Sodium-Glucose Cotransporter 2 Inhibitors Should Be Avoided for the Inpatient Management of Hyperglycemia

OBJECTIVE

Hyperglycemia in patients with type 2 diabetes mellitus is frequently encountered in the hospital setting. The recent guidelines for the management of inpatient hyperglycemia have included the use of dipeptidyl peptidase 4 inhibitors as an alternative to standard insulin therapy in select patients. This raises the question of the inpatient use of sodium-glucose cotransporter 2 inhibitors (SGLT2i), which have gained increasing popularity in the outpatient setting because of beneficial cardiovascular and renal outcomes. This article describes the risks associated with the use of SGLT2i for the management of inpatient hyperglycemia.

METHODS

A literature review was performed using PubMed and Google Scholar for studies assessing the inpatient use of SGLT2i. Search terms included "SGLT2 inhibitors," "euglycemic DKA," "inpatient hyperglycemia," "DPP4 inhibitors," "hypovolemia," and "urinary tract infections." Studies not written in English were excluded. Forty-eight articles were included.

RESULTS

Review of the literature showed significant safety concerns with the use of SGLT2i for the inpatient management of hyperglycemia. Hospitalized patients treated with SGLT2i were at increased risk of diabetic ketoacidosis, euglycemic diabetic ketoacidosis, hypovolemia, and urinary tract infections. When compared head-to-head, SGLT2i were not more effective for inpatient glycemic control than dipeptidyl peptidase 4 inhibitors and did not reduce insulin requirements when used in combination with insulin. Although SGLT2i can be considered for the treatment of congestive heart failure, they should be started close to or at the time of discharge.

CONCLUSION

Although SGLT2i are a preferred pharmacotherapy class for the outpatient management of type 2 diabetes mellitus, there are considerable safety concerns when using them in a hospital setting, and avoidance is recommended.

A Rare Case of NUT Carcinoma of the Thyroid

NUT carcinoma is an aggressive, poorly differentiated squamous cell carcinoma, defined by rearrangement of the NUTM1 (Nuclear Protein in Testis) gene. Diagnosis is challenging due to histologic similarities with other poorly differentiated tumors requiring advanced diagnostic techniques. There is no established treatment, and prognosis remains extremely poor. A 27-year-old woman without known medical history presented with a rapidly enlarging neck mass and compressive symptoms. Chemotherapy for presumed squamous cell carcinoma with a component of anaplastic thyroid cancer based on pathology was initiated. Next-generation sequencing revealed thyroid NUT carcinoma with high PD-L1 expression, prompting PD-1 targeted therapy. The patient expired shortly afterwards from progressive disease. NUT carcinoma of thyroid origin is an extremely rare disease. This case brings awareness to the disease, highlights the importance of advanced diagnostic techniques and complexities in managing patients with NUT carcinoma.

PSUN42 New-Onset Rheumatoid Arthritis After Surgical Treatment of Cushing Syndrome

Background

Cushing syndrome (CS) is a rare endocrinopathy resulting from prolonged exposure to endogenous or exogenous glucocorticoids. CS can be subclinical or can present with an array of overt signs and symptoms. The goal of treatment in CS is to reestablish normal cortisol levels in the body by eliminating the source of excess cortisol. Autoimmune diseases are often treated successfully with exogenous glucocorticoids. There are several case reports/series in the literature describing patients who developed autoimmune diseases, or experienced recrudescence of otherwise quiescent autoimmune processes, after the withdrawal of glucocorticoids. Such diseases include rheumatoid arthritis, Graves disease, Hashimoto's thyroiditis, systemic lupus erythematosus, psoriasis, and myasthenia gravis. Below we share a case of rheumatoid arthritis that presented after unilateral adrenalectomy for CS.

Clinical case

A 55 year old female with a history of Graves disease status post radioactive iodine ablation many years ago with post-ablative hypothyroidism was found to have a left adrenal mass on CT in 2016. An MRI in February 2021 showed interval growth from 3.8×2.9×3.6cm to 5.1×3.5×4.8cm. ACTH was suppressed to <1.5 pg/mL (7.2-63.3 pg/mL), 24 hour urine free cortisol was elevated to 256 ug/24hr (10-34 ug/24hr), midnight salivary cortisol was elevated to 219 ng/dL then 430 ng/dL on repeat (n<100 ng/dL), and AM cortisol was 13.7 ug/dL (6.0-18.4 ug/dL) after 1mg overnight dexamethasone administration. This biochemical testing was supportive of the diagnosis of ACTH-independent adrenal CS. Our patient underwent successful left adrenalectomy in March 2021 and was started on hydrocortisone postoperatively given long-standing suppression of her hypothalamic-pituitary-adrenal axis. Within three months, she developed muscle aches and pain in bilateral hands, ankles and feet with stiffness and swelling. These symptoms worsened with glucocorticoid taper. She was found to have a rheumatoid factor of 32 IU/mL (0-13 IU/mL) and was diagnosed with rheumatoid arthritis, for which she was started on hydroxychloroquine and briefly switched from hydrocortisone to prednisone. She has since been tapered off steroids with resolution of adrenal insufficiency. Her rheumatoid arthritis symptoms remain adequately controlled on hydroxychloroquine.

Conclusions

While it is known that withdrawal of exogenous chronic steroids can result in exacerbation of pre-existing autoimmune disease, the emergence of new autoimmune disease upon withdrawal of endogenous steroid production after treatment of pituitary ACTH-dependent or adrenal ACTH-independent CS is extremely rare. Of special interest, our patient described above had a history of Graves disease years before her CS diagnosis was made, suggesting an underlying proclivity towards autoimmunity. Further study may reveal the need for higher vigilance in postoperative monitoring in patients with preexisting autoimmune conditions.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Assessment of Insulin Infusion Requirements in COVID-19-Infected Patients with Diabetic Ketoacidosis

Background/Objective

Coronavirus disease 2019 (COVID-19) is thought to contribute to diabetic ketoacidosis (DKA) and worse outcomes in patients with diabetes. This study compared the cumulative insulin dose required to achieve DKA resolution in the intensive care unit among patients with type 2 diabetes and COVID-19 infection versus without COVID-19 infection.

Methods

This retrospective cohort study evaluated 100 patients—50 patients with COVID-19 in cohort 1 and 50 patients without COVID-19 in cohort 2—treated with insulin infusions for DKA at a tertiary care teaching hospital. The primary outcome was to compare the cumulative insulin dose required to achieve DKA resolution in each cohort. The secondary outcomes included time to DKA resolution, mean insulin infusion rate, and mean weight-based cumulative insulin infusion dose required to achieve DKA resolution. All endpoints were adjusted for confounders.

Results

The mean cumulative insulin dose was 190.3 units in cohort 1 versus 116.4 units in cohort 2 (P = .0038). Patients receiving steroids had a mean time to DKA resolution of 35.9 hours in cohort 1 versus 15.6 hours in cohort 2 (P = .0014). In cohort 1 versus cohort 2, the mean insulin infusion rate was 7.1 units/hour versus 5.3 units/hour (P = .0025), whereas the mean weight-based cumulative insulin infusion dose was 2.1 units/kg versus 1.5 units/kg (P = .0437), respectively.

Conclusion

COVID-19-infected patients required a significantly larger cumulative insulin dose, longer time to DKA resolution, higher insulin infusion rate, and higher weight-based insulin infusion dose to achieve DKA resolution versus non–COVID-19-infected patients with type 2 diabetes.

Multidisciplinary management of endocrinopathies and treatment-related toxicities in patients with Bloom syndrome and cancer

The treatment of malignancy in cancer predisposition syndromes that also confer exquisite sensitivity to standard chemotherapy and radiation regimens remains a challenge. Bloom syndrome is one such disorder that is caused by a defect in DNA repair, predisposing to the development of early-onset age-related medical conditions and malignancies. We report on two patients with Bloom syndrome who responded well to chemotherapy despite significant alterations to standard protocols necessitated by hypersensitivity. Both patients experienced severe toxicities and exacerbation of endocrine comorbidities during chemotherapy. A multidisciplinary team of oncologists and endocrinologists is best suited to care for this patient population.