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Umpierrez G, Pasquel FJ, Duggan E, Galindo RJ. Should We Stop Glucagon-Like Peptide-1 Receptor Agonists Before Surgical or Endoscopic Procedures? Balancing Limited Evidence With Clinical Judgment. J Diabetes Sci Technol 2024:19322968241231565. [PMID: 38465586 DOI: 10.1177/19322968241231565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The American Society of Anesthesiologists (ASA) Task Force recently recommended discontinuing glucagon-like peptide-1 receptor agonist (GLP-1 RA) agents before surgery because of the potential risk of pulmonary aspiration. However, there is limited scientific evidence to support this recommendation, and holding GLP-1 RA treatment may worsen glycemic control in patients with diabetes. As we await further safety data to manage GLP-1 RA in the perioperative period, we suggest an alternative multidisciplinary approach to manage patients undergoing elective surgery. Well-conducted observational and prospective studies are needed to determine the risk of pulmonary aspiration in persons receiving GLP-1 RA for the treatment of diabetes and obesity, as well as the short-term impact of discontinuing GLP-1 RA on glycemic control before elective procedures in persons with diabetes.
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Affiliation(s)
- Guillermo Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Elizabeth Duggan
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, University of Miami, Miami, FL, USA
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Bussiere C, Chauvin P, Josselin JM, Sevilla-Dedieu C. Assessing real-world effectiveness of therapies: what is the impact of incretin-based treatments on hospital use for patients with type 2 diabetes? HEALTH ECONOMICS REVIEW 2022; 12:53. [PMID: 36272025 PMCID: PMC9587565 DOI: 10.1186/s13561-022-00397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Managing type 2 diabetes represents a major public health concern due to its important and increasing prevalence. Our study investigates the impact of taking incretin-based medication on the risk of being hospitalized and the length of hospital stay for individuals with type 2 diabetes. METHOD We use claim panel data from 2011 to 2015 and provide difference-in-differences (DID) estimations combined with matching techniques to better ensure the treatment and control groups' comparability. Our propensity score selects individuals according to their probability of taking an incretin-based treatment in 2013 (N = 2,116). The treatment group includes individuals benefiting from incretin-based treatments from 2013 to 2015 and is compared to individuals not benefiting from such a treatment but having a similar probability of taking it. RESULTS After controlling for health-related and socio-economic variables, we show that benefiting from an incretin-based treatment does not significantly impact the probability of being hospitalized but does significantly decrease the annual number of days spent in the hospital by a factor rate of 0.621 compared with the length of hospital stays for patients not benefiting from such a treatment. CONCLUSION These findings highlight the potential implications for our health care system in case of widespread use of these drugs among patients with severe diabetes.
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Affiliation(s)
- Clémence Bussiere
- ERUDITE (CNRS-EA437), University of Paris Est Créteil, Paris, France
- MGEN Foundation for Public Health, Paris, France
| | - Pauline Chauvin
- LIRAES (URP4470), Université Paris Cité, F-75006, Paris, France.
- Centre des Saints-Pères, 45 rue des Saints-Pères, 75006, Paris, France.
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Pasquel FJ, Lansang MC, Dhatariya K, Umpierrez GE. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol 2021; 9:174-188. [PMID: 33515493 PMCID: PMC10423081 DOI: 10.1016/s2213-8587(20)30381-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/25/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
Hyperglycaemia in people with and without diabetes admitted to the hospital is associated with a substantial increase in morbidity, mortality, and health-care costs. Professional societies have recommended insulin therapy as the cornerstone of inpatient pharmacological management. Intravenous insulin therapy is the treatment of choice in the critical care setting. In non-intensive care settings, several insulin protocols have been proposed to manage patients with hyperglycaemia; however, meta-analyses comparing different treatment regimens have not clearly endorsed the benefits of any particular strategy. Clinical guidelines recommend stopping oral antidiabetes drugs during hospitalisation; however, in some countries continuation of oral antidiabetes drugs is commonplace in some patients with type 2 diabetes admitted to hospital, and findings from clinical trials have suggested that non-insulin drugs, alone or in combination with basal insulin, can be used to achieve appropriate glycaemic control in selected populations. Advances in diabetes technology are revolutionising day-to-day diabetes care and work is ongoing to implement these technologies (ie, continuous glucose monitoring, automated insulin delivery) for inpatient care. Additionally, transformations in care have occurred during the COVID-19 pandemic, including the use of remote inpatient diabetes management-research is needed to assess the effects of such adaptations.
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Affiliation(s)
- Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - M Cecilia Lansang
- Department of Endocrinology, Diabetes and Metabolism, Cleveland Clinic, Cleveland, OH, USA
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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4
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Koufakis T, Mustafa OG, Zebekakis P, Kotsa K. Oral antidiabetes agents for the management of inpatient hyperglycaemia: so far, yet so close. Diabet Med 2020; 37:1418-1426. [PMID: 32445407 DOI: 10.1111/dme.14329] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hyperglycaemia is an ongoing challenge in hospital settings and is associated with poor outcomes. Current recommendations for the management of inpatient hyperglycaemia suggest insulin as the main glucose-lowering treatment choice and limit the administration of oral antidiabetes agents to a small proportion of cases because of safety concerns. AIM To present and critically appraise the available evidence on the use of oral antidiabetes agents in the hospital setting and the risk-benefit balance of such an approach in the era of cardiovascular outcomes trials. METHODS PubMed, Embase and Google Scholar databases were searched to identify relevant published work. Available evidence on the efficacy and the safety profile of oral agents in the context of their use in hospitalized individuals are summarized and discussed in this narrative review. RESULTS There is no robust evidence to suggest the use of metformin, thiazolidinediones, sulfonylureas and sodium-glucose co-transporter-2 inhibitors in the hospital setting, although some of their effects on acute outcomes deserve further evaluation in future studies. However, the use of dipeptidyl peptidase-4 inhibitors in inpatients with type 2 diabetes is supported by a few, well-designed, randomized controlled trials. These trials have demonstrated good safety and tolerability profiles, comparable to insulin glucose-lowering efficacy, and a reduction in insulin dose when dipeptidyl peptidase-4 inhibitors are co-administered with insulin, in individuals with mild to moderate hyperglycaemia and a stable clinical condition. CONCLUSION The administration of dipeptidyl peptidase-4 inhibitors to specific groups of inpatients might be a safe and effective alternative to insulin.
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Affiliation(s)
- T Koufakis
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - O G Mustafa
- Department of Diabetes, King's College Hospital, London, UK
| | - P Zebekakis
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - K Kotsa
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Clark L, Weeda E, Griffin ML, Jones LA, Haney J. Outcomes Associated With the Adjunctive Use of Dipeptidyl Peptidase-4 Inhibitors With Insulin Versus Other Antihyperglycemic Medications in Patients With Prediabetes or Diabetes After Cardiac Surgery. J Pharm Pract 2019; 34:259-264. [PMID: 31409190 DOI: 10.1177/0897190019867850] [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: 11/16/2022]
Abstract
BACKGROUND Dipeptidyl peptidase-4 inhibitors (DPP-4i) plus basal insulin is noninferior to insulin monotherapy for glycemic control in medical-surgical patients, but data in postoperative cardiac surgery patients are sparse. OBJECTIVE To compare glucose control in postoperative cardiac surgery patients with prediabetes or diabetes receiving a DPP-4i plus insulin versus other antihyperglycemic regimens. METHODS We retrospectively identified patients with prediabetes or diabetes who underwent cardiac surgery at our hospital between May 2016 and June 2017. Included patients were stratified into cohorts: (1) DPP-4i plus insulin and (2) other antihyperglycemic regimens. Blood glucose levels were collected on postoperative days 2 to 7. Uncontrolled glucose (≥2 measurements <80 or >180 mg/dL in 1 day), hyperglycemia (>2 measurements ≥180 mg/dL in 1 day), and hypoglycemia (any measurement <70 mg/dL) were compared between cohorts using logistic regression adjusted for home antihyperglycemics. RESULTS We included 135 cardiac surgery patients, of which 65 received DPP-4i plus insulin. Eighty-two patients received antihyperglycemics at home. Uncontrolled glucose occurred in 61 (45.2%) patients; while hyperglycemia and hypoglycemia occurred in 50 (37.0%) and 24 (17.8%) patients, respectively. There was no difference in the adjusted odds of uncontrolled glucose (odds ratio [OR] = 1.43; 95% confidence interval [CI] = 0.65-3.11), hyperglycemia (OR = 1.20; 95% CI = 0.52-2.78), or hypoglycemia (OR = 0.69; 95% CI = 0.27-1.75) for those receiving DPP-4i plus insulin versus other regimens. CONCLUSION Glucose control was no different among postoperative cardiac surgery patients receiving a DPP-4i plus insulin versus other regimens. DPP-4i use was not associated with hypoglycemia.
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Affiliation(s)
- Lisa Clark
- 15472South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Erin Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA. Clark is now with the Department of Pharmacy at Tampa General Hospital, Tampa, FL, USA. Griffin is now with the Department of Pharmacy at the University of Virginia Health System, Charlottesville, VA, USA. Jones is now with the Department of Pharmacy at the University of North Carolina Health Care, Chapel Hill, NC, USA
| | - Mary Lewis Griffin
- 15472South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Lee Ann Jones
- 15472South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Jason Haney
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA. Clark is now with the Department of Pharmacy at Tampa General Hospital, Tampa, FL, USA. Griffin is now with the Department of Pharmacy at the University of Virginia Health System, Charlottesville, VA, USA. Jones is now with the Department of Pharmacy at the University of North Carolina Health Care, Chapel Hill, NC, USA
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6
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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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7
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Brand DA, Peragallo-Dittko V, Fazzari MJ, Islam S, Jacobson AM, Radin MS. CHANGING TO BASAL-BOLUS INSULIN THERAPY FOR THE INPATIENT MANAGEMENT OF HYPERGLYCEMIA-A NATURAL EXPERIMENT. Endocr Pract 2019; 25:836-845. [PMID: 31070947 DOI: 10.4158/ep-2018-0498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective: Most acute-care hospitals have transitioned from sliding-scale to basal-bolus insulin therapy to manage hyperglycemia during hospitalization, but there is limited scientific evidence demonstrating better short-term clinical outcomes using the latter approach. The present study sought to determine if using basal-bolus insulin therapy favorably affects these outcomes in noncritical care settings and, if so, whether the magnitude of benefit differs in patients with known versus newly diagnosed type 2 diabetes. Methods: This natural experiment compared outcomes in 10,120 non-critically ill adults with type 2 diabetes admitted to an academic teaching hospital before and after hospital-wide implementation of a basal-bolus insulin therapy protocol. A group of 30,271 inpatients without diabetes (type 1 or 2) served as controls. Binomial models were used to compare percentages of patients with type 2 diabetes who were transferred to intensive care, experienced complications, or died in the hospital before and after implementation of the protocol, controlling for changes in the control group. The analysis also evaluated before-after changes in length of stay and glucometric indicators. Results: Implementation of basal-bolus therapy did not reduce intensive care use (the primary outcome), complications, mortality, or median length of stay, except in patients with newly diagnosed diabetes (n = 234), who experienced a statistically significant decline in the incidence of complications (P<.01). The absence of effect in previously diagnosed patients was observed in spite of a 32% decline (from 3.7% to 2.5%) in the proportion of inpatient days with hypoglycemia <70 mg/dL (P<.01) and a 16% decline (from 13.5% to 11.3%) in the proportion of days with hyperglycemia >300 mg/dL (P<.01). Conclusion: Despite achieving significant reductions in both hyperglycemia and hypoglycemia, use of basal-bolus insulin therapy to manage hyperglycemia in non-critically ill hospitalized patients did not improve short-term clinical outcomes, except in the small minority of patients with newly diagnosed diabetes. The optimal management of hyperglycemia for improving these outcomes has yet to be determined. Abbreviation: ICD-9 = International Classification of Diseases-Ninth Revision.
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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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Umpierrez GE, Cardona S, Chachkhiani D, Fayfman M, Saiyed S, Wang H, Vellanki P, Haw JS, Olson DE, Pasquel FJ, Johnson TM. A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial. J Am Med Dir Assoc 2018; 19:399-404.e3. [PMID: 29289540 PMCID: PMC6093296 DOI: 10.1016/j.jamda.2017.11.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities. DESIGN This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM. SETTINGS Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia. PARTICIPANTS A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%. INTERVENTION Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL. MEASUREMENTS Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers. RESULTS Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations. CONCLUSION Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.
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Affiliation(s)
| | | | | | - Maya Fayfman
- Department of Medicine, Emory University, Atlanta, GA
| | - Sahebi Saiyed
- Department of Medicine, Emory University, Atlanta, GA
| | - Heqiong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - J Sonya Haw
- Department of Medicine, Emory University, Atlanta, GA
| | - Darin E Olson
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Theodore M Johnson
- Department of Medicine, Emory University, Atlanta, GA; Birmingham/Atlanta VA GRECC
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Levitt DL, Spanakis EK, Ryan KA, Silver KD. Insulin Pump and Continuous Glucose Monitor Initiation in Hospitalized Patients with Type 2 Diabetes Mellitus. Diabetes Technol Ther 2018; 20:32-38. [PMID: 29293367 PMCID: PMC5770096 DOI: 10.1089/dia.2017.0250] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Insulin pumps and continuous glucose monitoring (CGM) are commonly used by patients with diabetes mellitus in the outpatient setting. The efficacy and safety of initiating inpatient insulin pumps and CGM in the nonintensive care unit setting is unknown. MATERIALS AND METHODS In a prospective pilot study, inpatients with type 2 diabetes were randomized to receive standard subcutaneous basal-bolus insulin and blinded CGM (group 1, n = 5), insulin pump and blinded CGM (group 2, n = 6), or insulin pump and nonblinded CGM (group 3, n = 5). Feasibility, glycemic control, and patient satisfaction were evaluated among groups. RESULTS Group 1 had lower mean capillary glucose levels, 144.5 ± 19.5 mg/dL, compared with groups 2 and 3, 191.5 ± 52.3 and 182.7 ± 59.9 mg/dL (P1 vs. 2+3 = 0.05). CGM detected 19 hypoglycemic episodes (glucose <70 mg/dL) among all treatment groups, compared with 12 episodes detected by capillary testing, although not statistically significant. No significant differences were found for the total daily dose of insulin or percentage of time spent below target glucose range (<90 mg/dL), in target glucose range (90-180 mg/dL), or above target glucose range (>180 mg/dL). On the Diabetes Treatment Satisfaction Questionnaire-Change, group 3 reported increased hyperglycemia and decreased hypoglycemia frequency compared with the other two groups, although the differences did not reach statistical significance. CONCLUSIONS Insulin pump and CGM initiation are feasible during hospitalization, although they are labor intensive. Although insulin pump initiation may not lead to improved glycemic control, there is a trend toward CGM detecting a greater number of hypoglycemic episodes. Larger studies are needed to determine whether use of this technology can lower inpatient morbidity and mortality.
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Affiliation(s)
- David L. Levitt
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elias K. Spanakis
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Division of Endocrinology and Diabetes, Baltimore Veterans Administration Medical Center, Baltimore, Maryland
| | - Kathleen A. Ryan
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kristi D. Silver
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Gupta T, Hudson M. Update on Glucose Management Among Noncritically Ill Patients Hospitalized on Medical and Surgical Wards. J Endocr Soc 2017; 1:247-259. [PMID: 29264482 PMCID: PMC5686565 DOI: 10.1210/js.2016-1055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/17/2017] [Indexed: 01/08/2023] Open
Abstract
Hyperglycemia is a common issue affecting inpatient care. Although this is in part because of the higher rate of hospitalization among patients with preexisting diabetes, multiple factors complicate inpatient glucose management, including acute stress from illness or surgery, erratic dietary intake, and contribution of medications. It has been repeatedly demonstrated that poorly controlled blood glucose levels are associated with negative clinical outcomes, such as increased mortality, higher rate of surgical complications, and longer length of hospital stay. Given these concerns, there has been extensive study of the optimal strategy for management of glucose levels, with the bulk of existing literature focusing on insulin therapy in the intensive care unit setting. This review shifts the focus to the general adult medical and surgical wards, using clinical guidelines and sentinel studies to describe the scientific basis behind the current basal-bolus insulin-based approach to blood sugar management among noncritically ill inpatients. Patient-centered clinical trials looking at alternative dosing regimens and insulin analog and noninsulin agents, such as glucagon-like peptide-1 agonist therapies, introduce safe and effective options in the management of inpatient hyperglycemia. Data from these studies reveal that these approaches are of comparable safety and efficacy to the traditional basal-bolus insulin regimen, and may offer additional benefit in terms of less monitoring requirements and lower rates of hypoglycemia. Although existing data are encouraging, outcome studies will be needed to better establish the clinical impact of these more recently proposed approaches in an effort to broaden and improve current clinical practices in inpatient diabetes care.
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Affiliation(s)
- Tina Gupta
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115
| | - Margo Hudson
- Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115
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12
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Pasquel FJ, Gianchandani R, Rubin DJ, Dungan KM, Anzola I, Gomez PC, Peng L, Hodish I, Bodnar T, Wesorick D, Balakrishnan V, Osei K, Umpierrez GE. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial. Lancet Diabetes Endocrinol 2017; 5:125-133. [PMID: 27964837 DOI: 10.1016/s2213-8587(16)30402-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 10/29/2016] [Accepted: 11/01/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role of incretin-based drugs in the treatment of patients with type 2 diabetes admitted to hospital has not been extensively assessed. In this study, we compared the safety and efficacy of a dipeptidyl peptidase-4 inhibitor (sitagliptin) plus basal insulin with a basal-bolus insulin regimen for the management of patients with type 2 diabetes in general medicine and surgery in hospitals. METHODS We did a multicentre, prospective, open-label, non-inferiority randomised clinical trial (Sita-Hospital) in five hospitals in the USA, enrolling patients aged 18-80 years with type 2 diabetes and a random blood glucose concentration of 7·8-22·2 mmol/L who were being treated with diet or oral antidiabetic drugs or had a total daily insulin dose of 0·6 units per kg or less, admitted to general medicine and surgery services. We randomly assigned patients (1:1) to receive either sitagliptin plus basal glargine once daily (the sitagliptin-basal group) or a basal-bolus regimen with glargine once daily and rapid-acting insulin lispro or aspart before meals (the basal-bolus group) during the hospital stay. All other antidiabetic drugs were discontinued on admission. The randomisation was achieved by computer-generated tables with block stratification according to randomisation blood glucose concentrations (ie, higher or lower than 11·1 mmol/L). The primary endpoint of the trial was non-inferiority in mean differences between groups in their daily blood glucose concentrations during the first 10 days of therapy (point-of-care measurements; non-inferiority was deemed a difference <1 mmol/L). The safety endpoints included hypoglycaemia and uncontrolled hyperglycaemia leading to treatment failure. All participants who received at least one dose of study drug were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT01845831. FINDINGS Between Aug 23, 2013, and July 27, 2015, we recruited 279 patients, and randomly assigned 277 to treatment; 138 to sitagliptin-basal and 139 to basal-bolus. The length of stay in hospital was similar for both groups (median 4 days [IQR 3-8] vs 4 [3-8] days, p=0·54). The mean daily blood glucose concentration in the sitagliptin-basal group (9·5 mmol/L [SD 2·7]) was not inferior to that in the basal-bolus group 9·4 mmol/L [2·7]) with a mean blood glucose difference of 0·1 mmol/L (95% CI -0·6 to 0·7). No deaths occurred in this trial. Treatment failure occurred in 22 patients (16%) in the sitagliptin-basal group versus 26 (19%) in the basal-bolus group (p=0·54). Hypoglycaemia occurred in 13 patients (9%) in the sitagliptin-basal group and in 17 (12%) in the basal-bolus group (p=0·45). No differences in hospital complications were noted between groups. Seven patients (5%) developed acute kidney injury in the sitagliptin-basal group and six (4%) in the basal-bolus group. One patient (0·7%) developed acute pancreatitis (in the basal-bolus group). INTERPRETATION The trial met the non-inferiority threshold for the primary endpoint, because there was no significant difference between groups in mean daily blood glucose concentrations. Treatment with sitagliptin plus basal insulin is as effective and safe as, and a convenient alternative to, the labour-intensive basal-bolus insulin regimen for the management of hyperglycaemia in patients with type 2 diabetes admitted to general medicine and surgery services in hospital in the non-intensive-care setting. FUNDING Merck.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Tim Bodnar
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Kwame Osei
- Ohio State University, Columbus, OH, USA
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13
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Verma V, Kotwal N, Upreti V, Nakra M, Singh Y, Shankar KA, Nachankar A, Kumar KVSH. Liraglutide as an Alternative to Insulin for Glycemic Control in Intensive Care Unit: A Randomized, Open-label, Clinical Study. Indian J Crit Care Med 2017; 21:568-572. [PMID: 28970655 PMCID: PMC5613607 DOI: 10.4103/ijccm.ijccm_105_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Intravenous insulin is the cornerstone in the management of hyperglycemia in the Intensive Care Unit (ICU). We studied the efficacy of liraglutide compared with insulin in the ICU. Materials and Methods: In this prospective, open-labeled, randomized study, we included 120 patients (15–65 years, either sex) admitted to ICU with capillary blood glucose (CBG) between 181 and 300 mg/dl. We excluded patients with secondary diabetes and APACHE score >24. The patients were divided into two groups (n = 60) based on the CBG: Group 1 (181–240) and Group 2 (241–300). They were randomized further into four subgroups (n = 30) to receive insulin (Groups 1A and 2A), liraglutide (Group 1B), and insulin with liraglutide (Group 2B). The primary outcome was the ability to achieve CBG below 180 mg/dL at the end of 24 h. The secondary outcomes include mortality at 1 month and hospital stay. Data and results were analyzed using Mann-Whitney U-test, paired t- test, and Chi-square tests. Results: The mean age of the patients (93M and 27F) was 57.1 ± 13.9 years, hospital stay (16.9 ± 7.5 days), and CBG was 240.5 ± 36.2 mg/dl. The primary outcome was reached in 26, 27, 25, and 28 patients of Groups 1A, 2A, 1B, and 2B, respectively. The 30-day mortality and hospital stay were similar across all the four groups. Hypoglycemia was common with insulin and gastrointestinal side effects were more common with liraglutide (P < 0.001). Conclusion: Liraglutide is a viable alternative to insulin for glycemic control in the ICU. Further studies with a larger number of patients are required to confirm our findings.
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Affiliation(s)
- Vishesh Verma
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
| | - Narendra Kotwal
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
| | - Vimal Upreti
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
| | - Monish Nakra
- Department of Anesthesiology, Army Hospital (R and R), New Delhi, India
| | - Yashpal Singh
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
| | - K Anand Shankar
- Department of Anesthesiology, Army Hospital (R and R), New Delhi, India
| | - Amit Nachankar
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
| | - K V S Hari Kumar
- Department of Endocrinology, Army Hospital (R and R), New Delhi, India
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14
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Gosmanov AR. A practical and evidence-based approach to management of inpatient diabetes in non-critically ill patients and special clinical populations. J Clin Transl Endocrinol 2016; 5:1-6. [PMID: 29067228 PMCID: PMC5644436 DOI: 10.1016/j.jcte.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/05/2016] [Accepted: 05/06/2016] [Indexed: 12/13/2022] Open
Abstract
Inpatient diabetes is a common medical problem encountered in up to 25-30% of hospitalized patients. Several prospective trials showed benefits of structured insulin therapy in managing inpatient hyperglycemia albeit in the expense of high hypoglycemia risk. These approaches, however, remain underutilized in hospital practice. In this review, we discuss clinical applications and limitations of current therapeutic strategies. Considerations for glycemic strategies in special clinical populations are also discussed. We suggest that given the complexity of inpatient glycemic control factors, the "one size fits all" approach should be modified to safe and less complex patient-centered evidence-based treatment strategies without compromising the treatment efficacy.
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Affiliation(s)
- Aidar R. Gosmanov
- Endocrinology Section, Stratton VAMC, 113 Holland Avenue, Albany, NY 12208, USA
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Abstract
Hyperglycemia is common following organ transplantation, regardless of the pre-transplant diabetes status. Transient post-transplant hyperglycemia and/or new-onset diabetes after transplantation (NODAT) are common and are associated with increased morbidity and mortality. NODAT and type 2 diabetes share similar characteristics, but the pathophysiology may differ. Immunosuppressive agents and steroids play a key role in the development of NODAT. Glycemic control is challenging in this population due to fluctuating renal/end-organ function, immunosuppressive dosing, nutritional status, and drug-drug interactions. A proactive and multidisciplinary approach is essential, along with flexible protocols to adjust to patient status, type of organ transplanted, and corticosteroid regimens. Insulin is the preferred agent for hospitalized patients and during the early post-transplant period; optimal glycemic control (BG < 180 mg/dl with minimal hypoglycemia [<70 mg/dl]) is desired.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Hospital, 1111 Amsterdam Ave, Babcock Building, 10th floor, Room 1020, New York, NY, 10025, USA.
| | - Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, 654 N Michigan Avenue, Suite 530, Chicago, IL, 60611, USA.
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Mathioudakis N, Pronovost PJ, Cosgrove SE, Hager D, Golden SH. Modeling Inpatient Glucose Management Programs on Hospital Infection Control Programs: An Infrastructural Model of Excellence. Jt Comm J Qual Patient Saf 2015; 41:325-36. [PMID: 26108126 DOI: 10.1016/s1553-7250(15)41043-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Nestoras Mathioudakis
- Inpatient Diabetes Management Service, Johns Hopkins Hospital and Johns Hopkins University School of Medicine, Baltimore, USA
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Abstract
The concept of lower is better when considering the goal for glycemic control in patients with diabetes mellitus has recently been challenged due to recent studies, such as ACCORD, ADVANCE, and VADT, which have observed increased morbidity and mortality from intensive control, especially in older adults, and in those with long duration of diabetes disease and chronic complications. Although evidence in younger patients suggest that blood glucose levels should not be above 180 mg/dl (10.0 mmol/l), there are many unanswered questions and controversies regarding the benefits and risks, methods to achieve and maintain these levels while avoiding hypoglycemia (<70 mg% (3.9 mmol/l)) in the older population. Since the population is aging with a greater life expectancy, it is crucial that these questions be answered. Although several studies of inpatient non-ICU diabetes management have been published, few include older patients. This review will examine available recommendations and explore those controversies regarding non-ICU hospital management in this vulnerable patient population. Additional conditions that impact upon achieving glycemic control will also be discussed. Finally, the older individual has many special needs which may be more important to consider than in young or middle-aged individuals, when transitioning care from in-hospital to home in a patient-centered approach, as recommended by the American Diabetes Association (ADA) and European Society for the Study of Diabetes (EASD).
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Affiliation(s)
- Janice L Gilden
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, 60064, USA,
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Schwartz SS, DeFronzo RA, Umpierrez GE. Practical implementation of incretin-based therapy in hospitalized patients with type 2 diabetes. Postgrad Med 2014; 127:251-7. [PMID: 25547241 DOI: 10.1080/00325481.2015.996504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hyperglycemia in patients with and without a prior history of diabetes is an independent marker of morbidity and mortality in critically and noncritically ill patients. Improvement of glycemic control with insulin therapy has been shown to reduce hospital complications in patients with diabetes, but also results in increased rates of hypoglycemia, which have been linked to poor outcomes. Thus, alternative treatment options that can normalize blood glucose levels without undue hypoglycemia are being sought. Incretin-based therapies, such as glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, stimulate insulin secretion in a glucose-dependent fashion, thus not causing hypoglycemia. Alternative points of view exist regarding insulin versus incretin therapy for the care of these patients. We have brought together the authors on the opposite sides of this discussion with the objective of providing a rational synthesis on how to achieve the best possible control of glycemia in the hospital, using both standard insulin approaches and incretin-based therapies to improve patient outcomes. This review examines the benefits of incretin-based therapy in improving glycemic control in hospitalized patients with stress-induced diabetes and in diabetic patients in critical care and non-critical care settings.
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Affiliation(s)
- Stanley S Schwartz
- Affiliate, Main Line Health System, Clinical Associate Professor of Medicine Emeritus, University of Pennsylvania , Philadelphia, PA , USA
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