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Septic shock
Published in Hung N. Winn, Frank A. Chervenak, Roberto Romero, Clinical Maternal-Fetal Medicine Online, 2021
Bryan E. Freeman, Michael R. Foley
One final area of management that has received recent attention is that of glucose control in patients with severe sepsis and septic shock. The Efficacy of Volume Substitution and Insulin Therapy in Severe Sepsis (VISEP) is the most recent study to address this issue and their findings coincide with prior studies. The investigators randomized patients into groups of either conventional or intensive insulin therapy. The conventional insulin group was treated via insulin drip if blood glucose levels exceeded 200 mg/dL and were maintained in the range of 180 to 200 mg/dL. The intensive insulin therapy group received insulin via insulin drip once blood glucose levels exceeded 110 mg/dL and were maintained in the range of 80 to 110 mg/dL. No benefit was found to intensive insulin therapy. In fact, this treatment was terminated early by the data and safety monitoring board at the time of the first safety analysis due to the high incidence of hypoglycemia (18).
Immunosuppressants, rheumatic and gastrointestinal topics
Published in Evelyne Jacqz-Aigrain, Imti Choonara, Paediatric Clinical Pharmacology, 2021
Evelyne Jacqz-Aigrain, Imti Choonara
Traditionally, long- and short-acting insulins were given in combination twice daily (Fig. 3). More recently, 3- or 4-injection regimens have been introduced, which can provide more intensive insulin therapy. These regimens comprise combinations of soluble plus isophane /lente /ultralente insulin. Short-acting analogues, aspart and lipro, can be substituted for soluble insulin in these regimens. The new long-acting insulins, detemir /glargine, are most often used in 4 times a day or multiple-injection regimens, as they cannot be freely mixed with short-acting insulins.
Hematopoietic Stem Cell Transplantation as Treatment for Type 1 Diabetes
Published in Richard K. Burt, Alberto M. Marmont, Stem Cell Therapy for Autoimmune Disease, 2019
Júlio C. Voltarelli, Richard K. Burt, Norma Kenyon, Dixon B. Kaufman, Elizabeth C. Squiers
Diabetes is treated with either conventional insulin therapy or intensive insulin therapy (IIT). The goal of IIT is tight control of blood sugar. The risk of secondary complications (retinopathy, neuropathy, cardiovascular disease, nephropathy, extremity amputation, etc) from type 1 diabetes has changed over time and data on long term survival (i.e., 10, 20, and 25 years) using IIT is not yet available. For every 1% increase in HbAlc above normal (HgbAlc <6.5%), mortality increases 11%.31-34 With conventional insulin therapy, HgbAlc often remains between 9-12%. Since mortality in diabetes correlates with long term control of blood sugar, the current therapy for decreasing or delaying complications of diabetes is tight control of blood sugars using intensive insulin therapy.31-34 Intensive insulin therapy requires meticulous monitoring of blood sugar (4-10 times a day), frequent insulin injections (more than 3 times per day or an insulin pump), close control of diet, and is generally limited to motivated persons with regular access to health care. As quoted from the literature “Achieving optimal blood glucose control, without an unacceptable rate of hypoglycaemia or unacceptable restrictions on lifestyle, is not simple with presently available insulin preparations and monitoring tools. Accordingly, the appropriate use of insulin to obtain good metabolic control requires the continued and informed expertise of both patient and advising professional, but also attention from both to self-motivation in order to make the desired lifestyle changes possible”.35
Emerging drugs for the treatment of type 1 diabetes mellitus: a review of phase 2 clinical trials
Published in Expert Opinion on Emerging Drugs, 2023
Several potential barriers to intensive glycemic control have been identified, and hypoglycemia is considered as a major obstacle. Hypoglycemia is more common in patients with long duration of diabetes and those with impaired hypoglycemia awareness [25]. Recent advances in blood glucose monitoring system enable the reduction in hypoglycemia occurrence [26]. However, there is a geographical variation in the uptake and availability of the real-time blood glucose monitoring systems [27]. In addition, fear of hypoglycemia remains a major challenge in the clinical management of people with T1DM, affecting quality of life as well as glucose control [28,29]. Weight gain is another potential adverse effect of intensive insulin therapy, and it occurs when insulin doses are matched for nutritional intake and when glycosuria is eliminated [30]. Other potential barriers include the desire to avoid multiple daily injections and frequent self-monitoring of glucose, misconceptions about insulin treatment, reluctance to the adoption of newer technologies, therapeutic inertia [28], and factors related to patient’s lifestyle, education, and their environment [31].
Evaluation of the cost and medical resource use outcomes associated with nasal glucagon versus injectable glucagon for treatment of severe hypoglycemia in people with diabetes in Canada: a modeling analysis
Published in Journal of Medical Economics, 2022
Jean-François Yale, Beatrice Osumili, Beth D. Mitchell, Barnaby Hunt, Gurjeev Sohi, Mark Jeddi, Donna Mojdami, William J. Valentine
The use of continuous glucose monitoring and flash glucose monitoring may provide opportunities for patients, particularly those receiving intensive insulin therapy, to reduce the frequency of severe hypoglycemia, but technology use does not eliminate the risk entirely7–9. Severe hypoglycemia represents a barrier to achieving good glycemic control in patients with diabetes, as in an effort to avoid hypoglycemia, patients may target higher blood glucose levels and thereby increase their risk of related complications10,11. Severe hypoglycemic events can result in significant medical resource use, such as emergency medical services (EMS) and treatment in the emergency room, and therefore an economic burden to healthcare payers12,13. The majority of severe hypoglycemic events occur outside of a healthcare setting. A survey conducted in 184 people with diabetes and 140 caregivers found that 87.1 and 87.7% of severe hypoglycemic events occurred at home in people with type 1 and type 2 diabetes, respectively14.
Changing face of healthcare: digital therapeutics in the management of diabetes
Published in Current Medical Research and Opinion, 2021
Priyadharshini Ramakrishnan, Kevin Yan, Chakrapani Balijepalli, Eric Druyts
DTx models provide a comparatively effective system to monitor clinical progress and treatment adherence of patients with DM, in comparison to conventional healthcare model19. In conditions like DM requiring frequent monitoring, real time monitoring improves the efficiency of clinician visits. Patient education, periodic monitoring and self-management enhanced by DTx not only address the lack of motivation and compliance influencing therapeutic success, but have also proven to reduce the medical costs associated with diabetic care (including expenses related to treating comorbidities associated with DM)20. Individualized timely monitoring of glycemic status and subsequent therapeutic modification (known as “flexible intensive insulin therapy”) have shown to improve quality of life and glycemic control in T1D patients18. Clinical association, analytical validation and clinical validation of the collected metabolic and glycemic data will be beneficial in improving the current understanding of the disease status.