Frequency Of Hypoglycemic Episodes Research Articles

Insulin Pen Administration Efficacy and Safety in an Older Patient.

Objective To describe a successful pharmacist-led intervention to effectively and safely provide education and pharmacotherapy management for an older patient with uncontrolled type 2 diabetes mellitus (T2DM) who failed to remove the needle shield on insulin pens for injection. Setting: Family medicine residency clinic. Practice Description: The clinic, part of a major urban health system, consists of 27 medical residents, 15 attending physicians, and 1 ambulatory care pharmacist managing chronic diseases collaboratively. It primarily serves low-income patients in a Midwest city. Practice Innovation: A 93-year-old White female with T2DM, receiving insulin therapy, was referred to the ambulatory care pharmacist by her physician for diabetes management. The patient had been hospitalized recently for hyperosmolar hyperglycemic state with a hemoglobin A1c of 15.9%. The pharmacist identified a failure to remove the needle shield on the insulin pen resulting in ineffective insulin administration, which caused persistent hyperglycemia and subsequent hospitalizations. This also posed a safety concern for severe hypoglycemia if proper administration resumed without adjusting the inflated dosing. The pharmacist used demonstration devices and the teach-back method to provide education and implement pharmacotherapy adjustments, resulting in effective and safe insulin administration. Main Outcome Measurements: Change in diabetes medication regimen, home blood glucose readings including continuous glucose monitor data, hemoglobin A1c results, frequency of hypoglycemic episodes, and number of hospitalizations for T2DM. Results: Over seven months, dose adjustments to basal insulin, combined with proper administration technique and the addition of empagliflozin, resulted in a hemoglobin A1c below 7%, with no severe hypoglycemia or diabetes-related hospitalizations. Conclusion: Medication errors, including insulin administration errors, highlight the need for thorough education in insulin therapy management. Education and monitoring empower older patients to self-manage diabetes safely and effectively, aligning with guidelines. Further research is required to identify optimal strategies for educating older patients on self-managing T2DM with insulin therapy.

Efficacy and safety of intermittent fasting for type 2 diabetes mellitus: A systematic review and meta-analysis of randomized trials

Efficacy and safety of intermittent fasting for type 2 diabetes mellitus: A systematic review and meta-analysis of randomized trials

The role of clinical pharmacists in improving diabetic care of hospitalized heart patients

The role of clinical pharmacists in improving diabetic care of hospitalized heart patients

8129 A Case of Pituitary Stalk Interruption Syndrome Presenting With Panhypopituitarism

Abstract Disclosure: A. Salvat: None. M. Sevilla: None. Background: Pituitary stalk interruption syndrome (PSIS) is a rare congenital abnormality characterized by the classic triad of a thinned or interrupted pituitary stalk, an ectopic or absent neurohypophysis, and a hypoplastic or absent anterior pituitary gland. Clinical manifestations vary and can include neonatal hypoglycemia, short stature, cryptorchidism, and delayed puberty. Symptoms can present at birth or later in life with variable degrees of hormone deficiency. Clinical case: A 25-year-old male with hypothyroidism (on levothyroxine since age 13) presented for evaluation of hypogonadotropic hypogonadism. At birth, he was diagnosed with bilateral cryptorchidism and had frequent hypoglycemic episodes. During his childhood and early teenage years, his growth paralleled of his peers. However, at age 18, he experienced a growth spurt with unusually long arms and legs. He never developed secondary sexual characteristics. Physical examination showed blood pressure of 109/62 mmHg, height 193 cm, weight 76 kg, Tanner stage 1 pubic hair, microphallus, and nonpalpable testicles. The initial labs were consistent with panhypopituitarism: FSH 0.14 mIU/mL (0.95–11.95 mIU/mL), luteinizing hormone <0.09 mIU/mL (0.57–12.07 mIU/mL), total testosterone <4 ng/dL (240–871 ng/dL), prolactin 30.31 ng/dL (3.46–19.40 ng/dL), AM cortisol <1 ug/dL (3.7–19.4 ug/dL), ACTH 14 pg/mL (6–50 pg/mL ), cortisol levels 60 minutes after consyntropin stimulation test of 3.6 ug/dL (3.7–19.4 ug/dL), IFG-1 <16 ng/mL (63–373 ng/mL), TSH 7.24 uIU/mL (0.35–4.94 uIU/mL), free T4 0.53 ng/dL (0.70–1.48 ng/dL). Karyotype 46, XY, inv (9) (p12q13). The whole exome sequencing testing was negative. Pituitary magnetic resonance imaging showed hypoplasia of the anterior pituitary gland, ectopic location of the posterior pituitary gland at the expected base of the pituitary infundibulum anterior to the mammary bodies, and hypoplastic or absent pituitary infundibulum, findings suggestive of pituitary stalk interruption syndrome. Scrotal ultrasound showed no testicular or epididymal tissue within the scrotum. DEXA scan showed osteoporosis associated with a long history of non-treated testosterone deficiency. The levothyroxine was adjusted, and the patient was started on intramuscular testosterone, calcium, and vitamin D to manage the hypogonadism and improve the bone mineral density. Conclusion: Diagnosis of PSIS is often delayed due to its variable presentation and age of onset. Although this condition is considered rare, it should be in the differential diagnosis of patients presenting with panhypopituitarism. Early identification of deficient hormones, as well as prompt initialization of hormone replacement therapy, is essential to prevent serious complications associated with these deficiencies, such as adrenal crisis, osteoporosis, diminished quality of life, delayed puberty, and infertility. Presentation: 6/3/2024

Interesting Life Journey of a Type 1 Diabetes Individual from the Era of Injectable Insulins to the Hybrid Closed-Loop Insulin Pump

Abstract Continuous subcutaneous insulin infusion (CSII) pump has shown good outcomes in individuals with diabetes. An individual with type 1 diabetes (T1D) was diagnosed in 1996 at the age of 14 years with GAD-positive and absent C Peptide reserves confirming the diagnosis. Initially, the individual was started with the conventional treatment for T1D consisting of multiple insulin injections per day, however, with this treatment, there was a wide fluctuation in the blood sugar levels with frequent hyperglycemic and hypoglycemic episodes, and could not achieve strict HbA1c control. In 2019, the treatment was switched to a 620G CSII pump, the fluctuations in blood sugar levels were reduced, but still, there were occasional hyperglycemic and hypoglycemic episodes failing to achieve the target HbA1c control. In 2022, again the treatment was changed to the latest 780G CSII pump termed the artificial pancreas which helped the person with T1D to achieve strict blood sugar level control and excellent ‘Time in Range’ with no hyperglycemic and hypoglycemic episodes and a better quality of life.

Can flash glucose monitoring improve glucose management for Aboriginal and Torres Strait Islander peoples with type 2 diabetes? A protocol for a randomised controlled trial

BackgroundAboriginal and Torres Strait Islander peoples are disproportionately impacted by type 2 diabetes. Continuous glucose monitoring (CGM) technology (such as Abbott Freestyle Libre 2, previously referred to as Flash Glucose Monitoring) offers real-time glucose monitoring that is convenient and easy to use compared to self-monitoring of blood glucose (SMBG). However, this technology’s use is neither widespread nor subsidised for Aboriginal and Torres Strait Islander peoples with type 2 diabetes. Building on existing collaborations with a national network of Aboriginal and Torres Strait Islander communities, this randomised controlled trial aims to assess the effect of CGM compared to SMBG on (i) haemoglobin A1c (HbA1c), (ii) achieving blood glucose targets, (iii) reducing hypoglycaemic episodes and (iv) cost-effective healthcare in an Aboriginal and Torres Strait Islander people health setting.MethodsThis is a non-masked, parallel-group, two-arm, individually randomised, controlled trial (ACTRN12621000753853). Aboriginal and Torres Strait Islander adults with type 2 diabetes on injectable therapy and HbA1c ≥ 7.5% (n = 350) will be randomised (1:1) to CGM or SMBG for 6 months. The primary outcome is change in HbA1c level from baseline to 6 months. Secondary outcomes include (i) CGM-derived metrics, (ii) frequency of hypoglycaemic episodes, (iii) health-related quality of life and (iv) incremental cost per quality-adjusted life year gained associated with the CGM compared to SMBG. Clinical trial sites include Aboriginal Community Controlled Organisations, Aboriginal Medical Services, primary care centres and tertiary hospitals across urban, rural, regional and remote Australia.DiscussionThe trial will assess the effect of CGM compared to SMBG on HbA1c for Aboriginal and Torres Strait Islander people with type 2 diabetes in Australia. This trial could have long-term benefits in improving diabetes management and providing evidence for funding of CGM in this population.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12621000753853. Registered on 15th June 2021.

Insulin-induced Lipohypertrophy in a Patient with Type 2 Diabetes

Abstract Lipohypertrophy (LH) is a common side effect of insulin treatment in patients with diabetes, characterized by soft, benign nodules in the subcutaneous tissue. This case report describes the management of insulin-induced LH in a 66-year-old male with type 2 diabetes. The patient had been on a combination of oral antidiabetic agents (ODAs) and biphasic human insulin for 5 years, experiencing the symptoms of numbness, leg swelling, fatigue, and frequent hypoglycemic episodes. Upon examination, LH with skin pigmentation was observed at the insulin injection sites on both calves. The patient’s laboratory investigations revealed poor glycemic control with high glycated hemoglobin percentage. To address the condition, the patient was advised to change the injection site, use proper site rotation, and change the insulin needle daily. The insulin therapy was modified by switching to biphasic premixed analog insulin injected 5 min before meals using the insulin pen. In addition, ODAs were adjusted for better glycemic control. Following these interventions, the patient reported improved glucose levels and stable kidney function. This case report emphasizes the importance of early detection and appropriate management of insulin-induced LH through patient education and insulin therapy adjustments. Health-care providers should remain vigilant for LH and educate patients on proper injection practices to optimize diabetes management and prevent complications.

Continuous Glucose Monitoring in Intensive Care Unit Patients with Diabetes: Insights and Outcomes from a Single-center Study in India

Abstract Introduction: The use of continuous glucose monitoring (CGM) for in-hospital glucose control has been widely studied. However, its application in intensive care unit (ICU) settings is debatable owing to its perceived limitations. In ICU patients with diabetes, glycemic excursions, including frequent hypoglycemic episodes, are more prevalent. This retrospective study was undertaken to evaluate the utility of CGM in the management of diabetes patients admitted to the ICU. Methods: We collected data of patients with diabetes mellitus who were admitted to the ICU at our institution and were advised CGM by the intensivist. A retrospective analysis was conducted, examining demographic, clinical, and laboratory data, along with glucose meter readings and CGM data. The results are presented as numbers, percentages, or median values, as appropriate. Results: Out of 65 patients in the ICU, the median values of percentage time in range, time below range, and time above range were 59%, 2%, and 36%, respectively. The median HbA1C and capillary glucose on admission were 8.8% and 246 mg/dl, respectively. During the ICU stay, the CGM derived average glucose level was 167 mg/dl (percent coefficient of variation [%CV] =25.96) and the glucose management indicator was 7%. In total, 65 episodes of hypoglycemia were detected, all confirmed by capillary glucose tests. A total of 27 patients experienced hypoglycemia, of which 12 had nocturnal hypoglycemia. Conclusion: The use of CGM in the ICU improved glycemic control and helped to detect hypoglycemia, particularly nocturnal with acceptably low glycemic variability as measured by percentage CV. Further studies are required to corroborate and confirm these findings.

Predicting the dynamics of heart rate variability in patients with type 1 diabetes against improving glycemic control

The aim of the study: to analyze the effect of improvement of glycemic control on heart rate variability changes in patients with type 1 diabetes against the background of insulin therapy correction and to predict this dynamics based on the parameters of continuous glucose monitoring. We examined 49 patients with the level of glycosylated hemoglobin ≥7% and <10% without late diabetic complications. The average age – 32.0 (21.5; 38.0) years, the average disease duration – 9.5 (5.0; 17.5) years. The study was based on the simultaneous registration of heart rate variability and continuous glucose monitoring before and 3 months after correction of insulin therapy. Logistic regression analysis and ROC-analysis were used to predict the changes. After 3 months, the patients had significant decrease in the level of glycosylated hemoglobin, glycose variability, and a decrease in the frequency of hypoglycemic episodes. Heart rate variability increased in 73.5% of persons. The presence of hypoglycemia, standard deviation of blood glucose levels and glomerular filtration rate after treatment turned out to be prognostic factors for the predicting improvement in heart rate variability (the proportion of correct prediction of the patient's actual belonging to one or another prognostic group was 76.39%). Based on the calculation of the theoretical values of the positive result probability using the logistic equation, a detailed scale for predicting changes in heart rhythm variability for type 1 diabetes patients was proposed: up to 0.07 – a low probability of a positive result; 0.07-0.29 – the probability of a positive result is below average; 0.29-0.51 – a moderate probability of a positive result; 0.51-0.90 – high probability of a positive result; more than 0.90 – a very high probability of a positive result. We found that improvement of glycemic control leads to an increase in both frequency and time characteristics of heart rate variability. The increase in the likelihood of improvement of heart rate variability in patients with type 1 diabetes was more likely to be associated with reduced glycose variability and fewer hypoglycemic episodes. We developed a predictive mathematical model of heart rate variability based on the continuous glucose monitoring parameters for type 1 diabetes with sensitivity of 88.0% and specificity 68.18%, AUC 0.739 (p=0.001).

A patient diagnosed with new-onset type 1 diabetes and Addison's disease at initial presentation.

A previously healthy 17-year-old female presented to the emergency department with complaints of vomiting, shortness of breath, and tachycardia. She was found to have an elevated blood glucose and was admitted for presumed new onset type 1 diabetes mellitus (T1DM). During the admission, she was noted to have frequent episodes of hypoglycemia despite conservative insulin dosing and high urine output with glucosuria, which seemed out of proportion to her glucose levels and fluid status. She also had persistent hyponatremia despite normalization of blood glucose. Further work-up was initiated to investigate alternative or additional diagnoses to explain these atypical findings. Adrenocorticotropic hormone (ACTH) level was elevated, consistent with the diagnosis of Addison's disease, which led to the subsequent diagnosis of autoimmune polyglandular syndrome type II (APS-2). This is one of the first reports in the literature of concurrent diagnosis of T1DM and Addison's disease at initial presentation and demonstrates the importance of not anchoring to one diagnosis. This case shows the importance of considering multiple diagnoses and investigating atypical signs and symptoms. This case highlights the importance of a thorough history including review of systems. Hyponatremia and recurrent hypoglycemia in a person with type 1 diabetes should raise suspicion for adrenal insufficiency. This case makes us consider the screening for Addison's disease in a person with new onset type 1 diabetes in addition to autoimmune thyroid disease and celiac disease. People with an autoimmune disease should be monitored for other autoimmune diseases in the future.

Use of the Guardian Connect glycemic monitoring system in patients after total duodenopancreatectomy in the early postoperative period on intravenous insulin therapy

BACKGROUND: Among different subtypes of pancreatogenic diabetes mellitus the biggest difficulties of glycemic control arise in patients after total duodenopancreatectomy (TDPE), first of all due to the presence of absolute insulin insufficiency.AIM: Estimating safety and cost-effectiveness Guardian Connect CGM system in early postoperative period in hospitalized patients after TDPE on continuous intravenous insulin therapy (CIVIT).MATERIALS AND METHODS: Glucose measurement results of 26 patients in early postoperative period after TDPE were analyzed. In 12 of them, we used Guardian Connect CGM system. In this group 43 cycles (1 cycle — 6 days, 258 days total) of CGM and 971 glucometer measurements used for CGM calibration were analyzed; in other 14 patients in whom only glucometer was used we analyzed 2496 glycemic values.Cost-effectiveness was calculated over 6 days for CGM and only glucometer use (including cost of CGM, glucometers, disposable materials, clinic wage-costs to medical staff for time required for glucose control).RESULTS: Glucose levels of group #1 were in the target range 5.6 to 10.0 mmol/L (66.7 vs 61.2%, p=0.003) and the range 4.3–11.6 mmol/L (85.2% vs 82.2%, p=0.038) more than in comparison with group #2.The frequency of hypoglycemic episodes (<3.9 mmol/L) was statistically significantly lower in the CGM group (6 vs 54, p<0.001, RO 8.463 [3.579; 20.015], RR 1.746 [1.551; 1.966]).Cost analysis of glucose control using Guardian Connect CGM system for one cycle (6 days) and cost of glucose control using glucose meter for the same period showed that using Guardian Connect CGM system in patients after TDPE on intravenous insulin therapy reduced clinic costs by 21.7% in ICU and by 25.7% in the hospital department.CONCLUSION: Guardian Connect CGM have demonstrated its safety and cost-effectiveness during glucose control in patients in early postoperative period after TDPE on CIVIT.

Functional characterization of inactivating ABCC8 variants causing congenital hyperinsulinism.

Congenital hyperinsulinism (CHI; OMIM: 256450) is characterized by persistent insulin secretion despite severe hypoglycemia. The most common causes are variants in the ATP-binding cassette subfamily C member 8(ABCC8) and potassium inwardly-rectifying channel subfamily J member 11(KCNJ11) genes. These encode ATP-sensitive potassium (KATP) channel subunit sulfonylurea receptor 1 (SUR1) and inwardly rectifying potassium channel (Kir6.2) proteins. A 7-day-old male infant presented with frequent hypoglycemic episodes and was clinically diagnosed with CHI, underwent trio-whole-exome sequencing, revealing compound heterozygous ABCC8 variants (c.307C>T, p.His103Tyr; and c.3313_3315del, p.Ile1105del) were identified. In human embryonic kidney 293 (HEK293) and rat insulinoma cells (INS-1) transfected with wild-type and variant plasmids, KATP channels formed by p.His103Tyr were delivered to the plasma membrane, whereas p.Ile1105del or double variants (p.His103Tyr coupled with p.Ile1105del) failed to be transported to the plasma membrane. Compared to wild-type channels, the channels formed by the variants (p.His103Tyr; p.Ile1105del) had elevated basal [Ca2+]i, but did not respond to stimulation by glucose. Our results provide evidence that the two ABCC8 variants may be related to CHI owing to defective trafficking and dysfunction of KATP channels.

Efficacy of Raw Corn Starch in Insulinoma-Related Hypoglycemia: A Promising Supportive Therapy

Objective To investigate the efficacy of raw corn starch (RCS) in clinical management of insulinoma-induced hypoglycemia. Methods We retrospectively collected clinical data of insulinoma patients who received RCS-supplemented diet preoperatively, and analyzed the therapeutic effects of the RCS intervention on blood glucose control, weight change, and its adverse events. Results The study population consisted of 24 cases of insulinoma patients, 7 males and 17 females, aged 46.08±14.15 years. Before RCS-supplemented diet, all patients had frequent hypoglycemic episodes (2.51±3.88 times/week), concurrent with neuroglycopenia (in 83.3% of patients) and autonomic manifestations (in 75.0% of patients), with the median fasting blood glucose (FBG) of 2.70 (interquartile range [IQR]: 2.50-2.90) mmol/L. The patients' weight increased by 0.38 (IQR: 0.05-0.65) kg per month, with 8 (33.3%) cases developing overweight and 7 (29.2%) cases developing obesity. All patients maintained the RCS-supplemented diet until they underwent tumor resection (23 cases) and transarterial chemoembolization for liver metastases (1 case). For 19 patients receiving RCS throughout the day, the median FBG within one week of nutritional management was 4.30 (IQR: 3.30-5.70) mmol/L, which was a significant increase compared to pre-nutritional level [2.25 (IQR: 1.60-2.90) mmol/L; P < 0.001]. Of them, 10 patients receiving RCS throughout the day for over four weeks had sustained improvement in FBG compared to pre-treatment [3.20 (IQR: 2.60-3.95) mmol/L vs. 2.15 (IQR: 1.83-2.33) mmol/L; P < 0.001). Five patients who received RCS only at night also had a significant increase in FBG within one week of nutritional management [3.50 (IQR: 2.50-3.65) mmol/L vs. 2.20 (IQR:1.80-2.60) mmol/L; P < 0.001], but only one patient who continued to receive RCS for over four weeks did not have a significant improvement in FBG. No improvement in weight gain was observed upon RCS supplementation. Mild diarrhea (2 cases) and flatulence (1 case) occurred, and were relieved by reduction of RCS dose. Conclusion The RCS-supplemented diet is effective in controlling insulinoma-induced hypoglycemia.

Autoimmune disorders associated with type 1 diabetes: clinical overview and principles of management

Type 1 diabetes mellitus is an autoimmune disease in which patients with a genetic predisposition develop antibodies against pancreatic islet β-cells under certain conditions, resulting in the loss of insulin production. Genetic, infective, dietary, and humoral factors are potential predictors associated with the risk of β-cell destruction. The coexistence of another autoimmune disease can be found in up to 29% of patients with type 1 diabetes. The most common disorders are autoimmune thyroid disease, coeliac disease, autoimmune gastritis, pernicious anaemia, and vitiligo. Other conditions that can coexist with type 1 diabetes are rheumatoid arthritis, autoimmune hepatitis, alopecia, and psoriasis. This coexistence is often present in autoimmune polyendocrine syndromes. The likelihood of developing an autoimmune disease increases with age, and it is higher in the female population. Concomitant autoimmune diseases can negatively affect the patient’s quality of life and metabolic control of diabetes, potentially increasing the risk of micro- or macrovascular complications and the frequency of hypoglycaemic episodes. Determining organ-specific antibodies is useful in the active search for autoimmune diseases in type 1 diabetes patients to identify individuals at increased risk for the disease. This article aims to summarise the most recent research on type 1 diabetes-associated autoimmune disorders, including screening, diagnosis, and treatment principles.

Peptide Receptor Radionuclide Therapy Is Effective for Clinical Control of Symptomatic Metastatic Insulinoma: A Long-Term Retrospective Analysis.

Metastatic insulinoma is a rare malignant neuroendocrine tumor characterized by inappropriate insulin secretion, resulting in life-threatening hypoglycemia, which is often difficult to treat. There is currently very limited information about the efficacy of peptide receptor radionuclide therapy (PRRT) for clinical control of hypoglycemia. The aim of this long-term retrospective study was to evaluate the therapeutic efficacy of PRRT for improving hypoglycemia, to evaluate the change of medication after PRRT, and to calculate progression-free survival (PFS) and overall survival (OS). Methods: Inclusion criteria were histologically proven somatostatin receptor-positive metastatic malignant insulinoma and at least 2 cycles of [90Y]Y-DOTATOC or [177Lu]Lu-DOTATOC therapy from early 2000 to early 2022. A semiquantitative scoring system was used to quantify the severity and frequency of hypoglycemic episodes under background antihypoglycemic therapy (somatostatin analog, diazoxide, everolimus, corticosteroids): score 0, no hypoglycemic episodes; score 1, hypoglycemic events requiring additional conservative treatment with optimization of nutrition; score 2, severe hypoglycemia necessitating hospitalization and combined medication or history of hypoglycemic coma. Hypoglycemic score before and after PRRT was analyzed. Time of benefit was defined as a time range of fewer hypoglycemic episodes in the observation period than at baseline. Information on antihypoglycemic medication before and after therapy, PFS, and OS was recorded. Results: Twenty-six of 32 patients with a total of 106 [90Y]Y-DOTATOC/[177Lu]Lu-DOTATOC cycles were included. The average observation period was 21.5 mo (range, 2.3-107.4 mo). Before therapy, 81% (n = 21) of the patients had a hypoglycemia score of 2 and 19% (n = 5) had a score of 1. After PRRT, 81% of patients (n = 21) had a decreased score, and the remaining 5 patients showed a stable situation. There was temporary worsening of hypoglycemia just after injection of [90Y]Y-DOTATOC/[177Lu]Lu-DOTATOC in 19% of patients. The average time of benefit in the observation period was 17.2 mo (range, 0-70.2 mo). Antihypoglycemic medication reduction was achieved in 58% (n = 15) of patients. The median OS and PFS after the start of PRRT were 19.7 mo (95% CI, 6.5-32.9 mo) and 11.7 mo (95% CI, 4.9-18.5 mo), respectively. Conclusion: To our knowledge, our study included the largest cohort of patients with malignant insulinoma to be evaluated. Long-lasting symptom control and reduction of antihypoglycemic medications were shown in most patients after late-line PRRT.

SAT172 Unmasking A Pediatric Disease In Adult, A Belated Diagnosis

Abstract Disclosure: H. Syed: None. P. Au: None. M.J. Gardner: None. Background: Glycogen storage diseases (GSD) are a rare group of diseases that change the way the body uses and stores glycogen. They are usually diagnosed in the pediatric population. Hypoglycemia can be a sign. Clinical Case: A 32 year old female presented with worsening and more frequent episodes of hypoglycemia. She had no history of diabetes and was not on any hypoglycemic agents. She had been having episodes of spontaneous hypoglycemia since childhood and would get symptomatic as well. No comprehensive workup had been done prior. The episodes were becoming more frequent. A blinded continuous glucose monitor was placed on the patient to monitor her glucose levels. Results indeed showed few episodes of hypoglycemia with glucose levels in the 40s. Interestingly, she also had postprandial hyperglycemia with glucose level above 180 following an episode of hypoglycemia. She underwent a 72 hour fast in the hospital and became hypoglycemic within 24 hours with a low blood glucose of 55, consistent with hypoglycemia, and she was also symptomatic as well. At the same time, her beta hydroxybutyrate increased to 3.91 mmol/L, consistent with ketosis. Her insulin level and C-peptide level at the time of hypoglycemia were 4.35 mcunit/mL and 0.239 nmol/L, respectively, and thus insulinoma was ruled out. She next underwent a mixed meal study during which her postprandial blood glucose increased to at least 198 indicating postprandial hyperglycemia. At the same time, patient's postprandial lactate also elevated to 4 mmol/L, consistent with lactic acidosis. Her symptoms of hypoglycemia resolved once her blood sugar (BG) improved. She met criteria for Whipple’s triad. She also had had an 8 am cortisol of 13.06 mcg/dL and had an appropriate response to the ACTH stimulation test with a 60 minute post cortisol above 20 mcg/dL, thus ruling out adrenal insufficiency as a cause of hypoglycemia. These findings of the 72 hour fast that resulted in hypoglycemia, followed by postprandial hyperglycemia with lactic acidosis are consistent with Glycogen Storage Disorder Type 0. Treatment involves intake of uncooked cornstarch with protein. Patient incorporated both uncooked cornstarch along with increasing amount of protein in her diet and started using a continuous glucose monitor with alarm to monitor her BGs. As a result her episodes of frequent hypoglycemia improved. Conclusion: This case illustrates a rare case of hypoglycemia in an adult that was not thoroughly investigated when she was in her childhood and adolescence. This case teaches the importance of being familiar with pediatric conditions since it is possible that pediatric conditions, especially if they are missed by providers and not appropriately diagnosed. Presentation: Saturday, June 17, 2023

THU392 Type B Insulin Resistance: A Rare Cause Of Hypoglycemia

Abstract Disclosure: S.Z. Bhat: None. A. Sidhaye: None. A.H. Hamrahian: None. Introduction: Non-diabetic hypoglycemia in patients with diabetes mellitus is rare. Type B insulin resistance syndrome (TBIRS), caused by insulin receptor antibodies, presents with severe insulin resistance, but can uncommonly result in a hypoglycemic picture. Clinical Case: A 59-year-old woman with a history of SLE, T2DM, and primary hyperparathyroidism was admitted for acute confusion and found to have a POC glucose of 30 mg/dl. Her symptoms improved after IV glucose administration. She was on a stable basal-bolus insulin regimen of 0.8 U/kg/day and had unintentional 100-pound weight loss over 1 year. Significant exam findings included BMI of 29 kg/m2, gingival hyperplasia, and acanthosis nigricans. Aside from insulin, she took no medications strongly associated with hypoglycemia. Labs including CBC, CMP, TFTs, and morning cortisol were normal. HbA1C and adiponectin levels were 7.7%, and 28 µg/ml (5-28), respectively. Given the suspicion of exogenous insulin-mediated hypoglycemia, only correctional insulin was used during hospitalization. She had a repeat hypoglycemic episode on the 2nd day with minimal insulin use. A 72-hour fasting test showed a whole blood glucose of 44 mg/dL with concurrent serum C-peptide of 1.72 ng/mL, serum insulin 55 mIU/L and pro-insulin 21.9 pmol/L 12 hours into fasting. MRCP showed an 11 mm cystic lesion in the pancreas and widespread lymphadenopathy. The CGM noted significant fasting and post-prandial hypoglycemia. Diagnosis of insulinoma was considered unlikely due to persistent post-prandial hyperglycemia. Oral hypoglycemic panel and insulin autoantibodies were negative. The patient’s history of SLE, high-normal adiponectin, history of hyperglycemia and the presence of acanthosis nigricans favored work-up for insulin resistance syndromes. Due to the non-availability of insulin receptor antibody testing in the US, blood work was sent to Dr. Lutz Schomburg’s lab at Institute for Experimental Endocrinology, Berlin, Germany. The patient’serum was positive for insulin receptor antibodies, tested via an immunoassay technique, with elevated binding index (BI) of 248, 251 and 247 on 3 different samples of the patient, and normal binding index in the control sample, leading to the diagnosis of type B insulin resistance syndrome (BI &amp;gt;3 is positive, &amp;gt;10 indicates high positivity). The patient was treated with diet modification and CGM use, with improvement in the frequency of hypoglycemic episodes. She declined immunomodulation therapy. Conclusion: Hypoglycemia is an uncommon presentation of TBIRS and should be considered in the differential of non-diabetic hypoglycemia, particularly in patients with a history of auto-immune disease. The mechanism for hypoglycemia is purported to be an insulin-mimetic effect of insulin receptor antibodies at low titers. Presentation: Thursday, June 15, 2023

Cinematic rendering of leiomyosarcoma of the superior mesenteric vein.

Investigate the effectiveness of IDegLira, a fixed-ratio combination of insulin degludec/liraglutide, in a real-world setting in patients with type 2 diabetes mellitus in the United Arab Emirates.This non‐interventional study enrolled adults switching to IDegLira from basal insulin (BI) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) with/without concomitant oral antidiabetic drugs (OADs). Primary endpoint was change in HbA1c from baseline, assessed using a mixed model for repeated measurements.Among 263 patients (BI ± OADs, n=206; GLP-1 RA ± OADs, n=57), mean baseline HbA1c was 9.29% (78 mmol/mol). After 26 weeks, HbA1c was significantly reduced (BI ± OADs, –0.83% [–9.0 mmol/mol] and GLP-1 RA ± OADs, –1.24% [–13.5 mmol/mol]; both p<0.0001). Fasting plasma glucose (FPG) was significantly reduced (–39.48 mg/dL [BI ± OADs] and –82.49 mg/dL [GLP-1 RA ± OADs]; both p<0.0001). Before treatment initiation, 3/263 patients experienced ≥1 severe hypoglycaemic episode and 7/263 patients experienced ≥1 non-severe hypoglycaemic episode compared with 1/263 patients who had ≥1 severe and 1/263 who had ≥1 non-severe episode at end of study. Body weight decreased significantly among patients switching from BI ± OADs (–1.05 kg [p<0.0001]). Treatment was well tolerated.IDegLira significantly reduced HbA1c and FPG in this real-world setting, along with less frequent episodes of hypoglycaemia. Switching to IDegLira offers effective treatment intensification for type 2 diabetes patients with inadequate glycaemic control.

The Clinical Impact of Switching Basal Insulin to Insulin Degludec in Patients With Diabetes in Saudi Arabia: A Retrospective One-Group Pretest-Posttest Design Study.

Diabetes is a health problem that has an enormous and intolerable public health burden on the individual, family, and community. Diabetes affects nearly one-fifth of adults in Saudi Arabia and is expected to double by 2030. The study aims to evaluate the impact of switching patients from conventional basal insulin analogues to insulin degludec during a 90-day follow-up period. This was a retrospective observational pretest-posttest cohort study conducted at King Abdulaziz University Hospital between June 2019 and August 2020. Adult patients with diabetes who switched their basal insulin to insulin degludec were included and evaluated for its impact on insulin doses, hemoglobin A1c (HbA1c), hypoglycemic events, and/or body weight changes during a 90-day follow-up period. Out of 718 patients, 107 patients were included in the study, with 60.7% being females and their mean (± SD) age was 62.2 ± 14.6 years. There was a significant decrease in the mean baseline of HbA1c from 9.2% to 8.7% after 90 days of follow-up (P<0.001). A statistically significant reduction was noted in the total insulin requirements from a baseline of 71.70 (± 42.4) units to 46.5 (± 29) units, P=0.001, after switching to insulin degludec. However, there were no statistically significant differences in the body weight from the baseline mean (± SD) of 80.5 kg (± 19.4) to 79.9 kg (± 19.9), P=0.68, after switching to insulin degludec. Lastly, there were no statistically significant differences in the reported hypoglycemic episodes from a baseline of 48.7% vs 37.3% after 90 days of follow-up (P = 0.166). Switching to the novel insulin degludec conferred better blood glucose control and dose reduction. There was no increase in the frequency of hypoglycemic episodes or body weight.

Switching to a fixed-ratio combination of insulin degludec/liraglutide (IDegLira) is associated with improved glycaemic control in a real-world population with type 2 diabetes mellitus in the United Arab Emirates: Results from the multicentre, prospective INTENSIFY study

Investigate the effectiveness of IDegLira, a fixed-ratio combination of insulin degludec/liraglutide, in a real-world setting in patients with type 2 diabetes mellitus in the United Arab Emirates. This non-interventional study enrolled adults switching to IDegLira from basal insulin (BI) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) with/without concomitant oral antidiabetic drugs (OADs). Primary endpoint was change in HbA1c from baseline, assessed using a mixed model for repeated measurements. Among 263 patients (BI±OADs, n=206; GLP-1 RA±OADs, n=57), mean baseline HbA1c was 9.29% (78mmol/mol). After 26weeks, HbA1c was significantly reduced (BI±OADs, -0.83% [-9.0mmol/mol] and GLP-1 RA±OADs, -1.24% [-13.5mmol/mol]; both p<0.0001). Fasting plasma glucose (FPG) was significantly reduced (-39.48mg/dL [BI±OADs] and -82.49mg/dL [GLP-1 RA±OADs]; both p<0.0001). Before treatment initiation, 3/263 patients experienced≥1 severe hypoglycaemic episode and 7/263 patients experienced≥1 non-severe hypoglycaemic episode compared with 1/263 patients who had≥1 severe and 1/263 who had≥1 non-severe episode at end of study. Body weight decreased significantly among patients switching from BI±OADs (-1.05kg [p<0.0001]). Treatment was well tolerated. IDegLira significantly reduced HbA1c and FPG in this real-world setting, along with less frequent episodes of hypoglycaemia. Switching to IDegLira offers effective treatment intensification for type 2 diabetes patients with inadequate glycaemic control.