title: Interventions That Restore Awareness of Hypoglycemia in Adults With Type 1 Diabetes: A Systematic Review and Meta-analysis.
abstract: OBJECTIVE
  Impaired awareness of hypoglycemia (IAH) increases the risk of severe hypoglycemia (SH) sixfold and affects 30% of adults with type 1 diabetes (T1D). This systematic review and meta-analysis looks at the educational, technological, and pharmacological interventions aimed at restoring hypoglycemia awareness (HA) in adults with T1D.
  
  
  METHODS
  We searched The Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, Social Sciences Citation Index, PsycINFO, and CINAHL from inception until 1 October 2014. Included studies described HA status at baseline. Outcome measures were SH rates, change in HA, counterregulatory hormone responses, and glycemic control.
  
  
  RESULTS
  Forty-three studies (18 randomized controlled trials, 25 before-and-after studies) met the inclusion criteria, comprising 27 educational, 11 technological, and 5 pharmacological interventions. Educational interventions included structured diabetes education on flexible insulin therapy, including psychotherapeutic and behavioral techniques. These were able to reduce SH and improve glycemic control, with greater benefit from the latter two techniques in improving IAH. Technological interventions (insulin pump therapy, continuous glucose monitoring, and sensor-augmented pump) reduced SH, improved glycemic control, and restored awareness when used in combination with structured education and frequent contact. Pharmacological studies included four insulin studies and one noninsulin study, but with low background SH prevalence rates.
  
  
  CONCLUSIONS
  This review provides evidence for the effectiveness of a stepped-care approach in the management of patients with IAH, initially with structured diabetes education in flexible insulin therapy, which may incorporate psychotherapeutic and behavioral therapies, progressing to diabetes technology, incorporating sensors and insulin pumps, in those with persisting need.
authors.affiliation: Diabetes Department, King's College Hospital, London, U.K. esteryeoh@nhs.net.
authors.forename: Ester
authors.initials: E
authors.lastname: Yeoh
authors.affiliation: Diabetes Research Group, King's College London, London, U.K.
authors.forename: Pratik
authors.initials: P
authors.lastname: Choudhary
authors.affiliation: Diabetes Research Group, King's College London, London, U.K.
authors.forename: Munachiso
authors.initials: M
authors.lastname: Nwokolo
authors.affiliation: Division of Health and Social Care Research, Department of Primary Care and Public Health Sciences, King's College, London, U.K.
authors.forename: Salma
authors.initials: S
authors.lastname: Ayis
authors.affiliation: Diabetes Research Group, King's College London, London, U.K.
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Amiel
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001364:Awareness; D001521:Behavior Therapy / Q000379:methods; D001786:Blood Glucose / Q000378:metabolism; D015190:Blood Glucose Self-Monitoring / Q000379:methods; D003922:Diabetes Mellitus, Type 1 / Q000188:drug therapy*; D006801:Humans; D007003:Hypoglycemia / Q000517:prevention & control* / Q000523:psychology; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D007332:Insulin Infusion Systems; D008875:Middle Aged; D010353:Patient Education as Topic / Q000379:methods; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin