Interventions to improve the quality of life in patients living with endocrine conditions

Introduction
Patients living with chronic endocrine conditions experience a burden of disease which affects their quality of life compared to healthy controls. In people living with type 1 and type 2 diabetes, this may be due to micro or macrovascular complications, as well as the negative emotions associated with living with diabetes. In individuals with adrenal insufficiency, the reduced quality of life may be due to failure to mimic the circadian rhythm during glucocorticoid replacement. Interventions to improve the management of these endocrine conditions can have an impact on the specific disease related distress. This would in turn affect the quality of life in these individuals. The first study assessed the impact of intermittently scanned continuous glucose monitoring (isCGM) on glycaemic control and diabetes distress in a predominantly type 1 diabetes population with psychosocial issues. The effect of this technology on diabetes distress in people living with type 2 diabetes but not yet on insulin has been evaluated in the second study. In the final study, we compared the effect of prednisolone to hydrocortisone on the quality of life in patients with adrenal insufficiency.
Methods:
The first study was a retrospective analysis of baseline and follow-up data from the Association of British Clinical Diabetologists (ABCD) nationwide audit of people with diabetes who initiated the isCGM for psychosocial reasons in the United Kingdom. In the second study, a randomized controlled trial, the effect of use of Free Style Libre 2 over 12 weeks on glycaemic control and diabetes distress in patients with type 2 diabetes was assessed. The final study was an observational study that compared the cardiovascular risk and quality of life of patients with adrenal insufficiency, at the start and 4 months after switching from hydrocortisone to prednisolone.
Results
In the first study, with the initiation of isCGM, after a mean follow-up period of 6.9 months, there was a significant reduction in Diabetes Distress Scale score; 4 at baseline vs. 2.5 at follow up (P<0.001). The prevalence of high Diabetes Related Distress (DRD) reduced from 76% to 38% at follow-up (50% reduction in DRD, P<0.001). There was also a significant reduction in HbA1c (HbA1c 78.5 mmol/mol (9.3%) at baseline vs 66.5 mmol/mol (8.2%) at follow-up (P<0.001).
In the second study, the use of Libre 2, a form of isCGM, increased the mean time in range at 12 weeks by 18% (CI 2-35, p=0.028). Participants in the Libre 2 arm exhibited a non-significant reduction in HbA1c levels of 8 mmol/mol compared to the control arm. However, no significant differences were observed in other isCGM metrics or diabetes distress between the study arms.
In the final study, the use of prednisolone was associated with an average reduction in weight of 1.2kg (p=0.007) and relatedly, a reduction in body mass index (BMI) of 0.4kg/m2. The systolic blood pressure reduced by an average of 6mmHg (p=0.027). The total cholesterol, non-HDL cholesterol, triglycerides levels were lower at follow up compared to baseline levels. These changes were however not statistically significant (p>0.05). Data from the modified SF-36 quality of life questionnaire showed significant increase in the energy scores and scores relating to the participants’ general health (p=0.003 and p=0.019 respectively), indicating an improvement in the quality of life.

Conclusion:
Analysis of real-world data of people with T1DM using isCGM initiated for psychosocial reasons shows a significant improvement in diabetes related distress, glycaemic control and hospital admissions due to hyperglycaemia/diabetic ketoacidosis. The use of isCGM in T2DM patients on non-insulin therapy showed promise in improving glycaemic control, as evidenced by increased time in range. There was, however, no significant reduction in HbA1c or impact on diabetes distress. The use of prednisolone was associated with a significant reduction in systolic blood pressure, weight and BMI. Prednisolone did not affect the lipid profile, signifying no increase in cardiovascular risk. Patients felt more energetic and had higher general health scores. These findings suggest that low dose prednisolone may be a better glucocorticoid option than hydrocortisone. In this thesis, we have shown that the disease specific interventions had an overall positive impact on the management of individuals living with diabetes and adrenal insufficiency. This generally resulted in improvement in the quality of life as evidenced by the disease related distress. Interventions also had an impact on the individuals’ biochemical health as shown by various outcome measures.