Glycemic Variability in Inadequately Controlled Type 1 Diabetes and Type 2 Diabetes on Intensive Insulin Therapy: A Cross-Sectional, Observational Study

Greven, Wendela L; Beulens, Joline W.J.; Biesma, Douwe H.; Faiz, Sandra; Valk, Harold W. de

doi:10.1089/dia.2010.0044

Cited by 26 publications

(26 citation statements)

References 14 publications

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“…Of the glycemic lability indexes, only the LI correlated with the number of SMBG measurements per day [13]. As in a previous study, glycemic lability indexes in our group did not correlate with duration of diabetes [22].…”

Section: Discussionsupporting

confidence: 65%

Assessment of glycemic lability and severity of hypoglycemia in Korean patients with type 1 diabetes

et al. 2011

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Pancreas or islet transplantation is recommended for individuals with type 1 diabetes who present with frequent and severe hypoglycemia and/or severe glycemic lability, despite efforts to optimize glycemic control [1]. For these patients, pancreas or islet transplantation has led to successful treatment of these problems [2][3][4]. Pancreas and islet transplantations have previously been performed in Korea [5,6].Clinicians can judge whether patients with type 1 diabetes have problems with glycemic lability and/or severe hypoglycemia, but it is difficult to quantify the glycemic lability and hypoglycemia.Attempts have been made to quantify both hypoglycemia and glycemic lability to allow for betweenAssessment of glycemic lability and severity of hypoglycemia in Korean patients with type 1 diabetes abstract. Few studies have focused on the quantification of glycemic lability and hypoglycemic events in Asian patients with type 1 diabetes; therefore, we conducted a study to assess glycemic lability and the severity of hypoglycemia in type 1 diabetic patients in Korea. A total of 124 type 1 diabetic patients were enrolled. Several glycemic lability indexes and hypoglycemic indexes were calculated using four-week self-monitoring of blood glucose (SMBG) data. Due to the dependence of the lability index (LI) on the frequency of glucose measurements, we generated a modified LI by dividing by the number of SMBG measurements per day for a given patient. The numbers of patients in our study with a composite hypoglycemic score ≥ 1,047 or LI ≥ 433 mmol/L 2 /h·week -1 , which was found in a previous study to indicate high risk of severe hypoglycemia or lability, were 0 (0%) and 44 (35%), respectively. Compared to previously reported hypoglycemia indexes, the low blood glucose index was lower in our study. However, the glycemic lability indexes were similar to those in previous studies, with the exception of the LI. The modified LI and the average daily risk range (ADRR) showed higher concordance with other glycemic lability indexes than did the LI or mean amplitude of glycemic excursions (MAGE). The results showed that the hypoglycemic indexes in this study population were lower than the results from Ryan et al. Furthermore, the ADRR or modified LI were better measures for high risk of severe lability than were the LI and MAGE.Key words: Glycemic lability, Type 1 diabetes mellitus, Hypoglycemia center comparison as well as to establish standards for pancreas or islet transplantation [7]. Several indexes have been proposed for glycemic lability and hypoglycemia. The most familiar assessment of glycemic lability is the standard deviation (SD) of the glucose profile [8]. However, the SD has limited capacity to identify the extremes of hyperglycemia or hypoglycemia and is affected by the mean glucose [9]. The mean amplitude of glycemic excursions (MAGE) and average daily risk range (ADRR) also measure glucose lability in diabetic patients [10,11]. The MAGE using continuous glucose monitoring is a well-known index of glycemic labil...

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Section: Discussionsupporting

confidence: 65%

Assessment of glycemic lability and severity of hypoglycemia in Korean patients with type 1 diabetes

et al. 2011

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“…Individuals with type 1 diabetes usually develop severe endogenous insulin deficiency, which results in high glucose variability and hypoglycaemia risk [1–4]. Treatment guidelines for type 1 diabetes, therefore, incorporate early intensive strategies to minimise hypoglycaemia, including multiple daily insulin injections, carbohydrate counting and insulin pumps [5].…”

Section: Introductionmentioning

confidence: 99%

Random non-fasting C-peptide testing can identify patients with insulin-treated type 2 diabetes at high risk of hypoglycaemia

et al. 2017

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Aims/hypothesisThe aim of this study was to determine whether random non-fasting C-peptide (rCP) measurement can be used to assess hypoglycaemia risk in insulin-treated type 2 diabetes.MethodsWe compared continuous glucose monitoring-assessed SD of blood glucose and hypoglycaemia duration in 17 patients with insulin-treated type 2 diabetes and severe insulin deficiency (rCP < 200 pmol/l) and 17 matched insulin-treated control patients with type 2 diabetes but who had preserved endogenous insulin (rCP > 600 pmol/l). We then assessed the relationship between rCP and questionnaire-based measures of hypoglycaemia in 256 patients with insulin-treated type 2 diabetes and a comparison group of 209 individuals with type 1 diabetes.ResultsContinuous glucose monitoring (CGM)-assessed glucose variability and hypoglycaemia was greater in individuals with rCP < 200 pmol/l despite similar mean glucose. In those with low vs high C-peptide, SD of glucose was 4.2 (95% CI 3.7, 4.6) vs 3.0 (2.6, 3.4) mmol/l (p < 0.001). In the low-C-peptide vs high-C-peptide group, the proportion of individuals experiencing sustained hypoglycaemia ≤ 4 mmol/l was 94% vs 41% (p < 0.001), the mean rate of hypoglycaemia was 5.5 (4.4, 6.7) vs 2.1 (1.4, 2.9) episodes per person per week (p = 0.004) and the mean duration was 630 (619, 643) vs 223 (216, 230) min per person per week (p = 0.01). Hypoglycaemia ≤ 3 mmol/l was infrequent in individuals with preserved C-peptide (1.8 [1.2, 2.6] episodes per person per week vs 0.4 [0.1, 0.8] episodes per person per week for low vs high C-peptide, p = 0.04) and only occurred at night. In a population-based cohort with insulin-treated type 2 diabetes, self-reported hypoglycaemia was twice as frequent in those with rCP < 200 pmol/l (OR 2.0, p < 0.001) and the rate of episodes resulting in loss of consciousness or seizure was five times higher (OR 5.0, p = 0.001). The relationship between self-reported hypoglycaemia and C-peptide was similar in individuals with type 1 and type 2 diabetes.Conclusions/interpretationLow rCP is associated with increased glucose variability and hypoglycaemia in patients with insulin-treated type 2 diabetes and represents a practical, stable and inexpensive biomarker for assessment of hypoglycaemia risk.Electronic supplementary materialThe online version of this article (10.1007/s00125-017-4449-2) contains peer-reviewed but unedited supplementary material, which is available to authorised users.

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“…Secondary outcomes: 1) glycemic variability estimated by the standard deviation (SD) of 48 hours glucose values at the end of the study as measured by three days blinded continuous glucose measurement (CGM)) [21] 2) change in weight 3) hypoglycemia (defined as the total number of hypoglycemia during the study period (any glucose self-measurement < 4.0 mmol/L or symptoms which the patients recognises as hypoglycemia and clinically judged by the investigator as hypoglycemia)) 4) severe hypoglycemia (defined by help needed from others, seizure, or coma) 5) alpha and beta cell function (between group comparison of glucose, insulin, C-peptide and glucagon levels, measured after standardised meal) 6) cardiovascular analysis; change in blood pressure (mean ambulant 24 hour arterial pressure) and change in plasma lipids 7) change in skin Advanced glycation end products (AGEs) (measured as skin-autofluorescence by the AGE-reader) [22, 23]. …”

Section: Methodsmentioning

confidence: 99%

Patients with Type 2 Diabetes Mellitus failing on oral agents and starting once daily insulin regimen; a small randomized study investigating effects of adding vildagliptin

et al. 2014

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BackgroundThe addition of a DDP4-inhibitor to existing insulin therapy reduces HbA1c. However, no data exist about the addition of these agents at the beginning of insulin treatment in type 2 diabetes while this could especially be interesting because it is during this period that considerable residual beta cell function is still present. The benefit of such a strategy could be a lower insulin dose required for glycemic control. The hypothesis of our study was that adding a DPP4-inhibitor at the beginning of insulin treatment could lead to less exogenous insulin requirement, a reduction of hyperinsulinemia and side effects (hypoglycemia and weight gain), less glucose variability and improvement of insulin and glucagon dynamics during a mixed meal test.ResultsIn this small clinical trial (trial registration NTR2022) 9 patients were randomized to receive vildagliptin and 6 to receive placebo in addition to start of once daily insulin treatment. Unfortunately, due to a difficult inclusion, the preset sample size of 40 patients could not be met. Median units of insulin at the end of the study was 47 U in the placebo group and 34 U in the vildagliptin group. Median glycemic variability (SD) at the end of study was 2.1 in the placebo group and 1.5 in the vildagliptin group. Median weight gain at the end of study was 3 kg in the placebo and 0.5 kg in the vildagliptin group. Occurrence of hypoglycemia was low in both groups. Insulin, C-peptide, glucose and glucagon levels were comparable during mixed meal tests.ConclusionsThis small randomized study did not have sufficient power to detect effects of the addition of vildagliptin to the start of once daily long-acting insulin. However in our opinion adding a DPP4-inhibitor, especially in this group remains a very interesting approach. This study could be used as a guidance for larger studies that are required to investigate the effects of this intervention on insulin requirements, glycemic variability, hypoglycemia and weight gain.Electronic supplementary materialThe online version of this article (doi:10.1186/1756-0500-7-579) contains supplementary material, which is available to authorized users.

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Glycemic Variability in Inadequately Controlled Type 1 Diabetes and Type 2 Diabetes on Intensive Insulin Therapy: A Cross-Sectional, Observational Study

Abstract: SD(total) is a conveniently measurable parameter to express glycemic variability in patients with inadequate control with intensive insulin therapy. Patients with T1DM and long-lasting T2DM have the highest glycemic variability.

Cited by 26 publications

References 14 publications

Assessment of glycemic lability and severity of hypoglycemia in Korean patients with type 1 diabetes

Assessment of glycemic lability and severity of hypoglycemia in Korean patients with type 1 diabetes

Random non-fasting C-peptide testing can identify patients with insulin-treated type 2 diabetes at high risk of hypoglycaemia

Patients with Type 2 Diabetes Mellitus failing on oral agents and starting once daily insulin regimen; a small randomized study investigating effects of adding vildagliptin

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