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Oosterom-Eijmael MJP, Hermanides J, van Raalte DH, Kouw IWK, DeVries JH, Hulst AH. Continuous Glucose Monitoring and the Effect of Liraglutide in Cardiac Surgery Patients: A Substudy of the Randomized Controlled GLOBE Trial. J Cardiothorac Vasc Anesth 2024; 38:1965-1971. [PMID: 38977382 DOI: 10.1053/j.jvca.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/23/2024] [Accepted: 06/11/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVES The objectives of the current research were to evaluate the accuracy and reliability of continuous glucose monitoring (CGM) in patients undergoing cardiac surgery and assess the impact of preoperative liraglutide administration on perioperative glucose control as captured by CGM. DESIGN This was a prospective, single-center, prespecified analysis of the GLOBE trial, a randomized controlled trial comparing preoperative liraglutide treatment to placebo in patients undergoing cardiac surgery. SETTING The work took place at a single-center academic hospital in the Netherlands. PARTICIPANTS Twenty-five patients undergoing cardiac surgery were recruited from the hospital's cardiac surgery department. INTERVENTIONS Participants received the Dexcom G5 CGM system from the day before surgery until discharge from the intensive care unit after surgery. Additionally, participants were randomized to receive either preoperative liraglutide or placebo. MEASUREMENTS AND MAIN RESULTS Arterial blood gas (ABG) glucose measurements were collected as a reference and matched to CGM readings to assess accuracy and reliability. In 240 paired CGM-ABG glucose measurements, the mean absolute relative difference was 14.4 ± 12.5%. Temporary sensor interruption occurred mainly intraoperatively (92% of patients). The median duration of intraoperative sensor interruption was 65 (48-95) minutes. Liraglutide increased glycemic time in range 72% versus 47% in the control group (absolute difference 25%, 95% confidence interval -41.4 to -8.9, p = .004). CONCLUSIONS Despite intraoperative sensor interruption, CGM seems an accurate method for semi-invasive, real-time assessment of blood glucose levels. CGM can provide a detailed observation of the pre- and postoperative glycemic trajectory, demonstrating increased time in range following perioperative liraglutide treatment compared with placebo.
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Affiliation(s)
- Maartina J P Oosterom-Eijmael
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Endocrinology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands.
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Daniël H van Raalte
- Department of Endocrinology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Imre W K Kouw
- Department of Intensive Care Medicine, Intensive Care Research, Gelderse Vallei Hospital, Ede, The Netherlands; Wageningen University & Research, Division of Human Nutrition and Health, Wageningen, The Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Abraham H Hulst
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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Pasquel FJ, Urrutia MA, Cardona S, Coronado KWZ, Albury B, Perez-Guzman MC, Galindo RJ, Chaudhuri A, Iacobellis G, Palacios J, Farias JM, Gomez P, Anzola I, Vellanki P, Fayfman M, Davis GM, Migdal AL, Peng L, Umpierrez GE. Liraglutide hospital discharge trial: A randomized controlled trial comparing the safety and efficacy of liraglutide versus insulin glargine for the management of patients with type 2 diabetes after hospital discharge. Diabetes Obes Metab 2021; 23:1351-1360. [PMID: 33591621 PMCID: PMC8571803 DOI: 10.1111/dom.14347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 11/29/2022]
Abstract
AIM To compare a glucagon-like peptide-1 receptor agonist with basal insulin at hospital discharge in patients with uncontrolled type 2 diabetes in a randomized clinical trial. METHODS A total of 273 patients with glycated haemoglobin (HbA1c) 7%-10% (53-86 mol/mol) were randomized to liraglutide (n = 136) or insulin glargine (n = 137) at hospital discharge. The primary endpoint was difference in HbA1c at 12 and 26 weeks. Secondary endpoints included hypoglycaemia, changes in body weight, and achievement of HbA1c <7% (53 mmol/mol) without hypoglycaemia or weight gain. RESULTS The between-group difference in HbA1c at 12 weeks and 26 weeks was -0.28% (95% CI -0.64, 0.09), and at 26 weeks it was -0.55%, (95% CI -1.01, -0.09) in favour of liraglutide. Liraglutide treatment resulted in a lower frequency of hypoglycaemia <3.9 mmol/L (13% vs 23%; P = 0.04), but there was no difference in the rate of clinically significant hypoglycaemia <3.0 mmol/L. Compared to insulin glargine, liraglutide treatment was associated with greater weight loss at 26 weeks (-4.7 ± 7.7 kg vs -0.6 ± 11.5 kg; P < 0.001), and the proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia was 48% versus 33% (P = 0.05) at 12 weeks and 45% versus 33% (P = 0.14) at 26 weeks in liraglutide versus insulin glargine. The proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia and no weight gain was higher with liraglutide at 12 (41% vs 24%, P = 0.005) and 26 weeks (39% vs 22%; P = 0.014). The incidence of gastrointestinal adverse events was higher with liraglutide than with insulin glargine (P < 0.001). CONCLUSION Compared to insulin glargine, treatment with liraglutide at hospital discharge resulted in better glycaemic control and greater weight loss, but increased gastrointestinal adverse events.
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Affiliation(s)
- Francisco J. Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maria A. Urrutia
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Saumeth Cardona
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Karla W. Z. Coronado
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bonnie Albury
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mireya C. Perez-Guzman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ajay Chaudhuri
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Gianluca Iacobellis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami, Miami, Florida
| | - Juan Palacios
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami, Miami, Florida
| | - Javier M. Farias
- Division of Endocrinology Sanatorio Guemes, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Patricia Gomez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Isabel Anzola
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maya Fayfman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Georgia M. Davis
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alexandra L. Migdal
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Limin Peng
- Deartment of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Davis GM, DeCarlo K, Wallia A, Umpierrez GE, Pasquel FJ. Management of Inpatient Hyperglycemia and Diabetes in Older Adults. Clin Geriatr Med 2020; 36:491-511. [PMID: 32586477 PMCID: PMC10695675 DOI: 10.1016/j.cger.2020.04.008] [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] [Indexed: 10/24/2022]
Abstract
Diabetes is one of the world's fastest growing health challenges. Insulin therapy remains a useful regimen for many elderly patients, such as those with moderate to severe hyperglycemia, type 1 diabetes, hyperglycemic emergencies, and those who fail to maintain glucose control on non-insulin agents alone. Recent clinical trials have shown that several non-insulin agents as monotherapy, or in combination with low doses of basal insulin, have comparable efficacy and potential safety advantages to complex insulin therapy regimens. Determining the most appropriate diabetes management plan for older hospitalized patients requires consideration of many factors to prevent poor outcomes related to dysglycemia.
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Affiliation(s)
- Georgia M Davis
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Kristen DeCarlo
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave, Chicago, IL 60611, USA
| | - Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Ave, Chicago, IL 60611, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA
| | - Francisco J Pasquel
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Drive Southeast, Atlanta, GA 30303, USA.
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Abstract
Hypoglycemia in inpatients with diabetes remains the most common complication of diabetes therapies. Hypoglycemia is independently associated with increased morbidity and mortality, increased length of stay, increased readmission rate, and increased cost. This review describes the importance of reporting and addressing inpatient hypoglycemia; it further summarizes eight strategies that aid clinicians in the prevention of inpatient hypoglycemia: auditing the electronic medical record, formulary restrictions and dose-limiting strategies, hyperkalemia order sets, electronic glucose management systems, prediction tools, diabetes self-management, remote surveillance, and noninsulin medications.
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Affiliation(s)
- Paulina Cruz
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, MO, USA
- Paulina Cruz, MD, Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, Campus Box 8127, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA.
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Hulst AH, Visscher MJ, Godfried MB, Thiel B, Gerritse BM, Scohy TV, Bouwman RA, Willemsen MGA, Hollmann MW, Preckel B, DeVries JH, Hermanides J. Liraglutide for perioperative management of hyperglycaemia in cardiac surgery patients: a multicentre randomized superiority trial. Diabetes Obes Metab 2020; 22:557-565. [PMID: 31749275 PMCID: PMC7079116 DOI: 10.1111/dom.13927] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/07/2019] [Accepted: 11/19/2019] [Indexed: 12/13/2022]
Abstract
AIMS Most cardiac surgery patients, with or without diabetes, develop perioperative hyperglycaemia, for which intravenous insulin is the only therapeutic option. This is labour-intensive and carries a risk of hypoglycaemia. We hypothesized that preoperative administration of the glucagon-like peptide-1 receptor agonist liraglutide reduces the number of patients requiring insulin for glycaemic control during cardiac surgery. MATERIALS AND METHODS In this randomized, blinded, placebo-controlled, parallel-group, balanced (1:1), multicentre randomized, superiority trial, adult patients undergoing cardiac surgery in four Dutch tertiary hospitals were randomized to receive 0.6 mg subcutaneous liraglutide on the evening before surgery and 1.2 mg after induction of anaesthesia or matching placebo. Blood glucose was measured hourly and controlled using an insulin-bolus algorithm. The primary outcome was insulin administration for blood glucose >8.0 mmol/L in the operating theatre. Research pharmacists used centralized, stratified, variable-block, randomization software. Patients, care providers and study personnel were blinded to treatment allocation. RESULTS Between June 2017 and August 2018, 278 patients were randomized to liraglutide (139) or placebo (139). All patients receiving at least one study drug injection were included in the intention-to-treat analyses (129 in the liraglutide group, 132 in the placebo group). In the liraglutide group, 55 (43%) patients required additional insulin compared with 80 (61%) in the placebo group and absolute difference 18% (95% confidence interval 5.9-30.0, P = 0.003). Dose and number of insulin injections and mean blood glucose were all significantly lower in the liraglutide group. We observed no difference in the incidence of hypoglycaemia, nausea and vomiting, mortality or postoperative complications. CONCLUSIONS Preoperative liraglutide, compared with placebo, reduces insulin requirements while improving perioperative glycaemic control during cardiac surgery.
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Affiliation(s)
- Abraham H. Hulst
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
- Department of AnesthesiologyOLVGAmsterdamThe Netherlands
- Department of AnesthesiologyAmphia HospitalBredaThe Netherlands
| | - Maarten J. Visscher
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | | | - Bram Thiel
- Department of AnesthesiologyOLVGAmsterdamThe Netherlands
| | | | | | - R. Arthur Bouwman
- Department of AnesthesiologyCatharina HospitalsEindhovenThe Netherlands
| | | | - Markus W. Hollmann
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Benedikt Preckel
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - J. Hans DeVries
- Department of EndocrinologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
| | - Jeroen Hermanides
- Department of AnesthesiologyAmsterdam UMC, University of AmsterdamAmsterdamThe Netherlands
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Hulst AH, Visscher MJ, Cherpanath TGV, van de Wouw L, Godfried MB, Thiel B, Gerritse BM, Scohy TV, Bouwman RA, Willemsen MGA, Hollmann MW, DeVries JH, Preckel B, Hermanides J. Effects of Liraglutide on Myocardial Function After Cardiac Surgery: A Secondary Analysis of the Randomised Controlled GLOBE Trial. J Clin Med 2020; 9:E673. [PMID: 32131527 PMCID: PMC7141279 DOI: 10.3390/jcm9030673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Previous studies demonstrated the cardioprotective properties of glucagon-like peptide-1 receptor agonists in patients with diabetes or cardiac disease. We investigated whether preoperative subcutaneous liraglutide improves myocardial function after cardiac surgery. METHODS We performed a pre-planned secondary analysis of adult patients undergoing cardiac surgery included in the GLOBE trial. Patients were randomised to receive 0.6 mg subcutaneous liraglutide on the evening before surgery and 1.2 mg after induction of anaesthesia, or matching placebo. Perioperative echocardiographic assessments, haemodynamic parameters, doses of vasoactive inotropic support and postoperative measurements of troponin, Creatine Kinase-MB , creatinine and lactate were compared between groups. RESULTS The study population consisted of the entire intention-to-treat cohort of the GLOBE trial. In this study, 129 patients received liraglutide and 132 patients placebo. Baseline characteristics were comparable between groups. Postoperatively, 170 (65%) patients underwent echocardiography. In the liraglutide group, more patients had a normal left ventricular systolic function (68%, 59 patients) compared to placebo (53%, 44 patients), difference = 15%, 95%CI = 0-30, p = 0.049. Assessment of the right ventricle revealed no difference in function. CONCLUSIONS Patients receiving short-term preoperative liraglutide treatment better maintained normal myocardial function after cardiac surgery. This study warrants further evaluation of the potential beneficial effects of GLP-1 receptor agonists in cardiac surgery patients.
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Affiliation(s)
- Abraham H. Hulst
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (M.J.V.); (L.v.d.W.); (M.W.H.); (J.H.)
- Department of Anesthesiology, OLVG, Oosterpark 9, 1091 AC Amsterdam, The Netherlands; (M.B.G.); (B.T.)
- Department of Anesthesiology, Amphia, Molengracht 21, 4818 CK Breda, The Netherlands; (B.M.G.); (T.V.S.)
| | - Maarten J. Visscher
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (M.J.V.); (L.v.d.W.); (M.W.H.); (J.H.)
| | - Thomas G. V. Cherpanath
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands;
| | - Lieke van de Wouw
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (M.J.V.); (L.v.d.W.); (M.W.H.); (J.H.)
| | - Marc B. Godfried
- Department of Anesthesiology, OLVG, Oosterpark 9, 1091 AC Amsterdam, The Netherlands; (M.B.G.); (B.T.)
| | - Bram Thiel
- Department of Anesthesiology, OLVG, Oosterpark 9, 1091 AC Amsterdam, The Netherlands; (M.B.G.); (B.T.)
| | - Bastiaan M. Gerritse
- Department of Anesthesiology, Amphia, Molengracht 21, 4818 CK Breda, The Netherlands; (B.M.G.); (T.V.S.)
| | - Thierry V. Scohy
- Department of Anesthesiology, Amphia, Molengracht 21, 4818 CK Breda, The Netherlands; (B.M.G.); (T.V.S.)
| | - R. Arthur Bouwman
- Department of Anesthesiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands; (R.A.B.); (M.G.A.W.)
| | - Mark G. A. Willemsen
- Department of Anesthesiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands; (R.A.B.); (M.G.A.W.)
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (M.J.V.); (L.v.d.W.); (M.W.H.); (J.H.)
| | - J. Hans DeVries
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands;
| | - Benedikt Preckel
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (M.J.V.); (L.v.d.W.); (M.W.H.); (J.H.)
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands; (A.H.H.); (M.J.V.); (L.v.d.W.); (M.W.H.); (J.H.)
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Mustafa OG, Whyte MB. The use of GLP-1 receptor agonists in hospitalised patients: An untapped potential. Diabetes Metab Res Rev 2019; 35:e3191. [PMID: 31141838 PMCID: PMC6899667 DOI: 10.1002/dmrr.3191] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 12/15/2022]
Abstract
In the outpatient setting, glucagon-like peptide-1 (GLP-1) receptor agonists have proved to be highly efficacious drugs that provide glycaemic control with a low risk of hypoglycaemia. These characteristics make GLP-1 receptor agonists attractive agents to treat dysglycaemia in perioperative or high-dependency hospital settings, where glycaemic variability and hyperglycaemia are associated with poor prognosis. GLP-1 also has a direct action on the myocardium and vasculature-which may be advantageous in the immediate aftermath of a vascular insult. This is a narrative review of the work in this area. The aim was to determine the populations of hospitalised patients being evaluated and the clinical and mechanistic end-points tested, with the institution of GLP-1 therapy in hospital. We searched the PubMed, Embase, and Google scholar databases, combining the term "glucagon-like peptide 1" OR "GLP-1" OR "incretin" OR "liraglutide" OR "exenatide" OR "lixisenatide" OR "dulaglutide" OR "albiglutide" AND "inpatient" OR "hospital" OR "perioperative" OR "postoperative" OR "surgery" OR "myocardial infarction" OR "stroke" OR "cerebrovascular disease" OR "transient ischaemic attack" OR "ICU" OR "critical care" OR "critical illness" OR "CCU" OR "coronary care unit." Pilot studies were reported in the fields of acute stroke, cardiac resuscitation, coronary care, and perioperative care that showed advantages for GLP-1 therapy, with normalisation of glucose, lower glucose variability, and lower risk of hypoglycaemia. Animal and human studies have reported improvements in myocardial performance when given acutely after vascular insult or surgery, but these have yet to be translated into randomised clinical trials.
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Affiliation(s)
- Omar G. Mustafa
- Department of DiabetesKing's College Hospital NHS Foundation TrustLondonUK
| | - Martin B. Whyte
- Department of DiabetesKing's College Hospital NHS Foundation TrustLondonUK
- Department of Clinical and Experimental MedicineUniversity of SurreyGuildfordUK
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Pasquel FJ, Fayfman M, Umpierrez GE. Debate on Insulin vs Non-insulin Use in the Hospital Setting-Is It Time to Revise the Guidelines for the Management of Inpatient Diabetes? Curr Diab Rep 2019; 19:65. [PMID: 31353426 DOI: 10.1007/s11892-019-1184-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Hyperglycemia contributes to a significant increase in morbidity, mortality, and healthcare costs in the hospital. Professional associations recommend insulin as the mainstay of diabetes therapy in the inpatient setting. The standard of care basal-bolus insulin regimen is a labor-intensive approach associated with a significant risk of iatrogenic hypoglycemia. This review summarizes recent evidence from observational studies and clinical trials suggesting that not all patients require treatment with complex insulin regimens. RECENT FINDINGS Evidence from clinical trials shows that incretin-based agents are effective in appropriately selected hospitalized patients and may be a safe alternative to complicated insulin regimens. Observational studies also show that older agents (i.e., metformin and sulfonylureas) are commonly used in the hospital, but there are few carefully designed studies addressing their efficacy. Therapy with dipeptidyl peptidase-4 (DPP-4) inhibitors, alone or in combination with basal insulin, may effectively control glucose levels in patients with mild to moderate hyperglycemia. Further studies with glucagon-like peptide-1 (GLP-1) receptor analogs and older oral agents are needed to confirm their safety in the hospital.
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Affiliation(s)
- Francisco J Pasquel
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Maya Fayfman
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Guillermo E Umpierrez
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA.
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Hulst AH, Plummer MP, Hollmann MW, DeVries JH, Preckel B, Deane AM, Hermanides J. Systematic review of incretin therapy during peri-operative and intensive care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:299. [PMID: 30428906 PMCID: PMC6236901 DOI: 10.1186/s13054-018-2197-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/24/2018] [Indexed: 01/10/2023]
Abstract
Background Glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) are incretin hormones. By lowering blood glucose in a glucose-dependent manner, incretin-based therapies represent a novel and promising intervention to treat hyperglycaemia in hospital settings. We performed a systematic review of the literature for all current applications of incretin-based therapies in the peri-operative and critical care settings. Methods We searched MEDLINE, the Cochrane Library, and Embase databases for all randomised controlled trials using exogenous GLP-1, GLP-1 receptor agonists, exogenous GIP and dipeptidyl peptidase IV inhibitors in the setting of adult peri-operative care or intensive care. We defined no comparator treatment. Outcomes of interest included blood glucose, frequency of hypoglycaemia and insulin administration. Results Of the 1190 articles identified during the initial literature search, 38 fulfilled criteria for full-text review, and 19 single-centre studies were subsequently included in the qualitative review. Of the 18 studies reporting glycaemic control, improvement was reported in 15, defined as lower glucose concentrations in 12 and as reduced insulin administration (with similar glucose concentrations) in 3. Owing to heterogeneity, meta-analysis was possible only for the outcome of hypoglycaemia. This revealed an incidence of 7.4% in those receiving incretin-based therapies and 6.8% in comparator groups (P = 0.94). Conclusions In small, single-centre studies, incretin-based therapies lowered blood glucose and reduced insulin administration without increasing the incidence of hypoglycaemia. Trial registration PROSPERO, CRD42017071926. Electronic supplementary material The online version of this article (10.1186/s13054-018-2197-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Abraham H Hulst
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands
| | - Mark P Plummer
- Intensive Care Unit, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands.
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ, Amsterdam, the Netherlands
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