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

Choudhary, Pratik; Amiel, Stephanie A.

doi:10.1007/s00125-018-4566-6

Cited by 45 publications

(37 citation statements)

References 87 publications

(103 reference statements)

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“…Finally, habituation is best treated by avoidance of the habituating stimulus, namely hypoglycaemia, and this is currently best achieved through structured education, as discussed by Iqbal and Heller [8]. Further, for some individuals, habituation leads to chronic behavioural change that may require additional interventions, such as cognitive behavioural therapy, to support hypoglycaemia avoidance strategies, as discussed by Choudhary and Amiel [9]. In the future, novel strategies such as dishabituation or pharmacological interventions may also be an option as part of the package of care required to restore or reverse IAH.…”

Section: Discussionmentioning

confidence: 99%

“…In this review and the accompanying reviews by Iqbal and Heller [8] and Choudhary and Amiel [9], we outline our current understanding of why people with type 1 and longduration type 2 diabetes develop IAH and consider the options that are currently available to prevent IAH or restore hypoglycaemia awareness. Specifically, in this review, we briefly outline the principal reasons why people with diabetes are prone to hypoglycaemia and discuss the mechanisms that may contribute to the development of IAH.…”

Section: The Clinical Importance Of Impaired Hypoglycaemia Awarenessmentioning

confidence: 99%

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Impaired hypoglycaemia awareness in type 1 diabetes: lessons from the lab

McNeilly

McCrimmon

2018

Diabetologia

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Hypoglycaemia remains the most common metabolic adverse effect of insulin and sulfonylurea therapy in diabetes. Repeated exposure to hypoglycaemia leads to a change in the symptom complex that characterises hypoglycaemia, culminating in a clinical phenomenon referred to as impaired awareness of hypoglycaemia (IAH). IAH effects approximately 20-25% of people with type 1 diabetes and increases the risk of severe hypoglycaemia. This review focuses on the mechanisms that are responsible for the much higher frequency of hypoglycaemia in people with diabetes compared with those without, and subsequently how repeated exposure to hypoglycaemia leads to the development of IAH. The mechanisms that result in IAH development are incompletely understood and likely to reflect changes in multiple aspects of the counterregulatory response to hypoglycaemia, from adaptations within glucose and non-glucose-sensing cells to changes in the integrative networks that govern glucose homeostasis. Finally, we propose that the general process that incorporates many of these changes and results in IAH following recurrent hypoglycaemia is a form of adaptive memory called 'habituation'. external assistance to recover) [3,4], which has a wellrecognised impact on morbidity and mortality in those with type 1 diabetes [5] and places a significant psychosocial burden on family members involved with their care [6]. IAH also occurs in type 2 diabetes, affecting up to 10% of patients with insulin-treated type 2 diabetes and markedly increasing risk of severe hypoglycaemia [7]. In this review and the accompanying reviews by Iqbal and Heller [8] and Choudhary and Amiel [9], we outline our current understanding of why people with type 1 and longduration type 2 diabetes develop IAH and consider the options that are currently available to prevent IAH or restore hypoglycaemia awareness. Specifically, in this review, we briefly outline the principal reasons why people with diabetes are prone to hypoglycaemia and discuss the mechanisms that may contribute to the development of IAH. We also propose the hypothesis that IAH may result from a special form of adaptive memory called 'habituation'. Why do people with diabetes develop hypoglycaemia?Although hypoglycaemia can occur in people without diabetes (e.g. 'reactive hypoglycaemia'), it is not common and, with the exception of hypoglycaemia occurring during severe sepsis or malnutrition, it is not usually severe or of potential pathological consequence. As a fuel, glucose is so fundamental to the survival of an organism that multiple systems are in play to ensure that a continuous supply of glucose is provided to the tissues of the body. These systems act in concert to ensure that glucose utilisation by the brain, liver, muscle and adipose tissue (white and brown), and glucose production and release into the blood stream by the liver and kidney, are tightly regulated. It seems highly likely that these systems do not exist in isolation but form parts of a highly integrated network designed both to moni...

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Section: Discussionmentioning

confidence: 99%

Section: The Clinical Importance Of Impaired Hypoglycaemia Awarenessmentioning

confidence: 99%

Impaired hypoglycaemia awareness in type 1 diabetes: lessons from the lab

McNeilly

McCrimmon

2018

Diabetologia

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“…5. Dealing with impaired awareness of hypoglycemia [191]: If found in severe cases of HH it can be formally assessed using the validated Clarke [192] or Gold score [193]. The evidence base for managing impaired awareness of hypoglycemia is limited in the context of HH [194] and so, care is needed in managing these individuals.…”

Section: Empowering Self-managementmentioning

confidence: 99%

Hyperinsulinemic hypoglycemia in children and adolescents: Recent advances in understanding of pathophysiology and management

Güemes

Rahman

Kapoor

et al. 2020

Rev Endocr Metab Disord

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Hyperinsulinemic hypoglycemia (HH) is characterized by unregulated insulin release, leading to persistently low blood glucose concentrations with lack of alternative fuels, which increases the risk of neurological damage in these patients. It is the most common cause of persistent and recurrent hypoglycemia in the neonatal period. HH may be primary, Congenital HH (CHH), when it is associated with variants in a number of genes implicated in pancreatic development and function. Alterations in fifteen genes have been recognized to date, being some of the most recently identified mutations in genes HK1, PGM1, PMM2, CACNA1D, FOXA2 and EIF2S3. Alternatively, HH can be secondary when associated with syndromes, intra-uterine growth restriction, maternal diabetes, birth asphyxia, following gastrointestinal surgery, amongst other causes. CHH can be histologically characterized into three groups: diffuse, focal or atypical. Diffuse and focal forms can be determined by scanning using fluorine-18 dihydroxyphenylalanine-positron emission tomography. Newer and improved isotopes are currently in development to provide increased diagnostic accuracy in identifying lesions and performing successful surgical resection with the ultimate aim of curing the condition. Rapid diagnostics and innovative methods of management, including a wider range of treatment options, have resulted in a reduction in co-morbidities associated with HH with improved quality of life and long-term outcomes. Potential future developments in the management of this condition as well as pathways to transition of the care of these highly vulnerable children into adulthood will also be discussed.

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“…Both CSII and MDI have evolved and improved in recent decades so that the comparative treatment effects of trials of the 1980 and 1990s are no longer valid for current practice. This is because the introduction of several pump features that were not part of first‐generation CSII has notably improved metabolic control, such as bolus calculators , different meal profiles , computer download of data and continuous glucose monitoring (CGM) connectivity, with or without threshold or predictive low‐glucose basal insulin rate suspend .…”

Section: Difficulties In Interpreting Studies On Csii Effectivenessmentioning

confidence: 99%

Is insulin pump therapy effective in Type 1 diabetes?

Pickup

2018

Diabet. Med.

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There continues to be uncertainty about the effectiveness in Type 1 diabetes of insulin pump therapy (continuous subcutaneous insulin infusion, CSII) vs. multiple daily insulin injections (MDI). This narrative review discusses the reasons for this uncertainty, summarizes the current evidence base for CSII and suggests some future research needs. There are difficulties in interpreting trials of CSII because effectiveness varies widely due to factors such as differing baseline control, suboptimal use of best CSII practices, and psychological factors, for example, high external locus of control, non-adherence and lack of motivation. Many summary meta-analyses are also misleading because of poor trial selection (e.g. short duration, obsolete pumps, low baseline rate of hypoglycaemia) and reliance on mean effect size for decision-making. Both MDI and CSII can achieve strict glycaemic control without hypoglycaemia in some people with Type 1 diabetes, especially those who are motivated and have undergone structured diabetes education, and with high levels of ongoing input from healthcare professionals. CSII is particularly effective in those people with Type 1 diabetes who have not achieved target HbA levels without disabling hypoglycaemia using best attempts with MDI, and here there can be valuable and substantial improvement. Insulin pumps are safe, effective and accepted when used in newly diagnosed diabetes, particularly in children, where MDI may not be practicable. Future research needs include more studies on mortality associated with insulin pumps where registry data have suggested lower rates vs. MDI; and psychological strategies to improve non-adherence and suboptimal glycaemic outcomes on CSII.

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

Cited by 45 publications

References 87 publications

Impaired hypoglycaemia awareness in type 1 diabetes: lessons from the lab

Impaired hypoglycaemia awareness in type 1 diabetes: lessons from the lab

Hyperinsulinemic hypoglycemia in children and adolescents: Recent advances in understanding of pathophysiology and management

Is insulin pump therapy effective in Type 1 diabetes?

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