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Introduction: The UK national pediatric diabetes audit reports higher HbA1c for children and young people (CYP) with type 1 diabetes (T1D) of Black ethnicity compared with White counterparts. This is presumably related to higher mean blood glucose (MBG) due to lower socioeconomic status (SES) and less access to technology. We aimed to determine if HbA1c ethnic disparity persists after accounting for the above variables., Research Design and Methods: A retrospective analysis of participants who received structured education in continuous glucose monitoring (CGM) use was conducted at a tertiary center. HbA1c was paired with glucose metrics from 90-day CGM data. The influence of ethnicity, SES determined by Index of Multiple Deprivation (IMD), MBG and other covariates on HbA1c was evaluated using multiple variable regression analysis. Occurrence of hypoglycemia was evaluated., Results: A total of 168 (79 White, 61 South Asian, 28 Black) CYP with T1D were included. There were no differences between groups for age, MBG, time in range (3.9-10.0 mmol/L), diabetes duration, gender, insulin delivery method (multiple daily injections vs continuous subcutaneous insulin infusion), or percent sensor use (PSU). In multiple variable analysis, MBG (p<0.0001), ethnicity (p<0.0001), age (p<0.001), duration of diabetes (p<0.01) and PSU (p<0.05) accounted for 81% of the variability in HbA1c. Adjusted HbA1c in the Black group (67 mmol/mol) was higher than both South Asian (63 mmol/mol) and White groups (62 mmol/mol) (p<0.001). Despite significant IMD differences between groups, it did not influence HbA1c. Multiple variable analysis showed that the Black group experienced more hypoglycemia than South Asian and White groups (<3.9 and <3.0 mmol/L, p<0.05)., Conclusions: CYP from Black ethnic backgrounds have a higher HbA1c compared with their South Asian and White counterparts which is clinically significant and independent of MBG, potentially contributing to increased complications risk. Additionally, the Black group experienced a higher incidence of hypoglycemia, possibly due to a treat-to-HbA1c target approach., Competing Interests: Competing interests: JSP: Advisory Board for ROHCE and speaker payments for Dexcom., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Purpose: The optimal design for pharmacoepidemiologic drug-drug interactions (DDIs) studies is unclear. Using the association between concomitant use of sulfonylureas and warfarin and the risk of severe hypoglycemia as a case study, a DDI with little or no clinical impact, we tested whether the prevalent new-user design can be applied in the area., Methods: Among all patients initiating sulfonylureas in the UK's Clinical Practice Research Datalink (1998-2020), we identified those adding-on warfarin while on a sulfonylurea. For each co-exposed patient, we defined a prescription-based exposure set including other sulfonylurea users not adding-on warfarin (comparators). Within each exposure set, we matched each co-exposed patient to five comparators on time-conditional propensity scores (TCPS) and followed them using an as-treated approach. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) of severe hypoglycemia associated with concomitant use of sulfonylureas and warfarin compared to use of sulfonylureas alone. Sensitivity analyses addressed the impact of different potential sources of bias., Results: The study cohort included 17 890 patients co-exposed to sulfonylureas and warfarin and 88 749 matched comparators. After TCPS matching, patient characteristics were well-balanced between groups. Compared to use of sulfonylureas alone, concomitant use of sulfonylureas and warfarin was not associated with the risk of severe hypoglycemia (HR, 1.04; 95% CI, 0.92-1.17). Sensitivity analyses were consistent with the primary analysis (HRs ranging from 1.01 to 1.15, all not statistically significant)., Conclusions: Our study suggests that the prevalent new-user design could be used for the assessment of clinical effects of DDIs., (© 2024 The Author(s). Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.)

Aim: Fluoroquinolone-related hypoglycaemia is rare but may become clinically relevant in individuals at high baseline hypoglycaemic risk, such as patients with diabetes using sulphonylureas. Our population-based cohort study assessed whether fluoroquinolones are associated with an increased risk of severe hypoglycaemia compared with amoxicillin among patients treated with sulphonylureas., Materials and Methods: Using the UK's Clinical Practice Research Datalink Aurum linked to hospitalization and vital statistics data, we assembled a base cohort of patients who initiated second-generation sulphonylureas (1998-2020). The study cohort included patients initiating either fluoroquinolones or amoxicillin while on sulphonylureas. Using an intent-to-treat exposure definition, we assessed the 30-day risk of severe hypoglycaemia (hospitalization with or death because of hypoglycaemia) associated with fluoroquinolones compared with amoxicillin. Cox models estimated hazard ratios (HRs) with 95% confidence intervals (CIs) of severe hypoglycaemia after 1:5 matching on previous sulphonylurea use and propensity scores. Secondary analyses were stratified by demographics and glycated haemoglobin., Results: Overall, 143 417 patients initiated fluoroquinolones (n = 13 123) or amoxicillin (n = 130 294) while on sulphonylureas. Compared with amoxicillin, fluoroquinolones were not associated with the risk of severe hypoglycaemia (HR, 1.17; 95% CI, 0.91-1.50). Fluoroquinolones were associated with an increased risk in patients <65 years (HR, 2.90; 95% CI, 1.41-5.97) but not in those ≥65 years (HR, 1.03; 95% CI, 0.79-1.35) in stratified analyses. There was no evidence of effect modification by sex or glycated haemoglobin., Conclusions: In patients using second-generation sulphonylureas, fluoroquinolones were not associated with an increased risk of severe hypoglycaemia compared with amoxicillin. An increased risk among younger adults is possible., (© 2024 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Aims: Regional variations in the adoption of diabetes technology may be reflected in population-level metrics of glycaemic control. In this observational study, we aimed to assess the glycaemic impacts of transitioning from the Dexcom G5 Real-Time Continuous Glucose Monitoring (RT-CGM) System to the Dexcom G6 in three European countries., Methods: Anonymised RT-CGM data (uploaded to the Dexcom Clarity app) were from users in Germany, Sweden, and the United Kingdom (UK) who transitioned from G5 to G6 between 9-12 months after G6 launched in 2018. Primary endpoints were percent time in hypoglycaemia, percent time in range (TIR), user retention rates, device utilisation, and urgent low soon (ULS) alert utilisation. Metrics were computed for 3-month intervals in the 2-year study window., Results: In all three countries, the transition from G5 to G6 was associated with a clear decrease in hypoglycaemia. In months 0-3 after transitioning, the median percent time 〈3 mmol/L (54 mg/dL) and 〈3.9 mmol/L (70 mg/dL) decreased by [0.12-0.28] and [0.40-0.43] percentage points, respectively, with another [0.11-0.21] and [0.34-0.65] percentage point decrease in months 3-6 in the three countries analysed. TIR and CGM utilisation were sustained or improved slightly across all countries. At the end of the study window, the retention rate was [88.8-94.8%] and ULS utilization was [83.9-86.9%] in the three countries analysed., Conclusions: Similar RT-CGM trends were observed across Germany, Sweden, and the UK. Improvements in hypoglycaemia occurred in all countries. The high retention of users may lead to sustained glycaemic benefits associated with RT-CGM use., (© 2022 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Background: Polycystic kidney disease with hyperinsulinaemic hypoglycaemia (HIPKD) is a recently described disease caused by a single nucleotide variant, c.-167G>T, in the promoter region of PMM2 (encoding phosphomannomutase 2), either in homozygosity or compound heterozygosity with a pathogenic coding variant in trans. All patients identified so far are of European descent, suggesting a possible founder effect., Methods: We generated high density genotyping data from 11 patients from seven unrelated families, and used this information to identify a common haplotype that included the promoter variant. We estimated the age of the promoter mutation with DMLE+ software, using demographic parameters corresponding to the European population., Results: All patients shared a 0.312 Mb haplotype which was absent in 503 European controls available in the 1000 Genomes Project. The age of this mutation was estimated as 105-110 generations, indicating its occurrence around 600 BC, a time of intense migration, which might explain the presence of the same mutations in Europeans around the globe., Conclusion: The shared unique haplotype among seemingly unrelated patients is consistent with a founder effect in Europeans., (© 2021 The Authors. Molecular Genetics & Genomic Medicine published by Wiley Periodicals LLC.)

Aims/hypothesis: Several pathophysiological mechanisms would suggest a causal link between hypoglycaemia and cardiovascular death; conversely, current knowledge would not support a causal relationship with other causes of death. To clarify the nature and the magnitude of the association between hypoglycaemia and death, we investigated the 5 year mortality risks for cardiovascular disease, cancer and other causes in individuals with type 2 diabetes admitted to hospital for a severe hypoglycaemic episode., Methods: We defined in the UK Clinical Practice Research Datalink database a prevalent cohort of adults with type 2 diabetes diagnosed between 1 January 1998 and 1 January 2011 (index date), with available linkage to the Office for National Statistics (ONS) and the Hospital Episode Statistics (HES). A hospital admission reporting hypoglycaemia as the underlying cause was identified before the index date in the HES; date and underlying cause of death were obtained from the ONS. We quantified the 5 year risk of cause-specific death in people with and without admission to hospital for severe hypoglycaemia, adjusting for potential confounders and accounting for competing risk., Results: Of the 74,610 subjects included in the cohort, 388 (0.5%) were admitted at least once for a severe hypoglycaemic episode; subjects admitted were older, with higher HbA 1c and a greater prevalence of multimorbidity. During a median follow-up of 7.1 years, 236 (60.8%) and 18,539 (25.0%) deaths occurred in subjects with and without a previous severe hypoglycaemia, respectively. Non-cardiovascular causes accounted for 71% of all deaths in both subjects with and without hypoglycaemia. In a 60-year-old person with severe hypoglycaemia, the 5 year absolute risk of death, adjusted for age, sex, ethnicity, systolic blood pressure, total cholesterol, HbA 1c , BMI, eGFR, smoking status, alcohol consumption and deprivation (Townsend score), was 6.6%, 1.1% and 13.1% for cardiovascular, cancer and other causes, respectively, while the 5 year absolute risk difference compared with a subject without severe hypoglycaemia was 4.7% (95% CI 1.0, 8.3) for cardiovascular, -1.4% (-4.1, 1.4) for cancer and 11.1% (6.1, 16.1) for other causes of death. Results were consistent in models further adjusted for medications and comorbidities (myocardial infarction, stroke, peripheral artery disease, heart failure, atrial fibrillation, cancer), with sulfonylurea and insulin associated with increased mortality rates (from cause-specific hazard ratio of 1.06 [95% CI 0.99, 1.14] for cancer death with use of sulfonylurea to 1.42 [1.29, 1.56] for cardiovascular death with use of insulin). Results were robust to missing data., Conclusions/interpretation: The results of this study indicate severe hypoglycaemia as a marker of, rather than causally linked to, an increased risk of long-term mortality. Regardless of the nature of the association, a severe hypoglycaemic episode represents a strong negative prognostic factor in patients with type 2 diabetes. Graphical abstract.

Objective: The FreeStyle Libre (FSL) flash glucose-monitoring device was made available on the U.K. National Health Service (NHS) drug tariff in 2017. This study aims to explore the U.K. real-world experience of FSL and the impact on glycemic control, hypoglycemia, diabetes-related distress, and hospital admissions., Research Design and Methods: Clinicians from 102 NHS hospitals in the U.K. submitted FSL user data, collected during routine clinical care, to a secure web-based tool held within the NHS N3 network. The t and Mann-Whitney U tests were used to compare the baseline and follow-up HbA 1c and other baseline demographic characteristics. Linear regression analysis was used to identify predictors of change in HbA 1c following the use of FSL. Within-person variations of HbA 1c were calculated using [Formula: see text]., Results: Data were available for 10,370 FSL users (97% with type 1 diabetes), age 38.0 (±18.8) years, 51% female, diabetes duration 16.0 (±49.9) years, and BMI of 25.2 (±16.5) kg/m 2 (mean [±SD]). FSL users demonstrated a -5.2 mmol/mol change in HbA 1c , reducing from 67.5 (±20.9) mmol/mol (8.3%) at baseline to 62.3 (±18.5) mmol/mol (7.8%) after 7.5 (interquartile range 3.4-7.8) months of follow-up ( n = 3,182) ( P < 0.0001). HbA 1c reduction was greater in those with initial HbA 1c ≥69.5 mmol/mol (>8.5%), reducing from 85.5 (±16.1) mmol/mol (10%) to 73.1 (±15.8) mmol/mol (8.8%) ( P < 0.0001). The baseline Gold score (score for hypoglycemic unawareness) was 2.7 (±1.8) and reduced to 2.4 (±1.7) ( P < 0.0001) at follow-up. A total of 53% of those with a Gold score of ≥4 at baseline had a score <4 at follow-up. FSL use was also associated with a reduction in diabetes distress ( P < 0.0001). FSL use was associated with a significant reduction in paramedic callouts and hospital admissions due to hypoglycemia and hyperglycemia/diabetic ketoacidosis., Conclusions: We show that the use of FSL was associated with significantly improved glycemic control and hypoglycemia awareness and a reduction in hospital admissions., (© 2020 by the American Diabetes Association.)

The month of Ramadan forms one of the five pillars of the Muslim faith. Adult Muslims are obligated to keep daily fasts from dawn to sunset, with exceptions. This year Ramadan is due to begin on 23 April 2020 and the longest fast in the UK will be approximately 18 hours in length. In addition, due to the often high-calorie meals eaten to break the fast, Ramadan should be seen as a cycle of fasting and feasting. Ramadan fasting can impact those with diabetes, increasing the risk of hypoglycaemia, hyperglycaemia and dehydration. This year, Ramadan will occur during the global COVID-19 pandemic. Reports show that diabetes appears to be a risk factor for more severe disease with COVID-19. In addition, the UK experience has shown diabetes and COVID-19 is associated with dehydration, starvation ketosis, diabetic ketoacidosis and hyperosmolar hyperglycaemic state. This makes fasting in Ramadan particularly challenging for those Muslims with diabetes. Here, we discuss the implications of fasting in Ramadan during the COVID-19 pandemic and make recommendations for those with diabetes who wish to fast., (© 2020 Diabetes UK.)

Objective: We analyzed data from inpatients with diabetes admitted to a large university hospital to predict the risk of hypoglycemia through the use of machine learning algorithms., Research Design and Methods: Four years of data were extracted from a hospital electronic health record system. This included laboratory and point-of-care blood glucose (BG) values to identify biochemical and clinically significant hypoglycemic episodes (BG ≤3.9 and ≤2.9 mmol/L, respectively). We used patient demographics, administered medications, vital signs, laboratory results, and procedures performed during the hospital stays to inform the model. Two iterations of the data set included the doses of insulin administered and the past history of inpatient hypoglycemia. Eighteen different prediction models were compared using the area under the receiver operating characteristic curve (AUROC) through a 10-fold cross validation., Results: We analyzed data obtained from 17,658 inpatients with diabetes who underwent 32,758 admissions between July 2014 and August 2018. The predictive factors from the logistic regression model included people undergoing procedures, weight, type of diabetes, oxygen saturation level, use of medications (insulin, sulfonylurea, and metformin), and albumin levels. The machine learning model with the best performance was the XGBoost model (AUROC 0.96). This outperformed the logistic regression model, which had an AUROC of 0.75 for the estimation of the risk of clinically significant hypoglycemia., Conclusions: Advanced machine learning models are superior to logistic regression models in predicting the risk of hypoglycemia in inpatients with diabetes. Trials of such models should be conducted in real time to evaluate their utility to reduce inpatient hypoglycemia., (© 2020 by the American Diabetes Association.)

Aims: The Microalbuminuria Education Medication and Optimisation (MEMO) study, revealed improved cardiovascular risk and glycaemic control with 18 months of intensive multifactorial intervention in high-risk people with type 2 diabetes, without any increase in severe hypoglycaemia. Our aim was to assess longer-term outcomes at 4-year follow-up in these participants., Methods: Some 189 individuals with type 2 diabetes and microalbuminuria were recruited from a multi-ethnic population in Leicestershire, UK. The intervention group (n = 95) received multifactorial intervention with self-management education, and the control group (n = 94) received usual care. The primary outcome was change in HbA 1c , and secondary outcomes were blood pressure (BP), cholesterol, microalbuminuria, estimated GFR, cardiovascular risk scores and major adverse cardiovascular events., Results: Some 130 participants (68.7%), mean (sd) age 60.8 (10.4) years, duration of diabetes 11.5 (9.7) years, completed 4 years of follow-up. Mean change [95% confidence intervals (CI)] in HbA 1c over 4 years was greater with intensive intervention compared with control (-3 mmol/mol, 95% CI -4.95,-1.11; -0.4%, 95% CI -0.67,-0.15; P = 0.002). Significant improvements over the 4 years were also seen in systolic BP (-7.3 mmHg, 95% CI -11.1, -3.5; P < 0.001), diastolic BP (-2.9 mmHg, 95% CI -5.4, -0.3; P = 0.026), cholesterol (-0.3 mmol/l, 95% CI -0.52,-0.12; P = 0.002), and 10-year coronary heart disease (-5.3, 95% CI -8.2,-2.3; P < 0.001) and stroke risk (-4.4, 95% CI -7.5, -1.3; P < 0.001)., Conclusion: Multifactorial intervention with structured diabetes self-management education compared with usual diabetes care has benefits for cardio-metabolic risk factor profile. There was no increase in severe hypoglycaemia and cardiovascular mortality despite intensive glycaemic control, although the study was not powered to assess these outcomes., (© 2019 Diabetes UK.)

Aim: To assess the incidence of cardiovascular and hypoglycaemic adverse events associated with glimepiride compared with other second-generation sulphonylureas among patients with type 2 diabetes in a real-world clinical setting., Materials and Methods: We identified all sulphonylurea initiators between 1998 and 2017 in the UK Clinical Practice Research Datalink. Using a prevalent new-user design, glimepiride initiators were matched 1:4 with initiators of other second-generation sulphonylureas on calendar time, prior sulphonylurea use, and time-conditional high-dimensional propensity score. Cox proportional hazards models yielded adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for myocardial infarction, ischaemic stroke, severe hypoglycaemia, cardiovascular death, and all-cause mortality., Results: Among 66 032 sulphonylurea new users, 6438 initiated glimepiride and were matched to up to 20 582 initiators of other second-generation sulphonylureas. During a mean follow-up of 1.3 years, glimepiride was associated with a similar incidence of myocardial infarction (HR 0.99, 95% CI 0.75-1.30) and ischaemic stroke (HR 0.96, 95% CI 0.72-1.27) compared with other second-generation sulphonylureas, while there was a non-significant trend towards a higher incidence of severe hypoglycaemia (HR 1.24, 95% CI 0.92-1.68). Glimepiride was also associated with a lower incidence of all-cause mortality (HR 0.77, 95% CI 0.67-0.89), and a non-significant but similar trend for cardiovascular death (HR 0.83, 95% CI 0.65-1.05)., Conclusions: Glimepiride was associated with a lower incidence of all-cause mortality compared with other second-generation sulphonylureas., (© 2019 John Wiley & Sons Ltd.)

Aims: To assess the efficacy of insulin pumps with automated insulin suspension systems in a real-world setting., Methods: We analysed anonymized data uploaded to CareLink ™ by people (n=920) with Type 1 diabetes using the MiniMed Paradigm Veo system and the MiniMed 640G system (Medtronic International Trading Sàrl, Tolochanez, Switzerland) with SmartGuard technology, with or without automated insulin suspension enabled, between February 2016 and June 2018. Users with ≥15 days of sensor data and ≥70% sensor-wear time were classified as sensor-augmented pump alone, sensor-integrated pump with low glucose suspend enabled or sensor-integrated pump with predictive low glucose management enabled., Results: The median (25 th -75 th percentile) system use was 161 (58-348) days. The median time spent with sensor glucose values ≤3 mmol/l was 0.8 (0.3-1.7)% in the sensor-augmented pump group, 0.3 (0.1-0.7)% in the sensor-integrated pump with low glucose suspend group, and 0.3 (0.1-0.5)% in the sensor-integrated pump with predictive low glucose management group. In individuals switching from sensor-augmented pump to sensor-integrated pump with low glucose suspend (n=31), there were significant reductions in the monthly rate of hypoglycaemic events <3 mmol/l (rate ratio 0.63, 95% CI 0.45-0.89; P=0.009) and in the percentage of time with glucose values ≤3 mmol/l [sensor-augmented pump: 0.63% (95% CI 0.34-1.29), sensor-integrated pump with low glucose suspend: 0.33% (95% CI 0.16-0.64); P=0.001]. The monthly rate of hypoglycaemic events decreased further in individuals (n=139) switching from sensor-integrated pump with low glucose suspend to sensor-integrated pump with predictive low glucose management [rate ratio 0.82 (95% CI 0.69-0.98); P<0.0274]. Similar results were seen for events <3.9 mmol/l. There was no difference in median time spent in target glucose range., Conclusion: Real-world UK data show that increasing automation of insulin suspension reduces hypoglycaemia exposure in people with Type 1 diabetes., (© 2019 Diabetes UK.)

Aims: Most people with Type 1 diabetes have low levels of persistent endogenous insulin production. The Diabetes Control and Complications Trial showed that close to diagnosis preserved endogenous insulin was associated with lower HbA 1c , hypoglycaemia and complication rates, when intensively treated. We aimed to assess the clinical impact of persistent C-peptide on rate of hypoglycaemia and HbA 1c in those with long duration (> 5 years) Type 1 diabetes., Methods: We conducted a cross-sectional case-control study of 221 people (median age 24 years) with Type 1 diabetes. We confirmed ongoing endogenous insulin secretion by measuring C-peptide after a mixed-meal tolerance test. We compared self-reported hypoglycaemia (n = 160), HbA 1c , insulin dose and microvascular complications (n = 140) in those with preserved and low C-peptide., Results: Stimulated median (IQR) C-peptide was 114 (43, 273) pmol/l and < 3 (< 3, < 3) pmol/l in those with preserved and low C-peptide respectively. Participants with preserved C-peptide had lower reported monthly rates of hypoglycaemia, with 21% fewer symptomatic episodes, 5.9 vs. 7.5 [incidence rate ratio (IRR) 0.79, P = 0.001], and 65% fewer asymptomatic episodes, 1.0 vs. 2.9 (IRR 0.35, P < 0.001). Those with preserved C-peptide had a lower insulin dose (0.68 vs. 0.81 units/kg, P = 0.01) but similar HbA 1c (preserved 69 vs. low 67 mmol/mol, P = 0.06)., Conclusions: Adults with Type 1 diabetes and preserved endogenous insulin production receiving usual care in the UK have lower daily insulin doses and fewer self-reported hypoglycaemic episodes, but no difference in HbA 1c . This is consistent with non-intensive treatment in previous studies, and suggests a need to consider therapy intensification to gain full benefit of preserved endogenous insulin., (© 2019 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Aims: To determine the incidence and severity of self-reported hypoglycaemia in a primary care population with type 2 diabetes. The study also aimed to compare incidence by treatment regimen., Materials and Methods: A prospective observational study in 17 centres throughout the UK was conducted. Recruitment was based on treatment regimen (metformin alone, sulphonylurea-, insulin- or incretin-based therapy). Participants were asked to keep a blood glucose diary and self-report hypoglycaemia episodes [non-severe (self-treated) and severe (requiring external help)] over a 12-month period., Results: Three hundred and twenty-five participants were enrolled, of whom 274 (84%) returned ≥1 monthly diaries. Overall, 39% reported experiencing hypoglycaemia; 32% recorded ≥1 symptomatic, 36% ≥1 non-severe, and 7% ≥1 severe episodes. By treatment, incidence (events per person/year) for any hypoglycaemia type was 4.39 for insulin, 2.34 for sulphonylurea, 0.76 for metformin, and 0.56 for incretin-based therapy. Compared with metformin, risk of non-severe hypoglycaemia was ~3 times higher for participants on sulphonylureas and > 5 times higher for those on insulin [incidence rate ratio (IRR) 3.02 (1.76-5.18), P < 0.001, and IRR 5.96 (3.48-10.2), P < 0.001, respectively]. For severe episodes, the incidence for sulphonylurea (0.09) was similar to metformin (0.07) and incretin-based therapy (0.07); for insulin the risk remained almost 5 times higher than metformin [incidence 0.32; IRR 4.55 (1.28-16.20), P = 0.019]., Conclusions: Hypoglycaemia represents a substantial burden for people with type 2 diabetes. Sulphonylureas and insulin are both associated with a risk of reported non-severe hypoglycaemia, but only insulin with severe episodes. This suggests the importance of the continued use of sulphonylureas in appropriate patients with type 2 diabetes., (© 2019 John Wiley & Sons Ltd.)

Context: Diabetes mellitus (DM) has been associated with an increased risk of fractures. However, the effect of glycemic control on the risk of fracture is not well understood., Objective: To evaluate the association between glycemic control and the risk of low-trauma fractures in patients with type 1 DM (T1DM) and type 2 DM (T2DM)., Design: Nested case-control analysis., Setting: UK-based Clinical Practice Research Datalink., Patients or Other Participants: The study population was patients whose T1DM or T2DM had been newly diagnosed between 1995 and 2015. The cases were patients with a low-trauma fracture after DM onset. We matched four controls to each case by age, sex, general practice, fracture date, and DM type and duration., Statistical Analysis: Conditional logistic regression analyses were performed, adjusted for covariates, including body mass index, smoking, DM complications and medications., Results: The study population included 3329 patients with T1DM and 44,275 patients with T2DM. The median duration between DM onset and fracture date was 4.5 years for both T1DM and T2DM. The risk of fracture was increased in the patients with T1DM with a mean hemoglobin A1c >8.0% (adjusted OR, 1.39; 95% CI, 1.06 to 1.83) compared with those patients with T1DM and a mean hemoglobin A1c ≤7.0%. No such effect was found in the patients with T2DM. Independently of glycemic control, the risk of fracture was elevated in patients with T2DM and the current use of rosiglitazone and pioglitazone., Conclusions: The effect of glycemic control on the risk of low-trauma fracture differs between patients with T1DM and T2DM. Poor glycemic control increased the risk of fractures in patients with T1DM but not in those with T2DM., (Copyright © 2019 Endocrine Society.)

Hypoglycemia is a serious complication following treatment of hyperkalemia with intravenous insulin. The aims of this study were to determine the incidence of hypoglycemia (≤3.9 mmol/l, 70 mg/dL) and severe hypoglycemia (<3.0 mmol/l, 54 mg/dL) in noncritical care inpatients following treatment of hyperkalemia and to establish the risk factors predisposing to this complication. This was a single-center observational study reviewing the Electronic Patient Records of hyperkalemia treatment with intravenous insulin on the general wards of a large UK teaching hospital. A total of 662 episodes of hyperkalemia treated with insulin/dextrose were included. Among these episodes, 116 treatments (17.5%) resulted in hypoglycemia and 47 (7.1%) resulted in severe hypoglycemia. Lower pretreatment capillary blood glucose level, older age, and lower bodyweight were associated with a higher risk of posttreatment hypoglycemia. The incidence of hypoglycemia following hyperkalemia treatment in hospitalized patients is unacceptably high. Identifying individuals at high risk of hypoglycemia and adjusting prescriptions may reduce the incidence.

Aims: Insulin therapy is indicated for people with Type 1 diabetes mellitus; however, treatment-related weight gain and hypoglycaemia represent barriers to optimal glycaemic management. This study assessed the health economic value of maintained reductions in HbA 1c , BMI and hypoglycaemia incidence among the UK Type 1 diabetes population., Methods: The Cardiff Type 1 Diabetes Model was used to estimate lifetime costs, life-years and quality-adjusted life-years (QALYs) for individuals with Type 1 diabetes at different baseline HbA 1c , BMI and hypoglycaemic event rates. Results were discounted at 3.5%, and the net monetary benefit associated with improving Type 1 diabetes management was derived at £20 000/QALY gained. Per-person outputs were inflated to national levels using UK Type 1 diabetes prevalence estimates., Results: Modelled subjects with an HbA 1c of 86 mmol/mol (10.0%) were associated with discounted lifetime per-person costs of £23 795; £12 649 of which may be avoided by maintaining an HbA 1c of 42 mmol/mol (6.0%). Combined with estimated QALY gains of 2.80, an HbA 1c of 42 mmol/mol (6.0%) vs. 86 mmol/mol (10.0%) was associated with a £68 621 per-person net monetary benefit. Over 1 year, unit reductions in BMI produced £120 per-person net monetary benefit, and up to £197 for the avoidance of one non-severe hypoglyceamic event., Conclusions: Maintained reductions in HbA 1c significantly alleviate the burden associated with Type 1 diabetes in the UK. Given the influence of weight and hypoglycaemia on health economic outcomes, they must also be key considerations when assessing the value of Type 1 diabetes technologies in clinical practice., (© 2018 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Nursing home residents with diabetes have more complex care needs with higher levels of comorbidity, disability and cognitive impairment. We compared current practice in the 44 long-term residents in Peamount hospital with the standards recommended in the Diabetes UK "Good Clinical Practice Guidelines for Care Home Residents with Diabetes". Of 44 residents, 11 were diabetic. Residents did not have specific diabetes care plans. There were some elements of good practice with a low incidence of hypoglycaemia and in-house access to dietetics and chiropody. However, diabetes care was delivered on an ad-hoc basis without individualised care plans, documented glycaemic targets, or scheduled monitoring for complications and no formal screening for diabetes on admission. National and local policy to guide management of diabetes mellitus should be developed. There should be individualised diabetes care plans, clear policies for hypoglycaemia, hyperglycaemia and long-term diabetes complications, screening on admission and increased uptake of the national retinal screening and foot care programmes.

Aims: The purpose of this study was to explore the burden and impact of non-severe nocturnal hypoglycaemic events (NSNHEs) on diabetes management, patient functioning and well-being in order to better understand the role that NSNHEs play in caring for persons with diabetes and facilitate optimal diabetes treatment management strategies., Methods: A 20-min survey assessing the impact of NSNHEs was administered to patients with self-reported diabetes age 18 or older via the Internet in nine countries (USA, UK, Germany, Canada, France, Italy, Spain, The Netherlands and Sweden) who experienced an NSNHE in the last month. Questions captured reasons for and length of the event, and impacts on diabetes management, daily function, sleep and well-being., Results: A total of 20 212 persons with Type 1 diabetes mellitus (T1DM) and Type 2 diabetes mellitus (T2DM) were screened of which 2108 respondents were eligible. Respondents initiated, on average, an additional 3.6 glucose monitoring tests, and did not resume usual functioning for an average of 3.4 hours after the NSNHE. Of the respondents using insulin, 15.8% decreased their insulin dose over an average of 3.6 days. NSNHEs also impacted sleep, with 10.4% not returning to sleep that night. Next day functioning was affected with 60.3% (n = 1273) feeling the need to take a nap and/or rest (with 65.5% of those actually taking a nap/rest) and 40.2% (n = 848) wanting to go to bed earlier than usual. A total of 21.4% were restricted in their driving the next day. These events also resulted in decreased well-being with 39.6% of respondents feeling 'emotional low' the following day., Conclusions: NSNHEs have serious consequences for patients. Greater attention to patient and physician education regarding the burden of NSNHEs and incorporation of corrective actions in treatment plans is needed to facilitate patients reaching optimal glycaemic control., (© 2013 Blackwell Publishing Ltd.)

Objective: The objective of this study is to describe current self-monitoring of blood glucose (SMBG) practice for patients with type 2 diabetes by treatment type and adherence with healthcare professional advice concerning SMBG. In addition, the study aims to investigate the association of SMBG and self-reported episodes of low blood glucose., Design and Setting: This cross-sectional survey design study was carried out on patients with type 2 diabetes aged 18 years or over, attending community pharmacies in 97 sites across the United Kingdom., Methods: Patients picking up a prescription for blood glucose test strips or diabetes medicine from a community pharmacist were asked to complete a questionnaire. The pharmacist was available to assist if requested. Questions included: self-reports of frequency of blood glucose testing; type of diabetes treatment; advice given by healthcare professionals about frequency of blood glucose testing; frequency of episodes of low blood glucose; and last known HbA(1c) level. The final sample size was 554 respondents, who were grouped for analysis as follows: those being treated with insulin, either alone or with any oral medication (n = 167); those being treated with sulfonylureas, either alone or with any oral medication (n = 187); and those being treated with any other medication, or controlled by diet and exercise alone (n = 202)., Results: Frequency of SMBG was higher in patients using insulin (median 10 times per week, Q (1), Q (3) = 4.5, 14) than in patients on treatments other than insulin (four times per week, Q (1), Q (3) = 2, 7, p < 0.001). SMBG was carried out at the same frequency in patients not treated with insulin regardless of whether they were prescribed sulfonylureas. Greater frequency of SMBG was associated with self-reports of one or more episodes of low blood glucose in the previous six months., Conclusions: Among patients with type 2 diabetes, those treated with insulin used SMBG at a greater frequency than those not treated with insulin. Increased frequency of testing was associated with increased frequency of self-reported episodes of low blood glucose, even among patients not taking insulin or sulfonylureas. This raises the possibility that episodes of hypoglycaemia may not be accurately identified, leading to unnecessary fear, or conversely that treatment is not being adjusted to avoid such morbidity. Although further work is needed to explore this association in a representative, prospective cohort of patients, possible explanations for reports of low-blood glucose should be discussed with patients using SMBG more frequently to ensure they are able to accurately identify episodes of hypoglycaemia.

Background: Recent reports suggest an association between antipsychotic use and development or exacerbation of diabetes. This study evaluated the risk of incident diabetes associated with the use of atypical and conventional antipsychotics., Method: This nested case-control study included all patients in the U.K. General Practice Research Database treated with antipsychotic drugs between January 1994 and December 1998. The main outcome measures were the odds ratios of current (within prior 6 months) or recent (7 to 12 months) antipsychotic exposure among those with (N = 424) compared with those without incident diabetes (N = 1522)., Results: The adjusted odds ratio for current use of any antipsychotic drug compared with no use in the past year among those with diabetes was 1.7 (95% confidence interval [CI] = 1.3 to 2.3). The adjusted odds ratio for current use of atypical and conventional antipsychotic drugs compared with no use in the past year among those with diabetes was 4.7 (95% CI = 1.5 to 14.9) and 1.7 (95% CI = 1.2 to 2.3), respectively. The adjusted odds ratio for recent use of conventional antipsychotic drugs compared with no use in the past year among those with diabetes was 1.0 (95% CI = 0.6 to 1.6). The odds ratio for recent atypical antipsychotic drug use could not be calculated because no study subjects had this exposure., Conclusion: This study showed an increased risk of incident diabetes among current users of atypical and conventional antipsychotic medications. These results were independent of other established risk factors. The larger association observed for atypical antipsychotic users should be regarded as preliminary given the small number of incident diabetes cases in this group.