Scientific advisory on nocturnal hypoglycemia in insulin-treated patients with diabetes: Recommendations from Indian experts.

INTRODUCTION: Insulin is one of the commonly prescribed glucose lowering agents in diabetes. Hypoglycemia is the most common complication, and severe hypoglycemia is the most serious complication of insulin therapy. Almost half of all severe hypoglycemia episodes (HEs) occur at night. However, patients are often unaware of their nocturnal hypoglycaemia (NH) risk. Additionally, both healthcare professionals and patients find it difficult to manage NH. The purpose of this expert group meeting is to improve NH awareness and provide guidance for the physicians to recognize and manage NH. METHOD: The panel of experts in an e-board deliberated extensively upon the available literature and guidelines on hypoglycemia and NH discussed the consensus on definition, detection, reporting, monitoring, treatment, and optimization of therapy in NH. RESULT: & Conclusion: Though there are many guidelines on the management of HEs in patients with diabetes, very few touch the topic of NH. This scientific advisory on management of NH in insulin treated patients with diabetes is formulated to address this gap in understanding regarding management of NH. The experts provide recommendations for the nocturnal window, defining NH based on blood glucose values, recognition, prevention and management of NH.

Management of children and adolescents having type 1 diabetes during COVID-19 pandemic in India: challenges and solutions.

Purpose: Type 1 diabetes (T1D) requires a holistic approach and continuous care. The current COVID-19 pandemic has made the health care professionals realise its challenges even more ardently than in the normal times. In a country like India with its huge population burden and a significant number of people having T1D, the risk of COVID-19 in people having T1DM is considerably high. Methods: In this article, we are sharing our practical experiences of problems faced by children and adolescents having T1DM during the past 2 months of lockdown. Results: We have classified the challenges into 3 broad categories based on diabetes self-management, healthcare system and psychosocial aspects. We have tried to provide precise, comprehensive and region specific solutions to these challenges. Solutions briefly include maintaining the supply chain of essentials like insulin, syringes and glucose meter strips to psychological support, financial aid and support for hospitalization in case of COVID-19 itself or diabetes complications including diabetic ketoacidosis. Conclusions: Children and adolescents having T1DM require special care and attention during this period of COVID-19 pandemic because of various challenges as discussed. Our proposed solutions may help them overcome these problems and help them in better diabetes management during such emergency situations.

Once-daily initiation of basal insulin as add-on to metformin: a 26-week, randomized, treat-to-target trial comparing insulin detemir with insulin glargine in patients with type 2 diabetes.

AIMS: This study assessed the efficacy and safety of once-daily insulin initiation using insulin detemir (detemir) or insulin glargine (glargine) added to existing metformin in type 2 diabetes (T2D). METHODS: This 26-week, multinational, randomized, treat-to-target trial involved 457 insulin-naïve adults with T2D (HbA1c 7-9%). Detemir or glargine was added to current metformin therapy [any second oral antidiabetic drug (OAD) discontinued] and titrated to a target fasting plasma glucose (FPG) ≤90 mg/dl (≤5.0 mmol/l). Primary efficacy endpoint was change in HbA1c. RESULTS: Mean (s.d.) HbA1c decreased with detemir and glargine by 0.48 and 0.74%-points, respectively, to 7.48% (0.91%) and 7.13% (0.72%) [estimated between-treatment difference, 0.30 (95% CI: 0.14-0.46)]. Non-inferiority for detemir at the a priori level of 0.4%-points was not established. The proportions of patients reaching HbA1c ≤ 7% at 26 weeks were 38% and 53% (p = 0.026) with detemir and glargine, respectively. FPG decreased ∼43.2 mg/dl (∼2.4 mmol/l) in both groups [non-significant (NS)]. Treatment satisfaction was good for both insulins. Hypoglycaemia, which occurred infrequently, was observed less with detemir than glargine [rate ratio 0.73 (95% CI 0.54-0.98)]. The proportions of patients reaching HbA1c ≤ 7% without hypoglycaemia in the detemir and glargine groups were 32% and 38% (NS), respectively. Weight decreased with detemir [-0.49 (3.3) kg] and increased with glargine [+1.0 (3.1) kg] (95% CI for difference: -2.17 to -0.89 kg). CONCLUSION: While both detemir and glargine, when added to metformin therapy, improved glycaemic control, glargine resulted in greater reductions in HbA1c, while detemir demonstrated less weight gain and hypoglycaemia.

Gatifloxacin induced abnormalities in glucose homeostasis in a patient on glimepiride.

Gatifloxacin, a commonly prescribed antimicrobial can produce profound hypoglycemia and disturbances in glucose homeostasis especially in diabetes patients on sulphonylureas. Also new onset disturbances in glucose homeostasis can occur in patients who were unaffected by the previous use of gatifloxacin. Therefore it is suggested that gatifloxacin is better avoided in patients with diabetes and in the elderly.

Diabetes in old age: an emerging epidemic.

Diabetes in the elderly is emerging as one of the most important public health problems of the 21st century. In developing countries, the majority of people with diabetes are in the age range of 45-64 years. A better understanding on the pathogenesis of diabetes in the aging population is required to successfully treat and prevent its devastating complications. Changes in body composition with accumulation of fat in the abdomen is a key factor in the causation of diabetes in the aging population. The size and strength of skeletal muscle, a major tissue involved in glucose metabolism, also declines leading to muscle weakness and a reduction in physical activity. These changes lead to marked reduction in energy expenditure and abdominal fat accumulation causing insulin resistance. Recent evidence suggests that four months of aerobic exercise can improve muscle oxidative capacity similarly in younger and older people, but that insulin sensitivity is less likely to improve in older people. It appears that older people need to exercise more frequently to improve their insulin sensitivity. Diagnosis and management of diabetes in the elderly requires special attention since age, genetics, body composition and lifestyle factors all interact. Increasing evidence suggests that postprandial hyperglycemia is more sensitive to diagnose diabetes in elderly people than in the young. Age related changes in body function and cognition demand special caution in the selection of hypoglycemic drugs in the elderly. Targets of diabetes therapy in the elderly have to be individualized, considering the age of the patient, remaining life-expectancy and severity of co-morbid conditions. Short acting insulin secretogogues are preferred to avoid prolonged and frequent hypoglycemia. Judicious choice of insulin sensitizers, timely introduction of insulin, meticulous control of hypertension and hyperlipidemia are critical to prevent complications.