Reduction in Diabetes-Related Hospitalizations and Medical Costs After Dexcom G6 Continuous Glucose Monitor Initiation in People with Type 2 Diabetes Using Intensive Insulin Therapy

INTRODUCTION

Some people with type 2 diabetes (T2D) require intensive insulin therapy to manage their diabetes. This can increase the risk of diabetes-related hospitalizations. We hypothesize that initiation of real-time continuous glucose monitoring (RT-CGM), which continuously measures a user's glucose values and provides threshold- and trend-based alerts, will reduce diabetes-related emergency department (ED) and inpatient hospitalizations and concomitant costs.

METHODS

A retrospective analysis of US healthcare claims data using Optum's de-identified Clinformatics® Data Mart database was performed. The cohort consisted of commercially insured, CGM-naïve individuals with T2D who initiated Dexcom G6 RT-CGM system between August 1, 2018, and March 31, 2021. Twelve months of continuous health plan enrollment before and after RT-CGM initiation was required to capture baseline and follow-up rates of diabetes-related hospitalizations and associated healthcare resource utilization (HCRU) costs. Analyses were performed for claims with a diabetes-related diagnosis code in either (1) any position or (2) first or second position on the claim.

RESULTS

A total of 790 individuals met the inclusion criteria. The average age was 52.8 (10.5) [mean (SD)], 53.3% were male, and 76.3% were white. For claims with a diabetes-related diagnosis code in any position, the number of individuals with ≥ 1 ED visit decreased by 30.0% (p = 0.01) and with ≥ 1 inpatient visit decreased by 41.5% (p < 0.0001). The number of diabetes-related visits and average number of visits per person similarly decreased by at least 31.4%. Larger relative decreases were observed for claims with a diabetes-related diagnosis code in the first or second position on the claim. Total diabetes-related costs expressed as per-person-per-month (PPPM) decreased by $341 PPPM for any position and $330 PPPM for first or second position.

CONCLUSION

Initiation of Dexcom G6 among people with T2D using intensive insulin therapy was associated with a significant reduction in diabetes-related ED and inpatient visits and related HCRU costs. Expanded use of RT-CGM could augment these benefits and result in further cost reductions.

Association Between Adherence, A1C Improvement, and Type of Continuous Glucose Monitoring System in People with Type 1 Diabetes or Type 2 Diabetes Treated with Intensive Insulin Therapy

INTRODUCTION

Use of continuous glucose monitoring (CGM) systems by people with diabetes is associated with improved glycemic outcomes, including lower glycated hemoglobin (A1C). Less is known about adherence to CGM systems, whether glycemic outcomes are impacted by levels of adherence, or whether adherence rates differ between types of CGM systems-intermittently scanned CGM (isCGM) or real-time CGM (rtCGM).

METHODS

A retrospective analysis of de-identified US administrative health claims and linked laboratory data was conducted using the Merative™ MarketScan® Research Database. The cohort included CGM-naïve people with type 1 diabetes (T1D) or type 2 diabetes treated with intensive insulin therapy (T2D-IIT) who initiated rtCGM or isCGM between August 1, 2019 and March 31, 2021 (defined as the index date). Adherence was calculated over a 12-month period using the proportion of days covered (PDC) with PDC ≥ 0.8 defined as adherent. A1C values were obtained within 6 months of the index date.

RESULTS

A total of 7669 individuals were identified. Subgroups included T1D using isCGM (n = 1578), T1D using rtCGM (n = 1244), T2D-IIT using isCGM (n = 3567), and T2D-IIT using rtCGM (n = 1280). After 12 months, PDC was 0.71 (0.30)-0.72 (0.31) (mean(SD)) for T1D and T2D-IIT rtCGM users and 0.55 (0.34)-0.56 (0.34) for T1D and T2D-IIT isCGM users. The proportion of adherent users (PDC ≥ 0.8) was 56.8-59.7% for rtCGM users and 36.3-37.6% for isCGM users. Overall, regardless of diabetes type, the odds of adherence were over two times higher for rtCGM users compared to isCGM users. For those with available A1C information (T1D n = 213; T2D-IIT n = 346), independent of CGM type, adherence to CGM was associated with a greater reduction in A1C and more people reaching A1C targets of < 7.0% or < 8.0%.

CONCLUSION

For people with T1D or T2D-IIT, higher adherence to CGM is associated with greater reductions in A1C, and higher adherence rates were observed with rtCGM systems than with isCGM systems.

Clinical expert consensus on the assessment and protection of pancreatic islet β-cell function in type 2 diabetes mellitus

Islet β-cell dysfunction is a basic pathophysiological characteristic of type 2 diabetes mellitus (T2DM). Appropriate assessment of islet β-cell function is beneficial to better management of T2DM. Protecting islet β-cell function is vital to delay the progress of type 2 diabetes mellitus. Therefore, the Pancreatic Islet β-cell Expert Panel of the Chinese Diabetes Society and Endocrinology Society of Jiangsu Medical Association organized experts to draft the "Clinical expert consensus on the assessment and protection of pancreatic islet β-cell function in type 2 diabetes mellitus." This consensus suggests that β-cell function can be clinically assessed using blood glucose-based methods or methods that combine blood glucose and endogenous insulin or C-peptide levels. Some measures, including weight loss and early and sustained euglycemia control, could effectively protect islet β-cell function, and some newly developed drugs, such as Sodium-glucose cotransporter-2 inhibitor and Glucagon-like peptide-1 receptor agonists, could improve islet β-cell function, independent of glycemic control.

Intensive insulin therapy in sepsis patients: Better data enables better intervention

In clinics, sepsis is a critical disease that often develops into shock and multiple organ dysfunction, leading to a serious threat of death. Patients with sepsis are often accompanied by stress hyperglycemia which is an independent risk factor for poor prognosis in sepsis. Thus, the treatment for stress hyperglycemia has attracted more and more attention, among which intensive insulin therapy is widely concerned. However, the benefits and harms of intensive insulin therapy for sepsis patients remain controversial. What the existing literature discusses mostly are the clinical benefit and hypoglycemia risk of intensive insulin therapy, but there is no conclusion on the target range of blood glucose control, the applicable patients, the timing of treatment initiation, and how to avoid the risk. In this study, we have analyzed and summarized the existing literature, hoping to determine the adverse and clinical benefit of intensive insulin therapy in sepsis. And we attempt to assemble better evidence to propose a better recommendation on hyperglycemia intervention for sepsis patients.

Effect of intensive insulin therapy on inflammatory response after cardiac surgery using bedside artificial pancreas: a propensity score-matched analysis

BACKGROUND

Perioperative hyperglycemia leads to poor postoperative clinical outcomes, including compromised immune function, cardiovascular events, and mortality. The optimal perioperative blood glucose levels during cardiac surgery remain unclear. A closed-loop glycemic control system (artificial pancreas, target blood glucose range:120-150 mg/dL) prevents postoperative inflammatory response more effectively than conventional insulin therapy (< 200 mg/dL). However, the clinical effects of intensive insulin therapy with strict glycemic control (80-110 mg/dL) are controversial. This study aimed to determine whether intensive insulin therapy would further suppress postoperative inflammatory reactions.

METHODS

This study analyzed 262 patients who underwent cardiovascular surgery with cardiopulmonary bypass. The patients were divided into two groups according to their target blood glucose range: 80-110 mg/dL and 120-150 mg/dL. The primary outcome was the difference in the C-reactive protein levels between the two groups.

RESULTS

Propensity score matching resulted in 95 patients in each group based on their covariates. There was no difference in the postoperative maximum C-reactive protein levels between the two groups (14.81 ± 5.93 mg/dL vs. 14.34 ± 5.52 mg/dL; P = 0.571) following propensity score matching. Hypoglycemia did not occur during intensive insulin therapy.

CONCLUSIONS

Intensive insulin therapy following cardiac surgery with cardiopulmonary bypass did not demonstrate significant advantages in the suppression of postoperative inflammatory reactions compared to that with mild glycemic control. However, intensive insulin therapy using an artificial pancreas was found to be safe, with no hypoglycemic events.

Glycaemic Control Achieves Sustained Increases of Circulating Endothelial Progenitor Cells in Patients Hospitalized for Decompensated Diabetes: An Observational Study

BACKGROUND AND AIM

Diabetes reduces the levels of circulating endothelial progenitor cells (EPCs), which contribute to vascular homeostasis. In turn, low EPCs levels predict progression of chronic complications. Several studies have shown that hyperglycaemia exerts detrimental effects on EPCs. Improvement in glucose control with glucose-lowering medications is associated with an increase of EPCs, but only after a long time of good glycaemic control. In the present study, we examined the effect of a rapid glycaemic amelioration on EPC levels in subjects hospitalized for decompensated diabetes.

METHODS

We used flow cytometry to quantify EPCs (CD34⁺/CD133⁺KDR⁺) in patients hospitalized for/with decompensated diabetes at admission, at discharge, and 2 months after the discharge. During hospitalization, all patients received intensive insulin therapy.

RESULTS

Thirty-nine patients with type 1 or type 2 diabetes were enrolled. Average (± SEM) fasting glucose decreased from 409.2 ± 25.9 mg/dl at admission to 190.4 ± 12.0 mg/dl at discharge and to 169.0 ± 10.3 at 2 months (both p < 0.001). EPCs (per million blood cells) significantly increased from hospital admission (13.1 ± 1.4) to discharge (16.4 ± 1.1; p = 0.022) and remained stable after 2 months (15.5 ± 1.7; p = 0.023 versus baseline). EPCs increased significantly more in participants with newly-diagnosed diabetes than in those with pre-existing diabetes. The increase in EPCs was significant in type 1 but not in type 2 diabetes and in those without chronic complications.

CONCLUSION

In individuals hospitalized for decompensated diabetes, insulin therapy rapidly increases EPC levels for up to 2 months. EPC defect, reflecting impaired vascular repair capacity, may be reversible in the early diabetes stages.

Effects of intensive insulin therapy on the retinal microvasculature in patients with type 2 diabetes mellitus: a prospective observational study

Background

We examined the retinal microvascular changes and associated factors in type 2 diabetes mellitus (T2DM) before and after intensive insulin therapy.

Methods

This prospective observational study recruited patients with T2DM and divided them into intensive insulin therapy and oral hypoglycemic agent groups. All patients enrolled in this study had diabetes without retinopathy or non-proliferative diabetic retinopathy. Optical coherence tomography angiography (OCTA) was used in all patients before treatment and at 1, 3, and 6 months after treatment. Vessel density (VD) and thickness changes in the macular and optic disc areas were assessed.

Results

The study included 36 eyes in the intensive insulin therapy group and 36 in the oral hypoglycemic agent group. One month after treatment, VD in the deep capillary plexus (DCP) and peripapillary capillary VD (ppVD) were significantly decreased by intensification (P = 0.009, 0.000). At three months after treatment, decreases in VD induced by intensification were found in the superficial capillary plexus (SCP), DCP, foveal density in a 300-μm-wide region around the foveal avascular area (FD-300), and ppVD (P = 0.032, 0.000, 0.039, 0.000). Six months after treatment, decreases in VD by intensification were observed in the DCP and ppVD groups (P = 0.000, 0.000). Vessel density showed no significant change in the oral hypoglycemic agent group after treatment. The amount of DCP-VD reduction was correlated with macular thickening (r = 0.348, P = 0.038; r = 0.693, P = 0.000 and r = 0.417, P = 0.011, respectively) after intensive insulin therapy.

Conclusions

Insulin-intensive treatment caused a transient reduction in vessel density in the macular and optic disc areas. DCP-VD and ppVD were more susceptible at an earlier stage. Retinal microvasculature monitoring using OCTA is vital for patients with type 2 diabetes receiving intensive insulin therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02397-9.

Insulin resistance-associated genetic variants in type 1 diabetes

AIMS

To examine candidate insulin resistance single nucleotide polymorphisms (SNPs) for associations with glycemic control, insulin resistance, BMI, and complications in an observational type 1 diabetes (T1D) cohort: the Pittsburgh Epidemiology of Diabetes Complications (EDC) study.

METHODS

In 422 European-ancestry participants, we assessed associations using additive models between 15 candidate SNPs and 25-year mortality, cardiovascular disease, microalbuminuria, overt nephropathy and proliferative retinopathy, and 25-year mean HbA1c, estimated glucose disposal rate (eGDR, inverse measure of insulin resistance), and BMI.

RESULTS

The A allele of rs12970134 was associated with higher mean HbA1c (β = +0.34 ± 0.09, p = 0.00009) and nominally associated with worse eGDR (p = 0.02). Further analyses suggest the HbA1c association may be modified by diabetes therapy regimen: rs12970134 AA genotype was associated with higher HbA1c under non-intensive therapy conditions (<3 insulin injections/day or monitoring blood glucose<3 times/day [p = 0.004]), but not under intensive therapy (≥3 injections/day or insulin pump and monitoring glucose≥3 times/day [p = 0.71]). There were no significant associations between any SNPs and BMI or complications.

CONCLUSIONS

rs12970134, near MC4R, is strongly associated with HbA1c in this cohort. Further exploration of this genomic region is warranted, as it may hold promise for discovering new therapeutic targets to improve glycemic control in T1D.

Blood glucose levels should be considered as a new vital sign indicative of prognosis during hospitalization

BACKGROUND AND AIMS

The measurement of vital signs is an important part of clinical work up. Presently, measurement of blood glucose is a factor for concern mostly when treating individuals with diabetes. Significance of blood glucose measurement in prognosis of non-diabetic and hospitalized patients is not clear.

METHODS

A systematic search of literature published in the Electronic databases, PubMed and Google Scholar was performed using following keywords; blood glucose, hospital admissions, critical illness, hospitalizations, cardiovascular disease (CVD), morbidity, and mortality. This literature search was largely restricted to non-diabetic individuals.

RESULTS

Blood glucose level, even when in high normal range, or in slightly high range, is an important determinant of morbidity and mortality, especially in hospitalized patients. Further, even slight elevation of blood glucose may increase mortality in patients with COVID-19. Finally, blood glucose variability and hypoglycemia in critically ill individuals without diabetes causes excess in-hospital complications and mortality.

CONCLUSION

In view of these data, we emphasize the significance of blood glucose measurement in all patients admitted to the hospital regardless of presence of diabetes. We propose that blood glucose be included as the "fifth vital sign" for any hospitalized patient.

Diagnosis of hepatic nuclear factor 1A monogenic diabetes mellitus (HNF1A-MODY) impacts antihyperglycemic treatment

Monogenic mutations of the hepatocyte nuclear factor 1 homeobox A maturity onset diabetes of the young (HNF1A-MODY) is characterized by early onset, typically before the age of 25 years. Patients are often not clinically recognized; however, the identification of HNF1A-MODY patients is crucial because they require different antihyperglycemic medical treatment than patients with type 1 or type 2 diabetes mellitus. We describe two adult patients with monogenic diabetes, both identified as HNF1A-MODY, genetically c.815G>A, p.Arg272His and c675delC, p.Ser225Argfs*8, respectively. They were misdiagnosed as having type 1 diabetes mellitus, and consequently, initiating insulin therapy led to hypoglycemia and unstable blood glucose control. Usually, sulfonylureas represent the basis of antidiabetic treatment in patients with HNF1A-MODY; however, all medical personnel involved in diabetes care should be aware of monogenic diabetes mellitus and the possibilities for genetic testing. The patients observed have shown the necessity of the identification and appropriate genetic diagnosis of HNF1A-MODY in order to discontinue insulin therapy and to initiate adjusted diabetes management.

Lois Jovanovič: a giant in the field of diabetes and pregnancy

Lois Jovanovič (1947-2018) was a trailblazing and relentless clinical endocrinologist and researcher whose innovative approaches to diabetes and pregnancy changed the lives of thousands of women and their babies. Of her many accomplishments, she is best known for devising the diabetes and pregnancy protocols of intensive insulin delivery and glucose control that have made it possible for thousands of women with diabetes to deliver healthy babies and for pioneering the use of insulin analogues in pregnancy. Her research also paved the way for the development of the artificial pancreas. This biographical portrait describes her personal involvement with diabetes, her beginnings as a medical doctor, and highlights her main contributions to the field of diabetes.

Enhancing resources for healthcare professionals caring for people on intensive insulin therapy: Summary from a national workshop

In June 2019, the Leona M. and Harry B. Helmsley Charitable Trust and JDRF International (JDRF) co-sponsored the Healthcare Professional Resource Workshop in San Francisco, California. The workshop convened stakeholders in the diabetes field in order to: [1] review information and resources created for healthcare professionals (HCPs) caring for people with diabetes on intensive insulin therapy; [2] share knowledge to scale and decentralize diabetes care; [3] identify synergies across the leading diabetes information resources; and [4] determine the areas of unmet need for HCPs caring for people with diabetes on intensive insulin therapy. Here, we summarize the conclusions and recommendations from the workshop.

Efficacy and Safety of Basal Insulin-Based Treatment Versus Twice-Daily Premixed Insulin After Short-Term Intensive Insulin Therapy in Patients with Type 2 Diabetes Mellitus in China: Study Protocol for a Randomized Controlled Trial (BEYOND V)

INTRODUCTION

Many Chinese patients who are uncontrolled by oral antidiabetic drugs (OADs) receive short-term intensive insulin therapy (IIT) in hospital to rapidly relieve glucose-associated toxicity and to preserve/improve β-cell function. However, evidence for optimizing insulin algorithms for maintenance treatment after IIT is lacking. This study will compare the efficacy and safety of basal insulin-based treatment versus twice-daily premixed insulin in type 2 diabetes mellitus (T2DM) patients after short-term in-hospital IIT.

METHODS

This 26-week randomized, multicenter, positive-controlled, open-label, parallel-group study will enroll approximately 400 male and female patients aged 18-70 years with poorly-controlled T2DM (HbA1c > 7.5%) despite treatment with metformin plus at least one other OAD for 8 or more weeks. During a run-in period of 7-10 days, patients will be treated in-hospital with IIT comprising insulin glargine (Lantus^®) once daily and insulin glulisine (Apidra^®) three times daily; both regimens will be titrated daily to achieve the glycemic goal. Eligible patients will then be randomized in a 1:1 ratio to insulin glargine plus OADs or twice-daily premixed insulin (NovoLog^® Mix 70/30) for 24 weeks, with metformin maintained throughout the study in both treatment groups. The primary endpoint is HbA1c change from baseline to week 24. Secondary endpoints include assessment of fasting plasma glucose, total daily insulin dose, hypoglycemia incidence, body weight change, adverse events, and patient satisfaction.

DISCUSSION

Given the current lack of clinical data, this study will provide evidence supporting safe and effective glycemic control using basal insulin glargine-based therapy plus OADs compared with twice-daily premixed insulin in Chinese patients with T2DM after short-term IIT. This will assist physicians by providing a wider choice of treatments.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03359837 (registered on 2 December 2017).

Modulation of gut microbiota contributes to effects of intensive insulin therapy on intestinal morphological alteration in high-fat-diet-treated mice

AIMS

Disturbance of intestinal homeostasis promotes the development of type 2 diabetes. Although intensive insulin therapy has been shown to promote extended glycemic remission in newly diagnosed type 2 diabetic patients through multiple mechanisms, its effect on intestinal homeostasis remains unknown.

METHODS

This study evaluated the effects of intensive insulin therapy on intestinal morphometric parameters in a hyperglycemic mice model induced by high-fat diet (HFD). 16S rRNA V4 region sequencing and multivariate analysis were utilized to evaluate the structural changes of gut microbiota.

RESULTS

HFD-induced increases in the lengths of villus, microvillus and crypt depth were significantly reversed after intensive insulin therapy. Moreover, intestinal proliferation was notably decreased after intensive insulin therapy, whereas intestinal apoptosis was further increased. Importantly, intensive insulin therapy significantly shifted the overall structure of the HFD-disrupted gut microbiota toward that of mice fed a normal diet and changed the gut microbial composition. The abundances of 54 operational taxonomic units (OTUs) were changed by intensive insulin therapy. Thirty altered OTUs correlated with two or more intestinal morphometric parameters and were designated 'functionally relevant phylotypes.'

CONCLUSIONS

For the first time, our data indicate that intensive insulin therapy recovers diabetes-associated gut structural abnormalities and restores the microbiome landscape. Moreover, specific altered 'functionally relevant phylotypes' correlates with improvement in diabetes-associated gut structural alterations.

Impact of optimum diabetes care on the safety of fasting in Ramadan in adult patients with type 2 diabetes mellitus on insulin therapy

AIM

We aimed at evaluating the safety of fasting Ramadan for insulin treated type 2 diabetes patients by assessing the biochemical, biometric parameters, flash glucose monitoring (FGM) data as compared to pre-Ramadan and hospital admissions with diabetes or non-diabetes conditions. The risks of fasting between those treated with basal insulin vs intensive insulin during Ramadan was also assessed.

METHODS

We included insulin treated patients with type 2 diabetes and we excluded those with co-morbidities. Patients were provided with Ramadan-focused education, FGM before and during Ramadan and medical advice for treatment adjustment. We measured biologic and biometric data before and after Ramadan.

RESULTS

HbA1c reduced from 7.9 ± 1.20 pre-Ramadan to 7.7 ± 1.5% post Ramadan (p = 0.023). Average peak glucose reading was 330.1 ± 79.8 mg/dl before Ramadan improved significantly to reach 289.3 ± 77.7 mg/dl (p = 0.013). Average number of hypoglycemic episodes was higher in intensive insulin group between 1200 and 1800 h (p = 0.028).

CONCLUSION

People with type 2 diabetes treated with insulin who fast Ramadan and who are provided with Ramadan focused patient education, individualized treatment adjustment and FGMS were not at increased safety risks as measured by biochemical, biometric and FGM data.

The effect of short-term intensive insulin therapy on circulating T cell subpopulations in patients with newly diagnosed type 2 diabetes mellitus

AIMS

To evaluate the effect of short-term intensive insulin therapy on circulating T cell subpopulations in patients with newly diagnosed type 2 diabetes mellitus (T2DM).

METHODS

A total of 113 patients with T2DM and 28 normal subjects were enrolled. Demographic parameters and biochemical markers were collected at baseline, and flow cytometry was applied to determine the proportion of T cell subpopulations in participants. Then the patients underwent continuous subcutaneous insulin injection (CSII) treatment with euglycemia for 2 weeks, and the T cell subpopulations were measured again after CSII treatment.

RESULTS

Compared with normal subjects, the proportion of Th1 cells and the ratio of Th1/Th2 increased, the proportion of Treg cells decreased in patients with T2DM (p < 0.05 for all). The ratio of Th1/Th2 was positively correlated with glycosylated hemoglobin A1c (HbA1c) and negatively correlated with high density lipoprotein cholesterol (HDL-C). Furthermore, there were negative associations between the proportion of Treg cells and fasting plasma glucose, HbA1c, triglyceride, low density lipoprotein cholesterol, and positive association between the proportion of Treg cells and HDL-C. After CSII treatment, the proportion of Th1 cells and the ratio of Th1/Th2 decreased (p < 0.05 for both), the proportion of Treg cells increased in patients with T2DM (p < 0.05).

CONCLUSIONS

Short-term intensive insulin therapy could modulate circulating T cell subpopulations in patients with T2DM, which might alleviate inflammatory responses caused by hyperglycemia. This study was registered with ChiCTR-OPN-17010405.

Traceability to a primary reference measurement procedure (ID-LCMS); A key step in validating the clinical accuracy and safety of hospital blood glucose monitoring systems

OBJECTIVE

A key step in the evaluation of the accuracy of blood glucose monitoring systems (BGMS) is using a comparator method aligned to a high order definitive reference method. We describe how we achieved traceability to an isotope dilution liquid chromatography mass spectrometry (ID-LCMS) method. We used ID-LCMS to evaluate the accuracy and specificity of two hospital BGMS used in China.

METHOD

ID-LCMS was used to verify the calibration alignment of the laboratory plasma hexokinase reference method using NIST standard reference material and clinical samples. The ID-LCMS aligned hexokinase method was used to evaluate the clinical accuracy of two BGMS in hospitalized patients. System accuracy was evaluated using Chinese consensus guidelines. BGMS accuracy was also assessed with interference factors known to be present in critically ill patients' blood.

RESULTS

The laboratory plasma hexokinase reference method was shown to calibrate closely with ID-LCMS. Two BGMS demonstrated good correlation with this reference method. Only one BGMS met the Chinese guidelines. The interference factors didn't influence this BGMS but adversely affected the clinical accuracy of the other.

CONCLUSIONS

We advocate that our IDMS calibration alignment approach for ensuring the accuracy of the glucose reference method should be adopted in evaluations assessing the accuracy of blood glucose monitoring systems.

Prevention and Management of Severe Hypoglycemia and Hypoglycemia Unawareness: Incorporating Sensor Technology

PURPOSE OF REVIEW

In addition to assisting in achieving improved glucose control, continuous glucose monitoring (CGM) sensor technology may also aid in detection and prevention of hypoglycemia. In this paper, we report on the current scientific evidence on the effectiveness of this technology in the prevention of severe hypoglycemia and hypoglycemia unawareness.

RECENT FINDINGS

Recent studies have found that the integration of CGM with continuous subcutaneous insulin infusion (CSII) therapy, a system known as sensor-augmented pump (SAP) therapy, very significantly reduces the occurrence of these conditions by providing real-time glucose readings/trends and automatically suspending insulin infusion when glucose is low (LGS) or, even, before glucose is low but is predicted to soon be low (PLGS). Initial data indicate that even for patients with type 1 diabetes treated with multiple daily injections, real-time CGM alone has been found to reduce both severe hypoglycemia and hypoglycemia unawareness. Closed loop systems (artificial pancreas) comprised of CGM and CSII without patient intervention to adjust basal insulin, which automatically reduce, increase, and suspend insulin delivery, represent a potential new option that is moving toward becoming a reality in the near future. Sensor technology promises to continue to improve patients' lives not only by attaining glycemic control but also by reducing hypoglycemia, a goal best achieved in conjunction with structured individualized patient education.

Sodium-Glucose Cotransporter 2 Inhibitors Reduce Prandial Insulin Doses in Type 2 Diabetic Patients Treated With the Intensive Insulin Therapy

Background

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are anti-diabetic drugs which improve blood glucose control by blocking reabsorption of glucose from the proximal tubule of kidney. Anti-atherosclerotic properties and cardiovascular protective effects of SGLT2i have been demonstrated by recent studies; however, the efficacy and safety of addition of SGLT2i to the intensive insulin therapy remain largely unknown.

Methods

We retrospectively picked up patients hospitalized for treatment of type 2 diabetes, who had been treated by the intensive insulin therapy and whose treatment using by SGLT2i started during their hospitalization. Such patients were picked up between June 2014 and May 2017 based on medical charts.

Results

We found 12 eligible patients. Observation period was 10.2 ± 4.7 days, and SGLT2i was started at 12.2 ± 12.9 days after the admission. During observation period, nobody developed hypoglycemia. In spite of showing decrease of blood glucose (non-significant) before each meal, the addition of SGLT2i significantly reduced daily prandial insulin doses by approximately 4.6 units/day (-66%). The SGLT2i addition also decreased body weight by approximately 1.3 kg.

Conclusion

Present study demonstrated that the addition of SGLT2i to intensive insulin therapy reduced prandial insulin doses and body weight, without the development of hypoglycemia. This result may be due to SGLT2i-mediated improvement of postprandial hyperglycemia by increasing urinary glucose excretion not via insulin secretion.

Effect of short-term intensive insulin therapy on the incretin response in early type 2 diabetes

AIMS

Short-term intensive insulin therapy (IIT) and gastric bypass surgery are both interventions that can improve beta-cell function, reduce insulin resistance and induce remission of type 2 diabetes. Whereas gastric bypass yields an enhanced glucagon-like peptide-1 (GLP-1) response that may contribute to its metabolic benefits, the effect of short-term IIT on the incretin response is unclear. Thus, we sought to evaluate the impact of IIT on GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) secretion in early type 2 diabetes.

METHODS

In this study, 63 patients (age 59±8.3 years, baseline A1c 6.8±0.7%, diabetes duration 3.0±2.1 years) underwent 4 weeks of IIT (basal insulin detemir and pre-meal insulin aspart). GLP-1, GIP and glucagon responses were assessed by the area-under-the-curve (AUC) of these hormones on oral glucose tolerance tests at baseline and 1-day after the completion of therapy. Beta-cell function was assessed by Insulin Secretion-Sensitivity Index-2 (ISSI-2), with insulin resistance measured by Homeostasis Model Assessment (HOMA-IR).

RESULTS

As expected, comparing the post-therapy oral glucose tolerance test to that at baseline, IIT increased ISSI-2 (P=0.02), decreased HOMA-IR (P<0.001), and reduced AUC_glucagon (P<0.001). Of note, however, IIT had no significant impact on AUC_GLP-1 (P=0.24) and reduced AUC_GIP (P=0.02).

CONCLUSION

Despite improving beta-cell function, insulin resistance and glucagonemia, short-term IIT does not change GLP-1 secretion and decreases the GIP response to an oral glucose challenge in early type 2 diabetes. Thus, the beneficial impact of this therapy on glucose homeostasis is not attributable to its effects on incretin secretion.

Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis

Background

Optimal glycaemic targets in traumatic brain injury (TBI) remain unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing intensive with conventional glycaemic control in TBI requiring admission to an intensive care unit (ICU).

Methods

We systematically searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to November 2016. Outcomes of interest included ICU and in-hospital mortality, poor neurological outcome, the incidence of hypoglycaemia and infective complications. Data were analysed by pairwise random effects models with secondary analysis of differing levels of conventional glycaemic control.

Results

Ten RCTs, involving 1066 TBI patients were included. Three studies were conducted exclusively in a TBI population, whereas in seven trials, the TBI population was a sub-cohort of a mixed neurocritical or general ICU population. Glycaemic targets with intensive control ranged from 4.4 to 6.7 mmol/L, while conventional targets aimed to keep glucose levels below thresholds of 8.4–12 mmol/L. Conventional versus intensive control showed no association with ICU or hospital mortality (relative risk (RR) (95% CI) 0.93 (0.68–1.27), P = 0.64 and 1.07 (0.84–1.36), P = 0.62, respectively). The risk of a poor neurological outcome was higher with conventional control (RR (95% CI) = 1.10 (1.001–1.24), P = 0.047). However, severe hypoglycaemia occurred less frequently with conventional control (RR (95% CI) = 0.22 (0.09–0.52), P = 0.001).

Conclusions

This meta-analysis of intensive glycaemic control shows no association with reduced mortality in TBI. Intensive glucose control showed a borderline significant reduction in the risk of poor neurological outcome, but markedly increased the risk of hypoglycaemia. These contradictory findings should motivate further research.

Electronic supplementary material

The online version of this article (10.1186/s13054-017-1883-y) contains supplementary material, which is available to authorized users.

Potential link between post-acute ischemic stroke exposure to hypoglycemia and hemorrhagic transformation

Hemorrhagic transformation is a severe complication of acute ischemic stroke owing to its limited treatment options and poor prognosis. In the last decade, the rates of hemorrhagic transformation incidence have been associated with blood glucose levels. In particular, hyperglycemia at the time of admission has been associated with increased rates of hemorrhagic transformation in acute ischemic stroke patients. Recent pilot clinical trials have attempted to use intensive insulin therapy during stroke treatment to reduce the severity of cerebral infarction and possibly alleviate the risk of hemorrhagic transformation. However, the results of these studies have shown no clear clinical benefit. In addition, intensive insulin therapy has increased rates of hypoglycemia which may be associated with larger infarct growth. We hypothesize that hypoglycemia, similarly to hyperglycemia, is a risk factor for worse outcomes in acute ischemic stroke by promoting hemorrhagic transformation. This review serves to call attention to patterns present within intensive insulin therapy trials and shed light into the pathophysiological effects of hypoglycemia. It is critical that efforts be directed toward the prevention of hemorrhagic transformation by optimizing insulin therapy during the treatment of acute ischemic stroke.

Comparison between a novel and conventional artificial pancreas for perioperative glycemic control using a closed-loop system

This clinical study aimed to compare a novel and conventional artificial pancreas (AP) used in surgical patients for perioperative glycemic control, with respect to usability, blood glucose measurements, and glycemic control characteristics. From July in 2010 to March in 2015, 177 patients underwent perioperative glycemic control using a novel AP. Among them, 166 patients were eligible for inclusion in this study. Intensive insulin therapy (IIT) targeting a blood glucose range of 80-110 mg/dL was implemented in 82 patients (49 %), and the remaining 84 patients (51 %) received a less-intensive regime of insulin therapy. Data were collected prospectively and were reviewed or analyzed retrospectively. A comparison study of 324 patients undergoing IIT for glycemic control using a novel (n = 82) or conventional AP (n = 242) was conducted retrospectively. All patients had no hypoglycemia. The comparison study revealed no significant differences in perioperative mean blood glucose level, achievement rates for target blood glucose range, and variability in blood glucose level achieved with IIT between the novel AP and conventional AP groups. The usability, performance with respect to blood glucose measurement, and glycemic control characteristics of IIT were comparable between novel and conventional AP systems. However, the novel AP was easier to manipulate than the conventional AP due to its smaller size, lower weight, and shorter time for preparation. In the near future, this novel AP system might be accepted worldwide as a safe and useful device for use in perioperative glycemic control.

Cost effectiveness and value of information analyses of islet cell transplantation in the management of 'unstable' type 1 diabetes mellitus

BACKGROUND

Islet cell transplantation is a method to stabilize type 1 diabetes patients with hypoglycemia unawareness and unstable blood glucose levels by reducing insulin dependency and protecting against severe hypoglycemia through restoring endogenous insulin secretion. This study analyses the current cost-effectiveness of this technology and estimates the value of further research to reduce uncertainty around cost-effectiveness.

METHODS

We performed a cost-utility analysis using a Markov cohort model with a mean patient age of 49 to simulate costs and health outcomes over a life-time horizon. Our analysis used intensive insulin therapy (IIT) as comparator and took the provincial healthcare provider perspective. Cost and effectiveness data for up to four transplantations per patient came from the University of Alberta hospital. Costs are expressed in 2012 Canadian dollars and effectiveness in quality-adjusted life-years (QALYs) and life years. To characterize the uncertainty around expected outcomes, we carried out a probabilistic sensitivity analysis within the Bayesian decision-analytic framework. We performed a value-of-information analysis to identify priority areas for future research under various scenarios. We applied a structural sensitivity analysis to assess the dependence of outcomes on model characteristics.

RESULTS

Compared to IIT, islet cell transplantation using non-generic (generic) immunosuppression had additional costs of $150,006 ($112,023) per additional QALY, an average gain of 3.3 life years, and a probability of being cost-effective of 0.5 % (28.3 %) at a willingness-to-pay threshold of $100,000 per QALY. At this threshold the non-generic technology has an expected value of perfect information (EVPI) of $260,744 for Alberta. This increases substantially in cost-reduction scenarios. The research areas with the highest partial EVPI are costs, followed by natural history, and effectiveness and safety.

CONCLUSIONS

Current transplantation technology provides substantial improvements in health outcomes over conventional therapy for highly selected patients with 'unstable' type 1 diabetes. However, it is much more costly and so is not cost-effective. The value of further research into the cost-effectiveness is dependent upon treatment costs. Further, we suggest the value of information should not only be derived from current data alone when knowing that this data will most likely change in the future.

Intensive insulin therapy implementation by means of planned versus emergent change approach

BACKGROUND

Nurses' participation in decisions about new care procedures and protocols is potentially of benefit for patient outcomes. Whether nurses' participation in decisions is allowed in the implementation of innovations depends on the implementation approach used for the introduction. A planned change implementation approach does not allow it, an emergent change implementation approach does.

AIM

To compare a planned change and an emergent change implementation approach to introduce an intensive insulin therapy to an intensive care unit (ICU).

DESIGN

A prospective comparative study in an ICU in the Netherlands of two teams of nurses using either implementation approach.

METHODS

Pre-introduction of the comparability of the two teams was assessed. The nurse compliance to the protocol was assessed as being nurses' behaviour according to the protocol and leading to acceptable glucose values. The effectiveness of the implementation was assessed by measuring the percentage of patients' glucose values within the target range, the occurrence of hypoglycaemic events and the time to glucose value normalization. Data were collected from December 2007 till January 2009.

RESULTS

In the emergent change approach team there was better nurse compliance measurements than in the planned change approach team (83.5% vs 66,8% conform protocol), a better percentage of glucose values in the target range (53,5% vs 52.8%) and a shorter time to glucose value normalization.

CONCLUSION

The implementation approach allowing nurse participation was associated with better nurse compliance and patient outcome measurements. The implementation approach did not conflict with introducing an evidence-based innovation. It was also associated with more effective adaptation of the protocol to changing circumstances.

RELEVANCE FOR CLINICAL PRACTICE

When a new treatment requires adaptability to changing circumstances to be most effective, nurses' participation in decisions about the implementation of the treatment should be considered.

Insulin requirement profiles of short-term intensive insulin therapy in patients with newly diagnosed type 2 diabetes and its association with long-term glycemic remission

AIMS

To investigate the insulin requirement profiles during short-term intensive continuous subcutaneous insulin infusion (CSII) in patients with newly diagnosed type 2 diabetes and its relationship with long-term glycemic remission.

METHODS

CSII was applied in 104 patients with newly diagnosed type 2 diabetes. Daily insulin doses were titrated and recorded to achieve and maintain euglycemia for 2 weeks. Measurements of blood glucose, lipid profiles as well as intravenous glucose tolerance tests were performed before and after the therapy. Afterwards, patients were followed up for 1 year.

RESULTS

Total daily insulin dose (TDD) was 56.6±16.1IU at the first day when euglycemia was achieved (TDD-1). Thereafter, TDD progressively decreased at a rate of 1.4±1.0IU/day to 36.2±16.5IU at the end of the therapy. TDD-1 could be estimated with body weight, FPG, triglyceride and waist circumference in a multiple linear regression model. Decrement of TDD after euglycemia was achieved (ΔTDD) was associated with reduction of HOMA-IR (r=0.27, P=0.008) but not with improvement in β cell function. Patients in the lower tertile of ΔTDD had a significantly higher risk of hyperglycemia relapse than those in the upper tertile within 1 year (HR 3.4, 95%CI [1.4, 8.4], P=0.008).

CONCLUSIONS

There is a steady decline of TDD after euglycemia is achieved in patients with newly diagnosed type 2 diabetes treated with CSII, and ΔTDD is associated with a better long-term glycemic outcome.

Stabilization of postprandial blood glucose fluctuations by addition of glucagon like polypeptide-analog administration to intensive insulin therapy

Aims/Introduction

The nature of the action of concomitant liraglutide to stabilize postprandial blood glucose level (PBG) in patients on intensive insulin therapy with unstable PBG remains unclear. The aim was to identify the nature of liraglutide's actions to stabilize PBGs.

Materials and Methods

The study participants consisted of 20 diabetes patients showing unstable PBGs after dinner despite undergoing intensive insulin therapy. The dose of bolus insulin was reduced by three units for each meal, and 0.9 mg/day of liraglutide was added and used in combination. We evaluated the participants' data after the first evaluation (immediately before using liraglutide in combination) and the second evaluation (16 weeks after starting concomitant therapy). PBGs after dinner were measured every day for a period of 28 days immediately before carrying out both evaluations. The mean value of the 28 sets of blood glucose data and their standard deviation (SD) values were established as PBGs after dinner, as well as the SD for each participant. The changes in the mean values of the 20 participants, as well as their SD between before and after concomitant therapy, were evaluated.

Results

The mean value of PBGs (12.0 ± 1.0 to 10.1 ± 0.9 mmol/L) and SD values (5.1 ± 0.7–3.5 ± 0.8) after dinner both declined. A multiple regression analysis showed that the combined use of liraglutide was a significant independent variable of the SD values of PBGs after dinner.

Conclusion

The treatment of reducing the dose of insulin and using liraglutide in combination not only suppresses PBGs, but also stabilizes their blood glucose fluctuations.

Poorer glycaemic control in type 1 diabetes is associated with reduced self-management and poorer perceived health: a cross-sectional study

AIMS

Many people with type 1 diabetes do not achieve optimal treatment targets despite high patient and professional input. To investigate the reasons underlying suboptimal control we have studied clinical characteristics and self-management behaviours in adults with type 1 diabetes attending a large treatment centre.

METHODS

A questionnaire-based enquiry into self-care behaviours of 380 patients with type 1 diabetes (mean age: 48 (±15) years and mean duration of diabetes: 26 (±15) years), linked with validated measures of impact of treatment on perceived health and hypoglycaemia recognition (Insulin Treatment Satisfaction Questionnaire; and EuroQoL EQ-5D, Gold score) and retrospective case note review of biomedical parameters. The data were analysed using chi-square test, ANOVA, ANCOVA and post-hoc procedures (Tukey's-b) in SPSS-version 18. The minimum significance level was accepted as 0.05.

RESULTS

Sixty three percent of participants used multiple daily injections; 36% continuous subcutaneous insulin infusion. Mean HbA1c was 7.7% (±1.2) [61±-10mmol/mol]; 30% had impaired hypoglycaemia awareness (IHA). Factors significantly related to poor glycaemic control with IHA were longer duration of diabetes (p=0.01); less frequent glucose self-monitoring (p=0.05); and low level of patient-set glucose targets (p<0.001). Patients with IHA and poorer control had significantly lower insulin treatment satisfaction (p<0.001); and perceived health (p<0.001).

CONCLUSIONS

Suboptimal biomedical outcomes in adults with type 1 diabetes attending a specialist intensified insulin therapy clinic are associated with longer duration of diabetes, fewer self-management behaviours and a trend towards poorer perceived health. These data suggest a need for greater emphasis on integration of psychological and self-management support with intensive medical management of type 1 diabetes.

Conventional insulin vs insulin infusion therapy in acute coronary syndrome diabetic patients

AIM: To evaluate the impact on glucose variability (GLUCV) of an nurse-implemented insulin infusion protocol when compared with a conventional insulin treatment during the day-to-day clinical activity.

METHODS: We enrolled 44 type 2 diabetic patients (n = 32 males; n = 12 females) with acute coronary syndrome (ACS) and randomy assigned to standard a subcutaneous insulin treatment (n = 23) or a nurse-implemented continuous intravenous insulin infusion protocol (n = 21). We utilized some parameters of GLUCV representing well-known surrogate markers of prognosis, i.e., glucose standard deviation (SD), the mean daily δ glucose (mean of daily difference between maximum and minimum glucose), and the coefficient of variation (CV) of glucose, expressed as percent glucose (SD)/glucose (mean).

RESULTS: At the admission, first fasting blood glucose, pharmacological treatments (insulin and/or anti-diabetic drugs) prior to entering the study and basal glycated hemoglobin (HbA1c) were observed in the two groups treated with subcutaneous or intravenous insulin infusion, respectively. When compared with patients submitted to standard therapy, insulin-infused patients showed both increased first 24-h (median 6.9 mmol/L vs 5.7 mmol/L P < 0.045) and overall hospitalization δ glucose (median 10.9 mmol/L vs 9.3 mmol/L, P < 0.028), with a tendency to a significant increase in first 24-h glycaemic CV (23.1% vs 19.6%, P < 0.053). Severe hypoglycaemia was rare (14.3%), and it was observed only in 3 patients receiving insulin infusion therapy. HbA1c values measured during hospitalization and 3 mo after discharge did not differ in the two groups of treatment.

CONCLUSION: Our pilot data suggest that no real benefit in terms of GLUCV is observed when routinely managing blood glucose by insulin infusion therapy in type 2 diabetic ACS hospitalized patients in respect to conventional insulin treatment

The clinical impact of inpatient hypoglycemia

Hypoglycemia is common in hospitalized patients and is associated with poor outcomes, including increased mortality. Older individuals and those with comorbidities are more likely to suffer the adverse consequences of inpatient hypoglycemia. Observational studies have shown that spontaneous inpatient hypoglycemia is a greater risk factor for death than iatrogenic hypoglycemia, suggesting that hypoglycemia acts as a marker for more severe illness, and may not directly cause death. Initial randomized controlled trials of intensive insulin therapy in intensive care units demonstrated improvements in mortality with tight glycemic control, despite high rates of hypoglycemia. However, follow-up studies have not confirmed these initial findings, and the largest NICE-SUGAR study showed an increase in mortality in the tight control group. Despite these recent findings, a causal link between hypoglycemia and mortality has not been clearly established. Nonetheless, there is potential for harm from inpatient hypoglycemia, so evidence-based strategies to treat hyperglycemia, while preventing hypoglycemia should be instituted, in accordance with current practice guidelines.

Does serum cystatin C level reflect insulin resistance in patients with type 1 diabetes?

OBJECTIVES

The aim of study was to evaluate the relationship between serum cystatin C and insulin resistance (IR) in type 1 diabetic patients being the participants of Poznan Prospective Study.

DESIGN AND METHODS

The study was performed on 71 Caucasian patients (46 men); with type 1 diabetes, who were recruited into the Poznan Prospective Study, at the age of 39±6.1 meanly, and treated with intensive insulin therapy since the onset of the disease. The follow-up period and diabetes duration were 15±1.6 years. Insulin resistance (IR) was assessed by estimated glucose disposal rate (eGDR) calculation with cut-off point 7.5 mg/kg/min. Patients were divided into two groups, according to the presence or absence of IR.

RESULTS

From among 71 patients, 31 patients (43.7%) presented decreased sensitive to insulin with eGDR below 7.5 mg/kg/min. Patients who had eGDR <7.5 mg/kg/min (insulin resistant), compared with subjects with eGDR >7.5 mg/kg/min (insulin sensitive), had higher level of serum cystatin C [0.59 (IQR:0.44-0.84) vs 0.46 (IQR:0.37-0.55) mg/L, p=0.009]. A significant negative correlation between cystatin C and eGDR was revealed (Rs=-0.39, p=0.001). In regression model cystatin C was related to insulin resistance, adjusted for sex, BMI, eGFR and duration of diabetes [OR 0.03 (0.001-0.56), p=0.01].

CONCLUSIONS

Higher level of serum cystatin C is related to decreased insulin sensitivity in patients with type 1 diabetes. This relationship seems to have an important clinical implication.

Short acting insulin analogues in intensive care unit patients

Blood glucose control in intensive care unit (ICU) patients, addressed to actively maintain blood glucose concentration within defined thresholds, is based on two major therapeutic interventions: to supply an adequate calories load and, when necessary, to continuously infuse insulin titrated to patients needs: intensive insulin therapy (IIT). Short acting insulin analogues (SAIA) have been synthesized to improve the chronic treatment of patients with diabetes but, because of the pharmacokinetic characteristics that include shorter on-set and off-set, they can be effectively used also in ICU patients and have the potential to be associated with a more limited risk of inducing episodes of iatrogenic hypoglycemia. Medical therapies carry an intrinsic risk for collateral effects; this can be more harmful in patients with unstable clinical conditions like ICU patients. To minimize these risks, the use of short acting drugs in ICU patients have gained a progressively larger room in ICU and now pharmaceutical companies and researchers design drugs dedicated to this subset of medical practice. In this article we report the rationale of using short acting drugs in ICU patients (i.e., sedation and treatment of arterial hypertension) and we also describe SAIA and their therapeutic use in ICU with the potential to minimize iatrogenic hypoglycemia related to IIT. The pharmacodynamic and pharmachokinetic characteristics of SAIA will be also discussed.

Efficacy of liraglutide as a follow-up therapy after resolution of glucotoxicity with intensive insulin therapy

OBJECTIVE

To assess the utility of liraglutide, a GLP-1 receptor agonist, as additional therapy following resolution of glucotoxicity with insulin therapy.

METHODS

The subjects were 13 Japanese patients with short-duration type 2 diabetes mellitus (2.0 ± 2.1 years). At first, treatment with insulin therapy consisted of bolus insulin before each meal and basal insulin at bed time commenced to improve every preprandial glucose levels below 130 mg/dL. Then, insulin therapy was replaced with liraglutide monotherapy in case in which 50% or more self-monitoring of blood glucose (SMBG) tests revealed preprandial glucose levels of less than 130 mg/dL at least for one month. Liraglutide dosing was initiated at 0.3 mg/day and increased in weekly or biweekly increments of 0.3 mg/day, to the maximum permissible dose (in Japan) of 0.9 mg/day. The participants were treated with liraglutide for 24 weeks.

RESULTS

The average insulin therapy period was 13.2 ± 5.4 weeks, and insulin therapy significantly improved HbA1c values from 12.4% ± 1.6% to 6.8% ± 0.9% (P < 0.05). After improvement of hyperglycemia with insulin therapy and switching to liraglutide monotherapy for 24 weeks, HbA1c values remained constant (6.2% ± 1.0% at week 24) and the rates of hypoglycemic episodes significantly decreased (P < 0.05).

CONCLUSIONS

These data suggest that liraglutide is proposed as an alternative follow-up therapy subsequent to eliminate glucotoxicity with insulin therapy.

Glycemia management in critical care patients

Over the last decade, the approach to clinical management of blood glucose concentration (BGC) in critical care patients has dramatically changed. In this editorial, the risks related to hypo, hyperglycemia and high BGC variability, optimal BGC target range and BGC monitoring devices for patients in the intensive care unit (ICU) will be discussed. Hypoglycemia has an increased risk of death, even after the occurrence of a single episode of mild hypoglycemia (BGC < 80 mg/dL), and it is also associated with an increase in the ICU length of stay, the major determinant of ICU costs. Hyperglycemia (with a threshold value of 180 mg/dL) is associated with an increased risk of death, longer length of stay and higher infective morbidity in ICU patients. In ICU patients, insulin infusion aimed at maintaining BGC within a 140-180 mg/dL target range (NICE-SUGAR protocol) is considered to be the state-of-the-art. Recent evidence suggests that a lower BGC target range (129-145 mg/dL) is safe and associated with lower mortality. In trauma patients without traumatic brain injury, tight BGC (target < 110 mg/dL) might be associated with lower mortality. Safe BGC targeting and estimation of optimal insulin dose titration should include an adequate nutrition protocol, the length of insulin infusion and the change in insulin sensitivity over time. Continuous glucose monitoring devices that provide accurate measurement can contribute to minimizing the risk of hypoglycemia and improve insulin titration. In conclusion, in ICU patients, safe and effective glycemia management is based on accurate glycemia monitoring and achievement of the optimal BGC target range by using insulin titration, along with an adequate nutritional protocol.

Effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing gastrectomy

AIM: To investigate the effect of intensive vs conventional insulin therapy on perioperative nutritional substrates metabolism in patients undergoing radical distal gastrectomy.

METHODS: Within 24 h of intensive care unit management, patients with gastric cancer were enrolled after written informed consent and randomized to the intensive insulin therapy (IIT) group to keep glucose levels from 4.4 to 6.1 mmol/L or the conventional insulin therapy (CIT) group to keep levels less than 10 mmol/L. Resting energy expenditure (REE), respiratory quotient (RQ), resting energy expenditure per kilogram (REE/kg), and the lipid oxidation rate were monitored by the indirect calorimeter of calcium citrate malate nutrition metabolism investigation system. The changes in body composition were analyzed by multi-frequency bioimpedance analysis. Blood fasting glucose and insulin concentration were measured for assessment of Homeostasis model assessment of insulin resistance.

RESULTS: Sixty patients were enrolled. Compared with preoperative baseline, postoperative REE increased by over 22.15% and 11.07%; REE/kg rose up to 27.22 ± 1.33 kcal/kg and 24.72 ± 1.43 kcal/kg; RQ decreased to 0.759 ± 0.034 and 0.791 ± 0.037; the lipid oxidation ratio was up to 78.25% ± 17.74% and 67.13% ± 12.76% supported by parenteral nutrition solutions from 37.56% ± 11.64% at the baseline; the level of Ln-HOMA-IR went up dramatically (P < 0.05, respectively) on postoperative days 1 and 3 in the IIT group. Meanwhile the concentration of total protein, albumin and triglyceride declined significantly on postoperative days 1 and 3 compared with pre-operative levels (P < 0.05, respectively). Compared with the CIT group, IIT reduced the REE/kg level (27.22 ± 1.33 kcal/kg vs 29.97 ± 1.47 kcal/kg, P = 0.008; 24.72 ± 1.43 kcal/kg vs 25.66 ± 1.63 kcal/kg, P = 0.013); and decreased the Ln-HOMA-IR score (P = 0.019, 0.028) on postoperative days 1 and 3; IIT decreased the level of CRP on postoperative days 1 and 3 (P = 0.017, 0.006); the total protein and albumin concentrations in the IIT group were greater than those in the CIT group (P = 0.023, 0.009). Postoperative values of internal cell fluid (ICF), fat mass, protein mass (PM), muscle mass, free fat mass and body weight decreased obviously on postoperative 7th day compared with the preoperative baseline in the CIT group (P < 0.05, respectively). IIT reduced markedly consumption of fat mass, PM and ICF compared with CIT (P = 0.009 to 0.026).

CONCLUSION: There were some benefits of IIT in decreasing the perioperative insulin resistance state, reducing energy expenditure and consumption of proteins and lipids tissue in patients undergoing gastrectomy.

Perioperative insulin therapy using a closed-loop artificial endocrine pancreas after hepatic resection

Postoperative hyperglycemia is common in critically ill patients, even in those without a prior history of diabetes mellitus. It is well known that hyperglycemia induced by surgical stress often results in dysregulation of liver metabolism and immune function, impairing postoperative recovery. Current evidence suggests that maintaining normoglycemia postoperatively improves surgical outcome and reduces the mortality and morbidity of critically ill patients. On the basis of these observations, several large randomized controlled studies were designed to evaluate the benefit of postoperative tight glycemic control with intensive insulin therapy. However, intensive insulin therapy carries the risk of hypoglycemia, which is linked to serious neurological events. Recently, we demonstrated that perioperative tight glycemic control in surgical patients could be achieved safely using a closed-loop glycemic control system and that this decreased both the incidence of infection at the site of the surgical incision, without the appearance of hypoglycemia, and actual hospital costs. Here, we review the benefits and requirements of perioperative intensive insulin therapy using a closed-loop artificial endocrine pancreas system in hepatectomized patients. This novel intensive insulin therapy is safe and effectively improves surgical outcome after hepatic resection.