Endocrinol Metab.  2017 Jun;32(2):190-194. 10.3803/EnM.2017.32.2.190.

Stepwise Approach to Problematic Hypoglycemia in Korea: Educational, Technological, and Transplant Interventions

• Jin SM

• KMID: 2384077
• DOI: http://doi.org/10.3803/EnM.2017.32.2.190

Abstract

Impaired awareness of hypoglycemia has been found to be prevalent in 20% to 40% of people with type 1 diabetes. If a similar prevalence exists in Koreans with type 1 diabetes, at a minimum, thousands of people with type 1 diabetes suffer at least one unpredicted episode of severe hypoglycemia per year in Korea. For patients with problematic hypoglycemia, an evidence-based stepwise approach was suggested in 2015. The first step is structured education regarding multiple daily injections of an insulin analog, and the second step is adding a technological intervention, such as continuous subcutaneous insulin infusion or real-time continuous glucose monitoring. The next step is a sensor-augmented pump, preferably with a low glucose suspension feature or very frequent contact, and the final step is islet or pancreas transplantation. In Korea, however, none of these treatments are reimbursed by the National Health Insurance, and thus have not been widely implemented. The low prevalence of type 1 diabetes means that Korean physicians are relatively unfamiliar with the new technologies in this field. Therefore, the roles of new technologies and pancreas or islet transplantation in the treatment of problematic hypoglycemia need to be defined in the current clinical setting of Korea.

Keyword

Hypoglycemia; Continuous glucose monitoring; Islets of Langerhans transplantation

MeSH Terms

Education
Glucose
Humans
Hypoglycemia*
Insulin
Islets of Langerhans Transplantation
Korea*
National Health Programs
Pancreas
Pancreas Transplantation
Prevalence
Glucose
Insulin

Reference

1. Geddes J, Schopman JE, Zammitt NN, Frier BM. Prevalence of impaired awareness of hypoglycaemia in adults with type 1 diabetes. Diabet Med. 2008; 25:501–504.

2. Choudhary P, Rickels MR, Senior PA, Vantyghem MC, Maffi P, Kay TW, et al. Evidence-informed clinical practice recommendations for treatment of type 1 diabetes complicated by problematic hypoglycemia. Diabetes Care. 2015; 38:1016–1029.

3. Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia. Diabetes Care. 1994; 17:697–703.

4. Song SO, Song YD, Nam JY, Park KH, Yoon JH, Son KM, et al. Epidemiology of type 1 diabetes mellitus in Korea through an investigation of the national registration project of type 1 diabetes for the reimbursement of glucometer strips with additional analyses using claims data. Diabetes Metab J. 2016; 40:35–45.

5. Jin SM, Kim JH. Management of adults with type 1 diabetes: current status and suggestions. J Korean Diabetes. 2014; 15:1–6.

6. Beck RW, Tamborlane WV, Bergenstal RM, Miller KM, DuBose SN, Hall CA, et al. The T1D exchange clinic registry. J Clin Endocrinol Metab. 2012; 97:4383–4389.

7. Cox D, Gonder-Frederick L, Polonsky W, Schlundt D, Julian D, Clarke W. A multicenter evaluation of blood glucose awareness training-II. Diabetes Care. 1995; 18:523–528.

8. Hopkins D, Lawrence I, Mansell P, Thompson G, Amiel S, Campbell M, et al. Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the UK DAFNE experience. Diabetes Care. 2012; 35:1638–1642.

9. Samann A, Muhlhauser I, Bender R, Kloos C, Muller UA. Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study. Diabetologia. 2005; 48:1965–1970.

10. Rondags SM, de Wit M, Twisk JW, Snoek FJ. Effectiveness of HypoAware, a brief partly web-based psychoeducational intervention for adults with type 1 and insulin-treated type 2 diabetes and problematic hypoglycemia: a cluster randomized controlled trial. Diabetes Care. 2016; 39:2190–2196.

11. Rondags SM, de Wit M, van Tulder MW, Diamant M, Snoek FJ. HypoAware: a brief and partly web-based psycho-educational group intervention for adults with type 1 and insulin-treated type 2 diabetes and problematic hypoglycaemia: design of a cost-effectiveness randomised controlled trial. BMC Endocr Disord. 2015; 15:43.

12. van Beers CA, DeVries JH, Kleijer SJ, Smits MM, Geelhoed-Duijvestijn PH, Kramer MH, et al. Continuous glucose monitoring for patients with type 1 diabetes and impaired awareness of hypoglycaemia (IN CONTROL): a randomised, open-label, crossover trial. Lancet Diabetes Endocrinol. 2016; 4:893–902.

13. Bergenstal RM, Garg S, Weinzimer SA, Buckingham BA, Bode BW, Tamborlane WV, et al. Safety of a hybrid closed-loop insulin delivery system in patients with type 1 diabetes. JAMA. 2016; 316:1407–1408.

14. Grosman B, Ilany J, Roy A, Kurtz N, Wu D, Parikh N, et al. Hybrid closed-loop insulin delivery in type 1 diabetes during supervised outpatient conditions. J Diabetes Sci Technol. 2016; 10:708–713.

15. El-Khatib FH, Balliro C, Hillard MA, Magyar KL, Ekhlaspour L, Sinha M, et al. Home use of a bihormonal bionic pancreas versus insulin pump therapy in adults with type 1 diabetes: a multicentre randomised crossover trial. Lancet. 2017; 389:369–380.

16. Kropff J, Del Favero S, Place J, Toffanin C, Visentin R, Monaro M, et al. 2 Month evening and night closed-loop glucose control in patients with type 1 diabetes under free-living conditions: a randomised crossover trial. Lancet Diabetes Endocrinol. 2015; 3:939–947.

17. Thabit H, Tauschmann M, Allen JM, Leelarathna L, Hartnell S, Wilinska ME, et al. Home use of an artificial beta cell in type 1 diabetes. N Engl J Med. 2015; 373:2129–2140.

18. Dunn TB, Kirchner V, Bellin MD. Beta-cell replacement therapy: current outcomes and future landscape. Curr Opin Organ Transplant. 2015; 20:681–690.

19. Hering BJ, Bellin MD. Transplantation: sustained benefits of islet transplants for T1DM. Nat Rev Endocrinol. 2015; 11:572–574.

20. Lablanche S, Borot S, Wojtusciszyn A, Bayle F, Tetaz R, Badet L, et al. Five-year metabolic, functional, and safety results of patients with type 1 diabetes transplanted with allogenic islets within the Swiss-French GRAGIL network. Diabetes Care. 2015; 38:1714–1722.

21. Bellin MD, Barton FB, Heitman A, Harmon JV, Kandaswamy R, Balamurugan AN, et al. Potent induction immunotherapy promotes long-term insulin independence after islet transplantation in type 1 diabetes. Am J Transplant. 2012; 12:1576–1583.

22. Yang HK, Ham DS, Park HS, Rhee M, You YH, Kim MJ, et al. Reversal of hypoglycemia unawareness with a single-donor, marginal dose allogeneic islet transplantation in Korea: a case report. J Korean Med Sci. 2015; 30:991–994.

23. Yang TY, Oh SH, Jeong IK, Seo IA, Oh EY, Kim SJ, et al. First human trial of pancreatic islet allo-transplantation in Korea: focus on re-transplantation. Diabetes Res Clin Pract. 2002; 56:107–113.

24. Park JB, Kim YH, Song KB, Chung YS, Jang HJ, Park JY, et al. Single-center experience with pancreas transplantation. Transplant Proc. 2012; 44:925–928.