The present investigation provides evidence that SAP with LGS reduces the frequency of hypoglycemia without compromising safety.

Key words: autonomic nervous system, cardiovascular disease risk, diabetes mellitus, heart rate variability, vagus nerve. IntroductionAutonomic diabetic neuropathy (ADN) is a frequent and serious complication of diabetes mellitus. A clinical and subclinical disease, it can affect all organ systems, including the gastrointestinal tract, the urogenital tract and the cardiovascular system. 1 ADN with multiple organ involvement occurs only rarely, however. The clinical presentation is most often a heterogeneous pattern of symptoms in different organ systems, which can lead to misdiagnosis.2,3 Since they coincide in approximately 50% of cases, in a patient with ADN evidence of sensorimotor diabetic neuropathy should be sought. 4 There are also connections to other long-term diabetic complications, such as nephropathy and retinopathy. 5Cardiac autonomic diabetic neuropathy (CADN) Cardiac autonomic diabetic neuropathy (CADN) is the primary disease of ADN and is one of the most frequently researched complications of diabetes. 6 The earliest sign of CADN is a reduction in heart rate variability (HRV), which is detectable at the subclinical stage 5,7,8 and can, for instance, be clearly verified during deep respiration (figure 1).Further symptoms become apparent at advanced stages. Primarily the vagus (pneumogastric) nerve is damaged: this results in a resting tachycardia since sympathetic influences become predominant. After about five years of latency, regression of tachycardia occurs due to damage to the sympathetic nerve fibres; 9 however, the heart rate remains higher than in healthy patients.10 Additional symptoms such as exercise intolerance, orthostatic hypotension and an increasing limitation in heart rate variability are the manifestations of progressive damage to the autonomic balance.5 Often cardiac pain perception is impaired due to the additional damage to sensory nerve fibres, so that warning signs of myocardial ischaemia are not recognised in time to be adequately treated. A meta-analysis of 12 studies by Vinik et al. 2 found that patients with CADN had DIABETES AND VASCULAR DISEASE RESEARCH PERSPECTIVES Cardiac autonomic diabetic neuropathy MARTIN SCHÖNAUER, ANDREAS THOMAS, STEPHAN MORBACH, JOSEF NIEBAUER, ULRIKE SCHÖNAUER, HOLGER THIELE

Background: For decades, the major source of information used to make therapeutic decisions by patients with diabetes has been glucose measurements using capillary blood samples. Knowledge gained from clinical studies, for example, on the impact of metabolic control on diabetes-related complications, is based on such measurements. Different to traditional blood glucose measurement systems, systems for continuous glucose monitoring (CGM) measure glucose in interstitial fluid (ISF). The assumption is that glucose levels in blood and ISF are practically the same and that the information provided can be used interchangeably. Thus, therapeutic decisions, that is, the selection of insulin doses, are based on CGM system results interpreted as though they were blood glucose values. Methods: We performed a more detailed analysis and interpretation of glucose profiles obtained with CGM in situations with high glucose dynamics to evaluate this potentially misleading assumption. Results: Considering physical activity, hypoglycemic episodes, and meal-related differences between glucose levels in blood and ISF uncover clinically relevant differences that can make it risky from a therapeutic point of view to use blood glucose for therapeutic decisions. Conclusions: Further systematic and structured evaluation as to whether the use of ISF glucose is more safe and efficient when it comes to acute therapeutic decisions is necessary. These data might also have a higher prognostic relevance when it comes to long-term metabolic consequences of diabetes. In the long run, it may be reasonable to abandon blood glucose measurements as the basis for diabetes management and switch to using ISF glucose as the appropriate therapeutic target.

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Two types of continuous glucose monitoring (CGM) systems are currently available for daily diabetes self-management: real-time CGM and intermittently scanned CGM. Both approaches provide continuous measurement of glucose concentrations in the interstitial fluid; however, each has its own unique features that can impact their usefulness and acceptability within specific patient groups. This article explores the strengths and limitations of each approach and provides guidance to healthcare professionals in selecting the CGM type that is most appropriate to the individual needs of their patients.