强化胰岛素治疗后2型糖尿病夜间低血糖及其与睡前血糖关系的研究

目的探讨2型糖尿病患者强化胰岛素治疗时发生夜间未察觉低血糖的情况及与睡前血糖或晚餐后血糖的关系。方法对中山大学附属第二医院内分泌科2007—2008年收治的2型糖尿病患者45例,采用强化胰岛素治疗方案,血糖达标后进行72 h动态血糖监测,分析低血糖发生情况。结果低血糖(血糖≤3.9 mmol/L)发生率为79.5%,较严重的低血糖(血糖≤2.8 mmol/L)发生率为52.3%,其中86.0%的低血糖发生在夜间,患者均无诉不适。睡前血糖与夜间低血糖发生率存在相关性(列联系数rp=0.26,P<0.05),晚餐后血糖与夜间低血糖的相关性无统计学意义(rp=0.15,P>0.05);当睡前血糖处于4.0～9.9 mmol/L时,夜间低血糖或较严重低血糖的持续时间百分比并无差异(P>0.05)。结论强化胰岛素治疗的2型糖尿病患者夜间未察觉低血糖的发生率较高;监测睡前血糖较晚餐后血糖更能反映夜间低血糖的发生;血糖4.0～9.9 mmol/L时,不主张通过刻意提高睡前血糖来降低低血糖的发生。     

糖尿病患者空腹血糖的动态监测分析

应用72h动态血糖监测系统监测32例空腹血糖〉16mmol／L糖尿病患者空腹血糖水平，结果发现11例夜间血糖持续高水平为基础胰岛素不足；18例03：00以前血糖正常，03：00以后逐渐增高，为黎明现象；3例在00：00～03：00出现低血糖，后血糖开始增高，为低血糖后高血糖反应（Somogyi效应）。     

动态血糖监测在老年2型糖尿病患者中的临床应用

目的 通过动态血糖监测了解老年2型糖尿病患者的血糖控制情况,并评价动态血糖监测系统(CGMS)的临床应用价值.方法 选择36例平均年龄为(77.9±7.8)岁、平均糖尿病病程为(13.2±11.5)年、平均糖化血糖红蛋白(HbA1c)为(8.1±2.1)%的老年2型糖尿病患者为观察对象,根据人组时的HbAlc水平分为HbA1c≤7.0%组和HbA1c＞7.0%组.在进行35.0～94.6 h的连续动态血糖监测后,分析指尖血糖与CGMS血糖值的相关性,并比较两组患者低血糖和高血糖的发生率、高发时间段及持续时间.结果 CGMS血糖值与指尖血糖的平均差值为(0.05±1.02)mmol/L(P＞0.05),两者的相关性好(r＝0.96,P＜0.05),CCMS能发现更多的低血糖和高血糖事件.无论是血糖控制较好还是血糖控制较差的老年糖尿病患者均存在餐后高血糖现象,多发生在早餐和晚餐后2 h.HbAlc≤7.0%组患者更容易发生低血糖,发生率27.3%,高峰时段为凌晨2:00～4:00,均为无症状性低血糖反应;HbA1c＞7.0%组的低血糖发生率较低,发生率8.0%,高峰时段为上午10:00～12:00,有1例患者有低血糖的临床症状.结论 CGMS可全面反映老年2型糖尿病患者的血糖波动情况,与指尖血糖监测相比,能发现更多的低血糖和高血糖情况,为进一步调整治疗方案提供了重要信息.     

老年2型糖尿病患者低血糖特征的临床研究

目的探讨发生低血糖的老年T2DM患者临床特征及动态血糖谱特点。方法对2014年1月至2015年8月于我院老年内分泌科的146例70岁以上T2DM患者进行72h动态血糖监测(CGMS),分析其动态血糖谱特征;对比分析无低血糖组和低血糖组的临床特征及血糖波动特点。结果 28例(17.1%)发生低血糖。4次(10.5%)低血糖有自主症状,严重低血糖均无自主症状。严重低血糖和夜间低血糖分别占总低血糖持续时间的45.3%和81.8%。低血糖和严重低血糖均最常发生在00:00~01:59。低血糖组FC-P水平低于无低血糖组[(0.50±0.23)vs(0.42±0.16)nmol/L,P0.05]。低血糖组血糖最高值、血糖水平的标准差、最大血糖波动幅度、平均血糖波动幅度高于无低血糖组。结论 70岁以上发生低血糖的T2DM患者常伴随较大的血糖波动,易发生无症状性低血糖、严重低血糖和夜间低血糖。     

床边血糖监测系统监测睡前血糖预测住院2型糖尿病患者夜间低血糖发生情况的观察

目的 利用床边血糖监测系统回顾性分析住院T2DM患者睡前血糖与夜间低血糖的主要特点及危险因素. 方法 收集2008年1月至2011年12月接受稳步医院用（SureStep Flexx）床边血糖管理系统连续监测睡前及夜间血糖的2505例T2DM患者共14827次血糖数据行回顾性分析,探讨睡前血糖与夜间低血糖的关系. 结果 （1）夜间低血糖发生率10.8％（271/2505）,总夜间低血糖事件393次,其中严重低血糖发生率15.3％（60/393）,轻度低血糖84.7％（333/393）.（2）睡前血糖＜9.0 mmol/L时,预测夜间低血糖敏感性57.7％,特异性62.3％.（3）男性、≥60岁、胰岛素治疗且睡前血糖＜9.0mmol/L的住院T2DM患者,夜间低血糖发生风险升高（P＜0.05）. 结论 住院T2DM患者睡前血糖＜9.0 mmol/L时,夜间低血糖发生风险升高,应重视睡前血糖监测,预防夜间低血糖发生.     

动态血糖监测观察老年糖尿病患者低血糖的发生率及其影响因素

目的评估老年糖尿病患者低血糖的发生率及影响因素,寻求最大程度降低老年患者低血糖事件发生的方法。方法采用雷兰动态血糖监测系统对2013年11月至2015年9月,于我科住院的血糖控制平稳的337例老年糖尿病患者进行72~80 h连续血糖监测。结果 78例(23.1%)患者发生低血糖,其中,无症状低血糖者49例(14.5%),夜间低血糖者38例(11.2%),22:00~03:00是低血糖的高发时间段。使用预混胰岛素的患者低血糖发生率最高(36.2%),口服非胰岛素促泌剂的患者无低血糖发生。日平均血糖与低血糖发生率呈负相关(r=-0.393),日平均血糖控制目标为9.4~11.8 mmol/L。结论老年糖尿病患者低血糖发生率高,治疗需个体化且降糖水平需温和,尽量避免选用胰岛素治疗,尤其是预混胰岛素,同时应加强夜间血糖监测。     

糖尿病人昼夜血压变化与昼夜血糖变化的关系

高血压与高血糖是糖尿病人大血管与微血管病变的已知危险因子。糖尿病人如有夜间血压不降（非杓型）或餐后高血糖，心血管危险更高。该文研究糖尿病人昼夜高血压与高血糖的关系。107名高血压2型糖尿病人做24h血压监护（ABPM），同时也做昼夜血糖监测：早餐前、早餐后2h；午餐前、午餐后2h；晚餐前、晚餐后2h、10：00PM、午夜；     

门冬胰岛素30每天3次注射在胰岛素强化治疗中的作用

目的应用动态血糖监测（DGMS）评价门冬胰岛素30（Asp30）每日3次注射在胰岛素强化治疗中的有效性和安全性。方法将2008年1月q009年1月南昌大学第三附属医院住院2型糖尿病患者30例随机分为两纽,分别给予门冬胰岛素30每日3次（A组）和每日2次（B组）注射控制血糖,应用DGMS系统监测血糖变化。结果两组患者早餐前、早餐后2h、午餐后2h、晚餐后2h血糖问差异均有统计学意义（P〈0．05）。两组患者治疗后平均血糖、血糖达标时间及血糖〉10mmol／L的时间百分比间差异均有统计学意义（P〈0．05）。A组发生低血糖3例次．B组发生低血糖2例次,经过进食症状好转。两组均无伴有意识障碍的严重低血糖事件发生。结论应用Asp30每日3次皮下注射有效、安全改善糖尿病患者24h血糖控制。     

动态血糖监测在预防2型糖尿病患者低血糖的临床应用及护理

观察2型糖尿病患者在良好的血糖控制基础上,无症状性低血糖的发生率,为临床治疗及护理提供理论依据,更好地预防低血糖发生。方法:对46例确诊2型糖尿病患者经治疗后指端血糖监测(BGMS)血糖控制稳定,应用动态血糖监测系统(CGMS)连续3天监测血糖动态变化情况,以血糖﹤3.9且持续5min以上定为临床低血糖,以2小时为一时间段将全天分为12段。观察低血糖的发生及有无低血糖症。结果:本组患者检测出低血糖18例,占39%,以22:00—8:00时段无症状低血糖发生率最高(30.4%)。结论:CGMS能准确有效地监测无感知低血糖,为制定个性化治疗方案及护理提供重要依据,减少低血糖发生率,提高糖尿病患者的生活质量。     

三十八讲：高血糖临床分型及处理对策

一、空腹血糖高的原因及对策 原因之一：“苏木吉”现象 措施：监测夜间（尤其是凌晨）血糖，确认夜间曾有低血糖发作，而后导致次日空腹血糖反跳性增高，即所谓“苏木吉”现象。通过适当减少晚餐前口服降糖药（或睡前中长效胰岛素）的剂量，避免夜间低血糖发生，空腹血糖即可恢复正常。     

Morning blood glucose determination in the monitoring of metabolic control in type 2 elderly diabetic cases treated by oral hypoglycemic agents]

Daily blood glucose profiles were measured in 163 Type 2 elderly diabetic cases to evaluate whether a fasting (before breakfast) or a post-prandial (after breakfast) blood glucose concentration is able to predict blood glucose values throughout the day. In the diet-treated alone group (n = 61), the percentage of daily blood glucose profiles having plasma glucose values less than the 08:00 hours (before breakfast) value were as follows: 59.0%, 32.8%, 59.0%, and 55.7% at 18.00 (before supper), 24.00, 03.00, 06.00 hours, respectively. In group treated by oral hypoglycemic agents (OHA) (n = 102), these were as follows: 45.1%, 26.5%, 52.9%, and 67.6%, respectively. In the OHA group, the mean plasma glucose value at 08:00 hours was significantly higher in patients with the lowest plasma glucose levels between 60-79 mg/dl than in patients with these levels between 80-99 mg/dl (103.7 +/- 19.6 vs 118.7 +/- 16.9 mg/dl, p < 0.01), but that at 10:00 hours was similar in the two groups (218.8 +/- 43.9 vs 214.5 +/- 40.1 mg/dl). In patients with lowest plasma glucose levels of between 60-99 mg/dl, the 08:00 hours value correlated positively with that of 24:00 (r = 0.40), 03.00 (r = 0.53), and the 06.00 hours value (r = 0.69), but no correlation was observed with the 18.00 hours value. On the other hand, the 10:00 hours value was not associated with these time-points values. Our results reveal that before breakfast plasma glucose values are more predictive of low blood glucose values in the night during sleep than after-breakfast blood glucose values, but do not predict low blood glucose values before supper in patients on OHA.     

A randomized, blinded trial of uncooked cornstarch to diminish nocturnal hypoglycemia at Diabetes Camp

Objective: To determine if uncooked cornstarch, as part of the evening snack, can avert nocturnal hypoglycemia in type 1 diabetes. Research Design and Methods: Fifty-one campers and counselors at the American Diabetes Association Camp in San Bernardino, CA were randomly assigned to receive 5 g of uncooked cornstarch as part of the 21:00 evening snack vs. a standard snack of equivalent carbohydrate content. Each snack was given for five nights and the participants and medical personnel were blinded as to assignment. Midnight and 07:00 finger stick blood glucose levels were compared with values <60 mg/dl defined as hypoglycemia and values >250 mg/dl defined as hyperglycemia. Results: There were 218 midnight and 222 07:00 values for comparison. There were six episodes of hypoglycemia at midnight and nine episodes of hypoglycemia at 07:00 for the cornstarch snack nights vs. 30 hypoglycemia episodes at midnight and 21 at 07:00 for the standard snack nights (P < 0.001 and < 0.05, respectively). There was no difference in the number of hyperglycemic events at midnight or 07:00 for the cornstarch vs. standard snack nights. At midnight, 12% of campers had hypoglycemia after the cornstarch snack vs. 46% after the standard snack (P < 0.001), and at 07:00, 16% had hypoglycemia after cornstarch vs. 26% after the standard snack (P = 0.327). Conclusions: These data suggest that uncooked cornstarch, as part of the evening snack, can diminish the nighttime and morning hypoglycemia associated with type 1 diabetes, without causing hyperglycemia.     

Motor activity during asymptomatic nocturnal hypoglycemia in adolescents with type 1 diabetes mellitus

Abstract. Nocturnal hypoglycemia is reported in 13%–56% of adolescents with type 1 diabetes mellitus. It may be asymptomatic in more than 50% of patients. No noninvasive method for detecting asymptomatic nocturnal hypoglycemia (ANH) has so far proven successful. The aim of the present study was to evaluate quantitative changes of motor activity by actigraphy during episodes of ANH in adolescents with type 1 diabetes mellitus. A total of 18 patients aged 10–16 years with a history of ANH were investigated. Blood was sampled at half-hourly intervals between 22.30 and 06.00 hours with a micropump, and an actigraph was fastened to the right wrist. Blood glucose concentrations were measured and compared to motor activity. Nocturnal hypoglycemia was recorded in 10 patients (55%), with blood glucose during periods of hypoglycemia of 3.00+0.17 mmol/l (range, 1.2–3.4 mmol/l), and duration of hypoglycemia of 1.95+1.34 hours (range, 0.5–5.0 hours). All periods of hypoglycemia were clinically asymptomatic. Regression analysis revealed a statistically significant linear correlation (p=0.03) between blood glucose concentration and the respective 30-min activity counts. Activity counts in patients with nocturnal hypoglycemia were significantly (ANOVA, p<0.02) higher than in patients with normoglycemia. We conclude that low blood glucose was significantly correlated with an increase in motor activity as detected by actigraphy. This implies the possibility of noninvasive screening of asymptomatic nocturnal hypoglycemia.     

Evaluation of the superiority of insulin glargine as basal insulin replacement by continuous glucose monitoring system

To evaluate the superiority of insulin glargine as basal insulin replacement by continuous glucose monitoring system (CGMS). Twenty-four patients with type 2 diabetes mellitus (T2DM) whose blood glucose was not well controlled with sulphanylureas were enrolled. At first, they were treated with extended-release glipizide (glucotrol XL) 5mg/d before breakfast for 2 weeks, then randomized to combination treatment with glargine (16 patients) or NPH (8 patients) and treated for 12 weeks. CGMS were carried in the second week after treatment with glucotrol XL, and in the 12th week after combination treatment. The data of CGMS showed: (1) When FPG were well controlled in both groups (glargine group versus NPH group: 6.0+/-1.0 mmol/L versus 5.8+/-1.3 mmol/L), the blood glucose level at 3:00 a.m. (5.1+/-0.9 mmol/L versus 4.2+/-0.8 mmol/L) were higher (P<0.05), TPG< or =3.0 mmol/L at night were lower (2.56+/-1.79 versus 5.88+/-1.96), and the rate of nocturnal hypoglycemia (1/16 versus 4/8) were less (P=0.028) in glargine group than those in NPH group. (2) CGMS showed that the daily blood glucose profile excursion were more smoother in glargine group than those in NPH group. In conclusion, it was confirmed with CGMS that compared with traditionally basal insulin replacement with NPH, the combination treatment with glargine injection at bedtime may be predominant for stabilizing the daily blood glucose profile excursion and decreasing the nocturnal hypoglycemia events incidence. So glargine may be a more ideal basal insulin replacement than NPH.     

Biochemical evidence for the requirement of continuous glucose therapy in young adults with type 1 glycogen storage disease

Summary To determine whether patients with GSD-1 need nocturnal glucose therapy after completing physical growth and development, studies were performed on two consecutive nights. On the first night uncooked cornstarch (UCS) was given at the calculated glucose production rate at 21:00 h and 02:00 h. On the second night UCS was given at 21:00 h but omitted at 02:00 h. Six GSD-1 patients, aged 17.2–20.9 years, previously treated with continuous glucose therapy were studied. Measurements were made of plasma glucose (PG), serum insulin, growth hormone, cortisol, plasma glucagon (n=4), and blood lactate at 30–60-min intervals. Serum uric acid, cholesterol, and triglycerides were measured at 21:00 h and 07:00 h, and serum FFA at 21:00 h, 02:00 h and 07:00 h on the first night and immediately before treatment for hypoglycaemia on the second night.For five hours after UCS at 21:00 h, mean PG, serum insulin and blood lactate concentrations were similar on the two nights. With UCS at 02:00 h, mean PG concentrations were 4.1 mmol/L from 02:00 to 07:00 h. Without UCS at 02:00 h, in all subjects PG concentrations fell to <2.5 mmol/L after 6.5–8.5 h and mean blood lactate concentration increased to 7.4±3.0 mmol/L.Young adults with GSD-1 developed hypoglycaemia and hyperlactataemia after a relatively brief period without exogenous glucose and, therefore, need to continue nocturnal glucose therapy to prevent fasting hypoglycaemia.     

ASPIRE In-Home: Rationale,Design, and Methods of a Study to Evaluate the Safety and Efficacy of Automatic Insulin Suspension for Nocturnal Hypoglycemia

Nocturnal hypoglycemia is a barrier to therapy intensification efforts in diabetes. The Paradigm® Veo^TM system may mitigate nocturnal hypoglycemia by automatically suspending insulin when a prespecified sensor glucose threshold is reached. ASPIRE (Automation to Simulate Pancreatic Insulin REsponse) In-Home ({"type":"clinical-trial","attrs":{"text":"NCT01497938","term_id":"NCT01497938"}}NCT01497938) was a multicenter, randomized, parallel, adaptive study of subjects with type 1 diabetes. The control arm used sensor-augmented pump therapy. The treatment arm used sensor-augmented pump therapy with threshold suspend, which automatically suspends the insulin pump in response to a sensor glucose value at or below a prespecified threshold. To be randomized, subjects had to have demonstrated ≥2 episodes of nocturnal hypoglycemia, defined as ≥20 consecutive minutes of sensor glucose values ≤65 mg/dl starting between 10:00 pm and 8:00 am in the 2-week run-in phase. The 3-month study phase evaluated safety by comparing changes in glycated hemoglobin (A1C) values and evaluated efficacy by comparing the mean area under the glucose concentration time curves for nocturnal hypoglycemia events in the two groups. Other outcomes included the rate of nocturnal hypoglycemia events and the distribution of sensor glucose values. Data from the ASPIRE In-Home study should provide evidence on the safety of the threshold suspend feature with respect to A1C and its efficacy with respect to severity and duration of nocturnal hypoglycemia when used at home over a 3-month period.     

胰岛素联合阿卡波糖治疗改善血糖波动

目的 观察胰岛素治疗联合阿卡波糖对血糖波动的影响.方法 采用动态血糖监测系统(CGMS)对104例胰岛素治疗的糖尿病患者联合阿卡波糖治疗2周前后进行连续72 h的血糖监测,比较治疗前后血糖波动变化.结果 (1)加用阿卡波糖后明显减少血糖波动,空腹血糖变异系数(CV-FPG)、日间血糖平均绝对差(MODD)、日内平均血糖波动幅度(MAGE)、M值、日内血糖极差、高血糖时间(%)、高血糖曲线下面积(AUC)、餐后血糖尖峰值、餐后血糖达峰时间、餐后血糖波动幅度、餐后血糖波动总时间等波动指标均下降(均P＜0.05);(2)阿卡波糖治疗明显减少低血糖(尤其是夜间低血糖)的次数、幅度、持续时间(均P＜0.05);(3)治疗后胰岛素用量显著下降(均P＜0.05).结论 阿卡波糖治疗可以明显改善糖尿病患者的血糖波动,同时有效避免夜间低血糖;联合使用阿卡波糖,可减少胰岛素用量,并减少胰岛素引起的不良反应等.     

Hypoglycemia associated with the use of gatifloxacin

We present the histories, clinical findings, and hospital course of three patients who developed hypoglycemia after receiving gatifloxacin. Possible mechanisms for the hypoglycemia are outlined. CASE 1: A 89-year-old diabetic male receiving glyburide was given a single dose of gatifloxacin for bronchitis. Thirteen hours later, he was found to be unresponsive with a blood glucose level of 34 mg/dL. The hypoglycemia resolved within 24 hours of stopping gatifloxacin. CASE 2: A 80-year-old nondiabetic woman with end-stage renal disease and recent surgery was treated with gatifloxacin, cefepime, and metronidazole for pneumonia. Sixteen hours later, her serum glucose level was 61 mg/dL, and over the next 24 hours was as low as 39 mg/dL. The hypoglycemia resolved within 40 hours of stopping gatifloxacin. CASE 3: A 58-year-old diabetic man receiving glyburide was admitted for myocardial infarction and renal failure. Twelve hours after receiving gatifloxacin for pneumonia, his blood glucose level was 60 mg/dL and was as low as 42 mg/dL between 2 and 22.5 hours of a second dose of gatifloxacin. The hypoglycemia resolved within 24 hours of stopping gatifloxacin. CONCLUSIONS: Gatifloxacin use may precipitate hypoglycemia in diabetic patients receiving oral hypoglycemic agents and in nondiabetic patients with chronic renal failure. Discontinuation of gatifloxacin results in improvement in glucose homeostasis.