Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2021

Acceptance and Effect of Continuous Glucose Monitoring on Discharge From Hospital in Patients With Type 2 Diabetes: Open-label, Prospective, Controlled Study

Background

Continuous glucose monitors (CGM) can provide detailed information on glucose excursions. There is little information on safe transitioning from hospital back to the community for patients who have had diabetes therapies adjusted in hospital and it is unclear whether newer technologies may facilitate this process.

Objective

Our aim was to determine whether offering CGM on discharge would be acceptable and if CGM initiated on hospital discharge in people with type 2 diabetes (T2DM) would reduce hospital re-presentations at 1 month.

Methods

This was an open-label study. Adult inpatients with T2DM, who were to be discharged home and required postdischarge glycemic stabilization, were offered usual care consisting of clinic review at 2 weeks and at 3 months. In addition to usual care, participants in the intervention arm were provided with a Libre flash glucose monitoring system (Abbott Australia). An initial run-in phase for the first 20 participants was planned, where all consenting participants were enrolled in an active arm. Subsequently, all participants were to be randomized to the active arm or usual care control group.

Results

Of 237 patients screened during their hospital admission, 34 had comorbidities affecting cognition that prevented informed consent and affected their ability to learn to use the CGM device. In addition, 21 were not able to be approached as the material was only in English. Of 101 potential participants who fulfilled eligibility criteria, 19 provided consent and were enrolled. Of the 82 patients who declined to participate, 31 advised that the learning of a new task toward discharge was overwhelming or too stressful and 26 were not interested, with no other details. Due to poor recruitment, the study was terminated without entering the randomization phase to determine whether CGM could reduce readmission rate.

Conclusions

These results suggest successful and equitable implementation of telemedicine programs requires that any human factors such as language, cognition, and possible disengagement be addressed. Recovery from acute illness may not be the ideal time for introduction of newer technologies or may require more novel implementation frameworks.

Continuous Subcutaneous Insulin Infusions vs. Multiple Daily Injections of Insulin in Hospitalized Patients: Glycemic Trends in the First 24 Hours of Admission

BACKGROUND

Continuous subcutaneous insulin infusion (CSII) is a common diabetes treatment modality. Glycemic outcomes of patients using CSII in the first 24 hours of hospitalization have not been well studied. This timeframe is of particular importance because insulin pump settings are programmed to achieve tight outpatient glycemic targets which could result in hypoglycemia when patients are hospitalized.

METHODS

This retrospective cohort study evaluated 216 hospitalized adult patients using CSII and 216 age-matched controls treated with multiple daily injections (MDI) of insulin. Patients using CSII did not make changes to pump settings in the first 24 hours of admission. Blood glucose (BG) values within the first 24 hours of admission were collected. The primary outcome was frequency of hypoglycemia (BG < 70 mg/dL). Secondary outcomes were frequency of severe hypoglycemia (BG < 40 mg/dL) and hyperglycemia (BG ≥ 180 mg/dL).

RESULTS

There were significantly fewer events of hypoglycemia [incident rate ratio (IRR) 0.61, 95% confidence interval (CI) 0.42-0.88, p = 0.007] and hyperglycemia (IRR 0.79, 95% CI 0.65-0.96, p = 0.02) in the CSII group compared to the MDI group. There was a trend toward fewer events of severe hypoglycemia in the CSII group (IRR 0.15, 95% CI 0.02-0.93, p = 0.06).

CONCLUSIONS

Patients using CSII experienced fewer events of both hypoglycemia and hyperglycemia in the first 24 hours of hospital admission than those treated with MDI. Our study demonstrates that CSII use is safe and effective for the treatment of diabetes within the first 24 hours of hospital admission.

Comparison of Prevailing Insulin Regimens at Different Time Periods in Hospitalized Patients: A Real-World Experience from a Tertiary Hospital

BACKGROUND

Prevailing insulin regimens for glycemic control in hospitalized patients have changed over time. We aimed to determine whether the current basal-bolus insulin (BBI) regimen is superior to the previous insulin regimen, mainly comprising split-mixed insulin therapy.

METHODS

This was a single tertiary center, retrospective observational study that included non-critically ill patients with type 2 diabetes mellitus who were treated with split-mixed insulin regimens from 2004 to 2007 (period 1) and with BBI from 2008 to 2018 (period 2). Patients from each period were analyzed after propensity score matching. The mean difference in glucose levels and the achievement of fasting and preprandial glycemic targets by day 6 of admission were assessed. The total daily insulin dose, incidence of hypoglycemia, and length of hospital stay were also evaluated.

RESULTS

Among 244 patients from each period, both fasting glucose (estimated mean±standard error, 147.4±3.1 mg/dL vs. 129.4±3.2 mg/dL, P<0.001, day 6) and preprandial glucose (177.7±2.8 mg/dL vs. 152.8±2.8 mg/dL, P<0.001, day 6) were lower in period 2 than in period 1. By day 6 of hospital admission, 42.6% and 67.2% of patients achieved a preprandial glycemic target of <140 mg/dL in periods 1 and 2, respectively (relative risk, 2.00; 95% confidence interval, 1.54 to 2.59), without an increased incidence of hypoglycemia. Length of stay was shorter in period 2 (10.23±0.26 days vs. 8.70±0.26 days, P<0.001).

CONCLUSION

BBI improved glycemic control in a more efficacious manner than a split-mixed insulin regimen without increasing the risk of hypoglycemia in a hospital setting.

Practical approach to clinical controversies in glycemic control for hospitalized surgical patients

The importance of glycemic management in surgical patient populations stems from an association between hyperglycemia and increased rates of surgical site infections, sepsis, and mortality. Various guidelines provide recommendations regarding target glucose concentrations, but all stress the importance of avoiding hypoglycemia as well. Within the surgical patient population, glycemic targets may vary further depending on the surgical service, such as cardiac surgery, neurosurgery, or reconstructive burn surgery. Glycemic management in critically ill surgical patients is achieved primarily through the use of intravenous insulin infusion protocols. These protocols can include fixed protocols, multiplication factor protocols, and computerized algorithms. In contrast, noncritically ill surgical patients are generally managed through the utilization of subcutaneous insulin with a combination of basal, bolus, and sliding scale insulin. Insulin protocols should be effective at maintaining glucose concentrations within the specified target range with minimal hypoglycemic events. Monitoring glucose concentrations while on either an intravenous or subcutaneous insulin protocol is essential. Point-of-care testing is the primary method for monitoring glucose concentrations in both critically ill and noncritically ill surgical patients and allows for adjustment of the insulin regimen. As patients move between units and to the outpatient setting, ensuring adequate follow-up is essential to maintaining control of hyperglycemia.

Hyperglycemia in hospitalized patients of a tertiary care hospital: prevalence and treatment in two cross-sectional evaluations (2011-2020)

Objective

A study at Centro Hospitalar Universitário do Porto in 2011 revealed suboptimal control of inpatient hyperglycemia and a similar one was carried out in 2020. This study compares the results of 2011 and 2020 regarding prevalence of hyperglycemia, metabolic control, treatment and glycemic profile by infection/non-infection diagnosis.

Methods

We performed two cross-sectional studies on 13^th December 2011 and 9^th October 2020 that included all non-critical adults with at least 24 hours of hospitalization, with no specific intervention between them. Glycemic control evaluated by minimum and maximum capillary blood glucose (CBG) in the previous day categorized as hypoglycemia (<70 mg/dL), normoglycemia (70-179 mg/dL) and hyperglycemia (≥180 mg/dL) (SPSS v.20).

Results

A total of 418 and 445 patients were respectively included in 2011 and 2020 studies and the prevalence of hyperglycemia was similar. Glycemic control improved numerically although not significantly in 2020: increase in normoglycemia, reduction in hyperglycemia and reduction in hypoglycemia. There was an increase in the use of basal-bolus regimens (19.6% vs. 7.3%, p = 0.009) and a decrease in human basal (p < 0.01) and rapid-acting insulin use (p = 0.001) with a proportional increase in long-acting (p = 0.002) and rapid-acting analogs (p < 0.001) use. There was a higher prevalence of infection (39.8% vs. 23.1%, p = 0.006) in 2020 and, in the infection subgroup, there were higher insulinization rates (37.3% vs. 10.7%, p = 0.017) and a trend to glycemic control improvement.

Conclusion

Despite the higher insulinization rates, the preference for new insulin analogs and a trend to better glycemic control, we have not yet reached targets, so education still remains necessary.

Artificial intelligence in critically ill diabetic patients: current status and future prospects

Recent years have witnessed increasing numbers of artificial intelligence (AI) based applications and devices being tested and approved for medical care. Diabetes is arguably the most common chronic disorder worldwide and AI is now being used for making an early diagnosis, to predict and diagnose early complications, increase adherence to therapy, and even motivate patients to manage diabetes and maintain glycemic control. However, these AI applications have largely been tested in non-critically ill patients and aid in managing chronic problems. Intensive care units (ICUs) have a dynamic environment generating huge data, which AI can extract and organize simultaneously, thus analysing many variables for diagnostic and/or therapeutic purposes in order to predict outcomes of interest. Even non-diabetic ICU patients are at risk of developing hypo or hyperglycemia, complicating their ICU course and affecting outcomes. In addition, to maintain glycemic control frequent blood sampling and insulin dose adjustments are required, increasing nursing workload and chances of error. AI has the potential to improve glycemic control while reducing the nursing workload and errors. Continuous glucose monitoring (CGM) devices, which are Food and Drug Administration (FDA) approved for use in non-critically ill patients, are now being recommended for use in specific ICU populations with increased accuracy. AI based devices including artificial pancreas and CGM regulated insulin infusion system have shown promise as comprehensive glycemic control solutions in critically ill patients. Even though many of these AI applications have shown potential, these devices need to be tested in larger number of ICU patients, have wider availability, show favorable cost-benefit ratio and be amenable for easy integration into the existing healthcare systems, before they become acceptable to ICU physicians for routine use.

Association between dysglycemia and mortality by diabetes status and risk factors of dysglycemia in critically ill patients: a retrospective study

AIMS

Dysglycemia, including the three domains hyperglycemia, hypoglycemia, and increased glycemic variability (GV), is associated with high mortality among critically ill patients. However, this association differs by diabetes status, and reports in this regard are limited. This study aimed to evaluate the associations between the three dysglycemia domains and mortality in critically ill patients by diabetes status and determined the contributing factors for dysglycemia.

METHODS

This retrospective study included 958 critically ill patients (admitted to the ICU) with or without DM. Dysglycemia was defined as abnormality of any of the three dimensions. We evaluated the effects of the three domains of glucose control on mortality using binary logistic regression and then adjusted for confounders. The associations between dysglycemia and other variables were investigated using cumulative logistic regression analysis.

RESULT

GV independently and similarly affected mortality in both groups after adjustment for confounders (DM: odds ratio [OR], 1.05; 95% confidence interval [CI]: 1.03-1.08; p <0.001; non-DM: OR, 1.07; 95% CI, 1.03-1.11; p = 0.002). Hypoglycemia was strongly associated with ICU mortality among patients without DM (3.12; 1.76-5.53; p <0.001) and less so among those with DM (1.18; 0.49-2.83; p = 0.72). Hyperglycemia was non-significantly associated with mortality in both groups. However, the effects of dysglycemia seemed cumulative. The factors contributing to dysglycemia included disease severity, insulin treatment, glucocorticoid use, serum albumin level, total parenteral nutrition, duration of diabetes, elevated procalcitonin level, and need for mechanical ventilation and renal replacement therapy.

CONCLUSION

The association between the three dimensions of dysglycemia and mortality varied by diabetes status. Dysglycemia in critical patients is associated with excess mortality; however, glucose management in patients should be specific to the patient's need considering the diabetes status and broader dimensions. The identified factors for dysglycemia could be used for risk assessment in glucose management requirement in critically ill patients, which may improve clinical outcomes.

Adjustment of Anti-Hyperglycaemic Agents During Bowel Preparation for Colonoscopy in Patients with Diabetes

OBJECTIVE

Due to the growing diabetes pandemic, the number of colonoscopies performed in patients with diabetes is steadily rising. However, recommendations on adjustments of anti-hyperglycaemic agents (AHG) during bowel preparation for colonoscopy are limited.

METHODS

A total of nine articles were revealed on a PubMed search using the search terms "diabetes" and "colonoscopy", "sigmoidoscopy", "endoscopy", "endoscopic intervention", "endoscopic invasive diagnostics", "endoscopic surgery", or "diabetes care in the hospital" and manual screening of the references of the articles reporting on AHG adjustment during bowel preparation.

RESULTS

Regular glucose measurements and the opportunity to contact the diabetes team were commonly advised. Recommendations also agreed that all oral AHG and short-acting insulin should be omitted when patients are on clear fluids. Recent studies suggest discontinuation of sodium-glucose cotransporter-2 (SGLT2) inhibitors even three days before the colonoscopy. In contrast, recommendations differed regarding adjustment of basal insulin depending on diabetes type and time point in relation to the intervention.

CONCLUSIONS

While discontinuation of oral AHG and short-acting insulin during bowel preparation for colonoscopy is generally accepted, recommendations on the adaptation of basal insulin follow different approaches.

New Horizons: Next-Generation Insulin Analogues: Structural Principles and Clinical Goals

Design of "first-generation" insulin analogues over the past 3 decades has provided pharmaceutical formulations with tailored pharmacokinetic (PK) and pharmacodynamic (PD) properties. Application of a molecular tool kit-integrating protein sequence, chemical modification, and formulation-has thus led to improved prandial and basal formulations for the treatment of diabetes mellitus. Although PK/PD changes were modest in relation to prior formulations of human and animal insulins, significant clinical advantages in efficacy (mean glycemia) and safety (rates of hypoglycemia) were obtained. Continuing innovation is providing further improvements to achieve ultrarapid and ultrabasal analogue formulations in an effort to reduce glycemic variability and optimize time in range. Beyond such PK/PD metrics, next-generation insulin analogues seek to exploit therapeutic mechanisms: glucose-responsive ("smart") analogues, pathway-specific ("biased") analogues, and organ-targeted analogues. Smart insulin analogues and delivery systems promise to mitigate hypoglycemic risk, a critical barrier to glycemic control, whereas biased and organ-targeted insulin analogues may better recapitulate physiologic hormonal regulation. In each therapeutic class considerations of cost and stability will affect use and global distribution. This review highlights structural principles underlying next-generation design efforts, their respective biological rationale, and potential clinical applications.

Selection and Warning of Evidence-Based Antidiabetic Medications for Patients With Chronic Liver Disease

The global prevalence of chronic liver disease and diabetes mellitus (DM) has gradually increased potentially due to changes in diet and lifestyle. The choice of antidiabetic medications for patients with coexisting DM and chronic liver disease is complicated. Severe liver injury may decrease the metabolism of antidiabetic medications, resulting in elevated drug concentrations and adverse effects. The choice of antidiabetic medications in patients with chronic liver disease has not been well studied. The long-term outcomes of antidiabetic medications in patients with chronic liver disease have gained attention recently. Herein, we reviewed relevant articles to extend our understanding on the selection and warning of antidiabetic medications for patients with chronic liver disease.

Bedeutung von Glukosewerten im Krankenhaus

Hintergrund

Eine Hyperglykämie bei Menschen mit und ohne Diabetes, die ins Krankenhaus eingeliefert werden, ist mit einem erheblichen Anstieg von Morbidität, Mortalität und Gesundheitskosten verbunden. Während eines Krankenhausaufenthaltes treten Stoffwechseldekompensationen häufig als Folge unterschiedlicher Ereignisse oder Zusatztherapien auf. Aufgrund des erhöhten Risikos für eine Zunahme der Morbidität, verbunden mit längerem Krankenhausaufenthalt sowie höheren Kosten und Mortalität, erscheint eine genaue Betrachtung der Bedeutung von Glukosewerten und der Therapieformen im Krankenhaus sinnvoll und angebracht.

Material und Methode

Aktuelle Befunde, Übersichtsarbeiten und Grundlagendaten wurden analysiert und in einer kurzen Übersicht zusammengefasst und diskutiert.

Fazit

Eine persistierende Hyperglykämie im Krankenhaus ist häufig und oft mit unzureichenden Ergebnissen des Krankenhausaufenthaltes verbunden. Die kontinuierliche Insulininfusion bleibt die Therapie der Wahl während hyperglykämischer Krisen und kritischen Erkrankungen. Auch bei nicht kritisch kranken Menschen mit ausgeprägter Hyperglykämie, schon ambulant bekannten hohen Insulindosen, mit Typ-1-Diabetes oder mit steroidinduzierter Hyperglykämie bleibt Insulin das Mittel der Wahl.

Management of Diabetes in Candidates for Liver Transplantation and in Transplant Recipients

Diabetes is common in patients waitlisted for liver transplantation because of end-stage liver disease or hepatocellular cancer as well as in posttransplant phase (posttransplantation diabetes mellitus). In both conditions, the presence of diabetes severely affects disease burden and long-term clinical outcomes; careful monitoring and appropriate treatment are pivotal to reduce cardiovascular events and graft and recipients' death. We thoroughly reviewed the epidemiology of diabetes in the transplant setting and the different therapeutic options, from lifestyle intervention to antidiabetic drug use-including the most recent drug classes available-and to the inclusion of bariatric surgery in the treatment cascade. In waitlisted patients, the old paradigm that insulin should be the treatment of choice in the presence of severe liver dysfunction is no longer valid; novel antidiabetic agents may provide adequate glucose control without the risk of hypoglycemia, also offering cardiovascular protection. The same evidence applies to the posttransplant phase, where oral or injectable noninsulin agents should be considered to treat patients to target, limiting the impact of disease on daily living, without interaction with immunosuppressive regimens. The increasing prevalence of liver disease of metabolic origin (nonalcoholic fatty liver) among liver transplant candidates, also having a higher risk of noncirrhotic hepatocellular cancer, is likely to accelerate the acceptance of new drugs and invasive procedures, as suggested by international guidelines. Intensive lifestyle intervention programs remain however mandatory, both before and after transplantation. Achievement of adequate control is mandatory to increase candidacy, to prevent delisting, and to improve long-term outcomes.

Management of Hyperglycemia in Hospitalized Patients Receiving Parenteral Nutrition

Almost half of inpatients on parenteral nutrition experience hyperglycemia, which increases the risk of complications and mortality. The blood glucose target for hospitalized patients on parenteral nutrition is 7.8 to 10.0 mmol/L (140 to 180 mg/dL). For patients with diabetes, the same parenteral nutrition formulae as for patients without diabetes can be used, as long as blood glucose levels can be adequately controlled using insulin. Insulin can be delivered via the subcutaneous or intravenous route or, alternatively, added to parenteral nutrition admixtures. Combining parenteral with enteral and oral nutrition can improve glycemic control in patients with sufficient endogenous insulin stores. Intravenous insulin infusion is the preferred route of insulin delivery in critical care as doses can be rapidly adjusted to altered requirements. For stable patients, insulin can be added directly to the parenteral nutrition bag. If parenteral nutrition is infused continuously over 24 hours, the subcutaneous injection of a long-acting insulin combined with correctional bolus insulin may be adequate. The aim of this review is to give an overview of the management of parenteral nutrition-associated hyperglycemia in inpatients with diabetes.

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes - an updated guideline from the Joint British Diabetes Society for Inpatient Care

This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of glycaemia in pregnant women with diabetes on obstetric wards and delivery units, Joint British Diabetes Societies (JBDS) for Inpatient Care Group, ABCD (Diabetes Care) Ltd. The updated guideline offers two approaches - the traditional approach with tight glycaemic targets (4.0-7.0 mmol/L) and an updated pragmatic approach (5.0-8.0 mmol/L) to reduce the risk of maternal hypoglycaemia whilst maintaining safe glycaemia. This is particularly relevant for women with type 1 diabetes who are increasingly using Continuous Glucose Monitoring (CGM) and Continuous Subcutaneous Insulin Infusion (CSII) during pregnancy. All women with diabetes should have a documented delivery plan agreed during antenatal clinic appointments. Hyperglycaemia following steroid administration can be managed either by increasing basal and prandial insulin doses, typically by 50% to 80%, or by adding a variable rate of intravenous insulin infusion (VRIII). Glucose levels, either capillary blood glucose or CGM glucose levels, should be measured at least hourly from the onset of established labour, artificial rupture of membranes or admission for elective caesarean section. If intrapartum glucose levels are higher than 7.0 or 8.0 mmol/L on two consecutive occasions, VRIII is recommended. Hourly capillary blood glucose rather than CGM glucose measurements should be used to adjust VRIII. The recommended substrate fluid to be administered alongside a VRIII is 0.9% sodium chloride solution with 5% glucose and 0.15% potassium chloride (KCl) (20 mmol/L) or 0.3% KCl (40 mmol/L) at 50 ml/hr. Both the VRIII and CSII rates should be reduced by at least 50% after delivery.

Standardized hospital management of pediatric diabetic ketoacidosis reduces frequency of low blood glucose episodes

OBJECTIVE

In patients treated for DKA, decrease the rate of visits experiencing one or more BG < 80 mg/dl by 10% within 24 months.

RESEARCH DESIGN AND METHODS

Plan-do-study-act cycles tested interventions linked to key drivers including: standardized DKA guidelines incorporating a two-bag fluid system, efficient ordering process, and care team education. Inclusion criterion: treatment for DKA with a bicarbonate value (HCO₃ ) <15 mEq/L.

PRIMARY OUTCOME

the percent of patient visits experiencing a BG < 80 mg/dl while undergoing treatment for DKA. Process measures included: order panel and order set utilization rates. Balancing measures included: emergency department and hospital lengths of stay, time to acidosis resolution (time to HCO₃  ≥ 17 mEq/L), and admission rates. Outcomes were analyzed using statistical process control charts.

RESULTS

From January 2017 through May 2021, our institution treated 288 different patients during 557 visits for suspected DKA. Following our interventions, the overall percent of patient visits for DKA with a BG < 80 mg/dl improved from 32% to 5%. The team did see small improvements in emergency department and hospital lengths of stay; otherwise, there was no significant change in our balancing measures.

CONCLUSIONS

Use of quality improvement methodology and standardized DKA management resulted in a significant reduction of BG < 80 mg/dl in patients treated for DKA.

Early Post-Renal Transplant Hyperglycemia

CONTEXT

Though posttransplant diabetes mellitus (PTDM, occurring > 45 days after transplantation) and its complications are well described, early post-renal transplant hyperglycemia (EPTH) (< 45 days) similarly puts kidney transplant recipients at risk of infections, rehospitalizations, and graft failure and is not emphasized much in the literature. Proactive screening and management of EPTH is required given these consequences.

OBJECTIVE

The aim of this article is to promote recognition of early post-renal transplant hyperglycemia, and to summarize available information on its pathophysiology, adverse effects, and management.

METHODS

A PubMed search was conducted for "early post-renal transplant hyperglycemia," "immediate posttransplant hyperglycemia," "post-renal transplant diabetes," "renal transplant," "diabetes," and combinations of these terms. EPTH is associated with significant complications including acute graft failure, rehospitalizations, cardiovascular events, PTDM, and infections.

CONCLUSION

Patients with diabetes experience better glycemic control in end-stage renal disease (ESRD), with resurgence of hyperglycemia after kidney transplant. Patients with and without known diabetes are at risk of EPTH. Risk factors include elevated pretransplant fasting glucose, diabetes, glucocorticoids, chronic infections, and posttransplant infections. We find that EPTH increases risk of re-hospitalizations from infections (cytomegalovirus, possibly COVID-19), acute graft rejections, cardiovascular events, and PTDM. It is essential, therefore, to provide diabetes education to patients before discharge. Insulin remains the standard of care while inpatient. Close follow-up after discharge is recommended for insulin adjustment. Some agents like dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists have shown promise. The tenuous kidney function in the early posttransplant period and lack of data limit the use of sodium-glucose cotransporter 2 inhibitors. There is a need for studies assessing noninsulin agents for EPTH to decrease risk of hypoglycemia associated with insulin and long-term complications of EPTH.

Managing Patients Undergoing Orthopedic Surgery to Improve Glycemic Outcomes

PURPOSE OF REVIEW

Persons with diabetes are more likely to require orthopedic surgery and are at an increased risk of developing postoperative complications. Recognizing the impact of diabetes on musculoskeletal health provides an opportunity to educate healthcare professionals in standardizing the perioperative approach of persons with diabetes.

RECENT FINDINGS

Elevated hemoglobin A1C, fructosamine, and blood glucose levels have been associated with increased risk for complications in the orthopedic population. These risks can be mitigated by the early identification and optimization of these patients in the perioperative period. Intraoperative and postoperative glycemic management should support efforts to maintain glucose at safe levels while avoiding hyperglycemia and hypoglycemia. This paper considers factors surrounding diabetes care in the orthopedic surgical patient. Perioperative care discussed includes optimization, hospitalization to discharge, and special considerations such as steroids and diabetes wearable technology. Hospitals should consider these strategies towards enhancing the care of persons with diabetes requiring musculoskeletal care.

Degludec hospital trial: A randomized controlled trial comparing insulin degludec U100 and glargine U100 for the inpatient management of patients with type 2 diabetes

AIMS

Limited data exist about the use of insulin degludec in the hospital. This multicentre, non-inferiority, open-label, prospective randomized trial compared the safety and efficacy of insulin degludec-U100 and glargine-U100 for the management of hospitalized patients with type 2 diabetes.

METHODS

In total, 180 general medical and surgical patients with an admission blood glucose (BG) between 7.8 and 22.2 mmol/L, treated with oral agents or insulin before hospitalization were randomly allocated (1:1) to a basal-bolus regimen using degludec (n = 92) or glargine (n = 88), as basal and aspart before meals. Insulin dose was adjusted daily to a target BG between 3.9 and 10.0 mmol/L. The primary endpoint was the difference in mean hospital daily BG between groups.

RESULTS

Overall, the randomization BG was 12.2 ± 2.9 mmol/L and glycated haemoglobin 84 mmol/mol (9.8% ± 2.0%). There were no differences in mean daily BG (10.0 ± 2.1 vs. 10.0 ± 2.5 mmol/L, p = .9), proportion of BG in target range (54·5% ± 29% vs. 55·3% ± 28%, p = .85), basal insulin (29.6 ± 13 vs. 30.4 ± 18 units/day, p = .85), length of stay [median (IQR): 6.7 (4.7-10.5) vs. 7.5 (4.7-11.6) days, p = .61], hospital complications (23% vs. 23%, p = .95) between treatment groups. There were no differences in the proportion of patients with BG <3.9 mmol/L (17% vs. 19%, p = .75) or <3.0 mmol/L (3.7% vs. 1.3%, p = .62) between degludec and glargine.

CONCLUSION

Hospital treatment with degludec-U100 or glargine-U100 is equally safe and effective for the management of hyperglycaemia in general medical and surgical patients with type 2 diabetes.

Reducing Inpatient Hypoglycemic Events: A Focus on Mealtime Insulin

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to reduce iatrogenic insulin-associated hypoglycemia at the University of Chicago Medical Center in Chicago, IL.

Prognostic Value of Stress Hyperglycemia in Patients Admitted to Medical/Geriatric Departments for Acute Medical Illness

INTRODUCTION

Hyperglycemia is common in patients admitted to Italian medical/geriatric units and is associated with a poorer outcome. We tested the significance of diabetes and stress-induced hyperglycemia in clinical outcome.

MATERIALS AND METHODS

Three hundred seventy-eight consecutive patients with hyperglycemia at entry (≥ 126 mg/dl) (206 without known diabetes) were included, with a wide range of underlying diseases requiring hospital admission and independent of the presence of diabetes. Relative hyperglycemia was calculated as admission glucose divided by average glucose, estimated based of glycosylated hemoglobin. Values ≥ 1.20 were considered indicative of stress hyperglycemia (SHR). The association of SHR with outcome variables (all-cause complications, infections, non-infectious events, deaths) was tested by logistic regression analysis, adjusted for sex, BMI, age-adjusted comorbidities (Charlson index) and known diabetes.

RESULTS

During hospital stay, one or more events were registered in 96 patients (25.4%); 44 patients died in hospital, and fatality rate was borderline higher in patients without diabetes (14.6% vs. 8.1% in diabetes; P = 0.052) and nearly three times higher in patients with stress hyperglycemia (15.0%) vs. those with SHR < 1.2 (P = 0.005). Stress hyperglycemia-more common in the absence of diabetes (71% vs. 58%)-and age were the only independent prognostic factors for death. At multivariable analysis, the risks of death (OR 4.31, 95% CI 1.25-14.81), of all complications (OR 5.90, 95% CI 2.22-15.71) and of newly developed systemic infections (OR 5.67, 95% CI 1.61-19.92) were associated with stress hyperglycemia in subjects without diabetes, as was the risk in non-insulin-treated cases (OR 4.02, 95% CI 1.16-13.92; OR 5.47, 95% CI 2.21-13.52; OR 5.15, 95% CI 1.70-15.62, respectively).

CONCLUSION

The study confirms the prognostic value of stress-related hyperglycemia in patients requiring hospital admission to a geriatric/medical unit for a variety of acute medical conditions, contributing to adverse outcomes not limited to events commonly associated with hyperglycemia (e.g., infections).

Triglyceride-glucose index in the prediction of major adverse cardiovascular events in patients with type 2 diabetes mellitus after coronary artery bypass surgery: A retrospective cohort study

BACKGROUND

Insulin resistance (IR) is a significant risk factor for cardiometabolic diseases and a defining feature of type 2 diabetes mellitus (T2DM). This study aimed to examine the potential value of triglyceride-glucose (TyG) index as a predictor of prognosis in coronary heart disease (CHD) patients with T2DM after coronary artery bypass grafting (CABG) surgery and to facilitate the identification of those at high risk of major adverse cardiovascular events (MACEs) for closer monitoring or possible early intervention.

METHODS

This study enrolled 386 T2DM patients who underwent CABG surgery at Nanjing Drum Tower Hospital. Patients were separated into two groups according to the median preoperative TyG Index. The Kaplan-Meier plot was used to compare the rate of MACEs-free survival in T2DM patients after CABG. The independent risk factors for the occurrence of MACEs were investigated using multivariate analysis. Nomogram was used to depict the predictive model.

RESULTS

Significantly more MACEs occurred in individuals with higher medians of the TyG index (65 (33.7%) vs. 39 (20.2%), p=0.003). TyG index [hazard ratio (HR) 12.926], LVEF [hazard ratio (HR) 0.916], and NYHA functional class III/IV [hazard ratio (HR) 4.331] were identified as independent predictors of MACEs incidence in post-CABG T2DM patients by multivariate analysis. The area under the curve (AUC) for predicting MACEs using the TyG index was 0.89 at five years. Combining the TyG index, LVEF, and NYHA functional class III/IV to build a novel risk assessment model for postoperative MACEs, the AUC climbed to 0.93 at five years. With AUCs, the nomogram comprised of the TyG index, LVEF, and NYHA functional class III/IV demonstrated strong specificity in the training and test sets.

CONCLUSIONS

The incidence of MACEs is high among post-CABG T2DM patients with a high TyG index. TyG index improves the diagnostic accuracy of MACEs, especially at long-term follow-up. A high TyG index may serve as an early warning signal for individuals to undertake lifestyle adjustments that can reduce the progression or incidence of MACEs.

CANDIED: A Pan-Canadian Cohort of Immune Checkpoint Inhibitor-Induced Insulin-Dependent Diabetes Mellitus

Simple Summary

Immune checkpoint inhibitor-induced insulin-dependent diabetes mellitus (ICI-induced IDDM) is an emerging form of autoimmune diabetes. We describe the characteristics of 34 patients who developed ICI-induced IDDM across five Canadian cancer centres. We observed that presentation with hyperglycemic crisis is common and that patients treated with combination immunotherapy regimens develop ICI-induced IDDM earlier than those treated with monotherapy. Our results suggest that ICI-induced IDDM is irreversible but is associated with high tumor response rates and prolonged survival. The data generated by this study may help clinicians manage ICI-induced IDDM.

Abstract

Immune checkpoint inhibitor (ICI)-induced insulin-dependent diabetes mellitus (IDDM) is a rare but potentially fatal immune-related adverse event (irAE). In this multicentre retrospective cohort study, we describe the characteristics of ICI-induced IDDM in patients treated across five Canadian cancer centres, as well as their tumor response rates and survival. In 34 patients identified, 25 (74%) were male and 19 (56%) had melanoma. All patients received anti-programed death 1 (anti-PD1) or anti-programmed death ligand-1 (anti-PD-L1)-based therapy. From ICI initiation, median time to onset of IDDM was 2.4 months (95% CI 1.1–3.6). Patients treated with anti-PD1/PD-L1 in combination with an anti-cytotoxic T lymphocyte antigen 4 antibody developed IDDM earlier compared with patients on monotherapy (1.4 vs. 3.9 months, p = 0.05). Diabetic ketoacidosis occurred in 21 (62%) patients. Amongst 30 patients evaluable for response, 10 (33%) had a complete response and another 10 (33%) had a partial response. Median overall survival was not reached (95% CI NE; median follow-up 31.7 months). All patients remained insulin-dependent at the end of follow-up. We observed that ICI-induced IDDM is an irreversible irAE and may be associated with a high response rate and prolonged survival.

The Impact of Diabetes Mellitus and Hyperglycemia on the Severity and Outcome of Patients with COVID-19 Disease: A Single-Center Experience

Purpose

Diabetes mellitus (DM) has been reported to be associated with a  worse outcome of COVID-19 infection. The evidence is scarce in the Middle East and Saudi Arabia. We aimed to evaluate the impact of diabetes mellitus and hyperglycemia in non-diabetic individuals on the severity and outcome of COVID-19 infection.

Methods

This is a retrospective observational study, which included patients with confirmed COVID-19 infection [RT-PCR positive for SARS-CoV2] who were admitted to King Fahd Hospital of the University-Khobar-Eastern Province-Saudi Arabia from March to September 2020. Baseline demographic data, laboratory investigations, and markers of the severity of COVID-19 were analyzed. The collected data were categorized according to the Saudi Arabian Ministry of Health COVID-19 infection severity criteria. Patients were divided into three groups as follows: patients in Group 1 had pre-existing DM, patients in Group 2 did not have DM but were documented to have hyperglycemia at presentation, and patients in Group 3 were neither diabetics nor hyperglycemics at presentation and served as the control group. The severity and outcome of the control group were compared with the other two groups. The effect of risk factors on the severity and outcome of COVID-19 infection was studied in the DM group.

Results

A total of 414 patients were included (70.5% males and 29.5% females). The mean age (SD) of patients was 52.3 (±15.5) years. Compared to the control group, pre-existing DM was found to be significantly associated with severe (OR 3.61), critical disease (OR 4.32), intensive care unit (ICU) admission (OR 2.0), and death (OR 2.0) from COVID-19 infection. Hyperglycemia without known DM was also found to be associated with critical COVID-19 pneumonia (P 0.001), and had longer duration of hospitalization (P 0.014), higher ICU admission, mechanical ventilation, and death from COVID-19 infection (P < 0.0001).

Conclusion

Diabetes mellitus and hyperglycemia at presentation, even in the absence of pre-existing DM, are independent risk factors for disease severity and worse outcome of COVID-19 infection. These patients should be identified and managed accordingly. The COVID-19 vaccination program should also target those populations to improve their outcomes.

Hypoglycemia in diabetes: An update on pathophysiology, treatment, and prevention

Hypoglycemia is a common complication in patients with diabetes, mainly in those treated with insulin, sulfonylurea, or glinide. Impairments in counterregulatory responses and hypoglycemia unawareness constitute the main risk factors for severe hypoglycemia. Episodes of hypoglycemia are associated with physical and psychological morbidity. The fear of hypoglycemia constitutes a barrier that impairs the patient's ability to reach good glycemic control. To prevent hypoglycemia, much effort must be invested in patient education regarding risk factors, warning signs, and treatment of hypoglycemia at an early stage, together with setting personalized goals for glycemic control. In this review, we present a comprehensive update on the treatment and prevention of hypoglycemia in type 1 and type 2 diabetic patients.

Implementation of App-Based Diabetes Medication Management: Outpatient and Perioperative Clinical Decision Support

PURPOSE OF REVIEW

Outpatient and perioperative therapeutic decision making for patients with diabetes involves increasingly complex medical-decision making due to rapid advances in knowledge and treatment modalities. We sought to review mobile decision support tools available to clinicians for this essential and increasingly difficult task, and to highlight the development and implementation of novel mobile applications for these purposes.

RECENT FINDINGS

We found 211 mobile applications related to diabetes from the search, but only five were found to provide clinical decision support for outpatient diabetes management and none for perioperative decision support. We found a dearth of tools for clinicians to navigate these tasks. We highlight key aspects for effective development of future diabetes decision support. These include just-in-time availability, respect for the five rights of clinical decision support, and integration with clinical workflows including the electronic medical record.

Incretin-based therapy for glycemic control of hospitalized patients with type 2 diabetes: a systematic review

Incretin-based therapy leads to glycemic control in a glucose-dependent manner with a low risk of hypoglycemia, making it appealing for use in the hospital. The aim of this systematic review was to assess the benefits of incretin-based therapy in patients with type 2 diabetes hospitalized outside of the intensive care unit. We searched for studies published up to August 2021 in the PubMed and Scopus databases. Clinical trials comparing incretin-based therapy (alone or in combination with insulin) versus an insulin regimen were selected. The results of the included studies showed that incretin-based therapy showed mean blood glucose values, a percentage of records within the therapeutic target, and a percentage of treatment failure similar to insulin management, particularly in patients with mild to moderate hyperglycemia. Furthermore, incretin-based treatment was associated with a lower total insulin dose and a lower incidence of hypoglycemia. In conclusion, incretin-based therapy achieved glycemic control similar to insulin treatment in patients with type 2 diabetes hospitalized outside the intensive care unit and has the advantages of reducing the insulin requirement and a lower risk of hypoglycemia.

Impacts of diabetes mellitus on clinical and para-clinical parameters among COVID-19 patients

PURPOSE

Diabetes has several adverse effects on patients with coronavirus disease 2019 (COVID-19); however, the determinants of this effect are still poorly understood. It is tried in current study to evaluate impacts of type 2 diabetes, with and without other comorbidities, on the clinical, para-clinical, and outcome parameters among COVID-19 patients.

METHODS

A case series was applied, which involved 406 COVID-19 patients admitted in the city of Shiraz, south-central Iran, from February 20 to April 29, 2020. Demographic data, medical history, laboratory finding, chest computed tomography (CT) scan reports, and clinical outcomes of patients with and without type 2 diabetes were compared.

RESULTS

Results of the above-mentioned comparison showed that comorbidities such as HTN (35.5% vs. 13.7%, p < 0.001) and CVDs (26.2% vs. 13.4%, P = 0.002) were significantly more prevalent among the diabetic patients. Also, there was not any considerable difference between the chest CT severity parameters of both groups. After excluding all of the comorbidities except diabetes, it was found that the diabetic COVID-19 patients without other comorbidities had lower oxygen saturation level (P < 0.001), higher AST level (P = 0.037), higher BUN (P = 0.005), higher WBC counts (P = 0.025), lower lymphocyte counts (P = 0.029), and longer ICU admission duration (0.72 ± 2.83 vs. 1.71 ± 4.68, P = 0.046).

CONCLUSION

The diabetic COVID patients are at higher risks of hypoxemia, longer ICU stays, and more renal and hepatic dysfunction. These achievements could be useful in order to prevent the deterioration of clinical conditions among diabetic COVID-19 patients; also, they have to be considered in the management strategies.

The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycaemia, behavioural considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that healthcare professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors. Graphical abstract.

The Management of Type 1 Diabetes in Adults. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycemia, behavioral considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management, and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that health care professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors.

Prolonged ketosis and glycosuria secondary to SGLT2 inhibitor therapy

Clinicians should be aware of the potential for the pharmacologic activity of SGLT2 inhibitors to persist long after the standard drug clearance period of five half-lives, the typical duration used to guide pre-operative medication recommendations.

[Perioperative Management of Long-term Antidiabetic Therapy in Patients with Diabetes Mellitus]

Drug therapy, as well as diabetes technology, e.g. insulin pumps or sensor glucose measurement, have developed enormously in recent years. Their use differs according to the type of diabetes, secondary or concomitant diseases, and individual factors and target values. In the perioperative phase, diabetic patients are generally at increased risk of complications, including a derailment of glucose metabolism, an increased rate of cardiovascular events, worsening of preexisting renal insufficiency, and increased incidence of wound infections. In addition, drug class-specific side effects of antidiabetic therapy may occur. The prevalence of diabetes patients in anesthesiology is high and will continue to increase. In Germany, more than 8 million people are estimated to live with diabetes mellitus. The rate of new cases is about 600 000 per year. The distinction between type 1 and type 2 diabetes mellitus is essential. Diabetes therapy is becoming increasingly individualized; combination therapies are becoming more common. Therefore, the management of long-term medication should also be individualized. Substance-specific side effects or adverse effects, especially of oral antidiabetic agents, must be considered in the care of patients, e.g. euglycemic diabetic ketoacidosis under SGLT-2 inhibitors is a relevant problem. Insulin therapy is also evolving; knowledge of new preparations and of insulin pump therapy facilitates perioperative management. Both hypoglycemia and hyperglycemia, possibly with ketoacidosis, must be avoided. The purpose of this article is to provide an overview of the management of long-term medication in patients with diabetes mellitus.

Glycemic targets in critically ill adults: A mini-review

Illness-induced hyperglycemia impairs neutrophil function, increases pro-inflammatory cytokines, inhibits fibrinolysis, and promotes cellular damage. In turn, these mechanisms lead to pneumonia and surgical site infections, prolonged mechanical ventilation, prolonged hospitalization, and increased mortality. For optimal glucose control, blood glucose measurements need to be done accurately, frequently, and promptly. When choosing glycemic targets, one should keep the glycemic variability < 4 mmol/L and avoid targeting a lower limit of blood glucose < 4.4 mmol/L. The upper limit of blood glucose should be set according to casemix and the quality of glucose control. A lower glycemic target range (i.e., blood glucose 4.5-7.8 mmol/L) would be favored for patients without diabetes mellitus, with traumatic brain injury, or who are at risk of surgical site infection. To avoid harm from hypoglycemia, strict adherence to glycemic control protocols and timely glucose measurements are required. In contrast, a higher glycemic target range (i.e., blood glucose 7.8-10 mmol/L) would be favored as a default choice for medical-surgical patients and patients with diabetes mellitus. These targets may be modified if technical advances for blood glucose measurement and control can be achieved.

Structural principles of insulin formulation and analog design: A century of innovation

BACKGROUND

The discovery of insulin in 1921 and its near-immediate clinical use initiated a century of innovation. Advances extended across a broad front, from the stabilization of animal insulin formulations to the frontiers of synthetic peptide chemistry, and in turn, from the advent of recombinant DNA manufacturing to structure-based protein analog design. In each case, a creative interplay was observed between pharmaceutical applications and then-emerging principles of protein science; indeed, translational objectives contributed to a growing molecular understanding of protein structure, aggregation and misfolding.

SCOPE OF REVIEW

Pioneering crystallographic analyses-beginning with Hodgkin's solving of the 2-Zn insulin hexamer-elucidated general features of protein self-assembly, including zinc coordination and the allosteric transmission of conformational change. Crystallization of insulin was exploited both as a step in manufacturing and as a means of obtaining protracted action. Forty years ago, the confluence of recombinant human insulin with techniques for site-directed mutagenesis initiated the present era of insulin analogs. Variant or modified insulins were developed that exhibit improved prandial or basal pharmacokinetic (PK) properties. Encouraged by clinical trials demonstrating the long-term importance of glycemic control, regimens based on such analogs sought to resemble daily patterns of endogenous β-cell secretion more closely, ideally with reduced risk of hypoglycemia.

MAJOR CONCLUSIONS

Next-generation insulin analog design seeks to explore new frontiers, including glucose-responsive insulins, organ-selective analogs and biased agonists tailored to address yet-unmet clinical needs. In the coming decade, we envision ever more powerful scientific synergies at the interface of structural biology, molecular physiology and therapeutics.

Seeking Health Information and Social Support in the Diabetes Online Community

Purpose

People with type 1 diabetes (T1D) search for health information online in the Diabetes Online Community (DOC), where individuals with diabetes, researchers and caregivers post and respond to health questions. The aims of this study were 1) to understand how people with T1D are seeking health information and engaging in health behaviors in the DOC, and 2) develop a measure of online health information seeking in adults with T1D.

Research Method

Ninety-five adults with T1D completed qualitative prompts online.

Results

Themes that emerged in this study included sense of community, and multiple types of social support that are necessary in disease management.

Conclusions

This study used qualitative methods to develop a valid scale tailored for adults with T1D. Future research should seek to collect additional data to bolster validity and reliability.

Insulin management in hospitalized patients with diabetes mellitus on high-dose glucocorticoids: Management of steroid-exacerbated hyperglycemia

Background

Glucocorticoid (GC)-exacerbated hyperglycemia is prevalent in hospitalized patients with diabetes mellitus (DM) but evidence-based insulin guidelines in inpatient settings are lacking.

Methods and findings

Retrospective cohort study with capillary blood glucose (CBG) readings and insulin use, dosed with 50% basal (glargine)-50% bolus (lispro) insulin, analyzed in hospitalized patients with insulin-treated DM given GC and matched controls without GC (n = 131 pairs). GC group (median daily prednisone-equivalent dose: 53.36 mg (IQR 30.00, 80.04)) had greatest CBG differences compared to controls at dinner (254±69 vs. 184±63 mg/dL, P<0.001) and bedtime (260±72 vs. 182±55 mg/dL, P<0.001). In GC group, dinner CBG was 30% higher than lunch (254±69 vs. 199±77 mg/dL, P<0.001) when similar lispro to controls given at lunch. Bedtime CBG not different from dinner when 20% more lispro given at dinner (0.12 units/kg (IQR 0.08, 0.17) vs. 0.10 units/kg (0.06, 0.14), P<0.01). Despite receiving more lispro, bedtime hypoglycemic events were lower in GC group (0.0% vs. 5.9%, P = 0.03).

Conclusions

Since equal bolus doses inadequately treat large dinner and bedtime GC-exacerbated glycemic excursions, initiating higher bolus insulin at lunch and dinner with additional enhanced GC-specific insulin supplemental scale may be needed as initial insulin doses in setting of high-dose GC.

Association between maternal pregestational glucose level and adverse pregnancy outcomes: a population-based retrospective cohort study

OBJECTIVE

To investigate the association between maternal pregestational blood glucose level and adverse pregnancy outcomes.

DESIGN

Retrospective cohort study.

SETTING

This study was conducted in the Chongqing Municipality of China between April 2010 and December 2016.

PARTICIPANTS

A total of 60 222 women (60 360 pregnancies) from all 39 counties of Chongqing who participated in the National Free Preconception Health Examination Project and had pregnancy outcomes were included.

PRIMARY OUTCOME MEASURES

Adverse pregnancy outcomes included spontaneous abortion, induced abortion or labour due to medical reasons, stillbirth, preterm birth (PTB), macrosomia, large for gestational age, low birth weight (LBW) and small for gestational age.

RESULTS

Of the 60 360 pregnancies, rates of hypoglycaemic, normoglycaemia, impaired fasting glycaemia (IFG) and diabetic hyperglycaemic before conception were 5.06%, 89.30%, 4.59% and 1.05%, respectively. Compared with women with normoglycaemia, women with pregestational glucose at the diabetic level (≥7.0 mmol/L) might have a higher rate of macrosomia (6.18% vs 4.16%), whereas pregestational IFG seemed to be associated with reduced risks of many adverse outcomes, including spontaneous abortion, induced abortion due to medical reasons, PTB and LBW. After adjusting for potential confounders, pregestational diabetic hyperglycaemic was remained to be significantly associated with an increased risk of macrosomia (adjusted risk ratio 1.49, 95% CI 1.07 to 2.09). Abnormal maternal glucose levels before pregnancy (either hypoglycaemic or hyperglycaemic) seemed to have no significant negative effect on spontaneous abortion or induced abortion due to medical reasons.

CONCLUSION

Although without overt diabetes mellitus, women with once diabetic fasting glucose level during their preconception examinations could be associated with an increased risk for macrosomia. Uniform guidelines are needed for maternal blood glucose management during pre-pregnancy care to improve pregnancy outcomes.

Efficient and safe glycaemic control with basal-bolus insulin therapy during fasting periods in hospitalized patients with type 2 diabetes using decision support technology: A post hoc analysis

AIM

To evaluate the efficacy and safety of basal-bolus insulin therapy in managing glycaemia during fasting periods in hospitalized patients with type 2 diabetes.

MATERIALS AND METHODS

We performed a post hoc analysis of two prospective, uncontrolled interventional trials that applied electronic decision support system-guided basal-bolus (meal-related and correction) insulin therapy. We searched for fasting periods (invasive or diagnostic procedures, medical condition) during inpatient stays. In a mixed model analysis, patients' glucose levels and insulin doses on days with regular food intake were compared with days with fasting periods.

RESULTS

Out of 249 patients, 115 patients (33.9% female, age 68.3 ± 10.3 years, diabetes duration 15.1 ± 10.9 years, body mass index 30.1 ± 5.4 kg/m² , HbA1c 69 ± 20 mmol/mol) had 194 days with fasting periods. Mean daily blood glucose (BG) was lower (modelled difference [ModDiff]: -0.5 ± 0.2 mmol/L, P = .006), and the proportion of glucose values within the target range (3.9-10.0 mmol/L) increased on days with fasting periods compared with days with regular food intake (ModDiff: +0.06 ± 0.02, P = .005). Glycaemic control on fasting days was driven by a reduction in daily bolus insulin doses (ModDiff: -11.0 ± 0.9 IU, P < .001), while basal insulin was similar (ModDiff: -1.1 ± 0.6 IU, P = .082) compared with non-fasting days. Regarding hypoglycaemic events (BG < 3.9 mmol/L), there was no difference between fasting and non-fasting days (χ² 0.9% vs. 1.7%, P = .174).

CONCLUSIONS

When using well-titrated basal-bolus insulin therapy in hospitalized patients with type 2 diabetes, the basal insulin dose does not require adjustment during fasting periods to achieve safe glycaemic control, provided meal-related bolus insulin is omitted and correction bolus insulin is tailored to glucose levels.

Efficacy and Safety of Empagliflozin Continuation in Patients with Type 2 Diabetes Hospitalised for Acute Decompensated Heart Failure

There is little evidence on the use of sodium-glucose cotransporter 2 inhibitors in hospitalised patients. This work aims to analyse the glycaemic and clinical efficacy and safety of empagliflozin continuation in patients with type 2 diabetes hospitalised for acute decompensated heart failure. This real-world observational study includes patients treated using our in-hospital antihyperglycaemic regimens (basal-bolus insulin vs. empagliflozin-basal insulin) between 2017 and 2020. A propensity matching analysis was used to match a patient on one regimen with a patient on the other regimen. Our primary endpoints were the differences in glycaemic control, as measured via mean daily blood glucose levels, and differences in the visual analogue scale dyspnoea score, NT-proBNP levels, diuretic response, and cumulative urine output. Safety endpoints were also analysed. After a propensity matching analysis, 91 patients were included in each group. There were no differences in mean blood glucose levels (152.1 ± 17.8 vs. 155.2 ± 19.7 mg/dL, p = 0.289). At discharge, NT-proBNP levels were lower and cumulative urine output greater in the empagliflozin group versus the basal-bolus insulin group (1652 ± 501 vs. 2101 ± 522 pg/mL, p = 0.032 and 16,100 ± 1510 vs. 13,900 ± 1220 mL, p = 0.037, respectively). Patients who continued empagliflozin had a lower total number of hypoglycaemic episodes (36 vs. 64, p < 0.001). No differences were observed in adverse events, length of hospital stay, or in-hospital deaths. For patients with acute heart failure, an in-hospital antihyperglycaemic regimen that includes continuation of empagliflozin achieved effective glycaemic control, lower NT-proBNP, and greater urine output. It was also safer, as it reduced hypoglycaemic episodes without increasing other safety endpoints.

Comparison of various basal insulin dose adjustments for inpatients while unable to eat

Background The American Diabetes Association recommends basal insulin or basal plus correctional insulin regimen for non-critically ill patients with type 2 diabetes mellitus unable to eat. There is limited evidence available examining ideal basal insulin dose reductions in this patient population. Aim This study aimed to determine the percent reduction of maintenance basal insulin that would provide the least hypoglycemic incidence in patients with type 2 diabetes mellitus in the non-intensive care unit setting. Methods This retrospective cohort study evaluated adult patients with type 2 diabetes mellitus prescribed outpatient basal insulin with a minimum unable to eat status of two hours. Patients were divided into four groups; <25%, 25-50%, 51-75%, > 75% of basal insulin administered compared to home dose. The primary endpoint was the incidence of hypoglycemia while unable to eat. Secondary endpoints included incidence of hyperglycemia, severe hypoglycemia, median daily blood glucose and hospital length of stay. Results A total of 173 patients were included. The primary outcome of hypoglycemia (5.9% vs. 8.8% vs. 14.3% vs. 12.3%; P = 0.578) was similar in all groups. There were no differences in hyperglycemia (P = 0.0701), severe hypoglycemia (P = 0.578) and median daily blood glucose (P = 0.428). Patients receiving 25-50% of home basal insulin had the longest unable to eat duration (11.5 h; P = 0.026); however, this was not statistically significant when adjusted using the Bonferroni correction for multiple tests. Conclusions No differences were observed in hypoglycemic events for patients unable to eat receiving various basal insulin dose reductions.

Does a strict glycemic control during acute coronary syndrome play a cardioprotective effect? Pathophysiology and clinical evidence

A hyperglycemic state, also in non-diabetic subjects, may be associated with acute coronary syndrome (ACS). Aim of this review is to describe the pathophysiologic association between ACS and hyperglycemic state, the protective mechanisms of a tight glycaemic control in ACS on CV outcomes, and the supporting clinical evidence. Several mechanisms may be responsible of a poor CV outcome in subjects with hyperglycemia during ACS. Endothelial NAPDH oxidase-2 (NOX2) activation in response to high glucose alters the balance between Raf/MAPK-dependent vasoconstriction and PI3K/Akt-dependent vasodilation in favour of constriction. Hyperglycaemia induces an overproduction of superoxide by the mitochondrial electron transport chain through different molecular mechanisms. Moreover, hyperglycaemia increases the size of the infarct by causing myocardial cell death through apoptosis and reducing the collateral blood flow. High FFA concentrations lead to toxicity mechanisms in acutely ischemic myocardium. On the other hand, a tight glycaemic control in ACS exerts a cardioprotective action by anti-inflammatory and anti-apoptotic mechanisms, anti-oxidative stress, endothelium protection, FFA reduction, anti-glucotoxic effect, IR and cardiac fuel metabolisms improvement, heart stem cells protection and reduced activation of adrenergic system. Unfortunately, the clinical studies supporting the above pathophysiological background are few and sometimes controversial, more likely due the risk of hypoglycemia linked to the insulin therapy generally used during ACS. Intriguingly, GLP-1 RA and SGLT2i, demonstrated highly effective in the cardiovascular prevention in high-risk subjects without the risk of hypoglycemia, might keep this cardioprotective effect even in acute conditions such as ASC.

De-implementing low-value care in endocrinology

Low-value care exposes patients to ineffective, costly, and potentially harmful care. In endocrinology, low-value care practices are common in the care of patients with highly prevalent conditions. There is an urgent need to move past the identification of these practices to an active process of de-implementation. However, clinicians, researchers, and other stakeholders might lack familiarity with the frameworks and processes that can help guide successful de-implementation. To address this gap and support the de-implementation of low-value care, we provide a summary of low-value care practices in endocrinology and a primer on the fundamentals of de-implementation science. Our goal is to increase awareness of low-value care within endocrinology and suggest a path forward for addressing low-value care using principles of de-implementation science.

Outcomes of "Real-World" Insulin Strategies in the Management of Hospital Hyperglycemia

Context

Guidelines recommend scheduled long-acting basal and short-acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world,” insulin therapy is complicated, with limited data on the comparative effectiveness of different insulin strategies.

Objective

This work aimed to evaluate the association of different insulin strategies with glucose control and hospital outcomes after adjustment for patient and physician factors that influence choice of therapy.

Methods

This retrospective, observational study took place at an academic hospital. Participants included noncritically ill hospitalized medical/surgical patients (n = 4558) receiving subcutaneous insulin for 75% or longer during admission. Insulin therapy was grouped into 3 strategies within the first 48 hours: basal bolus (BB: scheduled long and short/rapid n = 2358), sliding scale (SS: short/rapid acting n = 1855), or basal only (BO: long only: n = 345). Main outcome measures included glucose control: hypoglycemic days, hyperglycemic days, euglycemic days, mean glucose; and hospitalization: in-hospital mortality, length of stay (LOS), and readmissions.

Results

Initial therapy with BB was associated with more hypoglycemic (2.40; CI, 2.04 to 2.82) (P < .001) and fewer euglycemic days (0.90; CI, 0.85 to 0.97) (P = .003) than SS, whereas BO was associated with fewer hyperglycemic days (0.70; CI, 0.62 to 0.79) (P < .001), lower mean glucose (–18.03; CI, –22.46 to –12.61) (P < .001), and more euglycemic days (1.22; CI, 1.09 to 1.37) (P < .001) compared to SS. No difference in mortality, LOS, and readmissions was found. However, decreased LOS was observed in the BB subgroup with a medical diagnostic related group (0.93; CI, 0.89 to 0.97) (P < .001).

Conclusion

BO had a more favorable hyperglycemia profile than SS. BB, on the other hand, showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.

Clinical interpretation of the flash continuous glucose monitoring data out of range in type 2 diabetes: A real-world study

AIMS

Flash continuous glucose monitoring system (FCGM) reports nocturnal hypoglycemia with low accuracy in low blood glucose. In our study, we aimed to evaluate the accuracy and clinic profile of FCGM data out of range in T2DM.

METHODS

FCGM data out of range were measured in T2DM patients at eight-time points of a day and compared with fingertip capillary blood glucose levels (REFs) as reference values.

RESULTS

A total of 307 out-of-range cases from 25,886 paired FCGM/REF data from 742 T2DM patients were evaluated. The distribution of "LO" and "HI" cases displayed the significant difference between eight-time points (P < 0.001) with the highest frequency (6.52%) of the "LO" value at 3 AM. The consistency rate between FCGM "LO" readings and REF < 40 mg/dl was far lower than that of FCGM "HI" readings with REF > 500 mg/dl (0.84% vs. 52.2%). In addition, the frequency of some clinical characteristics, including diabetes duration, hypoglycemia, hypertension, HbA1c, and Hb, were higher in patients with FCGM "LO" readings compared to those with "HI" readings.

CONCLUSIONS

These findings suggest the results and treatment regarding FCGM "LO" data should be interpreted with strong caution in the light of the emerging possible adverse measurement in patients.

Reliability of continuous glucose monitoring system in the inpatient setting

Aims/Hypothesis

Hyperglycemia and hypoglycemia are associated with increased morbidity and mortality in the inpatient setting. Standard point of care capillary glucose testing (POCT) is commonly used in hospitalized patients to monitor their glucose levels. The goal of this study was to examine the relationships between the glucose readings obtained by a continuous glucose monitoring system (CGMS) (Freestyle Libre) and the capillary blood glucose results obtained by the inpatient glucose POCT meter (Accuchek Inform II) as well as between CGMS readings and the serum glucose values obtained by the hospital laboratory. Study participants had either primary or secondary diagnosis of diabetes mellitus and were admitted to non-critical units. We hypothesized that there exists an acceptable agreement between the capillary blood glucose results obtained by the inpatient glucose POCT meter (Accuchek Inform II) and the readings obtained by the CGMS (Freestyle Libre); and that there exists an acceptable agreement between the serum glucose levels and the glucose values obtained by the CGMS.

Methods

This was an Institutional Review Board approved prospective cohort study for the non– critical inpatient setting. Fifty-two hospitalized patients with diabetes were recruited. After informed consent was obtained, patients were instructed on the application and use of the CGMS. The data were assessed using a standard regression analysis and modified Bland Altman analysis. All analyses were conducted using SAS, release 3.8 Enterprise Edition (SAS Institute Inc., Cary, NC).

Results

Fifty-two subjects recruited into the study represented a sample of convenience. There were a total of 467 AccuChek-Libre pairs, The regression analysis showed a negative bias between.

Libre and AccuChek, R² = 0.83, with Libre glucose readings on average being lower than those of AccuChek. Using Bland-Altman analysis, 42% of the 467 Libre-AccuChek pairs had a difference in glucose reading more than 15%. Mean absolute relative difference (MARD) between Libre and AccuChek was 15.6%; mean relative difference (MRD) between Libre and AccuChek was −11.4%.

The regression analysis showed a negative bias between Libre and serum glucose, R² = 0.89. Using Bland Altman analysis, 36% of the 44 Libre-serum pairs had a difference in glucose reading more than 15%. Mean absolute relative difference (MARD) between Libre and serum glucose was 13.2%; mean relative difference (MRD) between Libre and serum glucose was −12.5%.

A review of the data pairs showed that 71/467 Accuchek-Libre pairs had one result that was either below 70 mg/dl or above 200 mg/dl (combined American Diabetes Association-ADA-, American College of Physicians-ACP- and American College of Endocrinology-AACE- goals). Thus 85%, of these pairs would have yielded results that engendered the same intervention (e.g. treatment for hypoglycemia or hyperglycemia). Likewise 5/45 Serum-Libre pairs had one result that was either below 70 mg/dl or above 200 mg/dl; thus 89% of these pairs would have yielded results requiring the same intervention.

Conclusion/Interpretation

These findings confirm the existent literature and indicate acceptable agreement between the standard POCT and the CGMS as well as between serum glucose and the CGMS values. Because of the advantages of the CGMS over capillary blood glucose testing (reduced patient discomfort and reduced staff exposure to patients in isolation) CGMS use may be preferable to the current bedside capillary blood glucose testing in hospitalized patients with diabetes mellitus. As with other laboratory measures, clinical judgement needs to be exercised when the laboratory values are used to guide patient care.