: None. M. Hillard: None. F. El-Khatib: Other Relationship; Self; Beta Bionics, Inc. R. Selagamsetty: Employee; Self; Beta Bionics, Inc. Stock/Shareholder; Self; Beta Bionics, Inc. E. Damiano: Board Member; Self; Beta Bionics, Inc. Employee; Self; Beta Bionics, Inc. Stock/Shareholder; Self; Beta Bionics, Inc. Stock/Shareholder; Spouse/Partner; Beta Bionics, Inc. S.J. Russell: Consultant; Self; Beta Bionics, Inc., ConvaTec Inc., Novo Nordisk A/S, Senseonics. Research Support; Self; Beta Bionics, Inc., Novo Nordisk A/S, Zealand Pharma A/S. Stock/Shareholder; Self; Companion Medical. Other Relationship; Self; Ascensia Diabetes Care, Roche Diabetes Care. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Life after QOF

Life after QOF

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..

Lower Glucose Target Is Associated With Improved 30-Day Mortality in Cardiac and Cardiothoracic Patients

Practice guidelines recommend against intensive insulin therapy in patients who are critically ill based on trials that had high rates of severe hypoglycemia. Intermountain Healthcare uses a computerized IV insulin protocol that allows choice of blood glucose (BG) targets (80-110 vs90-140mg/dL) and has low rates of severe hypoglycemia. We sought to study the effects of BG target on mortality in adult patients in cardiac ICUs that have very low rates of severe hypoglycemia. Critically ill patients receiving IV insulin were treated with either of two BG targets (80-110 vs90-140mg/dL). We created a propensity score for BG target using factors thought to have influenced clinicians' choice, and then we performed a propensity score-adjusted regression analysis for 30-day mortality. There were 1,809 patients who met inclusion criteria. Baseline patient characteristics were similar. Median glucose was lower in the 80-110mg/dL group (104 vs122mg/dL, P< .001). Severe hypoglycemia occurred at very low rates in both groups (1.16% vs 0.35%,P= .051). Unadjusted 30-day mortality was lower in the 80-110mg/dL group (4.3%vs9.2%, P< .001). This remained after propensity score-adjusted regression (OR, 0.65; 95%CI, 0.43-0.98; P= .04). Tight glucose control can be achieved with low rates of severe hypoglycemia and is associated with decreased 30-day mortality in a cohort of largely patients in cardiac ICUs. Although such findings should not be used to guide clinical practice at present, the use of tight glucose control should be reexamined using a protocol that has low rates of severe hypoglycemia.

Management of Hyperglycemia in Acute Ischemic Stroke

There is considerable clinical evidence that hyperglycemia at the onset of acute ischemic stroke may negatively impact not only acute morbidity but also brain recovery. Establishing hyperglycemia treatment protocols is challenging, given the variation among patients and acute stroke care settings. Relatively few randomized trials have examined glycemic control protocols in this population, and there is not yet any clear evidence that "correcting" hyperglycemia in patients with acute stroke leads to better functional outcomes. Intensification of glucose regimens, using lower glucose targets, leads to more hypoglycemic events, but the immediate and long-term impact of these events on the acutely ischemic brain is unknown. It is reasonable to treat patients with acute ischemic stroke according to the American Diabetes Association inpatient glycemic control guidelines, initiating therapy to achieve glucose targets of 140 to 180mg/dL if fasting glucose is greater than 140mg/dL or random glucose is consistently higher than 180mg/dL. Lower glucose targets (<140mg/dL) may be appropriate for patients with well-controlled diabetes and those with stress hyperglycemia who were not known to be diabetic before admission, but glucose levels less than 80mg/dL should be avoided. Patients who present with extreme or persistent hyperglycemia, are critically ill, or who are treated with thrombolytic therapy should be started on an established and standardized intravenous insulin protocol to improve blood glucose control for at least the first 24 to 48h of hospitalization. They should then be transitioned to a subcutaneous insulin regimen that includes basal long-acting insulin along with correction rapid-acting insulin for glucose that is out of range. Prandial (meal) insulin should be added for patients who are eating; this would preferably be a rapid-acting insulin analogue that can be administered immediately before or after the meal. Caution and close glucose monitoring are necessary, especially for patients prone to hypoglycemia, such as those with type 1 diabetes mellitus or hepatic or renal impairment, or those on complicated feeding regimens.