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Progress in Insulin Management

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Editorial comment by Vivian Fonseca: Effects of Sotagliflozin Added to Insulin in Patients with Type 1 Diabetes

Achieving optimal glycemic control in type 1 diabetes remains challenging despite advances in insulins, pumps CGM etc. It is particularly hard to reduce variability in blood glucose from day to day with frequent high and low blood glucose causing patients a lot of distress. The application of knowledge gained from treating type 2 diabetes with new drugs may help alleviate these problems …

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  • Effects of Sotagliflozin Added to Insulin in Patients with Type 1 Diabetes

    Garg SK, Henry RR, Banks P, Buse JB, Davies MJ, et al.

    N Engl J Med. 2017 Sep 13. doi: 10.1056/NEJMoa1708337.

    Editorial comment by Vivian Fonseca

    Achieving optimal glycemic control in type 1 diabetes remains challenging despite advances in insulins, pumps CGM etc. It is particularly hard to reduce variability in blood glucose from day to day with frequent high and low blood glucose causing patients a lot of distress. The application of knowledge gained from treating type 2 diabetes with new drugs may help alleviate these problems.

    SGLT2 inhibitors are approved for treating type 2 diabetes and lower glucose by increasing glycosuria and work independent of insulin secretion / action etc., thus raising the possibility of using the drugs in type 1 diabetes. Small clinical trials have previously demonstrated a benefit with this class. Sotagliflozin is a new drug in this class that also inhibits SGLT1, which is present in the kidney and also the gut. It could therefore increase glycosuria further and decrease glucose absorption in the gut as well – both independent of insulin.

    This large clinical trial demonstrates a beneficial effect of the drug in improving glucose control and getting more patients’ A1c below 7 % than with insulin alone. Further addition of the drug led to weight loss and a decrease in blood pressure (both known effects of the class), as well as reduction in hypoglycemia (perhaps due to less insulin use). Thus, the benefits appear very promising. There was, however, an increase in keto acidosis – a problem previously recognized with this class, and some caution is needed with this possible side effect as it may not be always recognized.

  • Cumulative Kidney Complication Risk by 50 Years of Type 1 Diabetes: The Effects of Sex, Age, and Calendar Year at Onset

    Costacou T, Orchard TJ.

    Diabetes Care. 2017 Sep 20. pii: dc171118. doi: 10.2337/dc17-1118.

    Editorial comment by Vivian Fonseca

    Over the last 2-3 decades glycemic control has improved in type 1 diabetes, and other advances in health care have led to improved life expectancy in this disease with a large number of patients living with the disease for > 50 years. This gives us an opportunity to study the long term effect of the disease, that previously resulted in premature death at a young age. Interestingly a proportion of people with type 1 diabetes remain free of complications, though most get some degree of microvascular disease.

    This new study by Castacou and Orchard focuses on kidney disease in a cohort with long-standing disease. Despite a decline in rate of this complication in the last few years (perhaps related to widespread use of RAAS blockade), a significant proportion of patients develop end-stage renal disease (ESRD). Some of this may relate to hypoglycemia, complexity and cost of optimal treatment (pumps and CGMS etc.) leading to suboptimal control of both glucose and BP in a lot of patients. However, further research is needed to identify treatment targets beyond the RAAS system to treat advancing renal disease in patients with long standing diabetes. 

  • Accuracy and Longevity of an Implantable Continuous Glucose Sensor in the PRECISE Study: A 180-Day, Prospective, Multicenter, Pivotal Trial

    Kropff J, Choudhary P, Neupane S, Barnard K, Bain SC, Kapitza C, Forst T, Link M, Dehennis A, DeVries JH

    Diabetes Care 2017 Jan; 40(1): 63-68

    Editorial comment by Sarah Cvach

    Continuous Glucose Monitoring (CGM) has reached a certain level of use in the diabetes population. People with diabetes frequently use fingerstick capillary measurements to guide their dosing decisions. CGM systems provide glucose data in real time and detect hyper- and hypoglycaemic events and allow receiving trend information, which would not be known with fingerstick measurements alone. People with diabetes get temporal information from some systems which are able to alarm for hypo- or hyperglycaemic events. CGM systems on the one hand reduce the need for fingerstick testing and effectively lower mean glucose, but on the other hand the wear time of current transcutaneous CGM is low in some populations. Implantable CGM systems may provide additional ease of use over transcutaneous CGM.

    The current study used Eversense, an implantable CGM sensor in 71 participants with type 1 and 2 diabetes in a 180-day multinational, multicentre, pivotal trial. CGM accuracy was assessed with the mean absolute relative difference (MARD) for venous reference glucose values >4.2mmol/L (75mg/dL) as the primary endpoint. Secondary endpoints included alarm performance and Clark Error Grid Analysis. The primary safety outcome was device-related serious adverse events.

    The primary efficacy outcome over the study duration showed a MARD for reference samples >4.2mmol/L (75mg/dL) of 11.1%. Eighty-one percent of hypoglycaemic events were detected by the CGM system within 30 minutes. No device-related serious adverse events occurred during the study. Clarke Error Grid Analysis showed 99.2% of samples in the clinically acceptable error zones A and B.

    A quality of life questionnaire indicated a high device acceptance: “Using the system helped minimize the burden of diabetes in my life” got a 90% rating of 5 or higher on the scoring range from 1–7.

    Sensor survival at day 90 was estimated to be 82%. Median sensor lifetime is 149 days.

    The results seem to indicate the safety and accuracy of this new type of implantable CGM system and support it as an alternative for current transcutaneous CGM. 

  • Efficacy and Safety of Mini-dose Glucagon for Treatment of Non-severe Hypoglycemia in Adults with Type 1 Diabetes

    Haymond MW, DuBose SN, Rickels MR, Wolpert H, et al.

    J Clin Endocrinol Metab. 2017 Jun 7. doi: 10.1210/jc.2017-00591
  • The Risk of Severe Hypoglycemia in Type 1 Diabetes Over 30 Years of Follow-up in the DCCT/EDIC Study

    Gubitosi-Klug RA, Braffett BH, White NH, Sherwin RS, et al.

    Diabetes Care. 2017 May 26. pii: dc162723. doi: 10.2337/dc16-2723

Welcome Message by Stephen Colagiuri, Editor in Chief

  • We are all aware that diabetes is a major global health problem, affecting millions of people worldwide. Addressing global problems requires a combination of global resources and individual effort.


Editorial Board

Xavier Cos

Director of Sant Martí Primary Health Centres (Catalonian Health Institute), Barcelona, Spain.

Vivian Fonseca

Vivian A. Fonseca was awarded a Bachelor of Medicine and a Bachelor of Surgery from the Armed Forces Medical College in Poona, India, and earned his MD from University of Bombay.

Kamlesh Khunti

Professor, Primary Care Diabetes and Vascular Medicine, University of Leicester, Leicester, UK

Chantal Mathieu

Professor of Medicine and Chair of Endocrinology, Catholic University of Leuven and University Hospital Gasthuisberg, Leuven, Belgium

Thomas Pieber

Head of the Division of Endocrinology and Metabolism, Department of Internal Medicine at the Medical University Graz.

Sarah Cvach

Vice chair of Association of Austrian Diabetes Educators (VÖD) and member of FEND, EASD, IDF, ÖDG, ÖGKV and the committee for diabetes prevention of the Austrian Diabetes Association. Experienced clinical trials coordinator.

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