A Conversation on an Effective, Straightforward, Quantitative Approach to the Outpatient Use of Insulin

For primary care providers, using insulin can present challenges that can be met by a straightforward approach using the following principles. Depending on when it is injected, each component of the insulin regimen has a maximal effect on a specific period of the 24-hour cycle (e.g., overnight, morning, afternoon, or evening). The glucose pattern in that period determines whether the dose of that component of the insulin regimen requires adjusting. Regarding which insulin types and insulin regimens to use, human insulin (NPH and regular) is as effective as analog insulins, and a two-injection intensified insulin regimen is as effective as a four-injection regimen.

Universal Subsidized Continuous Glucose Monitoring Funding for Young People With Type 1 Diabetes: Uptake and Outcomes Over 2 Years, a Population-Based Study

<b>Objective:</b> Continuous glucose monitoring (CGM) is increasingly used in type 1 diabetes management however funding models vary. This study determined the uptake rate and glycaemic outcomes following a change in national health policy to introduce universal subsidised CGM funding for people with type 1 diabetes aged < 21 years. <p><b>Research Design and Methods:</b> Analysis of longitudinal data from 12 months prior to subsidy until 24 months after. Measures and outcomes included age, diabetes duration, HbA1c, episodes of diabetic ketoacidosis and severe hypoglycaemia, insulin regimen, CGM uptake and percentage CGM use. Two data sources were used: the Australasian Diabetes Database Network (ADDN) registry (a prospective diabetes database) and the National Diabetes Supply Scheme (NDSS) registry that includes almost all individuals with type 1 diabetes nationally.</p> <p><b>Results:</b> CGM uptake increased from 5% pre-subsidy to 79% after two years. After CGM introduction, the odds ratio (OR) of achieving the HbA1c target of <7.0% improved at 12 months (OR 2.5, p<0.001) and was maintained at 24 months (OR 2.3, p<0.001). The OR for suboptimal glycaemic control (HbA1c ≥ 9.0%) decreased to 0.34 (p<0.001) at 24 months. Of CGM users, 65% used CGM >75% of time: these had a lower HbA1c at 24 months compared to those with usage <25% (7.8±1.3% vs 8.6±1.8%, respectively, p<0.001). DKA was also reduced in this group (IRR 0.49, 95% CI 0.33-0.74, p<0.001).</p> <b>Conclusions:</b> <a></a>Following national subsidy, CGM use was high and associated with sustained improvement in glycaemic control. This information will inform economic analyses and future policy and serve as a model of evaluation diabetes technologies.

Universal Subsidized Continuous Glucose Monitoring Funding for Young People With Type 1 Diabetes: Uptake and Outcomes Over 2 Years, a Population-Based Study

<b>Objective:</b> Continuous glucose monitoring (CGM) is increasingly used in type 1 diabetes management however funding models vary. This study determined the uptake rate and glycaemic outcomes following a change in national health policy to introduce universal subsidised CGM funding for people with type 1 diabetes aged < 21 years. <p><b>Research Design and Methods:</b> Analysis of longitudinal data from 12 months prior to subsidy until 24 months after. Measures and outcomes included age, diabetes duration, HbA1c, episodes of diabetic ketoacidosis and severe hypoglycaemia, insulin regimen, CGM uptake and percentage CGM use. Two data sources were used: the Australasian Diabetes Database Network (ADDN) registry (a prospective diabetes database) and the National Diabetes Supply Scheme (NDSS) registry that includes almost all individuals with type 1 diabetes nationally.</p> <p><b>Results:</b> CGM uptake increased from 5% pre-subsidy to 79% after two years. After CGM introduction, the odds ratio (OR) of achieving the HbA1c target of <7.0% improved at 12 months (OR 2.5, p<0.001) and was maintained at 24 months (OR 2.3, p<0.001). The OR for suboptimal glycaemic control (HbA1c ≥ 9.0%) decreased to 0.34 (p<0.001) at 24 months. Of CGM users, 65% used CGM >75% of time: these had a lower HbA1c at 24 months compared to those with usage <25% (7.8±1.3% vs 8.6±1.8%, respectively, p<0.001). DKA was also reduced in this group (IRR 0.49, 95% CI 0.33-0.74, p<0.001).</p> <b>Conclusions:</b> <a></a>Following national subsidy, CGM use was high and associated with sustained improvement in glycaemic control. This information will inform economic analyses and future policy and serve as a model of evaluation diabetes technologies.

Faster Aspart: a fast-acting insulin analog for an optimal glycemic control

The basal-bolus insulin regimen in the management of diabetes is essential to achieve the recommended glycosylated hemoglobin (HbA1c) to reduce the incidence or the progression of chronic complications. HbA1c is influenced by either fasting plasma glucose and post-prandial hyperglycemia. Faster Aspart is an insulin Aspart with two additional excipients, L-arginine and niacinamide, which provide a faster subcutaneous absorption, the earlier onset of appearance, and consequently the optimization of post-prandial glucose control. Faster Aspart has been widely investigated in the ‘‘onset’’ clinical trials, which show better post-prandial glycemic excursions and noninferiority compared to insulin Aspart with HbA1c reduction. Clinical evidence demonstrates that faster Aspart is a therapeutic option able to provide clinical benefits over the current rapid-acting insulin analogs in terms of improved meal-related glycaemic control in subjects with diabetes. KEY WORDS post-prandial hyperglycemia; cardiovascular disease; insulin treatment; faster-acting insulin; faster aspart.

Drug induced Diabetes Mellitus (DIDM) in Pediatric Acute Lymphoblastic Leukemia (ALL): Approach to diagnosis and management

Corticosteroids and L-asparaginase used in the treatment of pediatric acute lymphoblastic leukemia (ALL) results in Drug induced Diabetes Mellitus (DIDM). Literature on the management of DIDM among children with ALL is sparse and the diagnostic criteria for pediatric diabetes should be carefully applied considering the acute and transient nature of DIDM during ALL therapy. Insulin remains the standard of care for DIDM management and the choice of Insulin regimen (standalone Neutral Protamine Hagedorn (NPH) or basal bolus) should be based on the type and dose of steroids used for ALL and the pattern of hyperglycemia. A modest glycemic control (140-180 mg/dl) to achieve euglycemia and prevent hypoglycemia would be the general approach. This review is intended to suggest a evidence based practical guidance in the diagnosis and management of DIDM during pediatric ALL therapy.

Evaluation the effects of insulin on oxidant/antioxidant status in type 1 diabetic patients

Earlier works have revealed increased generation of reactive oxygen species (ROS) and decreased antioxidant levels in type 1 diabetes mellitus (T1DM). The current study aimed to investigate the effect of mixed insulin therapy on oxidative stress and antioxidant status in patients with T1DM. This study involved 75 participants who were divided into three groups: 20 healthy subjects as a control, 25 newly diagnosed patients with T1DM (without treatment) and 30 patients with T1DM treated with insulin (regular and Human Neutral Protamine Hagedorn (NPH)) twice daily. Fasting serum glucose (FSG), serum concentrations of insulin, malondialdehyde (MDA), catalase (CAT), reduced glutathione (GSH), and vitamins (C and E) were measured in all participants. Compared with the healthy control, serum glucose and MDA concentrations were observed to be significantly higher, while significantly lower concentrations of CAT, GSH, and vitamins (C and E) were found in both the treated and untreated diabetic groups. Although insulin therapy caused a significant decrease in blood sugar with a marked elevation in the levels of insulin, CAT, GSH and vitamin E compared to the untreated patients, the changes in the levels of MDA and vitamin C between diabetic groups were not significant. Moreover, the level of insulin resistance was significantly increased in insulin-treated patients as compared to the control and untreated diabetic groups. In conclusion, twice daily treatment with regular and NPH insulin can ameliorate hyperglycemia and improve antioxidant levels in patients with T1DM. However, the insulin regimen used in this study did not reveal a beneficial effect on oxidative stress and insulin resistance. Hence, exogenous antioxidants (vitamins C and E) can be used in combination with insulin to control these parameters.

Acute Hepatitis due to Hepatic Glycogenosis after Insulin Overdose and Oral Glucose Administration in an Adolescent

Background Hepatic glycogenosis (HG) has been reported after intravenous (IV) dextrose administration to treat insulin overdose. We describe a case of HG in a patient with T1DM due to insulin overdose treated with oral glucose administration. Clinical course An adolescent boy with T1DM on a basal bolus insulin regimen presented with abdominal discomfort, nausea, vomiting and hypoglycemia of few hours. His glucose was 71 mg/dl, AST 119 U/L and ALT 65 U/L. Hypoglycemia was treated with juice, and 12 hours later AST and ALT were 979 U/L and 700 U/L respectively. Work up for infectious, autoimmune, metabolic, and toxic causes of hepatitis was negative. The transaminases improved by the next day and normalized within 3 weeks. Two weeks after discharge the patient returned with hypoglycemia, nausea, and right sided abdominal pain of 13 hours. Hypoglycemia persisted despite multiple courses of glucose tablets and juice. Laboratory studies showed glucose 58 mg/dl, AST 776 U/L, ALT 496 U/L, negative toxicology studies, and normal abdominal ultrasound. His serum insulin level was 249.7 mU/L and, c-peptide was &lt;0.1 ng/ml consistent with insulin overdose. He received IV fluids with dextrose, and insulin was held. Transaminases improved by the following day. Repeat serum insulin while on home regimen was normal. Conclusions Along with other diagnoses, HG should be considered in patients treated with insulin who present with hypoglycemia and acute hepatitis. HG can occur in cases of insulin overdose treated with repeated oral glucose administration.

Elevated lactate in Mauriac syndrome: still a mystery

Background The Mauriac syndrome was described in 1930 as a peculiar combination of poorly controlled diabetes mellitus type 1, stunted growth and glycogenic hepatopathy. More recently, lactic acidosis was recognized as an additional feature, often induced by insulin treatment. Case presentation A 17-year old girl known for diabetes type 1A and Mauriac syndrome was admitted to the emergency room with hyperglycemia of > 41 mmol/l without ketoacidosis. Under a standard insulin regimen, hyperglycemia was rapidly corrected but marked hyperlactatemia occurred. Conclusions The mechanism of impaired glucose utilization and lactate elevation independent of ketoacidosis in Mauriac syndrome is intriguing. The rarity of Mauriac syndrome and its resemblance to glycogen storage diseases suggest the presence of a specific metabolic or genetic predisposition that remains to be identified.

The Role of SGLT-2 Inhibitors as an Adjuvant to Insulin Therapy in Type-1 Diabetes Mellitus- Literature Review

Background: Type 1 diabetes mellitus is the main risk factor for cardiovascular complications. Therefore, intensified insulin therapy might be needed to achieve better glycemic control in some patients. However, insulin therapy might lead to increase body weight and induce hypoglycemia. Increase body weight is directly correlated to insulin resistance, the main factor for cardiovascular risk. Objective: To assess the effectiveness of adding SGLT2 inhibitors to insulin therapy in type 1 diabetes mellitus. Methods: We searched in the PubMed database looking for relevant articles on the topic. We used Mesh words search, including SGLT2 inhibitor, sotagliflozin, type 1 diabetes mellitus, insulin treatment. Conclusion: Adding oral antidiabetic agents, such as SGLT2 or dual SGLT inhibitors to insulin regimen might be beneficial in improving insulin resistance. Thus, it achieved better insulin resistance by decrease daily insulin requirements and bodyweight control, leading to better cardiovascular outcomes among Type-1 diabetes patients.

ANALYSIS OF PERI-OPERATIVE BLOOD SUGAR LEVELS IN VARIOUS ANESTHETIC APPROACHES IN NON-DIABETIC AND DIABETIC PATIENTS: COMPARATIVE STUDY FROM CENTRAL INDIA

Surgical procedures cause a stress response, which results in biochemical and hormonal changes. Elevated blood sugar is the most well-known metabolic disorder. Inadequate glycemic regulation affects perioperative morbidity and mortality. The hyperglycemic reaction varies depending on the anesthetic agent and technique used. The study's aim is to compare non-diabetics and diabetics in terms of the degree to which blood sugar levels rise as a measure of stress during anesthesia and surgery under different anesthetic techniques (controlled). Ninety adult patients (30 to 55 years old) underwent various elective surgeries lasting 60 to 90 minutes under three anesthetic techniques (general (GA), epidural (EA), and spinal (SA)) at a tertiary healthcare center in Central India. 45 of the patients were not diabetic and 45 were diabetics under care. Blood sugar levels were compared between three techniques in each group and between similar techniques in both groups. Blood sugar fluctuation is less with regional techniques and much less with spinal analgesia in diabetics and non-diabetics. Wherever possible, regional techniques can reduce a diabetic's response to surgical stress. The need for an intraoperative insulin regimen may not be required in all procedures, but it is more dependent on the length and severity of the procedure. Glycemic regulation is easier in spinal anesthesia than in general anesthesia since the stress response to surgery is comparatively lower. Where necessary, we prefer spinal anesthesia to epidural and general anesthesia for minimizing surgical stress response.