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Wright AP, Embi PJ, Nelson SD, Smith JC, Turchin A, Mize DE. Development and Validation of Inpatient Hypoglycemia Models Centered Around the Insulin Ordering Process. J Diabetes Sci Technol 2024; 18:423-429. [PMID: 36047538 PMCID: PMC10973866 DOI: 10.1177/19322968221119788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The insulin ordering process is an opportunity to provide clinicians with hypoglycemia risk predictions, but few hypoglycemia models centered around the insulin ordering process exist. METHODS We used data on adult patients, admitted in 2019 to non-ICU floors of a large teaching hospital, who had orders for subcutaneous insulin. Our outcome was hypoglycemia, defined as a blood glucose (BG) <70 mg/dL within 24 hours after ordering insulin. We trained and evaluated models to predict hypoglycemia at the time of placing an insulin order, using logistic regression, random forest, and extreme gradient boosting (XGBoost). We compared performance using area under the receiver operating characteristic curve (AUCs) and precision-recall curves. We determined recall at our goal precision of 0.30. RESULTS Of 21 052 included insulin orders, 1839 (9%) were followed by a hypoglycemic event within 24 hours. Logistic regression, random forest, and XGBoost models had AUCs of 0.81, 0.80, and 0.79, and recall of 0.44, 0.49, and 0.32, respectively. The most significant predictor was the lowest BG value in the 24 hours preceding the order. Predictors related to the insulin order being placed at the time of the prediction were useful to the model but less important than the patient's history of BG values over time. CONCLUSIONS Hypoglycemia within the next 24 hours can be predicted at the time an insulin order is placed, providing an opportunity to integrate decision support into the medication ordering process to make insulin therapy safer.
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Affiliation(s)
- Aileen P. Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter J. Embi
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott D. Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua C. Smith
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexander Turchin
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Dara E. Mize
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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2
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Zhang L, Yang L, Zhou Z. Data-based modeling for hypoglycemia prediction: Importance, trends, and implications for clinical practice. Front Public Health 2023; 11:1044059. [PMID: 36778566 PMCID: PMC9910805 DOI: 10.3389/fpubh.2023.1044059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
Background and objective Hypoglycemia is a key barrier to achieving optimal glycemic control in people with diabetes, which has been proven to cause a set of deleterious outcomes, such as impaired cognition, increased cardiovascular disease, and mortality. Hypoglycemia prediction has come to play a role in diabetes management as big data analysis and machine learning (ML) approaches have become increasingly prevalent in recent years. As a result, a review is needed to summarize the existing prediction algorithms and models to guide better clinical practice in hypoglycemia prevention. Materials and methods PubMed, EMBASE, and the Cochrane Library were searched for relevant studies published between 1 January 2015 and 8 December 2022. Five hypoglycemia prediction aspects were covered: real-time hypoglycemia, mild and severe hypoglycemia, nocturnal hypoglycemia, inpatient hypoglycemia, and other hypoglycemia (postprandial, exercise-related). Results From the 5,042 records retrieved, we included 79 studies in our analysis. Two major categories of prediction models are identified by an overview of the chosen studies: simple or logistic regression models based on clinical data and data-based ML models (continuous glucose monitoring data is most commonly used). Models utilizing clinical data have identified a variety of risk factors that can lead to hypoglycemic events. Data-driven models based on various techniques such as neural networks, autoregressive, ensemble learning, supervised learning, and mathematical formulas have also revealed suggestive features in cases of hypoglycemia prediction. Conclusion In this study, we looked deep into the currently established hypoglycemia prediction models and identified hypoglycemia risk factors from various perspectives, which may provide readers with a better understanding of future trends in this topic.
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3
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Wu Y, Li R, Zhang Y, Long T, Zhang Q, Li M. Prediction Models for Prognosis of Hypoglycemia in Patients with Diabetes: A Systematic Review and Meta-Analysis. Biol Res Nurs 2023; 25:41-50. [PMID: 35839096 DOI: 10.1177/10998004221115856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To systematically summarize the reported prediction models for hypoglycemia in patients with diabetes, compare their performance, and evaluate their applicability in clinical practice. METHODS We selected studies according to the PRISMA, appraised studies according to the Prediction model Risk of Bias Assessment Tool (PROBAST), and extracted and synthesized the data according to the CHARMS. The databases of PubMed, Web of Science, Embase, and Cochrane Library were searched from inception to 31 October 2021 using a systematic review approach to capture all eligible studies developing and/or validating a prognostic prediction model for hypoglycemia in patients with diabetes. The risk bias and clinical applicability were assessed using the PROBAST. The meta-analysis of the performance of the prediction models were also conducted. The protocol of this study was recorded in PROSPERO (CRD42022309852). RESULTS Sixteen studies with 22 models met the eligible criteria. The predictors with the high frequency of occurrence among all models were age, HbA1c, history of hypoglycemia, and insulin use. A meta-analysis of C-statistic was performed for 21 prediction models, and the summary C-statistic and its 95% confidence interval and prediction interval were 0.7699 (0.7299-0.8098), 0.7699 (0.5862-0.9536), respectively. Heterogeneity exists between different hypoglycemia prediction models (τ2 was 0.00734≠0). CONCLUSIONS The existing predictive models are not recommended for widespread clinical use. A high-quality hypoglycemia screening tool should be developed in future studies.
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Affiliation(s)
- Yi Wu
- Peking University Health Science Center, Beijing, China.,School of Nursing, 540405Peking University, Beijing, China.,Peking University Health Science Centre for Evidence-Based Nursing, A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Ruxue Li
- Peking University Health Science Center, Beijing, China.,School of Nursing, 540405Peking University, Beijing, China.,Peking University Health Science Centre for Evidence-Based Nursing, A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Yating Zhang
- Peking University Health Science Center, Beijing, China.,School of Nursing, 540405Peking University, Beijing, China.,Peking University Health Science Centre for Evidence-Based Nursing, A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Tianxue Long
- Peking University Health Science Center, Beijing, China.,School of Nursing, 540405Peking University, Beijing, China.,Peking University Health Science Centre for Evidence-Based Nursing, A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Qi Zhang
- Peking University Health Science Center, Beijing, China.,School of Nursing, 540405Peking University, Beijing, China.,Peking University Health Science Centre for Evidence-Based Nursing, A Joanna Briggs Institute Affiliated Group, Beijing, China
| | - Mingzi Li
- Peking University Health Science Center, Beijing, China.,School of Nursing, 540405Peking University, Beijing, China.,Peking University Health Science Centre for Evidence-Based Nursing, A Joanna Briggs Institute Affiliated Group, Beijing, China
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Huang J, Yeung AM, Armstrong DG, Battarbee AN, Cuadros J, Espinoza JC, Kleinberg S, Mathioudakis N, Swerdlow MA, Klonoff DC. Artificial Intelligence for Predicting and Diagnosing Complications of Diabetes. J Diabetes Sci Technol 2023; 17:224-238. [PMID: 36121302 PMCID: PMC9846408 DOI: 10.1177/19322968221124583] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Artificial intelligence can use real-world data to create models capable of making predictions and medical diagnosis for diabetes and its complications. The aim of this commentary article is to provide a general perspective and present recent advances on how artificial intelligence can be applied to improve the prediction and diagnosis of six significant complications of diabetes including (1) gestational diabetes, (2) hypoglycemia in the hospital, (3) diabetic retinopathy, (4) diabetic foot ulcers, (5) diabetic peripheral neuropathy, and (6) diabetic nephropathy.
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Affiliation(s)
| | | | - David G. Armstrong
- Keck School of Medicine, University of
Southern California, Los Angeles, CA, USA
| | - Ashley N. Battarbee
- Center for Women’s Reproductive Health,
The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jorge Cuadros
- Meredith Morgan Optometric Eye Center,
University of California, Berkeley, Berkeley, CA, USA
| | - Juan C. Espinoza
- Children’s Hospital Los Angeles,
University of Southern California, Los Angeles, CA, USA
| | | | | | - Mark A. Swerdlow
- Keck School of Medicine, University of
Southern California, Los Angeles, CA, USA
| | - David C. Klonoff
- Diabetes Technology Society,
Burlingame, CA, USA
- Diabetes Research Institute,
Mills-Peninsula Medical Center, San Mateo, CA, USA
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5
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Abstract
PURPOSE OF REVIEW Glucose management in the hospital is difficult due to non-static factors such as antihyperglycemic and steroid doses, renal function, infection, surgical status, and diet. Given these complex and dynamic factors, machine learning approaches can be leveraged for prediction of glucose trends in the hospital to mitigate and prevent suboptimal hypoglycemic and hyperglycemic outcomes. Our aim was to review the clinical evidence for the role of machine learning-based models in predicting hospitalized patients' glucose trajectory. RECENT FINDINGS The published literature on machine learning algorithms has varied in terms of population studied, outcomes of interest, and validation methods. There have been tools developed that utilize data from both continuous glucose monitors and large electronic health records (EHRs). With increasing sample sizes, inclusion of a greater number of predictor variables, and use of more advanced machine learning algorithms, there has been a trend in recent years towards increasing predictive accuracy for glycemic outcomes in the hospital setting. While current models predicting glucose trajectory offer promising results, they have not been tested prospectively in the clinical setting. Accurate machine learning algorithms have been developed and validated for prediction of hypoglycemia and hyperglycemia in the hospital. Further work is needed in implementation/integration of machine learning models into EHR systems, with prospective studies to evaluate effectiveness and safety of such clinical decision support on glycemic and other clinical outcomes.
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Affiliation(s)
- Andrew Zale
- Division of Endocrinology, Diabetes & Metabolism, Division of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Division of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287 USA
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6
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Crutzen S, Belur Nagaraj S, Taxis K, Denig P. Identifying patients at increased risk of hypoglycaemia in primary care: Development of a machine learning-based screening tool. Diabetes Metab Res Rev 2021; 37:e3426. [PMID: 33289318 PMCID: PMC8518928 DOI: 10.1002/dmrr.3426] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/05/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In primary care, identifying patients with type 2 diabetes (T2D) who are at increased risk of hypoglycaemia is important for the prevention of hypoglycaemic events. We aimed to develop a screening tool based on machine learning to identify such patients using routinely available demographic and medication data. METHODS We used a cohort study design and the Groningen Initiative to ANalyse Type 2 diabetes Treatment (GIANTT) medical record database to develop models for hypoglycaemia risk. The first hypoglycaemic event in the observation period (2007-2013) was the outcome. Demographic and medication data were used as predictor variables to train machine learning models. The performance of the models was compared with a model using additional clinical data using fivefold cross validation with the area under the receiver operator characteristic curve (AUC) as a metric. RESULTS We included 13,876 T2D patients. The best performing model including only demographic and medication data was logistic regression with least absolute shrinkage and selection operator, with an AUC of 0.71. Ten variables were included (odds ratio): male gender (0.997), age (0.990), total drug count (1.012), glucose-lowering drug count (1.039), sulfonylurea use (1.62), insulin use (1.769), pre-mixed insulin use (1.109), insulin count (1.827), insulin duration (1.193), and antidepressant use (1.05). The proposed model obtained a similar performance to the model using additional clinical data. CONCLUSION Using demographic and medication data, a model for identifying patients at increased risk of hypoglycaemia was developed using machine learning. This model can be used as a tool in primary care to screen for patients with T2D who may need additional attention to prevent or reduce hypoglycaemic events.
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Affiliation(s)
- Stijn Crutzen
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Sunil Belur Nagaraj
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Katja Taxis
- Unit of Pharmaco Therapy, Epidemiology and EconomicsGroningen Research Institute of PharmacyUniversity of GroningenGroningenThe Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and PharmacologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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7
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Mathioudakis NN, Abusamaan MS, Shakarchi AF, Sokolinsky S, Fayzullin S, McGready J, Zilbermint M, Saria S, Golden SH. Development and Validation of a Machine Learning Model to Predict Near-Term Risk of Iatrogenic Hypoglycemia in Hospitalized Patients. JAMA Netw Open 2021; 4:e2030913. [PMID: 33416883 PMCID: PMC7794667 DOI: 10.1001/jamanetworkopen.2020.30913] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/01/2020] [Indexed: 12/19/2022] Open
Abstract
Importance Accurate clinical decision support tools are needed to identify patients at risk for iatrogenic hypoglycemia, a potentially serious adverse event, throughout hospitalization. Objective To predict the risk of iatrogenic hypoglycemia within 24 hours after each blood glucose (BG) measurement during hospitalization using a machine learning model. Design, Setting, and Participants This retrospective cohort study, conducted at 5 hospitals within the Johns Hopkins Health System, included 54 978 admissions of 35 147 inpatients who had at least 4 BG measurements and received at least 1 U of insulin during hospitalization between December 1, 2014, and July 31, 2018. Data from the largest hospital were split into a 70% training set and 30% test set. A stochastic gradient boosting machine learning model was developed using the training set and validated on internal and external validation. Exposures A total of 43 clinical predictors of iatrogenic hypoglycemia were extracted from the electronic medical record, including demographic characteristics, diagnoses, procedures, laboratory data, medications, orders, anthropomorphometric data, and vital signs. Main Outcomes and Measures Iatrogenic hypoglycemia was defined as a BG measurement less than or equal to 70 mg/dL occurring within the pharmacologic duration of action of administered insulin, sulfonylurea, or meglitinide. Results This cohort study included 54 978 admissions (35 147 inpatients; median [interquartile range] age, 66.0 [56.0-75.0] years; 27 781 [50.5%] male; 30 429 [55.3%] White) from 5 hospitals. Of 1 612 425 index BG measurements, 50 354 (3.1%) were followed by iatrogenic hypoglycemia in the subsequent 24 hours. On internal validation, the model achieved a C statistic of 0.90 (95% CI, 0.89-0.90), a positive predictive value of 0.09 (95% CI, 0.08-0.09), a positive likelihood ratio of 4.67 (95% CI, 4.59-4.74), a negative predictive value of 1.00 (95% CI, 1.00-1.00), and a negative likelihood ratio of 0.22 (95% CI, 0.21-0.23). On external validation, the model achieved C statistics ranging from 0.86 to 0.88, positive predictive values ranging from 0.12 to 0.13, negative predictive values of 0.99, positive likelihood ratios ranging from 3.09 to 3.89, and negative likelihood ratios ranging from 0.23 to 0.25. Basal insulin dose, coefficient of variation of BG, and previous hypoglycemic episodes were the strongest predictors. Conclusions and Relevance These findings suggest that iatrogenic hypoglycemia can be predicted in a short-term prediction horizon after each BG measurement during hospitalization. Further studies are needed to translate this model into a real-time informatics alert and evaluate its effectiveness in reducing the incidence of inpatient iatrogenic hypoglycemia.
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Affiliation(s)
- Nestoras N. Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammed S. Abusamaan
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmed F. Shakarchi
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sam Sokolinsky
- Department of Quality Improvement and Clinical Analytics, Johns Hopkins Health System, Baltimore, Maryland
| | - Shamil Fayzullin
- Department of Quality Improvement and Clinical Analytics, Johns Hopkins Health System, Baltimore, Maryland
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, Bethesda, Maryland
| | - Suchi Saria
- Departments of Computer Science, Applied Math and Statistics, and Health Policy, Johns Hopkins University, Baltimore, Maryland
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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8
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Hu X, Xu W, Lin S, Zhang C, Ling C, Chen M. Development and Validation of a Hypoglycemia Risk Model for Intensive Insulin Therapy in Patients with Type 2 Diabetes. J Diabetes Res 2020; 2020:7292108. [PMID: 33015194 PMCID: PMC7525304 DOI: 10.1155/2020/7292108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/16/2020] [Accepted: 08/28/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS To develop a simple hypoglycemic prediction model to evaluate the risk of hypoglycemia during hospitalization in patients with type 2 diabetes treated with intensive insulin therapy. METHODS We performed a cross-sectional chart review study utilizing the electronic database of the Third Affiliated Hospital of Sun Yat-sen University, and included 257 patients with type 2 diabetes undergoing intensive insulin therapy in the Department of Endocrinology and Metabolism. Logistic regression analysis was used to derive the clinical prediction rule with hypoglycemia (blood glucose ≤ 3.9 mmol/L) as the main result, and internal verification was performed. RESULTS In the derivation cohort, the incidence of hypoglycemia was 51%. The final model selected included three variables: fasting insulin, fasting blood glucose, and total treatment time. The area under the curve (AUC) of this model was 0.666 (95% CI: 0.594-0.738, P < 0.001). CONCLUSIONS The model's hypoglycemia prediction and the actual occurrence are in good agreement. The variable data was easy to obtain and the evaluation method was simple, which could provide a reference for the prevention and treatment of hypoglycemia and screen patients with a high risk of hypoglycemia.
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Affiliation(s)
- Xiling Hu
- Department of Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Weiran Xu
- School of Nursing, Sun Yat-sen University, Guangzhou 510085, China
| | - Shuo Lin
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Cang Zhang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Cong Ling
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Miaoxia Chen
- Nursing Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
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9
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Abstract
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.
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Affiliation(s)
- Kristen DeCarlo
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave., Suite 530, Chicago, IL, 60611, USA
| | - Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave., Suite 530, Chicago, IL, 60611, USA.
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10
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Pérez-Belmonte LM, Gómez-Doblas JJ, Millán-Gómez M, López-Carmona MD, Guijarro-Merino R, Carrasco-Chinchilla F, de Teresa-Galván E, Jiménez-Navarro M, Bernal-López MR, Gómez-Huelgas R. Use of Linagliptin for the Management of Medicine Department Inpatients with Type 2 Diabetes in Real-World Clinical Practice (Lina-Real-World Study). J Clin Med 2018; 7:jcm7090271. [PMID: 30208631 PMCID: PMC6162816 DOI: 10.3390/jcm7090271] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/07/2018] [Accepted: 09/08/2018] [Indexed: 01/14/2023] Open
Abstract
The use of noninsulin antihyperglycaemic drugs in the hospital setting has not yet been fully described. This observational study compared the efficacy and safety of the standard basal-bolus insulin regimen versus a dipeptidyl peptidase-4 inhibitor (linagliptin) plus basal insulin in medicine department inpatients in real-world clinical practice. We retrospectively enrolled non-critically ill patients with type 2 diabetes with mild to moderate hyperglycaemia and no injectable treatments at home who were treated with a hospital antihyperglycaemic regimen (basal-bolus insulin, or linagliptin-basal insulin) between January 2016 and December 2017. Propensity score was used to match patients in both treatment groups and a comparative analysis was conducted to test the significance of differences between groups. After matched-pair analysis, 227 patients were included per group. No differences were shown between basal-bolus versus linagliptin-basal regimens for the mean daily blood glucose concentration after admission (standardized difference = 0.011), number of blood glucose readings between 100–140 mg/dL (standardized difference = 0.017) and >200 mg/dL (standardized difference = 0.021), or treatment failures (standardized difference = 0.011). Patients on basal-bolus insulin received higher total insulin doses and a higher daily number of injections (standardized differences = 0.298 and 0.301, respectively). Basal and supplemental rapid-acting insulin doses were similar (standardized differences = 0.003 and 0.012, respectively). There were no differences in hospital stay length (standardized difference = 0.003), hypoglycaemic events (standardized difference = 0.018), or hospital complications (standardized difference = 0.010) between groups. This study shows that in real-world clinical practice, the linagliptin-basal insulin regimen was as effective and safe as the standard basal-bolus regimen in non-critical patients with type 2 diabetes with mild to moderate hyperglycaemia treated at home without injectable therapies.
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Affiliation(s)
- Luis M Pérez-Belmonte
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain.
| | - Juan J Gómez-Doblas
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Mercedes Millán-Gómez
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - María D López-Carmona
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Ricardo Guijarro-Merino
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Fernando Carrasco-Chinchilla
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Eduardo de Teresa-Galván
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Manuel Jiménez-Navarro
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Unidad de Gestión Clínica Área del Corazón, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - M Rosa Bernal-López
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain.
| | - Ricardo Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain.
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11
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Mathioudakis NN, Everett E, Routh S, Pronovost PJ, Yeh HC, Golden SH, Saria S. Development and validation of a prediction model for insulin-associated hypoglycemia in non-critically ill hospitalized adults. BMJ Open Diabetes Res Care 2018; 6:e000499. [PMID: 29527311 PMCID: PMC5841507 DOI: 10.1136/bmjdrc-2017-000499] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/02/2018] [Accepted: 02/10/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To develop and validate a multivariable prediction model for insulin-associated hypoglycemia in non-critically ill hospitalized adults. RESEARCH DESIGN AND METHODS We collected pharmacologic, demographic, laboratory, and diagnostic data from 128 657 inpatient days in which at least 1 unit of subcutaneous insulin was administered in the absence of intravenous insulin, total parenteral nutrition, or insulin pump use (index days). These data were used to develop multivariable prediction models for biochemical and clinically significant hypoglycemia (blood glucose (BG) of ≤70 mg/dL and <54 mg/dL, respectively) occurring within 24 hours of the index day. Split-sample internal validation was performed, with 70% and 30% of index days used for model development and validation, respectively. RESULTS Using predictors of age, weight, admitting service, insulin doses, mean BG, nadir BG, BG coefficient of variation (CVBG), diet status, type 1 diabetes, type 2 diabetes, acute kidney injury, chronic kidney disease (CKD), liver disease, and digestive disease, our model achieved a c-statistic of 0.77 (95% CI 0.75 to 0.78), positive likelihood ratio (+LR) of 3.5 (95% CI 3.4 to 3.6) and negative likelihood ratio (-LR) of 0.32 (95% CI 0.30 to 0.35) for prediction of biochemical hypoglycemia. Using predictors of sex, weight, insulin doses, mean BG, nadir BG, CVBG, diet status, type 1 diabetes, type 2 diabetes, CKD stage, and steroid use, our model achieved a c-statistic of 0.80 (95% CI 0.78 to 0.82), +LR of 3.8 (95% CI 3.7 to 4.0) and -LR of 0.2 (95% CI 0.2 to 0.3) for prediction of clinically significant hypoglycemia. CONCLUSIONS Hospitalized patients at risk of insulin-associated hypoglycemia can be identified using validated prediction models, which may support the development of real-time preventive interventions.
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Affiliation(s)
- Nestoras Nicolas Mathioudakis
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Estelle Everett
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shuvodra Routh
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Peter J Pronovost
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Hsin-Chieh Yeh
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes and Metabolism, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Suchi Saria
- Department of Computer Science, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
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