Top

02-08-2018 | Hypoglycemia | Review | Article

Hypoglycaemia in type 1 diabetes: technological treatments, their limitations and the place of psychology

Journal: Diabetologia

Authors: Pratik Choudhary, Stephanie A. Amiel

Publisher: Springer Berlin Heidelberg

Abstract

Advances in technology allowing improved insulin delivery and glucose monitoring can significantly reduce the burden of hypoglycaemia when used appropriately. However, limitations of the current technology, and the skills, commitment and motivation required to use them, mean that it does not work for all people. Education and informed professional support are key to success. In the context of problematic hypoglycaemia, data suggest that newer technology has lower efficacy and uptake in those with most need. Identifying the causes of hypoglycaemia and understanding some of the underlying behavioural drivers may prove useful and psycho-educational strategies may be effective in selected individuals. Ultimately, as in many spheres of medicine, successful management of problematic hypoglycaemia depends upon matching the right treatment to the right individual.

Holl RW, Swift PG, Mortensen HB et al (2003) Insulin injection regimens and metabolic control in an international survey of adolescents with type 1 diabetes over 3 years: results from the Hvidore study group. Eur J Pediatr 162:22–29CrossRefPubMed

Gunn D, Mansell P (2012) Glycaemic control and weight 7 years after dose adjustment for normal eating (DAFNE) structured education in type 1 diabetes. Diabet Med 29:807–812CrossRefPubMed

Miller KM, Foster NC, Beck RW et al (2015) Current state of type 1 diabetes treatment in the U.S.: updated data from the T1D exchange clinic registry. Diabetes Care 38:971–978CrossRefPubMed

DCCT (1991) Epidemiology of severe hypoglycemia in the diabetes control and complications trial. The DCCT Research Group. Am J Med 90:450–459CrossRef

Weinstock RS, Xing D, Maahs DM et al (2013) Severe hypoglycemia and diabetic ketoacidosis in adults with type 1 diabetes: results from the T1D exchange clinic registry. J Clin Endocrinol Metab 98:3411–3419CrossRefPubMed

Pedersen-Bjergaard U, Pramming S, Heller SR et al (2004) Severe hypoglycaemia in 1076 adult patients with type 1 diabetes: influence of risk markers and selection. Diabetes Metab Res Rev 20:479–486CrossRefPubMed

Hendrieckx C, Halliday JA, Bowden JP et al (2014) Severe hypoglycaemia and its association with psychological well-being in Australian adults with type 1 diabetes attending specialist tertiary clinics. Diabetes Res Clin Pract 103:430–436CrossRefPubMed

Heller SR, Cryer PE (1991) Reduced neuroendocrine and symptomatic responses to subsequent hypoglycemia after 1 episode of hypoglycemia in nondiabetic humans. Diabetes 40:223–226CrossRefPubMed

Choudhary P, Amiel SA (2011) Hypoglycaemia: current management and controversies. Postgrad Med J 87:298–306CrossRefPubMed

10.

Choudhary P, Geddes J, Freeman JV, Emery CJ, Heller SR, Frier BM (2010) Frequency of biochemical hypoglycaemia in adults with type 1 diabetes with and without impaired awareness of hypoglycaemia: no identifiable differences using continuous glucose monitoring. Diabet Med 27:666–672CrossRefPubMed

11.

Davis RE, Morrissey M, Peters JR, Wittrup-Jensen K, Kennedy-Martin T, Currie CJ (2005) Impact of hypoglycaemia on quality of life and productivity in type 1 and type 2 diabetes. Curr Med Res Opin 21:1477–1483CrossRefPubMed

12.

Gonder-Frederick LA, Vajda KA, Schmidt KM et al (2013) Examining the Behaviour subscale of the Hypoglycaemia Fear Survey: an international study. Diabet Med 30:603–609CrossRefPubMed

13.

Speight J, Barendse SM, Singh H et al (2014) Cognitive, behavioural and psychological barriers to the prevention of severe hypoglycaemia: A qualitative study of adults with type 1 diabetes. SAGE Open Med 2:2050312114527443CrossRefPubMedPubMedCentral

14.

Gururaj Setty S, Crasto W, Jarvis J, Khunti K, Davies MJ (2016) New insulins and newer insulin regimens: a review of their role in improving glycaemic control in patients with diabetes. Postgrad Med J 92:152–164CrossRefPubMed

15.

Singh SR, Ahmad F, Lal A, Yu C, Bai Z, Bennett H (2009) Efficacy and safety of insulin analogues for the management of diabetes mellitus: a meta-analysis. CMAJ 180:385–397CrossRefPubMedPubMedCentral

16.

Bode BW, Johnson JA, Hyveled L, Tamer SC, Demissie M (2017) Improved postprandial glycemic control with faster-acting insulin aspart in patients with type 1 diabetes using continuous subcutaneous insulin infusion. Diabetes Technol Ther 19:25–33CrossRefPubMedPubMedCentral

17.

Mullins P, Sharplin P, Yki-Jarvinen H, Riddle MC, Haring HU (2007) Negative binomial meta-regression analysis of combined glycosylated hemoglobin and hypoglycemia outcomes across eleven Phase III and IV studies of insulin glargine compared with neutral protamine Hagedorn insulin in type 1 and type 2 diabetes mellitus. Clin Ther 29:1607–1619CrossRefPubMed

18.

Vague P, Selam JL, Skeie S et al (2003) Insulin detemir is associated with more predictable glycemic control and reduced risk of hypoglycemia than NPH insulin in patients with type 1 diabetes on a basal-bolus regimen with premeal insulin aspart. Diabetes Care 26:590–596CrossRefPubMed

19.

Landstedt-Hallin L (2015) Changes in HbA_1c, insulin dose and incidence of hypoglycemia in patients with type 1 diabetes after switching to insulin degludec in an outpatient setting: an observational study. Curr Med Res Opin 31:1487–1493CrossRefPubMed

20.

Elliott L, Fidler C, Ditchfield A, Stissing T (2016) Hypoglycemia event rates: a comparison between real-world data and randomized controlled trial populations in insulin-treated diabetes. Diabetes Ther 7:45–60CrossRefPubMedPubMedCentral

21.

Pickup JC, Keen H, Parsons JA, Alberti KG (1978) Continuous subcutaneous insulin infusion: an approach to achieving normoglycaemia. Br Med J 1:204–207

22.

Tamborlane WV, Sherwin RS, Genel M, Felig P (1979) Reduction to normal of plasma glucose in juvenile diabetes by subcutaneous administration of insulin with a portable infusion pump. N Engl J Med 300:573–578

23.

Pickup J, Viberti G, Keen H, Parsons J, Alberti G (1979) Infusion-pump treatment of diabetes mellitus. N Engl J Med 301:267CrossRefPubMed

24.

Yeh HC, Brown TT, Maruthur N et al (2012) Comparative effectiveness and safety of methods of insulin delivery and glucose monitoring for diabetes mellitus: a systematic review and meta-analysis. Ann Intern Med 157:336–347CrossRefPubMed

25.

Pickup JC, Sutton AJ (2008) Severe hypoglycaemia and glycaemic control in type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion. Diabet Med 25:765–774CrossRefPubMed

26.

Beato-Vibora P, Yeoh E, Rogers H, Hopkins D, Amiel SA, Choudhary P (2015) Sustained benefit of continuous subcutaneous insulin infusion on glycaemic control and hypoglycaemia in adults with type 1 diabetes. Diabet Med 32:1453–1459CrossRefPubMed

27.

Quiros C, Gimenez M, Rios P et al (2016) Long-term outcome of insulin pump therapy: reduction of hypoglycaemia and impact on glycaemic control. Diabet Med 33:1422–1426CrossRefPubMed

28.

The REPOSE Study Group (2017) Relative effectiveness of insulin pump treatment over multiple daily injections and structured education during flexible intensive insulin treatment for type 1 diabetes: cluster randomised trial (REPOSE). BMJ 356:j1285

29.

Choudhary P, Rickels MR, Senior PA et al (2015) Evidence-informed clinical practice recommendations for treatment of type 1 diabetes complicated by problematic hypoglycemia. Diabetes Care 38:1016–1029CrossRefPubMedPubMedCentral

30.

Hirsch IB, Abelseth J, Bode BW et al (2008) Sensor-augmented insulin pump therapy: results of the first randomized treat-to-target study. Diabetes Technol Ther 10:377–383CrossRefPubMed

31.

The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group (2008) Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med 359:1464–1476CrossRef

32.

Bergenstal RM, Tamborlane WV, Ahmann A et al (2010) Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med 363:311–320CrossRefPubMed

33.

Pickup JC, Freeman SC, Sutton AJ (2011) Glycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trials using individual patient data. BMJ 343:d3805CrossRefPubMedPubMedCentral

34.

Little SA, Leelarathna L, Walkinshaw E et al (2014) Response to comment on Little et al. Recovery of hypoglycemia awareness in long-standing type 1 diabetes: a multicenter 2 × 2 factorial randomized controlled trial comparing insulin pump with multiple daily injections and continuous with conventional glucose self-monitoring (HypoCOMPaSS). Diabetes Care 37:2114–2122CrossRefPubMed

35.

van Beers CA, DeVries JH, Kleijer SJ et al (2016) Continuous glucose monitoring for patients with type 1 diabetes and impaired awareness of hypoglycaemia (IN CONTROL): a randomised, open-label, crossover trial. Lancet Diabetes Endocrinol 4:893–902CrossRefPubMed

36.

Lind M, Polonsky W, Hirsch IB et al (2017) Continuous glucose monitoring vs conventional therapy for glycemic control in adults with type 1 diabetes treated with multiple daily insulin injections: the GOLD randomized clinical trial. JAMA 317:379–387CrossRefPubMed

37.

Beck RW, Riddlesworth T, Ruedy K et al (2017) Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND randomized clinical trial. JAMA 317:371–378CrossRefPubMed

38.

Choudhary P, Shin J, Wang Y et al (2011) Insulin pump therapy with automated insulin suspension in response to hypoglycemia: reduction in nocturnal hypoglycemia in those at greatest risk. Diabetes Care 34:2023–2025CrossRefPubMedPubMedCentral

39.

Choudhary P, Olsen BS, Conget I, Welsh JB, Vorrink L, Shin JJ (2016) Hypoglycemia prevention and user acceptance of an insulin pump system with predictive low glucose management. Diabetes Technol Ther 18:288–291CrossRefPubMedPubMedCentral

40.

Bergenstal RM, Klonoff DC, Garg SK et al (2013) Threshold-based insulin-pump interruption for reduction of hypoglycemia. N Engl J Med 369:224–232CrossRefPubMed

41.

Ly TT, Nicholas JA, Retterath A, Lim EM, Davis EA, Jones TW (2013) Effect of sensor-augmented insulin pump therapy and automated insulin suspension vs standard insulin pump therapy on hypoglycemia in patients with type 1 diabetes: a randomized clinical trial. JAMA 310:1240–1247CrossRefPubMed

42.

Bolinder J, Antuna R, Geelhoed-Duijvestijn P, Kroger J, Weitgasser R (2016) Novel glucose-sensing technology and hypoglycaemia in type 1 diabetes: a multicentre, non-masked, randomised controlled trial. Lancet 388:2254–2263CrossRefPubMed

43.

Reddy M, Jugnee N, El Laboudi A, Spanudakis E, Anantharaja S, Oliver N (2017) A randomized controlled pilot study of continuous glucose monitoring and flash glucose monitoring in people with type 1 diabetes and impaired awareness of hypoglycaemia. Diabet Med. https://doi.org/10.1111/dme.13561

44.

Reznik Y, Cohen O, Aronson R et al (2014) Insulin pump treatment compared with multiple daily injections for treatment of type 2 diabetes (OpT2mise): a randomised open-label controlled trial. Lancet 384:1265–1272CrossRefPubMed

45.

Shashaj B, Busetto E, Sulli N (2008) Benefits of a bolus calculator in pre- and postprandial glycaemic control and meal flexibility of paediatric patients using continuous subcutaneous insulin infusion (CSII). Diabet Med 25:1036–1042CrossRefPubMed

46.

Ramotowska A, Golicki D, Dzygalo K, Szypowska A (2013) The effect of using the insulin pump bolus calculator compared to standard insulin dosage calculations in patients with type 1 diabetes mellitus – systematic review. Exp Clin Endocrinol Diabetes 121:248–254CrossRefPubMed

47.

Gonzalez C, Picon MJ, Tome M, Pujol I, Fernandez-Garcia JC, Chico A (2016) Expert study: utility of an automated bolus advisor system in patients with type 1 diabetes treated with multiple daily injections of insulin-a crossover study. Diabetes Technol Ther 18:282–287CrossRefPubMed

48.

Ziegler R, Cavan DA, Cranston I et al (2013) Use of an insulin bolus advisor improves glycemic control in multiple daily insulin injection (MDI) therapy patients with suboptimal glycemic control: first results from the ABACUS trial. Diabetes Care 36:3613–3619CrossRefPubMedPubMedCentral

49.

Vallejo-Mora MD, Carreira-Soler M, Linares-Parrado F et al (2017) The Calculating Boluses on Multiple Daily Injections (CBMDI) study: a randomized controlled trial on the effect on metabolic control of adding a bolus calculator to multiple daily injections in people with type 1 diabetes. J Diabetes 9:24–33CrossRefPubMed

50.

Hommel E, Schmidt S, Vistisen D et al (2017) Effects of advanced carbohydrate counting guided by an automated bolus calculator in type 1 diabetes mellitus (StenoABC): a 12-month, randomized clinical trial. Diabet Med 34:708–715CrossRefPubMed

51.

Barnard K, Parkin C, Young A, Ashraf M (2012) Use of an automated bolus calculator reduces fear of hypoglycemia and improves confidence in dosage accuracy in patients with type 1 diabetes mellitus treated with multiple daily insulin injections. J Diabetes Sci Technol 6:144–149CrossRefPubMedPubMedCentral

52.

Shepard JA, Gonder-Frederick L, Vajda K, Kovatchev B (2012) Patient perspectives on personalized glucose advisory systems for type 1 diabetes management. Diabetes Technol Ther 14:858–861CrossRefPubMedPubMedCentral

53.

Huckvale K, Adomaviciute S, Prieto JT, Leow MK, Car J (2015) Smartphone apps for calculating insulin dose: a systematic assessment. BMC Med 13:106CrossRefPubMedPubMedCentral

54.

Byrne ML, Hopkins D, Littlejohn W et al (2015) Outcomes for adults with type 1 diabetes referred with severe hypoglycaemia and/or referred for islet transplantation to a specialist hypoglycaemia service. Horm Metab Res 47:9–15PubMed

55.

Lawton J, Kirkham J, Rankin D et al (2016) Who gains clinical benefit from using insulin pump therapy? A qualitative study of the perceptions and views of health professionals involved in the Relative Effectiveness of Pumps over MDI and Structured Education (REPOSE) trial. Diabet Med 33:243–251CrossRefPubMed

56.

Pettus J, Price DA, Edelman S (2015) How patients with type 1 diabetes translate continuous glucose monitoring data into diabetes management decisions. Endocr Pract 21:613–620CrossRefPubMed

57.

de Beaufort CE, Lange K, Swift PG et al (2013) Metabolic outcomes in young children with type 1 diabetes differ between treatment centers: the Hvidoere Study in Young Children 2009. Pediatr Diabetes 14:422–428CrossRefPubMed

58.

Yeoh E, Choudhary P, Nwokolo M, Ayis S, Amiel SA (2015) Interventions that restore awareness of hypoglycemia in adults with type 1 diabetes: a systematic review and meta-analysis. Diabetes Care 38:1592–1609CrossRefPubMed

59.

Hopkins D, Lawrence I, Mansell P et al (2012) Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the U.K. DAFNE experience. Diabetes Care 35:1638–1642CrossRefPubMedPubMedCentral

60.

Samann A, Muhlhauser I, Bender R, Hunger-Dathe W, Kloos C, Muller UA (2006) Flexible intensive insulin therapy in adults with type 1 diabetes and high risk for severe hypoglycemia and diabetic ketoacidosis. Diabetes Care 29:2196–2199CrossRefPubMed

61.

Kubiak T, Hermanns N, Schreckling H-J, Kulzer B, Haak T (2006) Evaluation of a self-management-based patient education program for the treatment and prevention of hypoglycemia-related problems in type 1 diabetes. Patient Educ Couns 60:228–234CrossRefPubMed

62.

Dinneen SF, O’Hara MC, Byrne M et al (2009) The Irish DAFNE study protocol: a cluster randomised trial of group versus individual follow-up after structured education for type 1 diabetes. Trials 10:88CrossRefPubMedPubMedCentral

63.

Hoogma RP, Hammond PJ, Gomis R et al (2006) Comparison of the effects of continuous subcutaneous insulin infusion (CSII) and NPH-based multiple daily insulin injections (MDI) on glycaemic control and quality of life: results of the 5-nations trial. Diabet Med 23:141–147CrossRefPubMed

64.

Binek A, Rembierz-Knoll A, Polanska J, Jarosz-Chobot P (2016) Reasons for the discontinuation of therapy of personal insulin pump in children with type 1 diabetes. Pediatr Endocrinol Diabetes Metab 21:65–69CrossRefPubMed

65.

Overgaard Ingeholm I, Svensson J, Olsen B et al (2015) Characterization of metabolic responders on CSII treatment amongst children and adolescents in Denmark from 2007 to 2013. Diabetes Res Clin Pract 109:279–286CrossRefPubMed

66.

Blackman SM, Raghinaru D, Adi S et al (2014) Insulin pump use in young children in the T1D exchange clinic registry is associated with lower hemoglobin A1c levels than injection therapy. Pediatr Diabetes 15:564–572CrossRefPubMed

67.

Liebl A, Hoogma R, Renard E et al (2009) A reduction in severe hypoglycaemia in type 1 diabetes in a randomized crossover study of continuous intraperitoneal compared with subcutaneous insulin infusion. Diabetes Obes Metab 11:1001–1008CrossRefPubMed

68.

Norgaard K, Scaramuzza A, Bratina N et al (2013) Routine sensor-augmented pump therapy in type 1 diabetes: the INTERPRET study. Diabetes Technol Ther 15:273–280CrossRefPubMedPubMedCentral

69.

Schutt M, Kern W, Krause U et al (2006) Is the frequency of self-monitoring of blood glucose related to long-term metabolic control? Multicenter analysis including 24,500 patients from 191 centers in Germany and Austria. Exp Clin Endocrinol Diabetes 114:384–388CrossRefPubMed

70.

O’Connell MA, Donath S, Cameron FJ (2011) Poor adherence to integral daily tasks limits the efficacy of CSII in youth. Pediatr Diabetes 12:556–559PubMed

71.

Battelino T, Conget I, Olsen B et al (2012) The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomised controlled trial. Diabetologia 55:3155–3162CrossRefPubMedPubMedCentral

72.

Raccah D, Sulmont V, Reznik Y et al (2009) Incremental value of continuous glucose monitoring when starting pump therapy in patients with poorly controlled type 1 diabetes: the RealTrend study. Diabetes Care 32:2245–2250CrossRefPubMedPubMedCentral

73.

Wong JC, Foster NC, Maahs DM et al (2014) Real-time continuous glucose monitoring among participants in the T1D Exchange clinic registry. Diabetes Care 37:2702–2709CrossRefPubMedPubMedCentral

74.

Picard S, Hanaire H, Baillot-Rudoni S et al (2016) Evaluation of the adherence to continuous glucose monitoring in the management of type 1 diabetes patients on sensor-augmented pump therapy: the SENLOCOR study. Diabetes Technol Ther 18:127–135CrossRefPubMed

75.

Kovatchev BP, Patek SD, Ortiz EA, Breton MD (2015) Assessing sensor accuracy for non-adjunct use of continuous glucose monitoring. Diabetes Technol Ther 17:177–186CrossRefPubMedPubMedCentral

76.

Basu A, Dube S, Veettil S et al (2015) Time lag of glucose from intravascular to interstitial compartment in type 1 diabetes. J Diabetes Sci Technol 9:63–68CrossRefPubMed

77.

Steil GM, Rebrin K, Hariri F et al (2005) Interstitial fluid glucose dynamics during insulin-induced hypoglycaemia. Diabetologia 48:1833–1840CrossRefPubMed

78.

Klonoff DC, Ahn D, Drincic A (2017) Continuous glucose monitoring: a review of the technology and clinical use. Diabetes Res Clin Pract 133:178–192CrossRefPubMed

79.

Buckingham B, Block J, Burdick J et al (2005) Response to nocturnal alarms using a real-time glucose sensor. Diabetes Technol Ther 7:440–447CrossRefPubMedPubMedCentral

80.

Barnard KD, Wysocki T, Thabit H et al (2015) Psychosocial aspects of closed- and open-loop insulin delivery: closing the loop in adults with type 1 diabetes in the home setting. Diabet Med 32:601–608CrossRefPubMed

81.

Anderbro T, Amsberg S, Adamson U et al (2010) Fear of hypoglycaemia in adults with type 1 diabetes. Diabet Med 27:1151–1158CrossRefPubMed

82.

Smith CB, Choudhary P, Pernet A, Hopkins D, Amiel SA (2009) Hypoglycemia unawareness is associated with reduced adherence to therapeutic decisions in patients with type 1 diabetes: evidence from a clinical audit. Diabetes Care 32:1196–1198CrossRefPubMedPubMedCentral

83.

Rogers HA, de Zoysa N, Amiel SA (2012) Patient experience of hypoglycaemia unawareness in type 1 diabetes: are patients appropriately concerned? Diabet Med 29:321–327CrossRefPubMed

84.

Lawton J, Rankin D, Elliott J et al (2014) Experiences, views, and support needs of family members of people with hypoglycemia unawareness: interview study. Diabetes Care 37:109–115CrossRefPubMed

85.

de Zoysa N, Rogers H, Stadler M et al (2014) A psychoeducational program to restore hypoglycemia awareness: the DAFNE-HART pilot study. Diabetes Care 37:863–866CrossRefPubMed

Be confident that your patient care is up to date

Medicine Matters is being incorporated into Springer Medicine, our new medical education platform.

Alongside the news coverage and expert commentary you have come to expect from Medicine Matters diabetes, Springer Medicine's complimentary membership also provides access to articles from renowned journals and a broad range of Continuing Medical Education programs. Create your free account »

Medicine Matters Diabetes

Abstract

Be confident that your patient care is up to date