The Development of New Composite Metrics for the Comprehensive Analytic and Visual Assessment of Hypoglycemia Using the Hypo-Triad

Abstract

Self-monitoring of blood glucose (SMBG) is the standard method by which the vast majority of patients assess their diabetes control. By virtue of the episodic nature, the limited number of times per day that it is actually performed, and the infrequent testing at night, SMBG can provide only a partial view of the frequency and severity of hypoglycemia. While multiple studies have used the nadir of the glucose level to differentiate between mild and severe hypoglycemia, 1-3 it is not possible to infer the intensity of hypoglycemia from SMBG because the duration of hypoglycemia is not known. This limits our ability to interpret the effect of various interventions for improving glycemic control as well as our understanding of the short-and long-term risks associated with hypoglycemia. On the other hand, continuous glucose monitoring (CGM) collects data on the frequency, duration and severity of hypoglycemia whether or not it is symptomatic. 4-6 The hypoglycemia triad (Hypo-Triad) consists of the three metrics that are usually reported in trials using CGM-area under the curve (AUC), time in hypoglycemia, and frequency of hypoglycemic excursions per day. However, it is unclear which individual metric or combination of metrics of the Hypo-Triad best characterizes the clinical and pathophysiologic impact of hypoglycemia. Figure 1 shows an example of a CGM tracing with two hypoglycemic episodes with different characteristics. Therefore, we developed two new 721242D STXXX10.

The Comprehensive Glucose Pentagon: A Glucose-Centric Composite Metric for Assessing Glycemic Control in Persons With Diabetes

“…The first is the intensity of hypoglycemia, which is not the product of duration and AUC, but rather the vector of these two metrics as described in the companion paper. 27 The inclusion of duration in both of the intensity terms provides additional weighting of this important metric, which is generally expressed as simple individual terms of frequency, duration, and/or AUC. There have been numerous ways to define hypoglycemia both clinically and numerically and but 28 and in an accompanying consensus document by the International Hypoglycemia Study Group, 29 there are revised definitions of clinical and biochemical hypoglycemia However, the biochemical definitions are unidimensional when obtained by blood glucose testing and thus provide no information about the depth or duration of hypoglycemia over time.…”

“…The first is the intensity of hypoglycemia, which is not the product of duration and AUC, but rather the vector of these two metrics as described in the companion paper. 27 The inclusion of duration in both of the intensity terms provides additional weighting of this important metric, which is generally expressed as simple individual terms of frequency, duration, and/or AUC. There have been numerous ways to define hypoglycemia both clinically and numerically and but no consensus has been reached until recently.…”

Going beyond HbA1c to understand the benefits of advanced diabetes therapies

“…Several published studies have used composite metrics, usually combining HbA1c with hypoglycemia or mean glucose with hypoglycemia, to display outcomes of intervention studies. We have developed a three‐component metric (“hypo‐triad”) and a five‐component metric (comprehensive glucose pentagon [CGP]) to help clinicians, researchers and patients better understand overall glycemic control at a glance …”

“…We have developed a three-component metric ("hypo-triad") and a five-component metric (comprehensive glucose pentagon [CGP]) to help clinicians, researchers and patients better understand overall glycemic control at a glance. 16,17 The "hypo-triad" uses frequency, severity and time to numerically and graphically display CGM data. An example of how the "hypo-triad" can provide a robust understanding is shown in Figure 2, where the CGM data from the first randomized controlled trial of a low glucose suspend (LGS) pump are displayed at baseline and at the end of 3 months in the control group (using a sensor-augmented pump [SAP]) and in the LGS group.…”

A Review of Continuous Glucose Monitoring-Based Composite Metrics for Glycemic Control

“…The Hypo-triad 31 uses three components in a threedimensional space model. This metric is made up of two composite metrics of glycemic fluctuations that are each twodimensional planes: intensity of hypoglycemia (IntHypo) and hypoglycemia risk volume (HypoRV).…”