Update on Glucose Management Among Noncritically Ill Patients Hospitalized on Medical and Surgical Wards

Treatment of glucocorticoid- induced hyperglycemia in hospitalized patients - a systematic review and meta- analysis

PURPOSE

Glucocorticoid (GC)-induced hyperglycemia is a frequent issue, however there are no specific guidelines for this diabetes subtype. Although treat-to-target insulin is recommended in general to correct hyperglycemia, it remains unclear which treatment strategy has a positive effect on outcomes. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess whether treating GC-induced hyperglycemia improves clinical outcomes.

METHODS

MEDLINE and EMBASE were systematically searched for RCTs on adults reporting treatment and outcomes of GC-induced hyperglycemia since the beginning of the data bases until October 21, 2023. Glucose-lowering strategies as compared to usual care were investigated.

RESULTS

We found 17 RCTs with 808 patients and included seven trials in the quantitative analysis. Patients with an intensive glucose-lowering strategy had lower standardized mean glucose levels of - 0.29 mmol/l (95%CI -0.64 to -0.05) compared to usual care group patients. There was no increase in hypoglycemic events in the intensively treated groups (RR 0.91, 95%CI 0.70-1.17). Overall, we did not have enough trials reporting clinical outcomes for a quantitative analysis with only one trial reporting mortality.

CONCLUSION

In GC-induced hyperglycemia, tight glucose control has a moderate effect on mean glucose levels with no apparent harmful effect regarding hypoglycemia. There is insufficient data whether insulin treatment improves clinical outcomes, and data on non-insulin based treatment regimens are currently too sparse to draw any conclusions.

SYSTEMATIC REVIEW REGISTRATION

Registered as CRD42020147409 at PROSPERO ( https://www.crd.york.ac.uk/prospero/ ) on April 28, 2020.

Early Post-Renal Transplant Hyperglycemia

CONTEXT

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

OBJECTIVE

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

METHODS

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

CONCLUSION

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

Adiponectin levels decrease independently of body mass index and diabetes type after the normalization of hyperglycemia

Background/aim

Acute hyperglycemia is generally a frequently encountered condition in the emergency department (ED), because it is seen as a complication of diabetes mellitus (DM). In this study, we aimed to detect the change in adiponectin levels during acute hyperglycemic states and after normalization of blood glucose with insulin treatment.

Materials and methods

Forty-eight patients over the age of 18 years who were admitted to the ED with acute hyperglycemia were included in the study. Serum samples were taken from patients on admission and 6 h after the normalization of blood glucose with insulin treatment, and adiponectin levels were measured in both samples.

Results

There were 21 female and 27 male patients with a median age of 58.7 ± 18 years. All patients’ blood glucose levels were normalized with insulin treatment according to international recommendations. Serum adiponectin levels decreased significantly after the normalization of blood glucose in the whole group. Adiponectin levels decreased from 28.9 ± 16.5 to 12.1 ± 10.9 μg/mL (P < 0.0001) in the whole group. This decrease was independent of diabetes type and body mass index. 

Conclusion

Normalization of blood glucose in patients with hyperglycemia caused a decrease in adiponectin levels, independent of diabetes type and/or body weight in an acute emergency setting. Inhibited upregulation of adiponectin secretion and/or blunted suppressive effect of insulin due to hyperglycemia or exogenous insulin administration may have caused the decrease in adiponectin levels.

Linagliptin plus insulin for hyperglycemia immediately after renal transplantation: A comparative study

AIMS

Post-renal-transplanted patients frequently present hyperglycemia immediately after the procedure. The goal of this work was to evaluate the effect of linagliptin + insulin in post-renal-transplanted patients with hyperglycemia.

METHODS

Retrospective comparative study in post-renal transplanted patients with hyperglycemia after transplantation who were treated with linagliptin 5 mg daily plus insulin vs insulin alone for 5 days after renal transplantation with hyperglycemia. Main outcomes were glucose levels, insulin dose and severity of hypoglycemia.

RESULTS

There were 14 patients treated with linagliptin + insulin and 14 patients treated only with insulin. Glucose levels and insulin doses were lower in the linagliptin + insulin group in comparison with the insulin alone group, 131.0 ± 15.1 vs 191.1 ± 22.5 mg/dl (7.27 ± 0.84 vs 10.61 ± 1.25 mmol/l) and 37.5 ± 6.3 vs 24.2 ± 6.6 U, respectively (p < 0.05). Hypoglycemia was less severe in the linagliptin + insulin group, 65.1 ± 2.2 vs 54.2 ± 3.3 mg/dl (3.61 ± 0.12 vs 3.00 ± 3.3 ± 0.18 mmol/l), p 0.036.

CONCLUSIONS

The combination of linagliptin + insulin provided better glycemic control with a lower insulin dose and less severe hypoglycemia in comparison to insulin alone in patients with hyperglycemia immediately after renal transplantation.