Experienced Hypoglycemia Research Articles

Persistent Hypoglycemia in Premature, Small for Term, and Low Birth Weight Neonates from Mothers with a History of Severe Preeclampsia

Background: Neonatal hypoglycemia is a metabolic problem that is often found in the NICU and is one of the causes of permanent brain damage in infants. The diagnosis of persistent hypoglycemia and its causes are still controversial. Case: A male baby was born to a mother with severe preeclampsia at 36 weeks of gestation, with a birth weight of 1600 grams. At 1 hour of age, he experienced hypoglycemia that lasted more than 72 hours with the lowest blood sugar of 18 mg/dL, and experienced hyperkalemia (potassium level 6.1 mmol/L). The baby is diagnosed as persistent hypoglycemia. The clinical condition improved after being given dextrose and dexamethasone, and was discharged in stable condition. Conclusion: Management of persistent hypoglycemia depends on the cause. Diagnosis refers to risk factors before or after birth.

Personalized management of hepatic glycogen storage disorders: The role of continuous glucose monitoring.

Glycogen storage disorders (GSD), inherent disorders of carbohydrate metabolism, feature hypoglycemia as a hallmark. Normoglycemia and glucose monitoring are pivotal in disease management. Conventional glucometer-based monitoring may overlook hypoglycemic trends. This study assesses glycemic control in Asian Indian GSD children using continuous glucose monitoring (CGM) and its role in facilitating dietary adjustments. A pre-post study enrolled molecularly confirmed GSDI, GSDIII, GSDVI, and GSDIX patients for baseline dietary compliance and CGM-based glycemic status evaluation. Hypoglycemic patients were stratified into diet-compliant and diet-noncompliant groups. Noncompliant patients received dietary reinforcement; compliant individuals underwent dietary adjustments. Repeat CGM (rCGM) was performed 6 weeks to 6 months postadjustments. Clinical and metabolic parameters were re-evaluated at 6 months. Of the 20 patients assessed at baseline, 11 were diet compliant. Six among these exhibited hypoglycemia, prompting diet adjustments. Among nine noncompliant patients, eight experienced hypoglycemia and received diet reinforcement. rCGM in 10 patients (five GSDI, three GSDIII, and two GSDIXc) showed a significant reduction in hypoglycemia duration in all. An improvement in height and body mass index was observed in all GSDI and GSDIII patients. Triglyceride levels, raised at baseline in two GSDI and one GSDIII, showed a substantial decline in one GSDI patient. Hepatic transaminase levels decreased in both GSDIXc patients. Plasma lactate levels decreased in all GSDI patients. CGM is an efficacious adjunct in the personalized management of hepatic GSD patients, in the Asian Indian population. The study also underscores the need for long-term follow-up to determine the role of glycemic management in growth, general well-being, and metabolic control in the GSD subtypes.

NEONATAL OUTCOMES IN INFANTS OF DIABETIC MOTHERS: FOCUS ON HYPOGLYCEMIA, RESPIRATORY DISTRESS SYNDROME AND MACROSOMIA

Background: Infants of diabetic mothers (IDMs) face heightened risks of various neonatal complications. This study evaluates the incidence of specific complications-macrosomia, hypoglycaemia, and neonatal respiratory distress syndrome (NRDS)-in this population. Methods: A cross-sectional observational study was conducted over 1.5 years at a tertiary hospital in Mumbai. We reviewed the medical records of infants born to mothers with diabetes (both pregestational and gestational). Data on the incidence of macrosomia (birth weight >4000 grams), hypoglycaemia (blood glucose <40 mg/dL), and NRDS (diagnosed based on clinical and radiographic criteria) were collected. Results: Among the 50 infants studied, 8% were diagnosed with macrosomia, 46% experienced hypoglycaemia, and 20% developed NRDS. The frequency of these complications was significantly higher in IDMs compared to the general neonatal population. Conclusion: This study reveals a high incidence of macrosomia, hypoglycaemia, and NRDS in IDMs, emphasizing the need for regular antenatal follow-up and strict glycaemic control throughout pregnancy. Enhanced monitoring and management strategies are essential to mitigate these risks and improve neonatal health outcomes.

6521 Continuation of Continuous Glucose Monitors in Hospitalized Diabetic Patients Decreased the Incidence of Hypoglycemia

Abstract Disclosure: C.E. DeClue: None. S. Bao: None. Objective: Glycemic control improves patient outcomes in hospitalized patients, and this is generally achieved by monitoring point-of-care (POC) capillary glucose levels. In the outpatient setting, continuous glucose monitoring (CGM) devices have shown improved glycemic control in diabetic patients, but their evidence in hospitalized patients is lacking. Methods: To evaluate CGM accuracy and safety of use in the inpatient setting, 567 consults were analyzed in a single-center inpatient diabetes service between November 2022 and January 2023. Patients were included if managed with multiple daily injections or insulin pump therapy and separated into four groups based on CGM continuation and type of diabetes. POC glucose and incidence of hypoglycemia were recorded over 72 hours from the time of consultation. Results: Forty-six Type-1 (T1DM) and 72 Type-2 (T2DM) diabetic patients were included in this study, with average hemoglobin A1c of 8.6% and 9.0%, respectively. Both diabetic groups showed an average POC glucose that was not statistically different based on CGM continuation (185 mg/dL for T1DM and 187 mg/dL for T2DM continued on CGM versus 183 mg/dL for T1DM and 188 mg/dL for T2DM not using CGM). However, only 2 of the 18 T1DM patients continued on CGM experienced hypoglycemia, whereas 17 of the 28 T1DM patients not using CGM experienced at least 1 hypoglycemic event. Similarly, only 2 of the 20 T2DM patients continued on CGM experienced hypoglycemia, whereas 13 of the 52 patients not using CGM experienced at least 1 hypoglycemic event. Additionally, less glucose variability was observed in both T1DM and T2DM patients continued on CGM (average standard deviation of 64 mg/dL and 55 mg/dL, respectively) compared to those not using CGM (average standard deviation of 84 mg/dL and 62 mg/dL, respectively). Conclusion: CGM has great potential to improve patient care and nursing workload in the hospital, but the safety and accuracy are not yet well-established. In this study, there seemed to be a statistically insignificant trend to less glycemic variability for CGM users despite no glycemic difference on average POC testing. Importantly, significantly fewer hypoglycemic events were observed in patients continued on CGM devices regardless of type of diabetes or baseline glycemic control. This study adds further evidence to the growing body of work supporting improved safety of CGM utilization in hospitalized diabetic patients. Presentation: 6/1/2024

The impact of hypoglycaemia on daily functioning among adults with diabetes: a prospective observational study using the Hypo-METRICS app

Aims/hypothesisThe aim of this work was to examine the impact of hypoglycaemia on daily functioning among adults with type 1 diabetes or insulin-treated type 2 diabetes, using the novel Hypo-METRICS app.MethodsFor 70 consecutive days, 594 adults (type 1 diabetes, n=274; type 2 diabetes, n=320) completed brief morning and evening Hypo-METRICS ‘check-ins’ about their experienced hypoglycaemia and daily functioning. Participants wore a blinded glucose sensor (i.e. data unavailable to the participants) for the study duration. Days and nights with or without person-reported hypoglycaemia (PRH) and/or sensor-detected hypoglycaemia (SDH) were compared using multilevel regression models.ResultsParticipants submitted a mean ± SD of 86.3±12.5% morning and 90.8±10.7% evening check-ins. For both types of diabetes, SDH alone had no significant associations with the changes in daily functioning scores. However, daytime and night-time PRH (with or without SDH) were significantly associated with worsening of energy levels, mood, cognitive functioning, negative affect and fear of hypoglycaemia later that day or while asleep. In addition, night-time PRH (with or without SDH) was significantly associated with worsening of sleep quality (type 1 and type 2 diabetes) and memory (type 2 diabetes). Further, daytime PRH (with or without SDH), was associated with worsening of fear of hyperglycaemia while asleep (type 1 diabetes), memory (type 1 and type 2 diabetes) and social functioning (type 2 diabetes).Conclusions/interpretationThis prospective, real-world study reveals impact on several domains of daily functioning following PRH but not following SDH alone. These data suggest that the observed negative impact is mainly driven by subjective awareness of hypoglycaemia (i.e. PRH), through either symptoms or sensor alerts/readings and/or the need to take action to prevent or treat episodes.Graphical

Risk Stratification, Intention to Fast, and Outcomes of Fasting During Ramadan in People With Diabetes Presenting to a Tertiary Care Hospital

ObjectiveThe objectives of this study were to evaluate the stratification of people with diabetes mellitus (DM) based on the International Diabetes Federation–Diabetes and Ramadan 2021 risk calculator into different risk categories and assess their intentions to fast and outcomes of fasting during the holy month of Ramadan. MethodsThis was a 3-month prospective study that was performed from February 9, 2023, to May 6, 2023 (6 weeks before Ramadan until 6 weeks after Ramadan), at a tertiary care hospital in Pakistan. Data regarding glycemic control, characteristics and complications of diabetes, comorbidities, and the various factors that influence fasting were gathered from patients of either sex aged 18 to 80 years with any type of diabetes. The International Diabetes Federation–Diabetes and Ramadan 2021 risk calculation and recommendation were made accordingly for each patient. ResultsThis study comprised of 460 participants with DM, with 174 males (37.8%) and 286 females (62.2%). The risk categorization showed that 209 (45.4%), 107 (23.3%), and 144 (31.3%) of the participants were in the low-, moderate-, and high-risk categories, respectively. Of the 144 high-risk patients who fasted, 57.9% experienced hypoglycemia (P <.0001). The recommendation of fasting showed statistically significant differences with risk categories, intention to fast, hypoglycemia, type of DM, duration of DM, level of glycemic control, and days of fasting (P <.001). ConclusionA statistically significant number of participants in the high-risk group who fasted experienced complications. This reiterates the importance of rigorous adherence to the medical recommendations.

Neonatal Hypoglycemia and Neurocognitive Function at School Age: A Prospective Cohort Study

To determine the relationship between transient neonatal hypoglycemia in at-risk infants and neurocognitive function at 6-7years of corrected age. The pre-hPOD Study involved children born with at least 1 risk factor for neonatal hypoglycemia. Hypoglycemia was defined as ≥1 consecutive blood glucose concentrations <47mg/dl (2.6mmol/L), severe as <36mg/dl (2.0mmol/L), mild as 36 to <47mg/dL (2.0 to <2.6mmol/L), brief as 1-2 episodes, and recurrent as ≥3 episodes. At 6-7years children were assessed for cognitive and motor function (NIH-Toolbox), learning, visual perception and behavior. The primary outcome was neurocognitive impairment, defined as >1 SD below the normative mean in ≥1 Toolbox tests. The 8 secondary outcomes covered children's cognitive, motor, language, emotional-behavioral, and visual perceptual development. Primary and secondary outcomes were compared between children who did and did not experience neonatal hypoglycemia, adjusting for potential confounding by gestation, birthweight, sex and receipt of prophylactic dextrose gel (pre-hPOD intervention). Secondary analysis included assessment by severity and frequency of hypoglycemia. Of 392 eligible children, 315 (80%) were assessed at school age (primary outcome, n=308); 47% experienced hypoglycemia. Neurocognitive impairment was similar between exposure groups (hypoglycemia 51% vs 50% no hypoglycemia; aRD -4%, 95% CI -15%, 7%). Children with severe or recurrent hypoglycemia had worse visual motion perception and increased risk of emotional-behavioral difficulty. Exposure to neonatal hypoglycemia was not associated with risk of neurocognitive impairment at school-age in at-risk infants, but severe and recurrent episodes may have adverse impacts. Hypoglycemia Prevention in Newborns with Oral Dextrose: the Dosage Trial (pre-hPOD Study): ACTRN12613000322730.

Asma eksaserbasi akut dengan hipertensi urgensi dan obesitas: sebuah laporan kasus

Introduction: Asthma is a chronic inflammatory disease characterized by the rapid and reversible narrowing of the airways. Various factors can influence exacerbations in asthma, and one of the comorbidities is obesity. Inflammation and compensatory mechanisms are related to the occurrence of urgent hypertension in patients with acute exacerbation of asthma, making the analysis and management of asthma exacerbation with comorbidities of obesity and urgent hypertension require special attention and consideration. Case Presentation: This study reports a 17-year-old adolescent with a history of asthma experiencing an acute exacerbation. Comorbidities include obesity with a BMI of 34.6 kg/m2 and urgent hypertension with a blood pressure of 200/100 mmHg. Physical examination revealed wheezing in both lung fields and epigastric tenderness. Radiological examination, including chest X-ray, was within normal limits, while hematological examination showed neutrophilia (8.65 x 103/uL) and 81.4% neutrophil percentage. The patient experienced hypoglycemia (blood glucose of 75 mg/dL). Nebulized bronchodilator therapy with ipratropium bromide, albuterol sulfate, and budesonide corticosteroids was initiated, but respiratory distress persisted. Initial management included oxygenation, intravenous saline, and ranitidine injection, followed by intravenous maintenance fluid with D5 ½ NS, nebulized bronchodilators and corticosteroids, intravenous dexamethasone, intravenous ranitidine, and oral therapy with azithromycin, cetirizine, N-acetylcysteine, and bisoprolol. The patient underwent intensive care for two days with a total treatment duration of six days. Conclusion: Asthma exacerbation with comorbidities of obesity and urgent hypertension requires holistic analysis and management to prevent complications and worsening exacerbations.

Association between low-carbohydrate-diet score, glycemia and cardiovascular risk factors in adults with type 1 diabetes

Background and aimsLow-carbohydrate-diets (LCDs) are gaining popularity in individuals with type 1 diabetes (T1D). However, the impact of such diets on glycemia and cardiovascular risk factors is debated. This study aims to evaluate associations between low-carbohydrate intakes using LCD score with glycemia and cardiovascular risk factors (lipid profile) in adults with T1D or LADA in Québec, Canada. Methods and resultsThis is a cross-sectional study using data collected in the BETTER registry (02/2019 and 04/2021) including self-reported 24-h dietary recalls to calculate LCD scores, waist circumference, level-2 and level-3 hypoglycemic episodes and measured biochemical data (HbA1c, LDL-cholesterol and non-HDL-cholesterol). Participants were divided into quartiles (Q) based on LCD scores. Two hundred eighty-five adults (aged 48.2 ± 15.0 years; T1D duration 25.9 ± 16.2 years) were included. Categorical variables underwent Chi-squared/Fisher's Exact tests, while continuous variables underwent ANOVA tests. Mean carbohydrate intake ranged from 31.2 ± 6.9% (Q1) to 56.5 ± 6.8% (Q4) of total daily energy. Compared to Q4, more people in Q1 reported HbA1c ≤ 7% [≤53.0 mmol/mol] (Q1: 53.4% vs. Q4: 29.4%; P = 0.011). The same results were found in the models adjusted for age, sex and T1D duration. A greater proportion of participants in Q1 never experienced level-3 hypoglycemia compared to Q3 (Q1: 60.0% vs. Q3: 31.0%; P = 0.004). There were no differences across quartiles for frequency of level-2 hypoglycemia events and lipid profile (LDL-cholesterol and non-HDL-cholesterol). ConclusionsLow-carbohydrate intakes are associated with higher probabilities of reaching HbA1c target and of never having experienced level-3 hypoglycemia. No associations with level-2 hypoglycemia frequency, nor cardiovascular risk factors were observed.

Evaluation of Efficacy and Safety of Empagliflozin in Bangladeshi Patients with Type 2 Diabetes Mellitus (EFFISAEM Study)

Abstract Background: Empagliflozin is a relatively newer glucose-lowering drug (GLD) with many extra-glycemic benefits. To date, no study has evaluated the efficacy and safety of empagliflozin in Bangladeshi patients with type 2 diabetes mellitus (T2DM). Objectives: To assess the efficacy and safety of empagliflozin as an add-on to ongoing GLDs in Bangladeshi adults with uncontrolled T2DM. Materials and Methods: This real-world, multicenter, open-label, prospective study was carried out at 21 sites throughout Bangladesh from 1 February 2022 to 31 July 2022. Patients with T2DM who met the criteria had Empagliflozin added to their existing GLD treatment, with necessary modifications to their ongoing medication regimen. The efficacy and safety data were collected 12 weeks after empagliflozin initiation. Results: Out of 1449 subjects initiating empagliflozin, 1340 subjects [age 50.3 ± 9.0 years, male 52.5%, overweight/obese 94.4%, insulin-treated 25.7%, baseline hemoglobin A1c (Hba1c) 9.9 ± 1.4%] completed the study. At 12 weeks, the reduction in HbA1c was 1.6% (95% CI 1.5-1.6, P &lt; 0.001); 12.5% of the study subjects achieved HbA1c &lt; 7%. There were also significant (P &lt; 0.001 in all instances) reductions in fasting plasma glucose (3.0 mmol/L), plasma glucose 2 hours after breakfast (4.8 mmoL/L), body weight (1.9 kg), body mass index (0.8 kg/m2), systolic blood pressure (BP) (10 mmHg), diastolic BP (7 mmHg), insulin dose (3 U), serum creatinine (0.06 mg/dL), total cholesterol (18 mg/dL), low-density lipoprotein cholesterol (13 mg/dL), high-density lipoprotein cholesterol (1 mg/dL), and triglyceride (42 mg/dL) and an increase in estimated glomerular filtration rate (4.2 mL/min/1.73 m2) from the baseline values. 6.62% experienced adverse events (lightheadedness 2.21%, genital tract infection 0.97%, urinary tract infection 1.24%, generalized weakness 0.48%, and nocturia 0.48%). 1.1% of subjects experienced hypoglycemia, and other 0.12% reported severe hypoglycemic events. Conclusion: Empagliflozin is effective, safe, and tolerable for treating Bangladeshi patients with uncontrolled T2DM as add-on therapy in routine clinical practice with favorable effects on body weight, BP, lipid profile, and renal function.

Challenges with glucagon-like peptide-1 (GLP-1) agonist initiation: a case series of semaglutide overdose administration errors

Background Prescriptions of semaglutide, a glucagon-like peptide-1 receptor agonist administered weekly for Type 2 diabetes mellitus and obesity, are increasing. Adverse effects from semaglutide overdose are poorly described. We report adverse effects from three unintentional semaglutide overdoses upon initiation. Case reports Case 1 : A 53-year-old man unintentionally injected semaglutide 2 mg instead of the recommended 0.1 mg. Case 2 : A 45-year-old woman unintentionally injected semaglutide 2.4 mg instead of 0.25 mg. Case 3 : A 33-year-old woman injected semaglutide 1.7 mg. All three of these patients developed nonspecific gastrointestinal symptoms. No patient experienced hypoglycemia. Discussion These unintentional semaglutide overdoses occurred due to deficits in patient and prescriber knowledge, and evasion of regulated access to pharmaceuticals. Nonspecific gastrointestinal symptoms predominated. The potential for hypoglycemia following glucagon-like peptide-1 agonist overdose is unclear, though it did not occur in our patients. It is thought that glucagon-like peptide-1 agonists are unlikely to cause hypoglycemia because their effects are glucose-dependent and diminish as serum glucose concentrations approach euglycemia. There is, however, an increase in hypoglycemia when glucagon-like peptide-1 agonists are combined with sulfonylureas. Conclusions This case series highlights the critical role of patient education and training upon initiation of semaglutide therapy to minimize administration errors and adverse effects from injection of glucagon-like peptide-1 receptor agonists.

Derived Time in Range and Other Metrics of Poor Glycemic Control Associated With Adverse Hospital Outcomes in Patients With Diabetes Mellitus Admitted to Non-ICU Wards at a Tertiary-Level Hospital in Colombia: A Cross-Sectional Study.

Aim: This study is aimed at assessing the prevalence of poor glycemic control using different metrics and its association with in-hospital adverse outcomes. Methods: This cross-sectional study was conducted in diabetic patients admitted to a third-level hospital in Colombia between January and July 2022. Poor glycemic control was determined using capillary glucose metrics, including mean glucose values outside the target range, derived time in range (dTIR) (100-180 mg/dL) < 70%, coefficient of variation (CV > 36%), and hypoglycemia (<70 mg/dL). Multiple regression models were adjusted for hospital outcomes based on glycemic control, as well as other sociodemographic and clinical covariates. Results: A total of 330 Hispanic patients were included. A total of 27.6% had mean glucose measurements outside the target range, 33% had a high CV, 64.8% had low dTIR, and 28.8% experienced hypoglycemia. The in-hospital mortality rate was 8.8%. An admission HbA1c level greater than 7% was linked to an increased mortality risk (p = 0.016), as well as a higher average of glucometer readings (186 mg/dL vs. 143 mg/dL; p < 0.001). A lower average of dTIR (41.0% vs. 60.0%; p < 0.001) was also associated with a higher mortality risk. Glycemic variability was correlated with an increased risk of mortality, hypoglycemia, delirium, and length of hospital stay (LOS). Conclusion: A significant number of hospitalized diabetic patients exhibit poor glycemic control, which has been found to be associated with adverse outcomes, including increased mortality. Metrics like dTIR and glycemic variability should be considered as targets for glycemic control, highlighting the need for enhanced management strategies.

Assessment of patient knowledge, practice and adverse events of insulin administration and storage techniques in patients with diabetes

Diabetes mellitus is a group of metabolic disorder characterised by hyperglycaemia. For effective therapy, correct injection procedures, adequate storage, insulin dose adjustment, meal timing, site rotation, and compliance. The aim of this work is to assess the knowledge and practice of insulin administration and storage techniques in diabetes patients. It is a survey based cross sectional study conducted through both online and offline modes among diabetic patients consuming insulin in Ernakulam district. 213 cases were included and it consist of diabetic patients on insulin therapy. About 54.4% of patients were males and 45.6% patients were females. Majority 57.3% experienced hypoglycaemia and 17.3% never experienced it. 51.6% patients were educated by nurse, 25.6% by doctors and only 17.6% were educated by pharmacist. The study presented an insight into the practices of insulin administration and awareness to the diabetic patients, study also extended to other health care professionals in the society.

Clopidogrel-induced non-diabetic hypoglycemia reported from Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: a case report

BackgroundRecurrent episodes of hypoglycemia may be caused by several factors, including drugs, critical illnesses, hormonal deficiency, non-islet cell tumor endogenous hyperinsulinism, and accidental, surreptitious, or malicious hypoglycemia. Multiple drugs have been previously reported as causes of hypoglycemia, with moderate and low-quality evidence. However, Clopidogrel as a cause of non-diabetic hypoglycemia is rarely reported. Here we describe a single non-diabetic patient who experienced recurrent episodes of hypoglycemia after initiation of clopidogrel for clinical suspicion of acute coronary syndrome.Case presentationThe patient, a 33-year-old Ethiopian male with documented hypertension on antihypertensive medication, has started receiving treatment for acute coronary syndrome after experiencing angina symptoms. He experienced hypoglycemia following the start of Clopidogrel, but it subsided once it was stopped. Currently, he has a follow-up at the cardiac clinic with a normal measurement of his serum blood glucose level.ConclusionNon-diabetic hypoglycemia is a rare illness characterized by low blood glucose levels in people who do not have diabetes. Patients with severe hypoglycemia may become unconscious or have seizures as a result of low blood sugar. Severe hypoglycemia is fatal and must be treated as soon as possible. Therefore, if non-diabetic hypoglycemia occurs, a thorough evaluation of the causes is essential, particularly any potential drug as a cause of hypoglycemia should be evaluated.

The risk of combined use of herbal and conventional medicines in diabetic patients

Background: The prevalence of diabetes mellitus (DM) continues to increase due to changes in human lifestyle. Adherence to taking medication becomes one of the keys to successful blood glucose control. Unfortunately, not all people with DM are obedient to take medicine because of various reasons, such as fear of the side effects. To avoid some concerns about medicine, some prefer to add herbal medicine. Objective: This study determined whether the addition of herbal medicine to conventional drugs increases the incidence of hypoglycemia. Methods: This study was carried out from October 2019-March 2020 on 350 Madurese patients with DM in 33 primary healthcare centres of Madura. Data were collected using a valid and reliable questionnaire. The independent variable in this study was the use of herbal medicine, while the dependent variable was the incidence of hypoglycemia. Results: About 41.4% of respondents used herbal medicine in addition to conventional drugs. Among those who consumed herbal medicine, 59.3% experienced hypoglycemia, while 24.4% did not take herbal medicine. The results showed a significant relationship between the use of herbal medicine and the incidence of hypoglycemia with a p-value of 0.0001. Conclusion: The use of herbal medicine increased the incidence of hypoglycemia.

SAT134 CGM Use During Pregnancy Complicated By CF-Induced Diabetes

Abstract Disclosure: A.Y. Mazori: None. E.S. Markovic: None. C.J. Levy: Advisory Board Member; Self; Dexcom, Eli Lilly &amp; Company. Research Investigator; Self; Abbott Laboratories, Insulet Corporation, Tandem Diabetes Care, Dexcom. Introduction: Glycemic control remains challenging in pregnancies complicated by diabetes mellitus. Strict glycemic targets are required to optimize maternal and neonatal outcomes, but euglycemia is hindered by fluctuating insulin sensitivity and the need for frequent blood-glucose monitoring (BGM). Consensus guidelines recommend therapeutic continuous glucose monitoring (CGM) for pregnant and nonpregnant individuals with type 1 and type 2 diabetes, but current data support therapeutic CGM use in cystic fibrosis (CF)-related diabetes (CFRD) only outside of pregnancy. We report the case of a patient with CFRD who achieved recommended glycemic targets with a therapeutic CGM during a singleton pregnancy. Methods: A case report and literature review are presented. Results: A 32-year-old nulliparous woman with CF became pregnant via frozen-embryo transfer. Prior CF complications included CFRD, pancreatic insufficiency, and recurrent pancreatitis. A therapeutic Dexcom G6 CGM and intermittent BGM were used to monitor glycemic control before and during pregnancy; sensor use exceeded 96%. Pressure-induced sensor attenuations yielded sporadic hypoglycemic values discordant with simultaneous BGM. CGM analysis for the 90 days preceding conception revealed: time in range of 63-140 mg/dL (TIR) was 90.8%, time above range (TAR) 6.3%, and time below range (TBR) 2.9%. Throughout pregnancy, TIR was 92.9%, TAR 3.4%, and TBR 3.6%; no severe hypoglycemia occurred. Daytime (6AM to midnight) and nighttime hypoglycemia were 4.6% and 2.2%, respectively. In the first trimester, TIR was 90.8%, TAR 3.7%, and TBR 5.5%. During the second trimester, the patient achieved TIR 94.2%, TAR 2.6%, and TBR 3.2%. In the third trimester, TIR was 95.7%, TAR 0.9%, and TBR 3.4%. The pregestational CFRD regimen consisted of insulin glargine 12 units and lispro 3-8 units. The basal-insulin dose was 10 units at 13 weeks’ gestation, 9 units at 27 weeks’ gestation, and 8 units at 38 weeks’ gestation. The prandial-insulin doses varied between 1.5-5 units at 13 weeks’ gestation, 0-7 units at 27 weeks’ gestation, and 0-5 units at 38 weeks’ gestation. After an uncomplicated vaginal delivery at 38 weeks and six days’ gestation, maternal fasting hypoglycemia occurred after one dose of glargine 3 units. Euglycemia was obtained without basal, prandial, or correctional insulin. The neonate experienced mild hypoglycemia that resolved with oral glucose gel and feeding. The neonate was neither macrosomic nor large for gestational age (birth weight, 3.54 kg, 71st percentile) and did not require intensive-care unit management. Both the patient and neonate were discharged on postpartum day two. Conclusion: Therapeutic CGM use in a pregnancy complicated by CFRD was effective for maternal and neonatal outcomes. Further study is warranted to examine CGM use and efficacy in this population. Presentation: Saturday, June 17, 2023

1072-P: Incidence of Inpatient Hypoglycemia by Specialty Area—A Case for Targeted Inpatient CGM

Inpatient hypoglycemia is traumatic for people with diabetes and increases length of stay, hospital costs and subsequent mortality (at least in the elderly). We report inpatient hypoglycemia by specialty ward in an 800-bed, acute hospital serving a largely deprived population (350,000) with diabetes prevalence 8%. Over 1 year, 21,089 inpatients with diabetes had 176,603 point of care (POC) tests (median 8.4, ward range 1.1-29.2, POC tests/person/stay); and 9.2 (ward range 2.1-24.7)% of subjects experienced hypoglycemia (CBG &amp;lt;72 mg/dl). Patients who experienced hypoglycemia had 2.6 (range 1.2-5.8) episodes of hypoglycemia either from early persistence (failure of protocol-driven hypoglycemia treatment) or late recurrence. There was a strong correlation between POC testing frequency and detection of hypoglycemia (Chi-square, Yates’ correction = 8.4374, p=0.004). Compared with the whole hospital (index 1.0), specialty wards hypo index ranged 10-fold from 0.2 to 5.1. A recent RCT demonstrated CGM superiority over POC testing in preventing recurrent inpatient hypoglycemia. Consistent with this RCT, our data suggest that increased POC testing is associated with increased hypoglycemia detection and our approach might guide initial targeting of CGM to highest risk specialty wards for hospitals unable to deploy CGM simultaneously in every inpatient specialty ward area. Disclosure G.A.Lewis: None. J.Cardwell: None. S.Bujawansa: Stock/Shareholder; Merck &amp; Co., Inc., GlaxoSmithKline plc. K.J.Hardy: Other Relationship; Sanofi, Speaker's Bureau; Napp Pharmaceuticals Limited.

Abstract #1401957: Hypoglycemia in a Patient with Malnutrition After Bariatric Surgery and Cirrhosis from Alpha-1 Antitrypsin Deficiency

Hypoglycemia is rare in patients who do not have diabetes treated by insulin or insulin secretagogues. However, severe malnutrition can predispose to hypoglycemia through substrate limitation of gluconeogenesis and glycogen depletion, and severe hepatic insufficiency may lead to hypoglycemia due to reduced capacity for gluconeogenesis and synthesis and storage of glycogen. We report a case of hypoglycemia occurring in a patient with malnutrition after Roux-en-Y gastric bypass (RYGB) surgery and cirrhosis due to alpha1-antitrypsin (AAT) deficiency. Endocrinology was consulted to evaluate a 67-year-old female for possible hypoglycemia. Her history was notable for RYGB surgery and AAT deficiency complicated by cirrhosis. The patient reported a 3-y history of dizziness and palpitations that resolved after eating. BMI was 18 kg/m2, and bitemporal wasting and sarcopenia were observed. Markers of liver function were abnormal, including prothrombin time (16.3 sec, 11.7-14.7) and albumin level (2.2 g/dL, 3.5-5.7). GFR calculated to 81 mL/min/1.73 m2. During a diagnostic fast, plasma glucose fell to 47 mg/dL, and simultaneously measured insulin and C-peptide levels were 0.8 mIU/mL (expected < 3) and 1.4 ng/dL (expected < 0.6), respectively. Beta-hydroxybutyrate level was 0.1 mM (expected > 2.7). An insulin secretagogues panel, ACTH-stimulation test, and IGF-2 level were unremarkable. Malnutrition is a well-known risk factor for hypoglycemia, and approximately 5% of hospitalized patients with malnutrition experience hypoglycemia. Significant protein-energy malnutrition, though uncommon after RYGB, has been documented in nearly 5% of patients in some series. Severe hepatic insufficiency is also an independent risk factor for hypoglycemia, and 10-15% of patients with AAT deficiency develop hepatic injury due to accumulation of Z-type AAT polymers in the liver. Though the patient had advanced liver failure as indicated by elevated prothrombin time and inability to mount a ketogenic response to hypoglycemia, AAT deficiency induced cirrhosis alone has not been documented to cause hypoglycemia in adults. C-peptide is metabolized mostly by the kidneys, and the discrepancy between insulin and C-peptide levels was most likely due to impaired renal function, with GFR artifactually high due to low serum creatinine level from sarcopenia. This case of hypoglycemia is unusual because it was due to the co-occurrence of two unusual disorders – severe protein malnutrition following RYGB and cirrhosis due to AAT deficiency – and measurements of C-peptide and beta-hydroxybutyrate were confounded by the patient’s renal and hepatic function, respectively.

Glycemia Around Exercise in Adults with Type 1 Diabetes Using Automated and Nonautomated Insulin Delivery Pumps: A Switch Pilot Trial.

In an in-patient switch study, 10 adults with type 1 diabetes (T1D) performed 45 min of moderate-intensity exercise on 2 occasions: (1) when using their usual insulin pump (UP) and (2) after transitioning to automated insulin delivery (AID) treatment (MiniMed™ 780G). Consensus glucose management guidelines for performing exercise were applied. Plasma glucose concentrations measured over a 3-h monitoring period were stratified into time below range (TBR, <3.9 mmol/L), time in range (TIR, 3.9-10.0 mmol/L), and time above range (TAR, >10.0 mmol/L). Overall, TBR (UP: 11 ± 21 vs. AID: 3% ± 10%, P = 0.413), TIR (UP: 53 ± 27 vs. AID: 66% ± 39%, P = 0.320), and TAR (UP: 37 ± 34 vs. AID: 31% ± 41%, P = 0.604) were similar between arms. A proportionately low number of people experienced exercise-induced hypoglycemia (UP: n = 2 vs. AID: n = 1, P = 1.00). In conclusion, switching to AID therapy did not alter patterns of glycemia around sustained moderate-intensity exercise in adults with T1D. Clinical Trial Registration number: NCT05133765.

Layered Meta-Learning Algorithm for Predicting Adverse Events in Type 1 Diabetes

Type 1 diabetes mellitus (T1D) is a chronic disease that, if not treated properly, can lead to serious complications. We propose a layered meta-learning approach based on multi-expert systems to predict adverse events in T1D. The base learner is composed of three deep neural networks and exploits only continuous glucose monitoring data as an input feature. Each network specializes in predicting whether the patient is about to experience hypoglycemia, hyperglycemia, or euglycemia. The output of the experts is passed to a meta-learner to provide the final model classification. In addition, we formally introduce a novel parameter, <inline-formula xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"> <tex-math notation="LaTeX">$\alpha $ </tex-math></inline-formula> , to evaluate the advance by which a prediction is performed. We evaluate the proposed approach on both a public and a private dataset and implement it on an edge device to test its feasibility in real life. On average, on the Ohio T1DM dataset, our system was able to predict hypoglycemia events with a time gain of 22.8 minutes, hyperglycemia ones with an advance of 24.0 minutes. Our model not only outperforms presented models in the literature in terms of events predicted with sufficient advance, but also with regard to the number of false positives, achieving on average 0.45 and 0.46 hypo- and hyperglycemic false alarms per day, respectively. Furthermore, the meta-learning approach effectively improves performance in a new cohort of patients by training only the meta-learner with a limited amount of data. We believe our approach would be an essential ally for the patients to control the glycemic fluctuations and adjust their insulin therapy and dietary intakes, enabling them to speed up decision-making and improve personal self-management, resulting in a reduced risk of acute and chronic complications. As our last contribution, we assessed the validity of the approach by exploiting only blood glucose variations as well as in combination with the information of the insulin boluses, the skin temperature, and the galvanic skin response. In general, we have observed that providing other information but CGM leads to slightly lower performances with respect to considering CGM alone.