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1.
Saudi Med J ; 42(1): 44-48, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33399170

RESUMEN

OBJECTIVES: To identify how children and adolescents with type 1 diabetes were coping with their condition during the COVID-19 lockdown, by detecting differences in blood glucose control and in lifestyle, including diet, physical activity, and mood deterioration, before and during the lockdown. METHODS: This descriptive, cross-sectional study was conducted between April and June 2020 at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Data were collected from interviews, using various forms of telecommunication. RESULTS: The total sample size was 150 patients, 48 (28%) of whom were males and 102 (72%) females. The mean age of the patients was 12.45 years. The lockdown was associated with a significant increase in patients' weight (p=0.001), body mass index (p=0.001), and blood glucose readings (p=0.007) compared to their values before the lockdown. Conclusion: A negative impact of the COVID-19 lockdown was found on blood glucose values and BMI, which may correlate with a lack of physical activity, increased consumption of carbohydrates and fast food, and mood deterioration.


Asunto(s)
Adaptación Psicológica , Diabetes Mellitus Tipo 1/psicología , Diabetes Mellitus Tipo 1/terapia , Adolescente , Afecto , Índice de Masa Corporal , Niño , Estudios Transversales , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Dieta , Ejercicio Físico , Estilo de Vida Saludable , Humanos , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Pandemias/prevención & control , Arabia Saudita , Aumento de Peso
2.
Nutr Diabetes ; 11(1): 1, 2021 01 05.
Artículo en Inglés | MEDLINE | ID: mdl-33414391

RESUMEN

BACKGROUND: Starting March 2020 the Italian Government imposed a lockdown to limit the spread of SARS-CoV-2. During lockdown outpatient visits were limited and telemedicine (TM) was encouraged. METHODS: We retrospectively analyzed data from continuous or flash glucose monitoring systems shared through different cloud systems during the lockdown by subjects with type 1 diabetes and compared data obtained 4 weeks before and 4 weeks after structured telephonic visit. Variables considered were mean glucose, time spent in target (70-180 mg/dl), hypoglycemia (<70 mg/dl) and hyperglycemia (>180 mg/dl), coefficient of variation, and length of sensor use. RESULTS: During the 4 weeks following the telephonic visit there was an improvement of glycemic control, with a significant reduction of mean glucose values (161.1 before vs 156.3 mg/dl after, p = 0.001), an increase of the time spent in target (63.6 vs 66.3, p = 0.0009) and a reduction of time spent in hyperglycemia (33.4 vs 30.5, p = 0.002). No changes were observed regarding glucose variability, time spent in hypoglycemia, and length of sensor use. Similar results were observed in subjects treated with multiple daily injections or continuous subcutaneous insulin infusion. CONCLUSIONS: A structured telephonic visit appears to be an effective way to replace or integrate routine visits in particular conditions.


Asunto(s)
Diabetes Mellitus Tipo 1/tratamiento farmacológico , Pandemias , Cuarentena , Telemedicina/tendencias , Adulto , Anciano , Glucemia/análisis , Automonitorización de la Glucosa Sanguínea , Femenino , Humanos , Hiperglucemia/epidemiología , Hipoglucemia/epidemiología , Hipoglucemiantes/administración & dosificación , Sistemas de Infusión de Insulina , Italia/epidemiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto Joven
3.
Curr Diab Rep ; 21(2): 7, 2021 01 15.
Artículo en Inglés | MEDLINE | ID: mdl-33449214

RESUMEN

PURPOSE OF REVIEW: As the prevalence of diabetes mellitus in the USA continues to rise, so does the popularity of diabetes management devices such as continuous glucose monitors (CGMs) and insulin pumps. The use of this technology has been shown to improve outpatient glycemic outcomes and quality of life and oftentimes may be continued in the hospital setting. Our aim is to review the current guidelines and available evidence on the continuation of insulin pumps and CGMs in the inpatient setting. RECENT FINDINGS: Patients with diabetes are at higher risk for hospitalizations and complications due to hyper- or hypoglycemia, metabolic co-morbidities, or as seen recently, more severe illness from infections such as SARS-CoV-2. The maintenance of euglycemia is important to decrease both morbidity and mortality in the hospital setting. There is consensus among experts and medical societies that inpatient use of diabetes technology in carefully selected patients with proper institutional protocols is safe and can improve inpatient glycemic outcomes and reduce hypoglycemia. During the COVID-19 pandemic, CGMs played a vital role in managing hyperglycemia in some hospitalized patients. Insulin pumps and CGMs have the potential to transform glycemic management in hospitalized patients. In order for institutions to safely and effectively incorporate these technologies on their inpatient units, hospital-based providers will need to be able to understand how to manage and utilize these devices in their practice in conjunction with diabetes experts.


Asunto(s)
Diabetes Mellitus Tipo 1 , Insulinas , Glucemia , Automonitorización de la Glucosa Sanguínea , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hospitales , Humanos , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Sistemas de Infusión de Insulina , Insulinas/uso terapéutico , Pandemias , Calidad de Vida
4.
Am J Case Rep ; 22: e928090, 2021 Jan 19.
Artículo en Inglés | MEDLINE | ID: mdl-33462171

RESUMEN

BACKGROUND Hypoglycemia is a frequent complication observed in diabetic patients under treatment. This metabolic complication is associated with an increased mortality rate in diabetic patients. The use of sensor-augmented pump therapy with predictive low glucose management systems has improved blood glucose level control and reduced the incidence of hypoglycemic attacks. However, this therapy may be associated with adverse events. CASE REPORT A 65-year-old Japanese woman with type 1 diabetes mellitus underwent hemodialysis with end-stage renal failure due to diabetic nephropathy. The patient received sensor-augmented pump therapy with the predictive low glucose management system to prevent recurrent severe hypoglycemia. Hypoglycemia was infrequent when the sensor-augmented pump therapy with a predictive low-glucose management system was properly working. However, the patient suddenly died 3 months after starting the treatment. A record of continuous glucose monitoring showed that hypoglycemia occurred before the sudden death of the patient. CONCLUSIONS The current case shows that sudden death associated with severe hypoglycemia may also occur during sensor-augmented pump therapy with a predictive low glucose management system. This case report underscores the need for close follow-up of diabetic patients receiving sensor-augmented pump therapy with the predictive low glucose management system and the critical importance of patient education on diabetes technology in high-risk patients.


Asunto(s)
Muerte Súbita/etiología , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hipoglucemia/etiología , Hipoglucemiantes/administración & dosificación , Sistemas de Infusión de Insulina/efectos adversos , Insulina/administración & dosificación , Anciano , Automonitorización de la Glucosa Sanguínea , Diabetes Mellitus Tipo 1/complicaciones , Femenino , Humanos , Hipoglucemia/prevención & control
8.
Endocr Pract ; 27(1): 44-50, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33475500

RESUMEN

OBJECTIVE: In type 1 diabetes mellitus (T1DM) management, continuous glucose monitoring (CGM)-derived parameters can provide additional insights, with time in range (TIR) and other parameters reflecting glycemic control and variability being put forward. This study aimed to examine the added and interpretative value of the CGM-derived indices TIR and coefficient of variation (CV%) in T1DM patients stratified according to their level of glycemic control by means of HbA1C. METHODS: T1DM patients with a minimum disease duration of 10 years and without known macrovascular disease were enrolled. Patients were equipped with a blinded CGM device for 7 days. TIR and time spent in hypoglycemia and hyperglycemia were determined, and CV% was used as a parameter for glycemic variability. Pearson (r) and Spearman correlations (rs) and a regression analysis were used to examine associations. RESULTS: Ninety-five patients (age: 45 ± 10 years; HbA1C level: 7.7% ± 0.8% [61 ± 7 mmol/mol]) were included (mean blood glucose [MBG]: 159 ± 31 mg/dL; TIR: 55.8% ± 14.9%; CV%: 43.5% ± 7.8%) and labeled as having good (HbA1C level ≤7% [≤53 mmol/mol]; n = 20), moderate (7%-8%; n = 44), or poor (>8% [>64 mmol/mol]; n = 31) glycemic control. HbA1C was significantly associated with MBG (rs = 0.48, P < .001) and time spent in hyperglycemia (total: rs = 0.52; level 2: r = 0.46; P < .001) but not with time spent in hypoglycemia and CV%, even after an analysis of the HbA1C subgroups. Similarly, TIR was negatively associated with HbA1C (r = -0.53; P < .001), MBG (rs = -0.81; P < .001), and time spent in hyperglycemia (total: rs = -0.90; level 2: rs = -0.84; P < .001) but not with time in hypoglycemia. The subgroup analyses, however, showed that TIR was associated with shorter time spent in level-2 hypoglycemia in patients with good (rs = -0.60; P = .007) and moderate (rs = -0.25; P = .047) glycemic control. In contrast, CV% was strongly positively associated with time in hypoglycemia (total: rs = 0.78; level 2: rs = 0.76; P < .001) but not with TIR or time in hyperglycemia in the entire cohort, although the subgroup analyses showed that TIR was negatively associated with CV% in patients with good glycemic control (r = -0.81, P < .001) and positively associated in patients with poor glycemic control (r = +0.47; P < .01). CONCLUSION: The CGM-derived metrics TIR and CV% are related to clinically important situations, TIR being strongly dependent on hyperglycemia and CV% being reflective of hypoglycemic risk. However, the interpretation and applicability of TIR and CV% and their relationship depends on the level of glycemic control of the individual patient, with CV% generally adding less clinically relevant information in those with poor control. This illustrates the need for further research and evaluation of composite measures of glycemic control in T1DM.


Asunto(s)
Diabetes Mellitus Tipo 1 , Adulto , Glucemia , Automonitorización de la Glucosa Sanguínea , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hemoglobina A Glucada/análisis , Humanos , Hipoglucemiantes/uso terapéutico , Persona de Mediana Edad
9.
Lancet ; 397(10270): 208-219, 2021 01 16.
Artículo en Inglés | MEDLINE | ID: mdl-33453783

RESUMEN

BACKGROUND: Management of type 1 diabetes is challenging. We compared outcomes using a commercially available hybrid closed-loop system versus a new investigational system with features potentially useful for adolescents and young adults with type 1 diabetes. METHODS: In this multinational, randomised, crossover trial (Fuzzy Logic Automated Insulin Regulation [FLAIR]), individuals aged 14-29 years old, with a clinical diagnosis of type 1 diabetes with a duration of at least 1 year, using either an insulin pump or multiple daily insulin injections, and glycated haemoglobin (HbA1c) levels of 7·0-11·0% (53-97 mmol/mol) were recruited from seven academic-based endocrinology practices, four in the USA, and one each in Germany, Israel, and Slovenia. After a run-in period to teach participants how to use the study pump and continuous glucose monitor, participants were randomly assigned (1:1) using a computer-generated sequence, with a permuted block design (block sizes of two and four), stratified by baseline HbA1c and use of a personal MiniMed 670G system (Medtronic) at enrolment, to either use of a MiniMed 670G hybrid closed-loop system (670G) or the investigational advanced hybrid closed-loop system (Medtronic) for the first 12-week period, and then participants were crossed over with no washout period, to the other group for use for another 12 weeks. Masking was not possible due to the nature of the systems used. The coprimary outcomes, measured with continuous glucose monitoring, were proportion of time that glucose levels were above 180 mg/dL (>10·0 mmol/L) during 0600 h to 2359 h (ie, daytime), tested for superiority, and proportion of time that glucose levels were below 54 mg/dL (<3·0 mmol/L) calculated over a full 24-h period, tested for non-inferiority (non-inferiority margin 2%). Analysis was by intention to treat. Safety was assessed in all participants randomly assigned to treatment. This trial is registered with ClinicalTrials.gov, NCT03040414, and is now complete. FINDINGS: Between June 3 and Aug 22, 2019, 113 individuals were enrolled into the trial. Mean age was 19 years (SD 4) and 70 (62%) of 113 participants were female. Mean proportion of time with daytime glucose levels above 180 mg/dL (>10·0 mmol/L) was 42% (SD 13) at baseline, 37% (9) during use of the 670G system, and 34% (9) during use of the advanced hybrid closed-loop system (mean difference [advanced hybrid closed-loop system minus 670G system] -3·00% [95% CI -3·97 to -2·04]; p<0·0001). Mean 24-h proportion of time with glucose levels below 54 mg/dL (<3·0 mmol/L) was 0·46% (SD 0·42) at baseline, 0·50% (0·35) during use of the 670G system, and 0·46% (0·33) during use of the advanced hybrid closed-loop system (mean difference [advanced hybrid closed-loop system minus 670G system] -0·06% [95% CI -0·11 to -0·02]; p<0·0001 for non-inferiority). One severe hypoglycaemic event occurred in the advanced hybrid closed-loop system group, determined to be unrelated to study treatment, and none occurred in the 670G group. INTERPRETATION: Hyperglycaemia was reduced without increasing hypoglycaemia in adolescents and young adults with type 1 diabetes using the investigational advanced hybrid closed-loop system compared with the commercially available MiniMed 670G system. Testing an advanced hybrid closed-loop system in populations that are underserved due to socioeconomic factors and testing during pregnancy and in individuals with impaired awareness of hypoglycaemia would advance the effective use of this technology FUNDING: National Institute of Diabetes and Digestive and Kidney Diseases.


Asunto(s)
Automonitorización de la Glucosa Sanguínea/instrumentación , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Sistemas de Infusión de Insulina , Insulina/uso terapéutico , Adulto , Femenino , Alemania , Humanos , Hiperglucemia/prevención & control , Israel , Masculino , Estados Unidos , Adulto Joven
10.
Adv Exp Med Biol ; 1307: 331-355, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-32034728

RESUMEN

In type 1 diabetes mellitus (T1DM) pancreas beta-cells do not segregate insulin. This hormone is necessary to convert glucose into energy. Thus, people with diabetes are required to maintain blood glucose (BG) levels within a safe range using external control solutions. Insulin recommender systems (IRS's) provide the precise amount of insulin to the patient when needed, reducing the effects of the disease. The goal of this paper is to review and summarize all current proposals of IRS's and, with this purpose, 70 papers have been analysed. The analysis of the works was performed taking the following aspects into account: (i) technology of the recommendation process, (ii) control procedures, (iii) complementary processes, (iv) hardware, testing and assessment, (v) pricing and (vi) results. Those are our main conclusions after the review: There is a lack of published research works providing real experimentation together with simulation processes. Information about the IRS's features is also lacking in a remarkable percentage of the publications. Due to the variability in how experiments are performed and results are presented, research work comparisons become difficult. In summary, this topic requires standards to be able to perform comparison analysis of published papers and therefore, progress adequately.


Asunto(s)
Diabetes Mellitus Tipo 1 , Hipoglucemiantes/administración & dosificación , Insulina/administración & dosificación , Informática Médica , Glucemia , Automonitorización de la Glucosa Sanguínea , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Humanos
11.
Adv Exp Med Biol ; 1307: 457-498, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-32314317

RESUMEN

Unveiling human genome through successful completion of Human Genome Project and International HapMap Projects with the advent of state of art technologies has shed light on diseases associated genetic determinants. Identification of mutational landscapes such as copy number variation, single nucleotide polymorphisms or variants in different genes and loci have revealed not only genetic risk factors responsible for diseases but also region(s) playing protective roles. Diabetes is a global health concern with two major types - type 1 diabetes (T1D) and type 2 diabetes (T2D). Great progress in understanding the underlying genetic predisposition to T1D and T2D have been made by candidate gene studies, genetic linkage studies, genome wide association studies with substantial number of samples. Genetic information has importance in predicting clinical outcomes. In this review, we focus on recent advancement regarding candidate gene(s) associated with these two traits along with their clinical parameters as well as therapeutic approaches perceived. Understanding genetic architecture of these disease traits relating clinical phenotypes would certainly facilitate population stratification in diagnosing and treating T1D/T2D considering the doses and toxicity of specific drugs.


Asunto(s)
Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Predisposición Genética a la Enfermedad , Alelos , Variaciones en el Número de Copia de ADN , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/genética , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/genética , Estudio de Asociación del Genoma Completo , Humanos , Fenotipo , Polimorfismo de Nucleótido Simple , Factores de Riesgo
12.
Adv Exp Med Biol ; 1307: 43-69, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-32406022

RESUMEN

In health hypoglycaemia is rare and occurs only in circumstances like extreme sports. Hypoglycaemia in type 1 Diabetes (T1D) and advanced type 2 Diabetes (T2D) are the result of interplay between absolute or relative insulin access and defective glucose counterregulation. The basic mechanism is, failure of decreasing insulin and failure of the compensatory increasing counterregulatory hormones at the background of falling blood glucose. Any person with Diabetes on anti-diabetic medication who behaves oddly in any way whatsoever is hypoglycaemic until proven otherwise. Hypoglycaemia can be a terrifying experience for a patient with Diabetes. By definition, hypoglycaemic symptoms are subjective and vary from person to person and even episode to episode in same person. Fear of iatrogenic hypoglycaemia is a major barrier in achieving optimum glycaemic control and quality of life which limits the reduction of diabetic complications. Diabetes patients with comorbidities especially with chronic renal failure, hepatic dysfunction, major limb amputation, terminal illness, cognitive dysfunction etc. are more vulnerable to hypoglycaemia. In most cases, prompt glucose intake reverts hypoglycaemia. Exogenous insulin in T1D and insulin treated advanced T2D have no control by pancreatic regulation. Moreover, failure of increase of glucagon and attenuated secretion in epinephrine causes the defective glucose counterregulation. In this comprehensive review, I will try to touch all related topics for better understanding of hypoglycaemia.


Asunto(s)
Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Hipoglucemia , Glucemia , Comorbilidad , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Humanos , Hipoglucemia/inducido químicamente , Hipoglucemia/tratamiento farmacológico , Insulina/uso terapéutico , Calidad de Vida
14.
Nat Rev Endocrinol ; 17(1): 11-30, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33188364

RESUMEN

Initial studies found increased severity of coronavirus disease 2019 (COVID-19), caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in patients with diabetes mellitus. Furthermore, COVID-19 might also predispose infected individuals to hyperglycaemia. Interacting with other risk factors, hyperglycaemia might modulate immune and inflammatory responses, thus predisposing patients to severe COVID-19 and possible lethal outcomes. Angiotensin-converting enzyme 2 (ACE2), which is part of the renin-angiotensin-aldosterone system (RAAS), is the main entry receptor for SARS-CoV-2; although dipeptidyl peptidase 4 (DPP4) might also act as a binding target. Preliminary data, however, do not suggest a notable effect of glucose-lowering DPP4 inhibitors on SARS-CoV-2 susceptibility. Owing to their pharmacological characteristics, sodium-glucose cotransporter 2 (SGLT2) inhibitors might cause adverse effects in patients with COVID-19 and so cannot be recommended. Currently, insulin should be the main approach to the control of acute glycaemia. Most available evidence does not distinguish between the major types of diabetes mellitus and is related to type 2 diabetes mellitus owing to its high prevalence. However, some limited evidence is now available on type 1 diabetes mellitus and COVID-19. Most of these conclusions are preliminary, and further investigation of the optimal management in patients with diabetes mellitus is warranted.


Asunto(s)
/tratamiento farmacológico , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/epidemiología , /antagonistas & inhibidores , Glucemia/efectos de los fármacos , Glucemia/metabolismo , Diabetes Mellitus Tipo 1/metabolismo , Diabetes Mellitus Tipo 2/metabolismo , Manejo de la Enfermedad , Humanos , Hipoglucemiantes/administración & dosificación , Hipoglucemiantes/metabolismo , Factores de Riesgo
15.
Microvasc Res ; 133: 104077, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-32979391

RESUMEN

While activation of cannabinoid (CB2) receptors has been shown to be neuroprotective, no studies have examined whether this neuroprotection is directed at cerebral arterioles and no studies have examined whether activation of CB2 receptors can rescue cerebrovascular dysfunction during a chronic disease state such as type 1 diabetes (T1D). Our goal was to test the hypothesis that administration of a CB2 agonist (JWH-133) would improve impaired endothelial (eNOS)- and neuronal (nNOS)-dependent dilation of cerebral arterioles during T1D. In vivo diameter of cerebral arterioles in nondiabetic and T1D rats was measured in response to an eNOS-dependent agonist (adenosine 5'-diphosphate; ADP), an nNOS-dependent agonist (N-methyl-d-aspartate; NMDA), and an NOS-independent agonist (nitroglycerin) before and 1 h following JWH-133 (1 mg/kg IP). Dilation of cerebral arterioles to ADP and NMDA was greater in nondiabetic than in T1D rats. Treatment with JWH-133 increased responses of cerebral arterioles to ADP and NMDA in both nondiabetic and T1D rats. Responses of cerebral arterioles to nitroglycerin were similar between nondiabetic and T1D rats, and JWH-133 did not influence responses to nitroglycerin in either group. The restoration in responses to the agonists by JWH-133 could be inhibited by treatment with a specific inhibitor of CB2 receptors (AM-630; 3 mg/kg IP). Thus, activation of CB2 receptors can potentiate reactivity of cerebral arterioles during physiologic and pathophysiologic states. We speculate that treatment with CB2 receptor agonists may have potential therapeutic benefits for the treatment of cerebral vascular diseases via a mechanism that can increase cerebral blood flow.


Asunto(s)
Arteriolas/efectos de los fármacos , Agonistas de Receptores de Cannabinoides/farmacología , Cannabinoides/farmacología , Trastornos Cerebrovasculares/prevención & control , Diabetes Mellitus Experimental/tratamiento farmacológico , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Receptor Cannabinoide CB2/agonistas , Vasodilatación/efectos de los fármacos , Vasodilatadores/farmacología , Animales , Arteriolas/enzimología , Encéfalo/irrigación sanguínea , Trastornos Cerebrovasculares/enzimología , Trastornos Cerebrovasculares/fisiopatología , Diabetes Mellitus Experimental/enzimología , Diabetes Mellitus Experimental/fisiopatología , Diabetes Mellitus Tipo 1/enzimología , Diabetes Mellitus Tipo 1/fisiopatología , Masculino , Óxido Nítrico Sintasa de Tipo I/metabolismo , Óxido Nítrico Sintasa de Tipo III/metabolismo , Ratas Sprague-Dawley , Receptor Cannabinoide CB2/metabolismo , Transducción de Señal
16.
Curr Opin Endocrinol Diabetes Obes ; 28(1): 14-20, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33315629

RESUMEN

PURPOSE OF REVIEW: Caring for patients with type 1 diabetes (T1D) in the hospital presents unique challenges. This review provides an update on significant issues relevant to the inpatient management of T1D. Topics include trends in diabetic ketoacidosis (DKA), hypoglycemia, and adapting ambulatory technologies for inpatient use. RECENT FINDINGS: Rates of DKA in the United States are rising. Although socioeconomic status, health insurance coverage, and hemoglobin A1c are persistently associated with DKA in individuals with T1D, newer risk factors have also emerged. These include the off-label use of sodium-glucose cotransporter inhibitor medications, immune checkpoint inhibitor-induced diabetes, and infection with severe acute respiratory syndrome coronavirus 2. Hypoglycemia is common among hospitalized patients with T1D. Use of validated hypoglycemia risk prediction models and multidisciplinary care initiatives can reduce the risk of inpatient hypoglycemia. Finally, continuous glucose monitoring is being adapted for use in the hospital setting and has shown promise during the coronavirus disease 2019 (COVID-19) pandemic. SUMMARY: Evidence-based treatment algorithms, risk prediction calculators, multidisciplinary interventions, and wearable technology hold promise for improved outcomes in hospitalized patients with T1D.


Asunto(s)
Diabetes Mellitus Tipo 1 , Glucemia , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hospitales , Humanos , Factores de Riesgo , Resultado del Tratamiento
18.
PLoS Med ; 17(12): e1003461, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-33373368

RESUMEN

BACKGROUND: Sodium-glucose cotransporter-2 (SGLT2) inhibitors (SGLT2i) showed benefits in type 1 diabetes mellitus (T1DM), but the risk of diabetic ketoacidosis (DKA) limits their use. Ability to predict DKA risk and therapeutic responses would enable appropriate patient selection for SGLT2i. We conducted a meta-analysis and meta-regression of randomized controlled trials (RCTs) evaluating SGLT2i in T1DM to assess moderators of the relative risk (RR) of DKA, of glycemic (HbA1c, fasting plasma glucose, continuous glucose monitoring parameters, insulin dose, and insulin sensitivity indices) and non-glycemic (body mass index (BMI), systolic BP, renal function, albuminuria, and diabetic eye disorders) efficacy, and of other safety outcomes (including hypoglycemia, infections, major adverse cardiovascular events, and death). METHODS AND FINDINGS: We searched MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, Cochrane CENTRAL Register of Controlled Trials, and other electronic sources through August 30, 2020, for RCTs comparing SGLT2i with active comparators or placebo in adult patients with T1DM. Reviewers extracted data for relevant outcomes, performed random effects meta-analyses, subgroup analyses, and multivariable meta-regression. The strength of evidence was summarized with the GRADE approach. Among 9,914 records identified, 18 placebo-controlled RCTs (7,396 participants, 50% males, mean age 42 y (range 23 to 55 y), 5 different SGLT2i evaluated), were included. Main outcome measures were effect sizes and moderators of glycemic and non-glycemic efficacy and of safety outcomes. In a multivariable meta-regression model, baseline BMI (ß = 0.439 [95% CI: 0.211, 0.666], p < 0.001) and estimated glucose disposal rate (eGDR) (ß = -0.766 [-1.276, -0.256], p = 0.001) were associated with the RR of DKA (RR: 2.81; 95% CI:1.97, 4.01; p < 0.001, R2 = 61%). A model including also treatment-related parameters (insulin dose change-to-baseline insulin sensitivity ratio and volume depletion) explained 86% of variance across studies in the risk of DKA (R2 = 86%). The association of DKA with a BMI >27 kg/m2 and with an eGDR <8.3 mg/kg/min was confirmed also in subgroup analyses. Among efficacy outcomes, the novel findings were a reduction in albuminuria (WMD: -9.91, 95% CI: -16.26, -3.55 mg/g, p = 0.002), and in RR of diabetic eye disorders (RR: 0.27[0.11, 0.67], p = 0.005) associated with SGLT2i. A SGLT2i dose-response gradient was consistently observed for main efficacy outcomes, but not for adverse events (AEs). Overall, predictors of DKA and of other AEs differed substantially from those of glycemic and non-glycemic efficacy. A limitation of our analysis was the relatively short (≤52 weeks) duration of included RCTs. The potential relevance for clinical practice needs also to be confirmed by real-world prospective studies. CONCLUSIONS: In T1DM, the risk of DKA and main therapeutic responses to SGLT2i are modified by baseline BMI and insulin resistance, by total insulin dose reduction-to-baseline insulin sensitivity ratio, and by volume depletion, which may enable the targeted use of these drugs in patients with the greatest benefit and the lowest risk of DKA.


Asunto(s)
Diabetes Mellitus Tipo 1/tratamiento farmacológico , Cetoacidosis Diabética/inducido químicamente , Inhibidores del Cotransportador de Sodio-Glucosa 2/efectos adversos , Adulto , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/diagnóstico , Cetoacidosis Diabética/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Adulto Joven
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