Hypoglycaemia among Insulin-Treated Patients with Diabetes: Southeast Asia Cohort of IO HAT Study

Faruque Pathan, Su-Yen Goh, Achmad Rudijanto, Arvind Gadekar, Anand Jain, Nemencio Nicodemus Jr.


Objective: To provide real-world data on hypoglycaemia incidence in patients with type 1 (T1D) or type 2 diabetes (T2D) from the Southeast Asian cohort of the International Operations Hypoglycaemia Assessment Tool (IO HAT) study.

Methodology: IO HAT was a non-interventional, multicentre, 6-month retrospective and 4-week prospective study of hypoglycaemic events among insulin-treated adults with T1D or T2D, including four countries in Southeast Asia (Singapore, Philippines, Indonesia, and Bangladesh). Data were collected using a two-part self-assessment questionnaire (SAQ1 for retrospective and SAQ2 for prospective). The primary endpoint was the percentage of patients experiencing at least one hypoglycaemic event during the 4-week prospective observational period.

Results: A total of 2594 patients completed SAQ1. Nearly all patients reported experiencing any hypoglycaemic event in the 4-week prospective period (T1D, 100%; T2D, 97.3%), with all patients reporting higher rates in the prospective versus retrospective period. Severe hypoglycaemia was also reported higher prospectively (57.2% and 76.9%) than retrospectively (33.9% and 12.2%) in both T1D and T2D, respectively. Nocturnal hypoglycaemia was reported higher retrospectively than prospectively.

Conclusion: Incidence of any and severe hypoglycaemia in the Southeast Asian cohort of IO HAT was higher prospectively versus retrospectively, suggesting hypoglycaemia has previously been under-reported in this region.


hypoglycaemia, insulin, diabetes

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Ramachandran A, Snehalatha C, Ma RC. Diabetes in South-East Asia: An update. Diabetes Res Clin Pract. 2014;103(2):231-7. PMID: 24300015. https://doi.org/10.1016/j.diabres.2013.11.011.

Chan JC, Gagliardino JJ, Baik SH, et al. Multifaceted determinants for achieving glycemic control: The International Diabetes Management Practice Study (IDMPS). Diabetes Care. 2009;32(2):227-33. PMID: 19033410. PMCID: PMC2628684. https://doi.org/10.2337/dc08-0435.

International Diabetes Federation. IDF Diabetes Atlas. 7th ed. Brussels, Belgium, 2015.

International Diabetes Federation. IDF Diabetes Atlas. 3rd ed. Brussels, Belgium, 2006.

Phan TP, Alkema L, Tai ES, et al. Forecasting the burden of type 2 diabetes in Singapore using a demographic epidemiological model of Singapore. BMJ Open Diabetes Res Care. 2014;2(1):e000012. PMID: 25452860. PMCID: PMC4212579. https://doi.org/10.1136/bmjdrc-2013-000012.

Jayawardena R, Ranasinghe P, Byrne NM, Soares MJ, Katulanda P, Hills AP. Prevalence and trends of the diabetes epidemic in South Asia: A systematic review and meta-analysis. BMC Public Health. 2012;12:380. PMID: 22630043. PMCID: PMC3447674. https://doi.org/10.1186/1471-2458-12-380.

Ramachandran A, Ma RC, Snehalatha C. Diabetes in Asia. Lancet. 2010;375(9712):408-18. PMID: 19875164. https://doi.org/10.1016/S0140-6736(09)60937-5.

Mohan V, Deepa M, Deepa R, et al. Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India–the Chennai Urban Rural Epidemiology Study (CURES-17). Diabetologia. 2006;49(6):1175-8. PMID: 16570158. https://doi.org/10.1007/s00125-006-0219-2.

Ramachandran A, Snehalatha C, Samith Shetty A, Nanditha A. Primary prevention of Type 2 diabetes in South Asians - challenges and the way forward. Diabet Med. 2013;30(1):26-34. PMID: 22827704. https://doi.org/10.1111/j.1464-5491.2012.03753.x.

Hu EA, Pan A, Malik V, Sun Q. White rice consumption and risk of type 2 diabetes: Meta-analysis and systematic review. BMJ. 2012;344:e1454. PMID: 22422870. PMCID: PMC3307808.

Goh SY, Hussein Z, Rudijanto A. Review of insulin-associated hypoglycemia and its impact on the management of diabetes in South East Asian countries. J Diabetes Investig. 2017;8(5):635-45. PMID: 28236664. PMCID: PMC5584309. https://doi.org/10.1111/jdi.12647.

Elliott L, Fidler C, Ditchfield A, Stissing T. Hypoglycemia event rates: A comparison between real-world data and randomized controlled trial populations in insulin-treated diabetes. Diabetes Ther. 2016;7(1):45-60. PMID: 26886441. PMCID: PMC4801820. https://doi.org/10.1007/s13300-016-0157-z.

Edridge CL, Dunkley AJ, Bodicoat DH, et al. Prevalence and incidence of hypoglycaemia in 532,542 people with type 2 diabetes on oral therapies and insulin: A systematic review and meta-analysis of population based studies. PLoS One. 2015;10(6):e0126427. PMID: 26061690. PMCID: PMC4465495. https://doi.org/10.1371/journal.pone.0126427

Khunti K, Alsifri S, Aronson R, et al. Rates and predictors of hypoglycaemia in 27 585 people from 24 countries with insulin-treated type 1 and type 2 diabetes: The global HAT study. Diabetes Obes Metab. 2016;18(9):907-15. PMID: 27161418. PMCID: PMC5031206. https://doi.org/10.1111/dom.12689.

Emral R, Pathan F, Yepes Cortés CAY, et al. Self-reported hypoglycemia in insulin-treated patients with diabetes: Results from an international survey on 7289 patients from nine countries. Diabetes Res Clin Pract. 2017;134:17-28. PMID: 28951336. https://doi.org/10.1016/j.diabres.2017.07.031.

Workgroup on Hypoglycemia‚ American Diabetes Association. Defining and reporting hypoglycemia in diabetes: A report from the American Diabetes Association Workgroup on Hypoglycemia. Diabetes Care. 2005;28(5):1245-9. PMID: 15855602.

Pedersen-Bjergaard U, Pramming S, Heller SR, et al. Severe hypoglycaemia in 1076 adult patients with type 1 diabetes: Influence of risk markers and selection. Diabetes Metab Res Rev. 2004;20(6):479-86. PMID: 15386817. https://doi.org/10.1002/dmrr.482.

Kalra S, Mukherjee JJ, Venkataraman S, et al. Hypoglycemia: The neglected complication. Indian J Endocrinol Metab. 2013;17(5):819-34.

Peyrot M, Barnett AH, Meneghini LF, Schumm-Draeger PM. Factors associated with injection omission/non-adherence in the Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabetes Obes Metab. 2012;14(12):1081-7. PMID: 22726104. https://doi.org/10.1111/j.1463-1326.2012.01636.x.

Shariful Islam SM, Lechner A, Ferrari U, et al. Healthcare use and expenditure for diabetes in Bangladesh. BMJ Global Health. 2017;2(1):e000033. PMID: 28588991 PMCID: PMC5321382. https://doi.org/10.1136/bmjgh-2016-000033.

Khunti K, Alsifri S, Aronson R, et al. Impact of hypoglycaemia on patient-reported outcomes from a global, 24-country study of 27,585 people with type 1 and insulin-treated type 2 diabetes. Diabetes Res Clin Pract. 2017;130:121-9. PMID: 28602812. https://doi.org/10.1016/j.diabres.2017.05.004.

McQueen RB, Ellis SL, Campbell JD, Nair KV, Sullivan PW. Cost-effectiveness of continuous glucose monitoring and intensive insulin therapy for type 1 diabetes. Cost Eff Resour Alloc. 2011;9:13. PMID: 21917132 PMCID: PMC3180394 https://doi.org/10.1186/1478-7547-9-13.

Tunis SL, Minshall ME. Self-monitoring of blood glucose (SMBG) for type 2 diabetes patients treated with oral anti-diabetes drugs and with a recent history of monitoring: cost-effectiveness in the US. Curr Med Res Opin. 2010;26(1):151-62. PMID: 19919376. https://doi.org/10.1185/03007990903400071.

Pollock RF, Valentine WJ, Goodall G, Brändle M. Evaluating the cost-effectiveness of self-monitoring of blood glucose in type 2 diabetes patients on oral anti-diabetic agents. Swiss Med Wkly. 2010;140:w13103. PMID: 21110238. https://doi.org/10.4414/smw.2010.13103.

Chen W, Qian L, Watada H, et al. Impact of diet on the efficacy of insulin lispro mix 25 and insulin lispro mix 50 as starter insulin in East Asian patients with type 2 diabetes: Subgroup analysis of the comparison between low mixed insulin and mid mixed insulin as starter insulin for patients with type 2 diabetes mellitus (CLASSIFY Study) randomized trial. J Diabetes Investig. 2017;8(1):75-83. PMID: 27287069. PMCID: PMC5217926. https://doi.org/10.1111/jdi.12547.

Liao Y, Xiang Y, Zhou Z. Diagnostic criteria of latent autoimmune diabetes in adults (LADA): A review and reflection. Front Med. 2012;6(3):243-7. PMID: 22843304. https://doi.org/10.1007/s11684-012-0201-y.