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Powers M.A.,International Diabetes Center at Park Nicollet
Journal of the American Dietetic Association | Year: 2010

This single-center, meal-intervention, crossover study was conducted to determine the glycemic response to fixed meals with varying carbohydrate content. Continuous glucose monitoring was used to document the glycemic response. Participants were 14 people with type 2 diabetes on metformin only. On 4 consecutive days in March or July 2008, study participants consumed a fixed breakfast and one of two test meals (lunch) provided in random order. The two lunch types varied only in carbohydrate content; the protein, fat, fiber, and glycemic index were similar. They consumed no caloric food or beverages for 4 hours after each meal. Consuming double the carbohydrate content did not double the glycemic response variables, yet most were substantially different in glucose value (mg/dL) or minutes. General linear model analyses revealed substantial differences for peak glucose, change from baseline glucose to peak, time to return to preprandial glucose, 4-hour glucose area under the curve, and 4-hour mean glucose. Continuous glucose monitoring data provided a robust description of the glycemic response to the two meals. Such data can help improve postprandial glucose levels through more informed nutrition recommendations and synchronization of food intake, diabetes medication, and/or physical activity. Copyright © 2010 American Dietetic Association. Published by Elsevier Inc. All rights reserved. Source


Heinemann L.,Science and Co. | Fleming G.A.,Kinexum | Petrie J.R.,University of Glasgow | Holl R.W.,University of Ulm | And 2 more authors.
Diabetes Care | Year: 2015

Insulin pump therapy, also known as continuous subcutaneous insulin infusion (CSII), is an important and evolving form of insulin delivery, which is mainly used for people with type 1 diabetes. However, even with modern insulin pumps, errors of insulin infusion can occur due to pump failure, insulin infusion set (IIS) blockage, infusion site problems, insulin stability issues, user error, or a combination of these. Users are therefore exposed to significant and potentially fatal hazards: interruption of insulin infusion can result in hyperglycemia and ketoacidosis; conversely, delivery of excessive insulin can cause severe hypoglycemia. Nevertheless, the available evidence on the safety and efficacy of CSII remains limited. The European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have therefore joined forces to review the systems in place for evaluating the safety of pumps from a clinical perspective. We found that useful information held by the manufacturing companies is not currently shared in a sufficiently transparent manner. Public availability of adverse event (AE) reports on the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database is potentially a rich source of safety information but is insufficiently utilized due to the current configuration of the system; the comparable database in Europe (European Databank on Medical Devices [EUDAMED]) is not publicly accessible. Many AEs appear to be attributable to human factors and/or user error, but the extent to which manufacturing companies are required by regulators to consider the interactions of users with the technical features of their products is limited. The clinical studies required by regulators prior to marketing are small and overreliant on bench testing in relation to "predicate" products. Once a pump is available on the market, insufficient data are made publicly available on its long-term use in a real-world setting; such data could provide vital information to help health care teams to educate and support users and thereby prevent AEs. As well as requiring more from the manufacturing companies, we call for public funding of more research addressing clinically important questions in relation to pump therapy: both observational studies and clinical trials. At present, there are significant differences in the regulatory systems between the US and European Union at both pre- and postmarketing stages; improvements in the European system are more urgently required. This statement concludes with a series of recommended specific actions for "meknovigilance" (i.e., a standardized safety approach to technology) that could be implemented to address the shortcomings we highlight. © 2015 by the American Diabetes Association. Source


Beck R.W.,Jaeb Center for Health Research | Tamborlane W.V.,Yale University | Bergenstal R.M.,International Diabetes Center at Park Nicollet | Miller K.M.,Jaeb Center for Health Research | And 2 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2012

Context: The T1D Exchange includes a clinic-based registry, a patient-centric web site called Glu, and a biobank. Objective: The aim of the study was to describe the T1D Exchange clinic registry and provide an overview of participant characteristics. Design: Data obtained through participant completion of a questionnaire and chart extraction include diabetes history, management, and monitoring; general health; lifestyle; family history; socioeconomic factors; medications; acute and chronic diabetic complications; other medical conditions; and laboratory results. Setting: Data were collected from 67 endocrinology centers throughout the United States. Patients: We studied 25,833 adults and children with presumed autoimmune type 1 diabetes (T1D). Results: Participants ranged in age from less than 1 to 93 yr, 50% were female, 82% were Caucasian, 50% used an insulin pump, 6% used continuous glucose monitoring, and 16% had a first-degree family member with T1D. Glycosylated hemoglobin at enrollment averaged 8.3% and was highest in 13 to 25 yr olds. The prevalence of renal disease was ≤4% until T1D was present for at least 10 yr, and retinopathy treatment was ≤2% until T1D was present for at least 20 yr. A severe hypoglycemic event (seizure or coma) in the prior 12 months was reported by 7% of participants and diabetic ketoacidosis in the prior 12 months by 8%. Conclusions: The T1D Exchange clinic registry provides a database of important information on individuals with T1D in the United States. The rich dataset of the registry provides an opportunity to address numerous issues of relevance to clinicians and patients, including assessments of associations between patient characteristics and diabetes management factors with outcomes. Copyright © 2012 by The Endocrine Society. Source


Fleming G.A.,Kinexum | Petrie J.R.,University of Glasgow | Holl R.W.,University of Ulm | Bergenstal R.M.,International Diabetes Center at Park Nicollet | Peters A.L.,University of Southern California
Diabetes care | Year: 2015

Insulin pump therapy, also known as continuous subcutaneous insulin infusion (CSII), is an important and evolving form of insulin delivery, which is mainly used for people with type 1 diabetes. However, even with modern insulin pumps, errors of insulin infusion can occur due to pump failure, insulin infusion set (IIS) blockage, infusion site problems, insulin stability issues, user error, or a combination of these. Users are therefore exposed to significant and potentially fatal hazards: interruption of insulin infusion can result in hyperglycemia and ketoacidosis; conversely, delivery of excessive insulin can cause severe hypoglycemia. Nevertheless, the available evidence on the safety and efficacy of CSII remains limited. The European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have therefore joined forces to review the systems in place for evaluating the safety of pumps from a clinical perspective. We found that useful information held by the manufacturing companies is not currently shared in a sufficiently transparent manner. Public availability of adverse event (AE) reports on the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database is potentially a rich source of safety information but is insufficiently utilized due to the current configuration of the system; the comparable database in Europe (European Databank on Medical Devices [EUDAMED]) is not publicly accessible. Many AEs appear to be attributable to human factors and/or user error, but the extent to which manufacturing companies are required by regulators to consider the interactions of users with the technical features of their products is limited. The clinical studies required by regulators prior to marketing are small and over-reliant on bench testing in relation to "predicate" products. Once a pump is available on the market, insufficient data are made publicly available on its long-term use in a real-world setting; such data could provide vital information to help health care teams to educate and support users and thereby prevent AEs. As well as requiring more from the manufacturing companies, we call for public funding of more research addressing clinically important questions in relation to pump therapy: both observational studies and clinical trials. At present, there are significant differences in the regulatory systems between the US and European Union at both pre- and postmarketing stages; improvements in the European system are more urgently required. This statement concludes with a series of recommended specific actions for "meknovigilance" (i.e., a standardized safety approach to technology) that could be implemented to address the shortcomings we highlight. © 2015 by the American Diabetes Association and Springer-Verlag. Copying with attribution allowed for any noncommercial use of the work. Source


Buse J.B.,University of North Carolina at Chapel Hill | Bergenstal R.M.,International Diabetes Center at Park Nicollet | Glass L.C.,Eli Lilly and Company | Heilmann C.R.,Eli Lilly and Company | And 4 more authors.
Annals of Internal Medicine | Year: 2011

Background: Insulin replacement in diabetes often requires prandial intervention to reach hemoglobin A1c (HbA1c) targets. Objective: To test whether twice-daily exenatide injections reduce HbA1c levels more than placebo in people receiving insulin glargine. Design: Parallel, randomized, placebo-controlled trial, blocked and stratified by HbA1c level at site, performed from October 2008 to January 2010. Participants, investigators, and personnel conducting the study were masked to treatment assignments. (ClinicalTrials.gov registration number: NCT00765817) Setting: 59 centers in 5 countries. Patients: Adults with type 2 diabetes and an HbA1c level of 7.1% to 10.5% who were receiving insulin glargine alone or in combination with metformin or pioglitazone (or both agents). Intervention: Assignment by a centralized, computer-generated, random-sequence interactive voice-response system to exenatide, 10 μg twice daily, or placebo for 30 weeks. Measurements: The primary outcome was change in HbA1c level. Secondary outcomes included the percentage of participants with HbA1c values of 7.0% or less and 6.5% or less, 7-point selfmonitored glucose profiles, body weight, waist circumference, insulin dose, hypoglycemia, and adverse events. Results: 112 of 138 exenatide recipients and 101 of 123 placebo recipients completed the study. The HbA1c level decreased by 1.74% with exenatide and 1.04% with placebo (between-group difference, -0.69% [95% CI, -0.93% to -0.46%]; P < 0.001). Weight decreased by 1.8 kg with exenatide and increased by 1.0 kg with placebo (between-group difference, -2.7 kg [CI, -3.7 to -1.7]). Average increases in insulin dosage with exenatide and placebo were 13 U/d and 20 U/d. The estimated rate of minor hypoglycemia was similar between groups. Thirteen exenatide recipients and 1 placebo recipient discontinued the study because of adverse events (P < 0.010); rates of nausea (41% vs. 8%), diarrhea (18% vs. 8%), vomiting (18% vs. 4%), headache (14% vs. 4%), and constipation (10% vs. 2%) were higher with exenatide than with placebo. Limitations: The study was of short duration. There were slight imbalances between groups at baseline in terms of sex, use of concomitant glucose-lowering medications, and HbA1c levels, and more exenatide recipients than placebo recipients withdrew because of adverse events. Conclusion: Adding twice-daily exenatide injections improved glycemic control without increased hypoglycemia or weight gain in participants with uncontrolled type 2 diabetes who were receiving insulin glargine treatment. Adverse events of exenatide included nausea, diarrhea, vomiting, headache, and constipation. Primary Funding Source: Alliance of Eli Lilly and Company and Amylin Pharmaceuticals. © 2011 American College of Physicians. Source

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