ΑΣΚΗΣΗ στον ΣΔ τυπου 1

Α.Μητράκου Καθηγήτρια Ε.Κ.Π.Α. Μονάδα Σακχαρώδη Διαβήτη Μεταβολισμού Θεραπευτική Κλθνική Νοσ.Αλεξάνδρα ΑΣΚΗΣΗ στον ΣΔ τυπου 1 Page 1 Α.Μητράκου Καθηγήτρια Ε.Κ.Π.Α. Μονάδα Σακχαρώδη Διαβήτη-Μεταβολισμού Θεραπευτική Κλινική Νοσ.Αλεξάνδρα 1

ΟΦΕΛΗ της ΑΣΚΗΣΗΣ Βελτίωση επιπέδων γλυκόζης Μείωση καρδιαγγειακού κινδύνου Απώλεια ΣΒ Ποιότητα ζωής Πρόληψη ΣΔ σε άτομα υψηλού κινδύνου Page 2 2

Type 1 diabetes factors affecting exercise blood glucose responses. Page 3 3

Αεροβια Ασκηση Page 4 4

Ασκηση Αντιστάσεων Αναερόβια Ασκηση Page 5 5

Φυσιολογία της Ασκησης Ινσουλίνη Γλυκαγόνη Κατεχολαμίνες Γλυκοκορτικοειδή Νευρικό σύστημα Μοριακοί μηχανισμοί των μυών και του ήπατος Page 6

Μεταβολικά προβλήματα στην άσκηση στον ΣΔ1 ΥΠΟΓΛΥΚΑΙΜΙΑ ΥΠΕΡΓΛΥΚΑΙΜΙΑ ΑΝΕΠΙΓΝΩΤΗ ΥΠΟΓΛΥΚΑΙΜΙΑ Page 7

Ασκηση και Αιτια Υπογλυκαιμίας Αυξημένη κατανάλωση γλυκόζης (μετά την άσκηση) Αυξημένη δράση της Ινσουλίνης(μετά την άσκηση) Αυξημένα επίπεδα ινσουλίνης στον ΣΔ 1 κατά την άσκηση(επηρεάζουν την ηπατική παραγωγή γλυκόζης) Διαταραγμένη counterregulation (κατά την άσκηση και στον ύπνο) Καταστολή της ηπατικής παραγωγής γλυκόζης (πιο επικίνδυνη επί συνύπαρξης λήψης αλκοόλ) Συχνά επεισόδια υπογλυκαιμίας (hypoglycemia begets hypoglycemia) Page 8 8

Αεροβια vs Αναεροβια ασκηση Page 9

Ανεπιγνωτη Υπογλυκαιμία ΔΙΑΡΚΕΙΑ ΔΙΑΒΗΤΗ ΕΝΤΑΤΙΚΟΠΟΙΗΜΕΝΗ ΡΥΘΜΙΣΗ Page 10

Summary of Impaired Counterregulation Page 11

Φαυλος Κυκλος Υπογλυκαιμίας και Ασκησης στον ΣΔ1 Diabetes Metab Res Rev 2004; 20: 124 130 Page 12

Φαυλος Κυκλος Υπογλυκαιμίας και Ασκησης σε φυσιολογικά άτομα 2h υπογλυκαιμια στα 50 mg/dl η Ασκηση 90 ποδηλατο 50% VO2max X2 Galassetti P Am J,Physiol 2001; 280: E908-E917 Page 13

Antecedent Hypoglycemia on Subsequent Counterregulatory Responses to Exercise in Type 1 90 min of continuous pedaling (at 60 70 rpm) on an upright cycle ergometer (50% VO2 max). Page 14 Calassetti P.Diabetes 52:1761 1769, 2003

Antecedent Hypoglycemia on Subsequent Counterregulatory Responses to Exercise in Type 1 Page 15 Calassetti P. Diabetes 52:1761 1769, 2003

Antecedent Hypoglycemia on Subsequent Counterregulatory Responses to Exercise in Type 1 Page 16 Copasetic P. Diabetes 52:1761 1769, 2003

Men vs Women type 1 exercise after hypo glucagon and EGP, were similar between genders, suggesting that the glucagon to insulin ratio may be the primary determinant of EGP during moderate intensity exercise in T1DM. Galassetti P. The Journal of Clinical Endocrinology & Metabolism 2002 87(11):5144 5150 Page 17

Προληψη της Υπογλυκαιμίας με την Ασκηση στον ΣΔ 1 Page 18 18

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factors that might affect BG concentrations duration and intensity of the activity, the glucose concentration at the start of exercise, circulating insulin levels, insulin sensitivity, time of day, prior hypoglycemia, recent exercise, ambient temperature, competition stress, electrolyte balance and perhaps menstrual cycle for 21 females. Page 21

Τιτλοποίηση της Ινσουλίνης και διαιτητικές προσαρμογέςγια την επιτευξη ευγλυκαιμιας και την αποφυγη νυχτερινών υπογλυκαιμιών Η ασκηση ιδιαιτερα τις απογευματινές ώρες είναι η αιτία σοβαρών υπογλυκαιμιών στον ΣΔ1.Ο φόβος των υπογλυκαιμιών οδηγεί τα άτομα με ΣΔ1 να αποφεύγουν την άσκηση. Συστασεις για την επίτευξη ευγλυκαιμίας περί την ώρα της ασκησης περιλαμβανουν προσαρμογή των γευματικών δόσεων ινσουλίνης και της συστασης των γευματων. Οι οδηγίες αυτές όμως παρεχουν βραχύχρονη πρόληψη της υπογλυκαιμίας. Campbell M. BMJ Open Diabetes Research and Care 2015 Page 22

Χαμηλου γλυκαιμικου δεικτη (LGI) δειπνο και μικρο Bedtime Snack προλαμβανει την μεταγευματικη υπεργλυκαιμια και προλαμβανει τις αμεσε υπογλυκαιμιες αλλα οχι τι απωτερες νυκτερινες υπογλυκαιμιες μετα απο απογευματινη ασκηση στον ΣΔ 1 75% reduction) of insulin aspart +pre exercise bolus CHO meal Patients remained at rest for 60 min following consumption of the preexercise carbohydrate bolus At 60 min postexe rcise, patients were adminis tered a 50%ins +HGI or LGI bedtime snack of either LGI or HGI -, LGI;, HGI -, The risk of late nocturnal HYPO remains 45 min of treadmill 70% Page 23 Diabetes Care 2014;37:1845 1853 23

LGI δείπνο με μειωμενη δοση ταχειας δρασης ινσουλινη μετα απο ασκηση τις απογευματινές ωρες προλαμβανει τισ βραδυνες μεταγευματικες υπεργλυκαιμιες και προστατευει απο τις υπογλυκαιμιες μεχρι 8 ωρες μετα την ασκηση Παρολα αυτα ο φοβο της υπογλυκαιμιας αργα το βραδυ παραμενει HGI LGI Page 24 24

ΑΣΚΗΣΗ μετα το ΠΡΩΙΝΟ γευμα : Σημαντικη μειωση προ και μετα την ασκηση ταχειας δρασης ινσουλινη προλαμβανει την πρωιμη αλλα οχι την απωτερη υπογλυκαιμια στον ΣΔ 1 Patients administered a 25% (1.8 IU) dose (i.e., a 75% reduction) of rapidacting insulin into the abdomen After consuming breakfast, patients remained rested Sixty minutes after breakfast, patients performed 45 min of steady-state treadmill running at 72.5 % VO2peak At 60 min postexercise, in a randomized and counter-balanced fashion,patients administered a Full (7.5 6 IU), 75% (5.6 IU), or 50% (3.7 IU) rapid-acting insulin dose, which was injected into the abdominal site Patients then consumed a pasta-based lunch meal (pasta, tomato-based sauce, cheddar cheese), equating to 1 g carbohydrate/kg BM (660 kcal), and then remained at rest for 180 min postmeal Page 25 Black line, Full; blue line, 75%; red line, 50%. CAMPBELL Diabetes Care 36:2217 2224, 2013 25

Triangles, Full; squares, 75%; diamonds, 50%. 50% reduction was the best Page 26 CAMPBELL Diabetes Care 36:2217 2224, 2013 26

Algorithm that delivers an individualized rapid-acting insulin dose after morning resistance exercise counters post-exercise hyperglycaemia in people with Type 1 diabetes Turner et al Diabet.Medicine 2015 Administration of rapid-acting insulin according to an individualized algorithm reduced the hyperglycaemia associated with morning resistance exercise without causing hypoglycaemia in the 2 h post-exercise period in people with Type 1 diabetes fasting, having taken their usual basal insulin the previous evening. These people performed a resistance exercise session the participants were administered an individualized dose of rapid-acting insulin (2 1 units, range 0 4 units) immediately after resistance exercise Page 27

individualized rapid-acting insulin dose after morning resistance exercise Administration of rapidacting insulin according to an individualized algorithm reduced the hyperglycaemia associated with morning resistance exercise without causing hypoglycaemia in the 2 h post-exercise period in people with Type 1 diabetes (a) Blood glucose and (b) plasma insulin responses to insulin group (diamonds) and no-insulin group (squares) Page 28

Insulin therapy and dietary adjustments to normalize glycemia and prevent nocturnal hypoglycemia after evening exercise in type 1 diabetes: a randomized controlled trial by reducing basal insulin dose in combination with reduced prandial bolus insulin and llgi(ow glycemic index carbohydrate) feeding, exercise-induced hypoglycemia can be avoided for 24 h following evening exercise. Moreover,this strategy is not associated with hyperglycemia,or adverse metabolic disturbance Black trace=100%, red trace=80%. Time-course changes in interstitial glucose concentrations throughout the postlaboratory period Page 29 Campbell M. BMJ Open Diabetes Research and Care 2015

Effect of caffeine during exercise in Type 1 diabetes Caffeine intake should be considered as another strategy that may modestly attenuate hypoglycaemia in individuals with Type 1 diabetes during exercise, but should be taken with precautionary measures as it may increase the risk of late-onset hypoglycaemia. Page 30 ZaharievaDiabetic Medicine 2015 30

Effect of caffeine during exercise in Type 1 diabetes Page 31 Zaharieva Diabetic Medicine 2015 31

Similar risk of exercise-related hypoglycaemia for insulin degludec compared with insulin glargine in patients with type 1 diabetes: a randomised cross-over trial Insulin and carbohydrate were reduced by ~60% (median 40 g carbohydrate, both treatments) to achieve consistent preexercise BG levels, avoiding high BG levels >10 mmol/l (~180 mg/dl). Three hours after lunch (3:00 p.m.) patients performed a 30- min ergometer bicycle exercise bout at 65% VO2peak. Page 32 Heise T. Diab Obes Metab 2015

Effects of High-Intensity Interval Exercise versus Moderate Continuous Exercise on Glucose Homeostasis in Patients with Type 1 Diabetes Mellitus Using Degludec 50% reduction was the best Before exercise, standardized meals were administered, and shortacting insulin dose was reduced by 25% (A), 50% (B), and 75% (C) dependent on mean exercise intensity. No differences were found for post-exercise interstitial glucose, acute hormone response, and carbohydrate utilization between HIIE and 33 CON for A,B or C PLOS ONE DOI:10.1371/journal.pone.0136489 August 28, 2015 Page 33

Αντλίες Ινσουλίνης και CGM για την πρόληψη της υπογλυκαιμίας στην άσκηση Accuchec Combo Aimas Vibe Navigator Page 34 Dexcom G4 Dana

Insulin-based strategies to prevent hypoglycaemia during and after exercise in adult patients with type 1 diabetes on pump therapy: the DIABRASPORT randomized study Frank S.Diabetes, Obesity and Metabolism 17: 1150 1157, 2015 Page 35

Afternoon values after late exercise (A) BR reduction of 50% (purple) (B) BR reduction of 80% (blue). 75% VO2max exercise with (C) 80% BR reduction (orange) (D) pump stop (red). Franc S. Diabetes, Obesity and Metabolism 17: 1150 1157, 2015 Page 36

Conclusions from the study Για Ασκηση 50%VO 2max 3h μετα το γευμα :80%μείωση βασικου ρυθμου κατά τη διάρκεια άσκησης και τις επόμενες 2 ωρες. Αυτη ειναι μια ενδιάμεση λύση μεταξύ της μείωσης κατά 50%του βασικου ρυθμου πριν απο την άσκηση και σταματώντας την αντλία κατά την ώρα της άσκησης Για Ασκηση 75% VO2max, η καλύτερη λύση είναι stop την αντλία κατα την διάρκεια της άσκησης, που συμφωνεί και με την επιθυμία του ασθενούς να βγαζουν την αντλία. Για άσκηση άμεσα μετά το γεύμα (90min),η καλύτερη λύση είναι μείωση κατά 30 50% στην προγευματική δόση ινσουλίνης παρά μείωση του βασικού ρυθμού. Page 37 37

CGM για την προληψη της Υπογλυκαιμιας Page 38

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Effect of Aerobic Exercise in Children With Type 1 Diabetes Page 40 Direcnet Study Group: J Peds 2005

Comparison of Two Continuous Glucose Monitoring Systems, Dexcom G4 Platinum and Medtronic Paradigm Veo Enlite System, at Rest and During Exercise Dexcom and Enlite demonstrated comparable overall performances during rest and physical activity. However, a lower accuracy was observed during exercise for both sensors, necessitating a fine-tuning of their performance with physical activity Page 41 Diabetes Technol Ther 2016; 18: 561 77 : 338 47. 41

CGM vs SBGM in exercise Page 42 42

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Use of CGM for sport in type 1 CHO intake Page 44 44

Use of CGM for sport in type 1 Insulin Dosage Page 45 45

Use of CGM for sport in type 1 Page 46 46

Avoiding hypoglycemia: the use of insulin pump combined with continuous glucose monitor in type 1 diabetes crossing a Rocky Gorge. Thomakos P, Vazeou A, Mitrakou A. QJM. 2018 Sep 1;111(9):629-633. doi: 10.1093/qjmed/hcy136. Page 47

Αυτόματη διακοπή παροχής ινσουλίνης Ασφάλεια ειδικά την νύχτα Page 48

640G, PLGM Technology PLGM technology Basal and bolus presets Remote bolusing from meter Active insulin on home screen Ns PLGM Technology Veo LGS Feature Vs: Suspends at 70mg/dL Vr: Resumes after 2hr Blood glucose Vs Nr Vr NGP PLGM Feature Ns: Suspends if user is below 140 mg/dl and is predicted to be below 70mg/dl in 30 min Time Nr: Resumes if user is above 80 mg/dl and is predicted to be at or above 110mg/dl in 30min and insulin has been suspended for at least 30 min Page 49

CLOSED LOOP / ARTIFICIAL PANCREAS AP@HOME JDRF3 Page 50

Closed-loop glucose control in young people with type 1 diabetes during and after unannounced physical activity: a randomised controlled crossover trial Dovc K. Diabetologia 2017;60:2157-2167 Page 51 51

Closed-loop glucose control in young people with type 1 diabetes during and after unannounced physical activity: a randomised controlled crossover trial Dovc K. Diabetologia 2017;60:2157-2167 Page 52 52

Basal rate insulin reductions for patients receiving a continuous subcutaneous insulin infusion D.P. Zaharieva, M.C. Riddell / Can J Diabetes 41 (2017) 507 516 Page 53 53

Basal insulin adjustment strategies for patients receiving continuous subcutaneous insulin infusion D.P. Zaharieva, M.C. Riddell / Can J Diabetes 41 (2017) 507 516 Page 54 54

Basal insulin adjustment strategies for patients receiving multiple daily injection therapy Page 55 55

Bolus insulin adjustments based on the timing of exercise relative to mealtime D.P. Zaharieva, M.C. Riddell / Can J Diabetes 41 (2017) 507 516 Page 56 56

Bolus insulin adjustments for postprandial exercise D.P. Zaharieva, M.C. Riddell / Can J Diabetes 41 (2017) 507 516 Page 57 57

CONCLUSIONS For individuals living with type 1 diabetes, although regular physical activity is associated with a number of health benefits, it can also lead to increased glucose excursions Reduction of basal insulin and/or additional carbohydrate consumption have been recommended as strategies to reduce the risk of hypoglycemia during exercise. However, these strategies often require advanced planning and only focus on the periods involving exercise rather than how to effectively reduce hypoglycemia during exercise as well as in recovery. Closed Loop insulin delivery is safe and effective during and following exercise in adolescents living with type 1 diabetes. Page 58 58

Mini-Dose Glucagon as a Novel Approach to Prevent ExerciseInduced Hypoglycemia in T1D During exercise and early recovery from exercise, plasma glucose increased slightly with MDG compared with a decrease with control and insulin reduction,and a greater increase with glucose tablets (P < 0.001). Insulin levels were not different among sessions, whereas glucagon increased with MDG administration (P < 0.001). Hypoglycemia (plasma glucose Hypoglycemia (plasma glucose <70 mg/dl was experienced in 6 subjects during control 5 subjects during decrease of insulin 0 with tablets or MGD Hyperglycemia: 5 subjects on tablets O on MGD 59 Page 59

VΕΟ vs 640 Page 60 60

640 Page 61

VEO Page 62 62