Management of hyperglycemia in hospitalized patients with renal insufficiency or steroid-induced diabetes

Polystyrene nanoparticles strengthen high glucose toxicity associated with alteration in insulin signaling pathway in C. elegans

Using Caenorhabditis elegans as animal model, we investigated the effect of exposure to polystyrene nanoparticles (PS-NPs) in the range of μg/L on high glucose toxicity induction. With lifespan and locomotion behavior as endpoints, we observed that PS-NP (10 and 100 μg/L) enhanced toxicity in 50 mM glucose treated animals. In insulin signaling pathway, expressions of genes encoding insulin receptor (daf-2), kinases (age-1 and akt-1/2), and insulin peptides (ins-9, ins-6, and daf-28) were increased, and expressions of daf-16 and its target of sod-3 were decreased in high glucose treated nematodes followed by PS-NP exposure. Toxicity enhancement in high glucose treated nematodes by PS-NP exposure was inhibited by RNAi of daf-2, age-1, akt-2, akt-1, and 3 insulin peptides genes, but increased by RNAi of daf-16 and sod-3. The resistance of animals with RNAi of daf-2 to toxicity in high glucose treated nematodes followed by PS-NP exposure could be suppressed by RNAi of daf-16. Moreover, in high glucose treated animals followed by PS-NP exposure, daf-2 expression was inhibited by RNAi of ins-6, ins-9, and daf-28. Our data demonstrated the risk of PS-NP exposure in enhancing the high glucose toxicity. More importantly, alteration in expression of genes in insulin signaling pathway was associated with the toxicity enhancement in high glucose treated nematodes followed by PS-NP exposure.

Paeoniflorin mitigates high glucose-induced lifespan reduction by inhibiting insulin signaling in Caenorhabditis elegans

In organisms, high glucose can cause several aspects of toxicity, including the lifespan reduction. Paeoniflorin is the major component of Paeoniaceae plants. Nevertheless, the possible effect of paeoniflorin to suppress high glucose toxicity in reducing lifespan and underlying mechanism are largely unclear. Thus, in this study, we examined the possible effect of paeoniflorin in suppressing high glucose (50 mM)-induced lifespan reduction and the underlying mechanism in Caenorhabditis elegans. Administration with 16-64 mg/L paeoniflorin could prolong the lifespan in glucose treated nematodes. Accompanied with this beneficial effect, in glucose treated nematodes, expressions of daf-2 encoding insulin receptor and its downstream kinase genes (age-1, akt-1, and akt-2) were decreased and expression of daf-16 encoding FOXO transcriptional factor was increased by 16-64 mg/L paeoniflorin administration. Meanwhile, the effect of paeoniflorin in extending lifespan in glucose treated nematodes was enhanced by RNAi of daf-2, age-1, akt-1, and akt-2 and inhibited by RNAi of daf-16. In glucose treated nematodes followed by paeoniflorin administration, the increased lifespan caused by daf-2 RNAi could be suppressed by RNAi of daf-16, suggesting that DAF-2 acted upstream of DAF-16 to regulate pharmacological effect of paeoniflorin. Moreover, in glucose treated nematodes followed by paeoniflorin administration, expression of sod-3 encoding mitochondrial Mn-SOD was inhibited by daf-16 RNAi, and the effect of paeoniflorin in extending lifespan in glucose treated nematodes could be suppressed by sod-3 RNAi. Molecular docking analysis indicated the binding potential of paeoniflorin with DAF-2, AGE-1, AKT-1, and AKT-2. Therefore, our results demonstrated the beneficial effect of paeoniflorin administration in inhibiting glucose-induced lifespan reduction by suppressing signaling cascade of DAF-2-AGE-1-AKT-1/2-DAF-16-SOD-3 in insulin signaling pathway.

Immunomodulatory Therapy for Giant Cell Myocarditis: A Narrative Review

Giant cell myocarditis (GCM) is a rare, often rapidly progressive, and potentially fatal disease because of myocardium inflammation due to the infiltration of giant cells triggered by infectious as well as non-infectious etiologies. Several studies have reported that GCM can occur in patients of all ages but is more commonly found in adults. It is relatively more common among African American and Hispanic patients than in the White population. Early diagnosis and treatment are critical. Electrocardiogram (EKG), complete blood count, erythrocyte sedimentation rate, C-reactive protein, and cardiac biomarkers such as troponin and brain natriuretic peptide (BNP), echocardiogram, cardiac magnetic resonance imaging (MRI), myocardial biopsy, and myocardial gene profiling are useful diagnostic tools. Current research has identified several potential biomarkers for GCM, including myocarditis-associated immune cells, cytokines, and other chemicals. The standard of care for GCM includes aggressive immunosuppressive therapy with corticosteroids and immunomodulatory agents like rituximab, cyclosporine, and infliximab, which have shown promising results in GCM by balancing the immune system and preventing the attack on healthy tissues, resulting in the reduction of inflammation, promotion of healing, and decreasing the necessity for cardiac transplantation. Without immunosuppression, the chance of mortality or cardiac surgery was 100%. Multiple studies have revealed that a treatment combination of corticosteroids and immunomodulatory agents is superior to corticosteroids alone. Combination therapy significantly increased transplant-free survival (TFS) and decreased the likelihood of heart transplantation, hence improving overall survival. It is important to balance the benefits of immunosuppression with its potentially adverse effects. In conclusion, immunomodulatory therapy adds significant long-term survival benefits to GCM.

Hyperglycemia and Glycemic Variability Associated with Glucocorticoids in Women without Pre-Existing Diabetes Undergoing Neoadjuvant or Adjuvant Taxane Chemotherapy for Early-Stage Breast Cancer

Glucocorticoids, which are administered with chemotherapy, cause hyperglycemia. Glycemic variability among breast cancer patients without diabetes is not well known. A retrospective cohort study was conducted involving early-stage breast cancer patients without diabetes who received dexamethasone prior to neoadjuvant or adjuvant taxane chemotherapy between August 2017-December 2019. Random blood glucose levels were analyzed, and steroid-induced hyperglycemia (SIH) was defined as a random glucose level of >140 mg/dL. A multivariate proportional hazards model was used to identify the risk factors of SIH. Out of 100 patients, the median age was 53 years (IQR: 45-63.5). A total of 45% of patients were non-Hispanic White, 28% Hispanic, 19% Asian, and 5% African American. The incidence of SIH was 67%, and glycemic fluctuations were highest in those with glucose levels of >200 mg/dL. Non-Hispanic White patients represented a significant predictor for time to SIH, with a hazard ratio of 2.5 (95% CI: 1.04, 5.95, p = 0.039). SIH was transient in over 90% of the patients, and only seven patients remained hyperglycemic after glucocorticoid and chemotherapy completion. Pretaxane dexamethasone-induced hyperglycemia was observed in 67% of the patients, with the greatest glycemic lability in those patients with blood glucose levels of >200 mg/dL. The non-Hispanic White patients had a higher risk of developing SIH.

A Pragmatic Approach to Inpatient Diabetes Management during the COVID-19 Pandemic

The pandemic of COVID-19 has presented new challenges to hospital personnel providing care for infected patients with diabetes who represent more than 20% of critically ill patients in intensive care units. Appropriate glycemic management contributes to a reduction in adverse clinical outcomes in acute illness but also requires intensive patient interactions for bedside glucose monitoring, intravenous and subcutaneous insulin administration, as well as rapid intervention for hypoglycemia events. These tasks are required at a time when minimizing patient interactions is recommended as a way of avoiding prolonged exposure to COVID-19 by health care personnel who often practice in settings with limited supplies of personal protective equipment. The purpose of this manuscript is to provide guidance for clinicians for reconciling recommended standards of care for infected hospitalized patients with diabetes while also addressing the daily realities of an overwhelmed health care system in many areas of the country. The use of modified protocols for insulin administration, bedside glucose monitoring, and medications such as glucocorticoids and hydroxychloroquine that may affect glycemic control are discussed. Continuous glucose monitoring systems have been proposed as an option for reducing time spent with patients, but there are important issues that need to be addressed if these are used in hospitalized patients. On-site and remote glucose management teams have potential to provide guidance in areas where there are shortages of personnel who have expertise in inpatient glycemic management.

Inpatient Management of T2DM and Hyperglycemia in Older Adults

PURPOSE OF REVIEW

This review aims to provide a summary of the evaluation and treatment of older adults (≥ 65 years) with type 2 diabetes and/or hyperglycemia in the hospital.

RECENT FINDINGS

Caring for these older adults requires special considerations. Diabetes is a risk factor for hospitalization and hyperglycemia in the hospital is associated with increased complications and mortality. Treatment plans for hospitalized older adults with diabetes should include a comprehensive geriatric assessment. This team-based approach aims to develop an individualized care plan, with consideration of the patients' personal goals, comorbidities, functional status, life expectancy, and hypoglycemia risk. Studies from hospitalized middle age and older adults with hyperglycemia can help guide diabetes treatment goals and management in older adults. Further studies, examining both glucose targets and care management assessments and treatment plan specifically targeting older adults in the hospital setting, are needed.

Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review

OBJECTIVES

What is the most effective pharmacological intervention for glycaemic control in known type 2 diabetes mellitus (DM) without prior insulin treatment and newly started on systemic glucocorticoid therapy?

DESIGN

We conducted a systematic literature review.

DATA SOURCES

We searched MEDLINE, Embase and Cochrane Library databases and Google for articles from 2002 to July 2018.

ELIGIBILITY CRITERIA

We combined search terms relating to DM (patients, >16 years of age), systemic glucocorticoids, glycaemic control, randomised controlled trials (RCTs) and observational studies.

DATA EXTRACTION AND SYNTHESIS

We screened and evaluated articles, extracted data and assessed risk of bias and quality of evidence according to Grading of Recommendations Assessment, Development and Evaluation guidelines.

RESULTS

Eight of 2365 articles met full eligibility criteria. Basal-bolus insulin (BBI) strategy for patients under systemic glucocorticoid therapy was comparatively effective but provided insufficient glucose control, depending on time of day. BBI strategy with long-acting insulin and neutral protamin Hagedorn as basal insulin provided similar overall glycaemic control. Addition of various insulin strategies to standard BBI delivered mixed results. Intermediate-acting insulin (IMI) as additional insulin conferred no clear benefits, and glycaemic control with sliding scale insulin was inferior to BBI or IMI. No studies addressed whether anticipatory or compensatory insulin adjustments are better for glycaemic control.

CONCLUSION

The lack of suitably designed RCTs and observational studies, heterogeneity of interventions, target glucose levels and glucose monitoring, poor control of DM subgroups and low to moderate quality of evidence render identification of optimal pharmacological interventions for glycaemic control and insulin management difficult. Even findings on the widely recommended BBI regimen as intensive insulin therapy for patients with DM on glucocorticoids are inconclusive. High-quality evidence from studies with well-defined DM phenotypes, settings and treatment approaches is needed to determine optimal pharmacological intervention for glycaemic control.

PROSPERO REGISTRATION NUMBER

CRD42015024739.

Assessment of the efficacy and safety of a protocol to manage glucocorticoid-induced hyperglycemia in diabetic patients during hospital stay

INTRODUCTION

There are no agreed protocols on hospital management of hyperglycemic decompensation induced by pharmacological doses of glucocorticoids (GCs). The study objective was to assess the efficacy and safety of an insulin therapy protocol specific for patients treated with glucocorticoids (CP) as compared to a general protocol (GP) in diabetes decompensation secondary to glucocorticoids. Materials and methods An experimental study in patients with glucocorticoids-induced decompensated diabetes admitted to a respiratory ward including a non-randomized control group. Two protocols (CP and GP), both based on basal-bolo insulin regimens, but with different insulin doses and distribution, were compared. The difference in mean blood glucose (MBG) levels between both protocols was measured during hospital stay, as was the risk of having MBG levels > 200mg/dL, adjusted for potential confounding factors (related to patients and to the glucocorticoid therapy used).

RESULTS

A total of 131 patients were included, 60 assigned to the GP and 71 to the CP groups. Seventy-four percent of patients had been admitted due to COPD exacerbation. There was a significant difference in the total daily insulin dose used between the CP and GP groups (29.4 vs. 57.4 IU; P<.0001). The adjusted difference in MBG levels (CP-GP) was -14.8 (95% CI, -26.2 to -3.3) mg/dL. Patients in the CP group had a lower adjusted risk of having MBG levels >200mg/dL during hospital admission (OR=0.31; 95% CI, 0.11-0.91; P=.033). There were no differences in the risk of severe hypoglycemia between the CP and GP groups (0% vs. 1.4%; P=.36).

CONCLUSIONS

The study protocol has been shown to decrease MBG levels in patients with glucocorticoids-induced decompensation of diabetes during hospital admission without compromising their safety.

Development and validation of a scoring system for prediction of insulin requirement for optimal control of blood glucose during glucocorticoid treatments

AIMS

We have developed and validated a novel scoring system to predict insulin requirement for optimal control of blood glucose during glucocorticoid (GC) treatments, by retrospective analyses of clinical parameters before GC treatment.

METHODS

Three hundred-three adults (the Developing set) undergoing their first treatment of prednisolone (PSL) were divided into two groups, depending on treatment with or without insulin. Independent risk factors for insulin requirement were identified by a stepwise logistic regression analysis after univariate analyses between the two groups. We constructed a point-addition scoring system consisting of several categories and their coefficients in each risk factor derived from another logistic regression analysis. We validated it to two validation sets, A and B.

RESULTS

Male, higher levels of fasting plasma glucose (FPG), HbA1c, and serum creatinine (CRE) and a higher initial dose of PSL were identified as the risk factors. The sensitivity, specificity, and accuracy were 90.0%, 88.1%, and 88.4%; 87.5%, 66.7%, and 70.5%; 83.3%, 76.1%, and 76.6% in the Developing set, Validation set A, and Validation set B, respectively, when the scoring system was applied.

CONCLUSIONS

The scoring system is a valid and reliable tool to predict insulin requirements in advance during GC treatment.

Oncologic 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: What All Physicians Need to Know

Fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) hybrid examinations (PET/computed tomography, PET/magnetic resonance imaging) have become the most common PET imaging tools in the evaluation of the oncologic patient. Therefore it is of paramount importance that physicians who take care of oncology patients in any capacity are familiar with the basics of when these examinations are indicated, know how to best prepare the patients, and understand the benefits and limitations of the procedure. Additionally, it is important to understand which medical conditions and medications need to be controlled to maintain the diagnostic accuracy of these tests. In this article we aim to explain what ¹⁸F-FDG is, how to best prepare our patients, what PET is, and how these examinations are interpreted. Finally, we discuss some of the limitations of these examinations.

Hypoglycemia Reduction Strategies in the ICU

PURPOSE OF REVIEW

We reviewed the strategies associated with hypoglycemia risk reduction among critically ill non-pregnant adult patients.

RECENT FINDINGS

Hypoglycemia in the ICU has been associated with increased mortality in a number of studies. Insulin dosing and glucose monitoring rules, response to impending hypoglycemia, use of computerization, and attention to modifiable factors extrinsic to insulin algorithms may affect the risk for hypoglycemia. Recurring use of intravenous (IV) bolus doses of insulin in insulin-resistant cases may reduce reliance upon higher IV infusion rates. In order to reduce the risk for hypoglycemia in the ICU, caregivers should define responses to interruption of continuous carbohydrate exposure, incorporate transitioning strategies upon initiation and interruption of IV insulin, define modifications of antihyperglycemic therapy in the presence of worsening renal function or chronic kidney disease, and anticipate the effects traceable to other medications and substances. Institutional and system-wide quality improvement efforts should assign priority to hypoglycemia prevention.

Glucocorticoid-Induced Diabetes Mellitus: An Important but Overlooked Problem

Glucocorticoids are widely used as potent anti-inflammatory and immunosuppressive drugs to treat a wide range of diseases. However, they are also associated with a number of side effects, including new-onset hyperglycemia in patients without a history of diabetes mellitus (DM) or severely uncontrolled hyperglycemia in patients with known DM. Glucocorticoid-induced diabetes mellitus (GIDM) is a common and potentially harmful problem in clinical practice, affecting almost all medical specialties, but is often difficult to detect in clinical settings. However, scientific evidence is lacking regarding the effects of GIDM, as well as strategies for prevention and treatment. Similarly to nonsteroid-related DM, the principles of early detection and risk factor modification apply. Screening for GIDM should be considered in all patients treated with medium to high doses of glucocorticoids. Challenges in the management of GIDM stem from wide fluctuations in postprandial hyperglycemia and the lack of clearly defined treatment protocols. Together with lifestyle measures, hypoglycemic drugs with insulin-sensitizing effects are indicated. However, insulin therapy is often unavoidable, to the point that insulin can be considered the drug of choice. The treatment of GIDM should take into account the degree and pattern of hyperglycemia, as well as the type, dose, and schedule of glucocorticoid used. Moreover, it is essential to instruct the patient and/or the patient's family about how to perform the necessary adjustments. Prospective studies are needed to answer the remaining questions regarding GIDM.

Management of hospitalized type 2 diabetes mellitus patients

Both hyperglycemia and hypoglycemia in hospitalized patients are associated with adverse outcomes including increased rates of infection, longer hospital length of stay, and even death. Clinical trials in patients with type 2 diabetes mellitus proved that by improving glycemic control, we can reduce all of them. Insulin is the preferred treatment for glycemic control in most cases, but alternative treatment options that can normalize blood glucose levels without hypoglycemia are being sought. Moreover, hospitalized patients are particularly vulnerable to severe, prolonged hypoglycemia since they may be unable to sense or respond to the early warning signs and symptoms of low blood glucose. Finally, nutritional support, corticosteroid therapy, and surgery increase the risk of hyperglycemia that leads to an increased risk of morbidity and mortality. We review the management of type 2 diabetes mellitus patients who are admitted to the general medical wards of the hospital for a procedure of intercurrent illness.

Transitioning safely from intravenous to subcutaneous insulin

The transition from intravenous (IV) to subcutaneous (SQ) insulin in the hospitalized patient with diabetes or hyperglycemia is a key step in patient care. This review article suggests a stepwise approach to the transition in order to promote safety and euglycemia. Important components of the transition include evaluating the patient and clinical situation for appropriateness, recognizing factors that influence a safe transition, calculation of proper SQ insulin doses, and deciding the appropriate type of SQ insulin. This article addresses other clinical situations including the management of patients previously on insulin pumps and recommendations for patients requiring glucocorticoids and enteral tube feedings. The use of institutional and computerized protocols is discussed. Further research is needed regarding the transition management of subgroups of patients such as those with type 1 diabetes and end-stage renal disease.

Brain glucose metabolism in an animal model of depression

An increasing number of data support the involvement of disturbances in glucose metabolism in the pathogenesis of depression. We previously reported that glucose and glycogen concentrations in brain structures important for depression are higher in a prenatal stress model of depression when compared with control animals. A marked rise in the concentrations of these carbohydrates and glucose transporters were evident in prenatally stressed animals subjected to acute stress and glucose loading in adulthood. To determine whether elevated levels of brain glucose are associated with a change in its metabolism in this model, we assessed key glycolytic enzymes (hexokinase, phosphofructokinase and pyruvate kinase), products of glycolysis, i.e., pyruvate and lactate, and two selected enzymes of the tricarboxylic acid cycle (pyruvate dehydrogenase and α-ketoglutarate dehydrogenase) in the hippocampus and frontal cortex. Additionally, we assessed glucose-6-phosphate dehydrogenase activity, a key enzyme in the pentose phosphate pathway (PPP). Prenatal stress increased the levels of phosphofructokinase, an important glycolytic enzyme, in the hippocampus and frontal cortex. However, prenatal stress had no effect on hexokinase or pyruvate kinase levels. The lactate concentration was elevated in prenatally stressed rats in the frontal cortex, and pyruvate levels remained unchanged. Among the tricarboxylic acid cycle enzymes, prenatal stress decreased the level of pyruvate dehydrogenase in the hippocampus, but it had no effect on α-ketoglutarate dehydrogenase. Like in the case of glucose and its transporters, also in the present study, differences in markers of glucose metabolism between control animals and those subjected to prenatal stress were not observed under basal conditions but in rats subjected to acute stress and glucose load in adulthood. Glucose-6-phosphate dehydrogenase activity was not reduced by prenatal stress but was found to be even higher in animals exposed to all experimental conditions, i.e., prenatal stress, acute stress, and glucose administration. Our data indicate that glycolysis is increased and the Krebs cycle is decreased in the brain of a prenatal stress animal model of depression.

A comparison of inpatient glucose management guidelines: implications for patient safety and quality

Inpatient glucose management guidelines and consensus statements play an important role in helping to keep hospitalized patients with diabetes and hyperglycemia safe and in optimizing the quality of their glycemic control. In this review article, we compare and contrast seven prominent US guidelines on recommended glycemic outcome measures and processes of care, with the goal of highlighting how variation among them might influence patient safety and quality. The outcome measures of interest include definitions of glucose abnormalities and glycemic targets. The relevant process measures include detection and documentation of diabetes/hyperglycemia, methods of and indications for insulin therapy, management of non-insulin agents, blood glucose monitoring, management of special situations (e.g., parenteral/enteral nutrition, glucocorticoids, surgery, insulin pumps), and appropriate transitions of care. In addition, we address elements of quality improvement, such as glycemic control program infrastructure, glucometrics, insulin safety, and professional education. While most of these guidelines align with respect to outcome measures such as glycemic targets, there is significant heterogeneity among process measures, which we propose might introduce variation or even confusion in clinical practice and possibly affect quality of care. Guideline-related factors, such as rigor of development, clarity, and presentation, may also affect provider trust in and adherence to guidelines. There is a need for high-quality research to address knowledge gaps in optimal glucose management practice approaches in the hospital setting.

Hyperglycemia in patients with hematologic malignancies

Patients with hematologic malignancies are at high risk for hyperglycemia due to factors such as frequent exposure to glucocorticoids, immunosuppressants, total parenteral nutrition, and medical stress. Hyperglycemia in these patients has been associated with poor outcomes including increased risk of infection, organ dysfunction, durability of remission, graft-versus-host disease, and mortality. However, the appropriate glucose targets are not well established, and there are few prospective data assessing whether glucose control improves outcomes. HbA1c should be interpreted with caution in patients with hematologic malignancies, due to inaccuracies imposed by disordered hematopoiesis and frequent transfusions, and short-term perturbations imposed by acute illness or medications. Management of diabetes or glucocorticoid-induced hyperglycemia in the hospital generally requires insulin therapy, which is tailored based upon nutritional needs, baseline glucose control, and concomitant factors such as type and dose of glucocorticoid administration. Close follow-up and adjustment of therapy, ideally with the assistance of patient self-titration algorithms, is required after discharge. Patients are at increased long-term risk for developing diabetes and therefore should undergo regular screening.

Achieving glycemic control in special populations in hospital: perspectives in practice

Achieving and maintaining glycemic control in patients with diabetes admitted to hospital is challenging because of the many competing factors of nutrition, pharmacotherapy and other patient-related and systemic factors. For patients receiving enteral or parenteral feeding, eating irregularly or receiving glucocorticoid therapy, the challenges are even greater. The basic principles to follow when managing glycemia in these populations are as follows: 1) Recognition of those at risk for hyperglycemia; 2) frequent bedside glucose monitoring; 3) a proactive approach with routine insulin administration based on the predicted glucose patterns; 4) constant reassessment of the glycemic status and titration of the routine insulin accordingly.

Sliding-scale versus basal-bolus insulin in the management of severe or acute hyperglycemia in type 2 diabetes patients: a retrospective study

Sliding-scale and basal-bolus insulin regimens are two options available for the treatment of severe or acute hyperglycemia in type 2 diabetes mellitus patients. Although its use is not recommended, sliding-scale insulin therapy is still being used widely. The aims of the study were to compare the glycemic control achieved by using sliding-scale or basal-bolus regimens for the management of severe or acute hyperglycemia in patients with type 2 diabetes and to analyze factors associated with the types of insulin therapy used in the management of severe or acute hyperglycemia. This retrospective study was conducted using the medical records of patients with acute or severe hyperglycemia admitted to a hospital in Malaysia from January 2008 to December 2012. A total of 202 patients and 247 admissions were included. Patients treated with the basal-bolus insulin regimen attained lower fasting blood glucose (10.8±2.3 versus 11.6±3.5 mmol/L; p = 0.028) and mean glucose levels throughout severe/acute hyperglycemia (12.3±1.9 versus 12.8±2.2; p = 0.021) compared with sliding-scale insulin regimens. Diabetic ketoacidosis (p = 0.043), cardiovascular diseases (p = 0.005), acute exacerbation of bronchial asthma (p = 0.010), and the use of corticosteroids (p = 0.037) and loop diuretics (p = 0.016) were significantly associated with the type of insulin regimen used. In conclusion, type 2 diabetes patients with severe and acute hyperglycemia achieved better glycemic control with the basal-bolus regimen than with sliding-scale insulin, and factors associated with the insulin regimen used could be identified.

Reducing the risk of hypoglycemia associated with intravenous insulin: experience with a computerized insulin infusion program in 4 adult intensive care units

Computerized insulin infusion protocols have facilitated more effective blood glucose (BG) control in intensive care units (ICUs). This is particularly important in light of the risks associated with hypoglycemia. End stage renal disease (ESRD) increases the risk of insulin-induced hypoglycemia. We evaluated BG control in 210 patients in 2 medical ICUs and in 2 surgical ICUs who were treated with a computerized insulin infusion program (CIIP). Our CIIP was programmed for a BG target of 140-180 mg/dL for medical ICU patients or 120-160 mg/dL for surgical ICU patients. In addition, we focused on BG control in the 11% of our patients with ESRD. Mean BG was 147 ± 20 mg/dL for surgical ICU patients and 171 ± 26 mg/dL for medical ICU patients. Of both surgical and medical ICU patients, 17% had 1 or more BG 60-79 mg/dL, while 3% of surgical ICU and 8% of medical ICU patients had 1 or more BG < 60 mg/dL. Mean BG in ESRD patients was 147 ± 16 mg/dL similar to 152 ± 23 mg/dL in patients without ESRD. Of ESRD patients, 41% had 1 or more BG < 79 mg/dL as compared with 17.8% of non-ESRD patients (P < .01). A higher BG target for medical ICU patients as compared with surgical ICU patients yielded comparably low rates of moderate or severe hypoglycemia. However, hypoglycemia among ESRD patients was more common compared to non-ESRD patients, suggesting a need for a higher BG target specific to ESRD patients.

Effects of korean red ginseng on hearing and blood glucose levels in steroid therapy for sudden sensorineural hearing loss

OBJECTIVES

Korean red ginseng (KRG) has hypoglycemic, antioxidant, antithrombotic, and other beneficial effects in human. The present study evaluate the therapeutic effects of KRG on hearing recovery and glucocorticoid-induced hyperglycemia in patients with idiopathic sudden sensorineural hearing loss (SSNHL) undergoing systemic steroid therapy.

METHODS

The patients were divided into 2 groups: the steroid, and the combination of steroid and red ginseng. Pure tone averages (PTA) were assessed at the first visit and 2-month follow-up. All patients underwent fasting blood glucose analyses just before and on the fifth day of treatment. Both groups were treated with a 10-day course of oral methylprednisolone at tapering doses starting from a daily dose of 48 mg. To the combination group, KRG extract was administered by mouth at a daily dose of 3 g for 20 days in addition to methylprednisolone. Hearing gain was calculated comparing the initial PTA and PTA at 2 months' follow-up. Treatment responses were classified according to Siegel's criteria.

RESULTS

Pretreatment conditions were similar between the steroid (n=37) and combination groups (n=36). At 2 months after the treatment, PTA improved significantly in both groups, but there was no significant difference in the mean hearing gain & recovery rate. The non-diabetic subjects in the steroid group (n=27) exhibited a 24% increase in the mean blood glucose level during the systemic steroid therapy, while those in the combination group (n=34) showed no changes.

CONCLUSION

Although the KRG did not provide greater therapeutic effects on hearing recovery, we suggest that red ginseng can be a useful adjuvant to the current steroid therapy to normalize glucocorticoid-induced hyperglycemia in non-diabetic patients during the treatment of SSNHL.

Steroid-induced diabetes: a clinical and molecular approach to understanding and treatment

Since the advent of glucocorticoid therapy for autoimmune disease in the 1940s, their widespread application has led to the concurrent therapy-limiting discovery of many adverse metabolic side effects. Unanticipated hyperglycemia associated with the initiation of glucocorticoids often leads to preventable hospital admissions, prolonged hospital stays, increased risks for infection and reduced graft function in solid organ transplant recipients. Challenges in managing steroid-induced diabetes stem from wide fluctuations in post-prandial hyperglycemia and the lack of clearly defined treatment protocols. The mainstay of treatment is insulin therapy coincident with meals. This article aims to review the pathogenesis, risk factors, diagnosis and treatment principles unique to steroid-induced diabetes.