1
|
Idrees T, Castro-Revoredo IA, Oh HD, Gavaller MD, Zabala Z, Moreno E, Moazzami B, Galindo RJ, Vellanki P, Cabb E, Johnson TM, Peng L, Umpierrez GE. Continuous Glucose Monitoring-Guided Insulin Administration in Long-Term Care Facilities: A Randomized Clinical Trial. J Am Med Dir Assoc 2024; 25:884-888. [PMID: 38460943 PMCID: PMC11283256 DOI: 10.1016/j.jamda.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES To evaluate the efficacy of real-time continuous glucose monitoring (rt-CGM) in adjusting insulin therapy in long-term care facilities (LTCF). DESIGN Prospective randomized clinical trial. SETTINGS AND PARTICIPANTS Insulin-treated patients with type 2 diabetes (T2D) admitted to LTCF. METHODS Participants in the standard of care wore a blinded CGM with treatment adjusted based on point-of-care capillary glucose results before meals and bedtime (POC group). Participants in the intervention (CGM group) wore a Dexcom G6 CGM with treatment adjusted based on daily CGM profile. Treatment adjustment was performed by the LTCF medical team, with a duration of intervention up to 60 days. The primary endpoint was difference in time in range (TIR 70-180 mg/dL) between treatment groups. RESULTS Among 100 participants (age 74.73 ± 11 years, 80% admitted for subacute rehabilitation and 20% for nursing home care), there were no significant differences in baseline clinical characteristics between groups, and CGM data were compared for a median of 17 days. There were no differences in TIR (53.38% ± 30.16% vs 48.81% ± 28.03%, P = .40), mean daily mean CGM glucose (184.10 ± 43.4 mg/dL vs 190.0 ± 45.82 mg/dL, P = .71), or the percentage of time below range (TBR) <70 mg/dL (0.83% ± 2.59% vs 1.18% ± 3.54%, P = .51), or TBR <54 mg/dL (0.23% ± 0.85% vs 0.56% ± 2.24%, P = .88) between rt-CGM and POC groups. CONCLUSIONS AND IMPLICATIONS The use of rtCGM is safe and effective in guiding insulin therapy in patients with T2D in LTCF resulting in a similar improvement in glycemic control compared to POC-guided insulin adjustment.
Collapse
Affiliation(s)
- Thaer Idrees
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | | | - Hyungseok D Oh
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Monica D Gavaller
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Zohyra Zabala
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Emmelin Moreno
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Bobak Moazzami
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Elena Cabb
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Theodore M Johnson
- Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA; Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Limin Peng
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA.
| |
Collapse
|
2
|
Mori T, Nyumura I, Hanai K, Shinozaki T, Babazono T. Effects of simultaneous pancreas and kidney transplantation in Japanese individuals with type 1 diabetes and end-stage kidney disease. Diabetol Int 2024; 15:278-289. [PMID: 38524933 PMCID: PMC10959910 DOI: 10.1007/s13340-024-00691-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/08/2024] [Indexed: 03/26/2024]
Abstract
This single-center observational cohort study aimed to assess the potential benefits of simultaneous pancreas and kidney transplantation (SPK) in terms of mortality and kidney graft outcomes in Japanese individuals with type 1 diabetes (T1D) and end-stage kidney disease (ESKD). We first compared all-cause mortality rates between 78 SPK recipients and 108 non-transplanted individuals with T1D and ESKD. To mitigate the bias stemming from immortal time before receiving SPK, we utilized Cox regression models treating SPK as a time-dependent covariate. Next, we compared all-cause mortality rates and kidney graft loss rates between 65 SPK recipients and 58 kidney transplantation alone (KTA) recipients. Multivariate Cox hazard models and Fine and Gray competing-risk models were employed. SPK recipients experienced significantly lower all-cause mortality rates than non-transplanted individuals, even after accounting for immortal time bias (p = 0.015 by log-rank test, hazard ratio [HR] = 0.334, p = 0.025). When comparing SPK and KTA recipients, no statistically significant difference was observed in mortality rates (HR = 0.627, p = 0.588 by Cox model; HR = 0.385, p = 0.412 by Fine and Gray model) or kidney graft loss rates (HR = 0.612, p = 0.436 by Cox model; HR = 0.639, p = 0.376 by Fine and Gray model). Dysglycemia-associated mortality were observed in non-transplanted individuals and KTA recipients, but not in SPK recipients. These findings highlight the potential life-saving impact of SPK compared with intensive insulin therapy and dialysis. Additionally, this study suggests that both SPK and KTA may offer comparable outcomes. These findings have significant implications for clinical decision-making in the context of organ transplantation for individuals with T1D and ESKD.
Collapse
Affiliation(s)
- Tomomi Mori
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666 Japan
| | - Izumi Nyumura
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666 Japan
| | - Ko Hanai
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666 Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Tetsuya Babazono
- Division of Diabetology and Metabolism, Department of Internal Medicine, Tokyo Women’s Medical University School of Medicine, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666 Japan
| |
Collapse
|
3
|
Jandovitz N, George SJ, Abate M, Kressel AM, Bolognese AC, Lau L, Nair V, Grodstein E. A randomized trial of continuous glucose monitoring to improve post-transplant glycemic control. Clin Transplant 2023; 37:e15139. [PMID: 37725341 DOI: 10.1111/ctr.15139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/22/2023] [Accepted: 09/09/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION This study examines whether the use of inpatient Continuous Glucose Monitors provides improved glycemic control over finger-stick glucose monitoring post-transplant. METHODS This is a single-site, prospective randomized controlled trial of 40 patients receiving conventional finger-stick glucose monitoring or continuous monitoring using the Medtronic Guardian Sensor 3 during the first 5 days post-transplant. Included patients were adult renal transplant recipients with a diagnosis of diabetes. Assessed endpoints included post-transplant daily median glucose level, hyperglycemic (≥180 mg/dL) and hypoglycemic (≤80 mg/dL) episodes, number of post-transplant bacterial infections and length of stay. RESULTS Groups were well matched in demographic variables. Median daily glucose was significantly lower in the intervention group. There were also significantly less episodes of hyperglycemia on postoperative days 2, 3, 4, and 5. There were no differences in the incidences of hypoglycemia, postoperative bacterial infections, or length of stay. CONCLUSION In this randomized study, the use of a continuous glucose monitor to guide post-transplant glucose management significantly lowered the incidence of hyperglycemic episodes and median glucose levels through the first 5 days post-transplant without increasing the number of hypoglycemic episodes. The use of these devices can be considered in the immediate post-renal transplant setting.
Collapse
Affiliation(s)
- Nicholas Jandovitz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Sam J George
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Mersema Abate
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Adam M Kressel
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Alexandra C Bolognese
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Lawrence Lau
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Vinay Nair
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| | - Elliot Grodstein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
| |
Collapse
|
4
|
Dmitriev IV, Severina AS, Zhuravel NS, Yevloyeva MI, Salimkhanov RK, Shchelykalina SP, Bezunov EA, Shamkhalova MS, Semenova JF, Klimontov VV, Shestakova MV. Continuous Glucose Monitoring in Patients Following Simultaneous Pancreas-Kidney Transplantation: Time in Range and Glucose Variability. Diagnostics (Basel) 2023; 13:diagnostics13091606. [PMID: 37174997 PMCID: PMC10177867 DOI: 10.3390/diagnostics13091606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Simultaneous pancreas-kidney transplantation (SPKT) can improve long-term patient survival and restore endogenous insulin secretion in recipients with type 1 diabetes (T1D). There are currently few data on glucose fluctuations assessed by continuous glucose monitoring (CGM) after SPKT. Aim: to evaluate CGM-derived time in range (TIR) and glucose variability (GV) in patients with T1D and functioning pancreatic grafts after SPKT. Fifty-four CGM recordings from 43 patients, 15 men and 28 women, aged 34 (31; 39) years were analyzed. Time since SKPT was up to 1 year (group 1, n = 13), from 1 to 5 years (group 2, n = 15), and from 5 to 12 years (group 3, n = 26). TIR (3.9-10 mmol/L), Time Above Range (TAR), Time Below Range (TBR), and GV parameters were estimated. There were no differences in mean glucose (5.5 [5.1; 6.2], 5.9 [5.4; 6.2], and 5.9 [5.6; 6.7] mmol/L), TIR (97.6 [92.8-99.1], 97.2 [93.2; 99.1], and 97.5 [93.4; 99]%); TAR (0, 1.8 [1.3; 3.7], and 2.5 [2; 5]%), TBR (5 [3.3; 12.7], 4.1 [2.2; 10.1], and 3.5 [1.3; 6.5]%) and GV parameters between three groups (all p > 0.05). Thus, recipients with functioning pancreatic grafts demonstrate remarkably high TIR and low GV after SPKT.
Collapse
Affiliation(s)
- Ilya V Dmitriev
- Sklifosovsky Research Institute for Emergency Medicine, 129090 Moscow, Russia
| | | | - Nikita S Zhuravel
- Sklifosovsky Research Institute for Emergency Medicine, 129090 Moscow, Russia
| | | | | | - Svetlana P Shchelykalina
- Department of Medical Cybernetics and Computer Science MBF Pirogov Russian National Research Medical University (RNRMU), 117997 Moscow, Russia
| | - Evgeniy A Bezunov
- FSBI "Central Clinical Hospital with Polyclinic" of the Presidential Department of the Russian Federation, 121359 Moscow, Russia
| | | | - Julia F Semenova
- Research Institute of Clinical and Experimental Lymphology-Branch of the Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences (RICEL-Branch of IC&G SB RAS), 630060 Novosibirsk, Russia
| | - Vadim V Klimontov
- Research Institute of Clinical and Experimental Lymphology-Branch of the Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences (RICEL-Branch of IC&G SB RAS), 630060 Novosibirsk, Russia
| | | |
Collapse
|
5
|
Buschur EO, Faulds E, Dungan K. CGM in the Hospital: Is It Ready for Prime Time? Curr Diab Rep 2022; 22:451-460. [PMID: 35796882 PMCID: PMC9261155 DOI: 10.1007/s11892-022-01484-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The use of continuous glucose monitoring (CGM) in the hospital setting is growing with more patients using these devices at home and when admitted to the hospital, especially during the COVID-19 pandemic. RECENT FINDINGS Historically, most evidence for CGM use in the inpatient setting was limited to small studies utilizing outdated CGM technology and analyzing accuracy of sensor measurements. Previous studies have shown reduced sensor accuracy during extreme hypo- or hyperglycemia, rapid fluctuations of glucose, compression of the sensor itself, and in those who are critically ill. Studies that are more recent have shown CGM to have adequate accuracy and may be effective in reducing hypoglycemia in hospitalized patients; some studies have also showed improvement in time in target glycemic range. Furthermore, CGM may reduce nursing workload, cost of inpatient care, and use of personal protective equipment and face-to-face patient care especially for patients during the COVID-19 pandemic. This review will describe the evidence for use of CGM in hospitalized critically ill or non-critically ill patients, address accuracy and safety considerations, and outline paths for future implementation.
Collapse
Affiliation(s)
- Elizabeth O. Buschur
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
| | - Eileen Faulds
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
- grid.261331.40000 0001 2285 7943The Ohio State University College of Nursing, Columbus, OH USA
| | - Kathleen Dungan
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
| |
Collapse
|
6
|
Idrees T, Castro-Revoredo IA, Migdal AL, Moreno EM, Umpierrez GE. Update on the management of diabetes in long-term care facilities. BMJ Open Diabetes Res Care 2022; 10:10/4/e002705. [PMID: 35858714 PMCID: PMC9305812 DOI: 10.1136/bmjdrc-2021-002705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.
Collapse
Affiliation(s)
- Thaer Idrees
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Iris A Castro-Revoredo
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Alexandra L Migdal
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Emmelin Marie Moreno
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
7
|
Chowdhury TA, Wahba M, Mallik R, Peracha J, Patel D, De P, Fogarty D, Frankel A, Karalliedde J, Mark PB, Montero RM, Pokrajac A, Zac-Varghese S, Bain SC, Dasgupta I, Banerjee D, Winocour P, Sharif A. Association of British Clinical Diabetologists and Renal Association guidelines on the detection and management of diabetes post solid organ transplantation. Diabet Med 2021; 38:e14523. [PMID: 33434362 DOI: 10.1111/dme.14523] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/24/2020] [Accepted: 01/09/2021] [Indexed: 01/06/2023]
Abstract
Post-transplant diabetes mellitus (PTDM) is common after solid organ transplantation (SOT) and associated with increased morbidity and mortality for allograft recipients. Despite the significant burden of disease, there is a paucity of literature with regards to detection, prevention and management. Evidence from the general population with diabetes may not be translatable to the unique context of SOT. In light of emerging clinical evidence and novel anti-diabetic agents, there is an urgent need for updated guidance and recommendations in this high-risk cohort. The Association of British Clinical Diabetologists (ABCD) and Renal Association (RA) Diabetic Kidney Disease Clinical Speciality Group has undertaken a systematic review and critical appraisal of the available evidence. Areas of focus are; (1) epidemiology, (2) pathogenesis, (3) detection, (4) management, (5) modification of immunosuppression, (6) prevention, and (7) PTDM in the non-renal setting. Evidence-graded recommendations are provided for the detection, management and prevention of PTDM, with suggested areas for future research and potential audit standards. The guidelines are endorsed by Diabetes UK, the British Transplantation Society and the Royal College of Physicians of London. The full guidelines are available freely online for the diabetes, renal and transplantation community using the link below. The aim of this review article is to introduce an abridged version of this new clinical guideline ( https://abcd.care/sites/abcd.care/files/site_uploads/Resources/Position-Papers/ABCD-RA%20PTDM%20v14.pdf).
Collapse
Affiliation(s)
| | | | | | | | - Dipesh Patel
- Diabetes & Endocrinology, Royal Free NHS foundation Trust, UCL, London, UK
| | | | | | | | - Janaka Karalliedde
- Guy's and St Thomas NHS Foundation Trust and King's College London, London, UK
| | | | | | - Ana Pokrajac
- West Hertfordshire Hospitals NHS Trust, Watford, UK
| | | | | | - Indranil Dasgupta
- Heartlands Hospital, Birmingham, UK
- Warwick Medical School, Warwick, UK
| | - Debasish Banerjee
- Renal and Transplant Unit, St George's University Hospitals NHS Foundation Trust and MCSRI, St George's University of London, London, UK
| | | | | |
Collapse
|
8
|
Montero AR, Dubin JS, Sack P, Magee MF. Future technology-enabled care for diabetes and hyperglycemia in the hospital setting. World J Diabetes 2019; 10:473-480. [PMID: 31558981 PMCID: PMC6748879 DOI: 10.4239/wjd.v10.i9.473] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/13/2019] [Accepted: 08/27/2019] [Indexed: 02/05/2023] Open
Abstract
Patients with diabetes are increasingly common in hospital settings where optimal glycemic control remains challenging. Inpatient technology-enabled support systems are being designed, adapted and evaluated to meet this challenge. Insulin pump use, increasingly common in outpatients, has been shown to be safe among select inpatients. Dedicated pump protocols and provider training are needed to optimize pump use in the hospital. Continuous glucose monitoring (CGM) has been shown to be comparable to usual care for blood glucose surveillance in intensive care unit (ICU) settings but data on cost effectiveness is lacking. CGM use in non-ICU settings remains investigational and patient use of home CGM in inpatient settings is not recommended due to safety concerns. Compared to unstructured insulin prescription, a continuum of effective electronic medical record-based support for insulin prescription exists from passive order sets to clinical decision support to fully automated electronic Glycemic Management Systems. Relative efficacy and cost among these systems remains unanswered. An array of novel platforms are being evaluated to engage patients in technology-enabled diabetes education in the hospital. These hold tremendous promise in affording universal access to hospitalized patients with diabetes to effective self-management education and its attendant short/long term clinical benefits.
Collapse
Affiliation(s)
- Alex Renato Montero
- MedStar Diabetes Institute, Washington, DC 20010, United States
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Jeffrey S Dubin
- MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Paul Sack
- MedStar Diabetes Institute, Washington, DC 20010, United States
- MedStar Union Memorial Hospital, Baltimore, MD 21218, United States
| | - Michelle F Magee
- MedStar Diabetes Institute, Washington, DC 20010, United States
- MedStar Health Research Institute, Washington, DC 20010, United States
| |
Collapse
|
9
|
Wallia A, Umpierrez GE, Rushakoff RJ, Klonoff DC, Rubin DJ, Hill Golden S, Cook CB, Thompson B. Consensus Statement on Inpatient Use of Continuous Glucose Monitoring. J Diabetes Sci Technol 2017; 11:1036-1044. [PMID: 28429611 PMCID: PMC5950996 DOI: 10.1177/1932296817706151] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In June 2016, Diabetes Technology Society convened a panel of US experts in inpatient diabetes management to discuss the current and potential role of continuous glucose monitoring (CGM) in the hospital. This discussion combined with a literature review was a follow-up to a meeting, which took place in May 2015. The panel reviewed evidence on use of CGM in 3 potential inpatient scenarios: (1) the intensive care unit (ICU), (2) non-ICU, and (3) transitioning outpatient CGM use into the hospital setting. Panel members agreed that data from limited studies and theoretical considerations suggested that use of CGM in the hospital had the potential to improve patient clinical outcomes, and in particular reduction of hypoglycemia. Panel members discussed barriers to widespread adoption of CGM, which patients would benefit most from use of this technology, and what type of outcome studies are needed to guide use of CGM in the inpatient setting.
Collapse
Affiliation(s)
- Amisha Wallia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Daniel J. Rubin
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Curtiss B. Cook
- Arizona State University, Scottsdale, AZ, USA
- Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Bithika Thompson
- Mayo Clinic Arizona, Scottsdale, AZ, USA
- Bithika Thompson, MD, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA.
| | | |
Collapse
|
10
|
Tura A, Hecking M, Wolzt M, Saemann MD, Pacini G. Assessment of beta-cell function and insulin secretion in subjects that underwent renal transplantation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:2371-4. [PMID: 26736770 DOI: 10.1109/embc.2015.7318870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In this study we aimed to assess the performance of various indices of beta-cell function derived from oral glucose tolerance test (OGTT) in subjects that underwent renal transplantation. Impaired insulin secretion seems in fact central for development of new onset diabetes after transplantation, but its assessment has not been systematically evaluated. Twenty subjects underwent a 75 g 2h-OGTT for measurement of glucose, insulin, C-peptide. OGTT indices of beta-cell function were either derived by mathematical modeling (yielding the reference index: glucose sensitivity) or were empirical: insulinogenic index (IGI), IGI derived indices, whole shape C-peptide (WHOSH_CP). Indices of beta cell function, showed significant correlation with glucose sensitivity (R(2)=0.40-0.86, all P<;0.003). The majority of beta-cell function indices provided comparable results also when subjects were divided into subgroups according to sex, age, body mass index, mean glycemia. In conclusion, in transplanted subjects OGTT empirical indices are typically acceptable for the estimation of beta-cell function.
Collapse
|
11
|
Werzowa J, Pacini G, Hecking M, Fidler C, Haidinger M, Brath H, Thomas A, Säemann MD, Tura A. Comparison of glycemic control and variability in patients with type 2 and posttransplantation diabetes mellitus. J Diabetes Complications 2015; 29:1211-6. [PMID: 26264400 DOI: 10.1016/j.jdiacomp.2015.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/09/2015] [Accepted: 07/11/2015] [Indexed: 12/14/2022]
Abstract
AIM Posttransplantation diabetes mellitus (PTDM) is a common complication after renal transplantation leading to increased cardiovascular morbidity and mortality. In subjects with type 2 diabetes (T2DM) increased glycemic variability and poor glycemic control have been associated with cardiovascular complications. We therefore aimed at determining glycemic variability and glycemic control in subjects with PTDM in comparison to T2DM subjects. METHODS In this observational study we analyzed 10 transplanted subjects without diabetes (Control), 10 transplanted subjects with PTDM, and 8 non-transplanted T2DM subjects using Continuous Glucose Monitoring (CGM). Several indices of glycemic control quality and variability were computed. RESULTS Many indices of both glycemic control quality and variability were different between control and PTDM subjects, with worse values in PTDM. The indices of glycemic control, such as glucose mean, GRADE and M-value, were similar in PTDM and T2DM, but some indices of glycemic variability, that is CONGA, lability index and shape index, showed a markedly higher (i.e., worse) value in T2DM than in PTDM (P value range: 0.001-0.035). CONCLUSIONS Although PTDM and T2DM subjects showed similar glycemic control quality, glycemic variability was significantly higher in T2DM. These data underscore potential important pathophysiological differences between T2DM and PTDM indicating that increased glycemic variability may not be a key factor for the excess cardiovascular mortality in patients with PTDM.
Collapse
Affiliation(s)
- Johannes Werzowa
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
| | | | - Manfred Hecking
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Catharina Fidler
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Michael Haidinger
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Helmut Brath
- Diabetes Outpatient Clinic, Health Center South, Vienna, Austria
| | | | - Marcus D Säemann
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Andrea Tura
- CNR Institute of Neuroscience, Padova, Italy
| |
Collapse
|
12
|
Werzowa J, Hecking M, Haidinger M, Döller D, Sharif A, Tura A, Säemann MD. The diagnosis of posttransplantation diabetes mellitus: meeting the challenges. Curr Diab Rep 2015; 15:27. [PMID: 25777999 DOI: 10.1007/s11892-015-0601-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Posttransplantation diabetes mellitus (PTDM) is a major complication after renal transplantation due to its negative impact on patient and graft survival, and affects up to 40% of renal transplant recipients. The generation of evidence regarding its optimal treatment is now progressing with some emphasis on early postoperative insulin treatment that targets β-cell failure. This therapy seems to benefit renal transplant patients but contrasts with previous PTDM guidelines that were following treatment of type 2 diabetes mellitus (DM): oral antidiabetics first, insulin last. Similarly, in the current PTDM consensus recommendations, diagnostic procedures are in accordance with the American Diabetes Association (ADA) recommendations for diagnosis of DM. PTDM and type 2 DM, however, are distinct disease entities with different pathophysiological backgrounds. This review will discuss the significance of the standard diagnostic criteria for DM in patients after renal transplantation without prior DM. In particular, the role of glycated hemoglobin (HbA1c) and oral glucose tolerance testing (OGTT) will be reviewed. In addition, the potential role of other glycated proteins and continuous glucose monitoring will be covered, although these parameters are not yet part of the consensus recommendations.
Collapse
Affiliation(s)
- J Werzowa
- Department of Internal Medicine III, Section of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria,
| | | | | | | | | | | | | |
Collapse
|
13
|
Mittal S, Franklin RH, Policola C, Sharples E, Friend PJ, Gough SCL. Early postoperative continuous glucose monitoring in pancreas transplant recipients. Transpl Int 2015; 28:604-9. [DOI: 10.1111/tri.12541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 01/07/2015] [Accepted: 02/09/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Shruti Mittal
- Oxford Transplant Centre; Oxford University Hospital NHS Trust; Oxford UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
| | - Rachel H. Franklin
- Oxford Centre for Diabetes, Endocrinology and Diabetes; University of Oxford; Oxford UK
| | - Caterina Policola
- Dipartimento di Endocrinologia e Malattie del Metabolismo; Università Cattolica Del Sacro Cuore; Rome Italy
| | - Edward Sharples
- Oxford Transplant Centre; Oxford University Hospital NHS Trust; Oxford UK
| | - Peter J. Friend
- Oxford Transplant Centre; Oxford University Hospital NHS Trust; Oxford UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
- NIHR Biomedical Research Centre; Oxford UK
| | - Stephen C. L. Gough
- Oxford Centre for Diabetes, Endocrinology and Diabetes; University of Oxford; Oxford UK
- NIHR Biomedical Research Centre; Oxford UK
| |
Collapse
|
14
|
Stadler M, Krššák M, Jankovic D, Göbl C, Winhofer Y, Pacini G, Bischof M, Haidinger M, Saemann M, Mühlbacher F, Korbonits M, Baumgartner-Parzer SM, Luger A, Prager R, Anderwald CH, Krebs M. Fasting and postprandial liver glycogen content in patients with type 1 diabetes mellitus after successful pancreas-kidney transplantation with systemic venous insulin delivery. Clin Endocrinol (Oxf) 2014; 80:208-13. [PMID: 23302039 DOI: 10.1111/cen.12146] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 12/04/2012] [Accepted: 01/07/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with type 1 diabetes mellitus (T1DM), insulin is usually replaced systemically (subcutaneously) and not via the physiological portal route. According to previous studies, the liver's capacity to store glycogen is reduced in T1DM patients, but it remains unclear whether this is due to hyperglycaemia, or whether the route of insulin supply could contribute to this phenomenon. T1DM patients after successful pancreas-kidney transplantation with systemic venous drainage (T1DM-PKT) represent a suitable human model to further investigate this question, because they are normoglycaemic, but their liver receives insulin from the pancreas transplant via the systemic route. MATERIALS AND METHODS In nine T1DM-PKT, nine controls without diabetes (CON) and seven patients with T1DM (T1DM), liver glycogen content was measured at fasting and after two standardized meals employing (13) C-nuclear-magnetic-resonance-spectroscopy. Circulating glucose and glucoregulatory hormones were measured repeatedly throughout the study day. RESULTS The mean and fasting concentrations of peripheral plasma glucose, insulin, glucagon and C-peptide were comparable between T1DM-PKT and CON, whereas T1DM were hyperglycaemic and hyperinsulinaemic (P < 0·05 vs T1DM-PKT and CON). Total liver glycogen content at fasting and after breakfast did not differ in the three groups. After lunch, T1DM-PKT and T1DM had a 14% and 21% lower total liver glycogen content than CON (P < 0·02). CONCLUSION In spite of normalized glycaemic control, postprandial liver glycogen content was reduced in T1DM-PKT with systemic venous drainage. Thus, not even optimized systemic insulin substitution is able to resolve the defect in postprandial liver glycogen storage seen in T1DM patients.
Collapse
Affiliation(s)
- M Stadler
- 3rd Medical Department of Metabolic Diseases and Nephrology, Hietzing Hospital, Vienna, Austria; Karl Landsteiner Institute of Metabolic Diseases and Nephrology, Vienna, Austria; Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Pasti K, Szabo AJ, Prokai A, Meszaros K, Peko N, Solyom R, Sallay P, Reusz G, Rusai K. Continuous glucose monitoring system (CGMS) in kidney-transplanted children. Pediatr Transplant 2013; 17:454-60. [PMID: 23902603 DOI: 10.1111/petr.12106] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 01/03/2023]
Abstract
NODAT and IGT are well-known complications of immunosuppressive therapy after transplantation being a risk factor for cardiovascular disease affecting patient and graft survival. Therefore, early identification and treatment are of high importance. In this study, we examined the glycemic homeostasis of 20 renal-transplanted children using routine laboratory tests and the continuous glucose monitoring system (CGMS). Six patients (30%) had IGT, and one patient had NODAT (5%). The HOMA index was in an abnormal range in 35% of all patients and was abnormal in 67% of the IGT patients. CGMS analysis showed that IGT patients had higher "lowest glucose" level, and the incidence of hypoglycemic episodes was significantly lower compared with patients with normal OGTT result. In IGT patients, glucose variability tended to be lower. Furthermore, in the whole patient cohort, glucose variability significantly decreased with time after transplantation. Summarizing, these novel data show that "lowest glucose" level and hypoglycemic episodes are significantly influenced and altered in renal-transplanted patients with IGT. Furthermore, there is a decrease in glucose variability with time after transplantation. The mechanism and relevance of these data need further investigations.
Collapse
Affiliation(s)
- Krisztina Pasti
- First Department of Pediatrics and Nephrology, Research Laboratory of the Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Light J, Tucker M. Simultaneous pancreas kidney transplants in diabetic patients with end-stage renal disease: the 20-yr experience. Clin Transplant 2013; 27:E256-63. [PMID: 23480129 DOI: 10.1111/ctr.12100] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION We are reporting the results over a 20 yr period of simultaneous pancreas-kidney transplants in patients with end-stage renal disease and diabetes mellitus. The outcomes of the transplants, performed between 1989 and 2008, are stratified by pretransplant c-peptide value. METHODS One hundred and seventy-three patients with end-stage renal disease due to diabetes, and were stratified according to undetectable c-peptide (x < 0.8 ng/mL) and detectable c-peptide (x > 0.8 ng/mL) levels. RESULTS Patients with detectable c-peptide (x > 0.8 ng/mL) were the oldest at diabetes diagnosis (24.2 vs. 15.4 yr, p < 0.0001), and oldest at transplant (42.8 vs. 38.5, p < 0.0001) had fewer years of insulin use (19.19 vs. 22.57 yr, p = 0.012), and were heavier pre transplant (BMI: 26.09 vs. 23.1, p < 0.0001), and heavier post transplant (29.8 vs. 24.7, p < 0.0001). Those with detectable c-peptide levels (x > 0.8 ng/mL) had better graft survival than those with an undetectable c-peptide level (x < 0.8 ng/mL), p = 0.064; while those with undetectable levels, had better patient survival than those with detectable c-peptide levels (p = 0.019). CONCLUSION Despite the differences between groups by BMI, age of onset of insulin use, and age at transplant, there was a difference in patient but not graft survival within the 20 yr follow-up period.
Collapse
Affiliation(s)
- Jimmy Light
- Division of Transplantation, Washington Hospital Center, Washington, DC 20010, USA
| | | |
Collapse
|
17
|
Vantyghem MC, Raverdy V, Balavoine AS, Defrance F, Caiazzo R, Arnalsteen L, Gmyr V, Hazzan M, Noël C, Kerr-Conte J, Pattou F. Continuous glucose monitoring after islet transplantation in type 1 diabetes: an excellent graft function (β-score greater than 7) Is required to abrogate hyperglycemia, whereas a minimal function is necessary to suppress severe hypoglycemia (β-score greater than 3). J Clin Endocrinol Metab 2012; 97:E2078-83. [PMID: 22996144 PMCID: PMC3485599 DOI: 10.1210/jc.2012-2115] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
CONTEXT For the last 10 yr, continuous glucose monitoring (CGM) has brought up new insights into the accuracy of blood glucose analysis. OBJECTIVE Our objective was to determine how islet graft function was able to influence the various components of dysglycemia after islet transplantation (IT). DESIGN AND SETTING We conducted a single-arm open-labeled study with a 3-yr follow-up in a referral center (ClinicalTrial.gov identifiers NCT00446264 and NCT01123187). PATIENTS Twenty-three consecutive patients with type 1 diabetes (14 islet alone, nine islet after kidney) received IT within 3 months using the Edmonton protocol. INTERVENTION INTERVENTION included 72-h CGM before and 3, 6, 9, 12, 24, and 36 months after transplantation. MAIN OUTCOME MEASURE Graft function was estimated via β-score, a previously validated index (range 0-8) based on treatment requirements, C-peptide, blood glucose, and glycated hemoglobin. RESULTS At the 3-yr visit, graft function persisted in 19 patients (82%), and 10 (43%) remained insulin independent. Glycated hemoglobin decreased in the whole cohort from 8.3% (7.3-9.0%) at baseline to 6.7% (5.9-7.7%) at 3 yr [median (interquartile range), P < 0.01]. Mean glucose, glucose sd, and time spent with glycemia above 10 mmol/liter (hyperglycemia) and below 3 mmol/liter (hypoglycemia) were significantly lower after IT (P < 0.05 vs. baseline). The four CGM outcomes were related to β-score (P < 0.001). However, partial function (β-score >3) was sufficient to abrogate hypoglycemia; suboptimal function (β-score >5) was necessary to significantly improve mean glucose, glucose sd, and hyperglycemia; and optimal function (β score >7) was necessary to normalize them. CONCLUSION The four components of dysglycemia were not equally affected by the degree of islet graft function, which could have important implications for future development of β-cell replacement. A β-score above 3 dramatically reduced the occurrence of hypoglycemia.
Collapse
Affiliation(s)
- Marie-Christine Vantyghem
- Endocrinologie et Métabolisme, hôpital Huriez, Institut National de la Santé et de la Recherche Médicale Unité 859, Centre Hospitalier et Universitaire de Lille, 1 rue Polonovski, F-59045 Lille, France.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Boggi U, Vistoli F, Egidi FM, Marchetti P, De Lio N, Perrone V, Caniglia F, Signori S, Barsotti M, Bernini M, Occhipinti M, Focosi D, Amorese G. Transplantation of the pancreas. Curr Diab Rep 2012; 12:568-79. [PMID: 22828824 DOI: 10.1007/s11892-012-0293-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.
Collapse
Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Meyer G, Hackemann A, Reusch J, Badenhoop K. Nocturnal hypoglycemia identified by a continuous glucose monitoring system in patients with primary adrenal insufficiency (Addison's Disease). Diabetes Technol Ther 2012; 14:386-8. [PMID: 22242902 PMCID: PMC3338953 DOI: 10.1089/dia.2011.0158] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Hypoglycemia can be a symptom in patients with Addison's disease. The common regimen of replacement therapy with oral glucocorticoids results in unphysiological low cortisol levels in the early morning, the time of highest insulin sensitivity. Therefore patients with Addison's disease are at risk for unrecognized and potentially severe nocturnal hypoglycemia also because of a disturbed counterregulatory function. Use of a continuous glucose monitoring system (CGMS) could help to adjust hydrocortisone treatment and to avoid nocturnal hypoglycemia in these patients. METHODS Thirteen patients with Addison's disease were screened for hypoglycemia wearing a CGMS for 3-5 days. RESULTS In one patient we identified a hypoglycemic episode at 3:45 a.m. with a blood glucose level of 46 mg/dL, clearly beneath the 95% tolerance interval of minimal glucose levels between 2 and 4 a.m. (53.84 mg/dL). After the hydrocortisone replacement scheme was changed, the minimum blood glucose level between 2 and 4 a.m. normalized to 87 mg/dL. CONCLUSIONS Continuous glucose monitoring can detect nocturnal hypoglycemia in patients with primary adrenal insufficiency and hence prevent in these patients an impaired quality of life and even serious adverse effects.
Collapse
Affiliation(s)
- Gesine Meyer
- Department of Endocrinology and Diabetes, University Hospital, Frankfurt, Germany.
| | | | | | | |
Collapse
|
20
|
Abstract
This article presents strategies on how to meet the challenges presented by the use of insulin in the hospital setting and describes trends seen in current hospital practice. Insulin provides the greatest flexibility in the hospital setting to achieve optimal blood glycemic control in patients with known type 2 diabetes, thereby reducing complications and death. Important challenges include implementing protocols for use of subcutaneous insulin injection (including optimal use of insulin pens), conversion from continuous subcutaneous insulin infusion or intravenous infusion to subcutaneous administration by multiple injections, and dosing of insulin in patients receiving corticosteroids. One important trend is a move away from the use of sliding-scale insulin to the use of correction-dose insulin as an adjunct to basal/bolus insulin. In this approach, insulin treatment is closely tailored to changing levels of glycemia, and a protocol is put in place for administration of a correction dose of rapid-acting insulin in response to a glycemic excursion. Insulin analogs can more closely mimic physiological insulin profiles than regular insulin, and rapid-acting analogs are invaluable agents as correction insulin administered by pump or in transition to multiple daily injections and as part of basal/bolus therapy. Good glycemic control can improve outcomes of hospital patients in several ways, including facilitating more rapid recovery from infections, shortening intensive care stays, and minimizing costs. Strategies employed to meet the challenges of insulin use in the hospital setting include the increasing use of continuous glucose monitoring systems and the development of insulin dosing algorithms.
Collapse
Affiliation(s)
- R. Keith Campbell
- College of Pharmacy, Washington State University, P.O. Box 6510, Pullman, WA 99164-6510
| |
Collapse
|