Glucose Monitoring Research Articles

8642 Continuous glucose monitor: reclaiming type 2 diabetes self-efficacy and mitigating disparities

Abstract Disclosure: K. Ni: None. C.A. Tampe: None. K. Sol: Employee; Self; Patient accepted job with Dexcom Jan 2024. L. Cervantes: None. R.I. Pereira: None. Context: The increase in continuous glucose monitor (CGM) use has been notable for widening disparities between the least and most socially marginalized. Given access barriers, there is limited CGM patient experience information that is inclusive of those with type 2 diabetes mellitus from socially marginalized backgrounds. Objective: To understand the CGM usage experience across a U.S. Medicaid population with type 2 diabetes at federally qualified health centers (FQHCs). Methods: This qualitative study used semi-structured phone interviews with 28 English or Spanish speaking participants prescribed CGM who were enrolled in a U.S. Medicaid program that subsidized CGM. Audio-recordings of interviews were transcribed and analyzed by inductive thematic analysis. Results: Participants had a median age 56 (interquartile range 48-60) with varying levels of formal schooling (55% with 9 years or less) and were from diverse racial or ethnic backgrounds (57% Hispanic, 18% non-Hispanic Black, 21% non-Hispanic White). Interviews were conducted in English (68%) or Spanish (32%). We identified six major themes: initial expectations and overcoming initiation barriers (subthemes: initial expectations, overcoming initiation barriers), convenience and ease promote daily use (subthemes: benefits over fingersticks), increased knowledge leads to improved self-management (subthemes: increased understanding and knowledge, glucose level self-awareness, motivating healthy behaviors), collaboration with provider and clinical team, improved self-reported outcomes (subthemes: improved glucose and non-glucose targets, positive emotional effect, essential for management), and barriers and burdens are generally tolerated (subthemes: barriers to monitoring, burden of self-monitoring). Conclusions: CGM was experienced as easy to understand and use and viewed as a tool for diabetes self-efficacy. Expanded CGM access for socially marginalized patients with type 2 diabetes can enhance diabetes self-management to help mitigate diabetes outcome disparities. Presentation: 6/2/2024

12450 Beyond the Surface: A Deep Dive into Pancreatic Insulinoma

Abstract Disclosure: S. Bhandari: None. R. Elhag: None. J. Singh: None. N. Rastogi: None. Background: Pancreatic neuroendocrine tumors (NET) are rare lesions that are typically sporadic, solitary and usually <2cm in diameter, with reported incidence of 4 cases per 1 million patients per year[1]. The most common hormone secreting NET are insulinomas. The hallmark of insulinomas is hypersecretion of insulin, leading to neuroglycopenic symptoms and uncontrolled sympathoadrenal activity. Clinical case: 51 years old female with no significant past medical history was referred to endocrine clinic by her primary care physician for hypoglycemia with a blood glucose level of 48 mg/dl. She reported an increased frequency of headaches and dizziness which began with intermittent fasting (10-12 hours) for past 6 months. These symptoms improved upon increasing meal frequency. Initial laboratory investigations revealed glucose of 54 mg/dl, normal HbA1c, and negative sulfonylurea panel. The patient had normal liver and kidney function with no malnutrition or malabsorption issues. Further work up showed C-peptide level 1.56 ng/ml (n 0.80-3.85ng/ml), insulin level 7.9 uIU/mL (n <18.4 uIU/mL), pro-insulin level significantly elevated at 77.6 pmol/L (n </= 18.8pmol/L) and beta hydroxybutyrate of 0.12 mmol/l (n 0.02-0.27mmol/l). Insulin like growth factor was normal. Insulin antibodies were negative, and pituitary hormones were within normal limits. Pancreatic ultrasound was normal. CT abdomen/pelvis showed a 0.8x1.1 cm homogenously hypervascular anterior pancreatic body soft tissue lesion consistent with NET. Patient was started on diazoxide and continuous glucose monitoring (CGM). She was referred to general surgery and underwent successful tumor resection. Insulinoma is suggested by Whipple's triad, which is presence of hypoglycemic symptoms, documented hypoglycemia and resolution of hypoglycemic symptoms after glucose administration. As clinical manifestations are non-specific, diagnosing an insulinoma is challenging and depends on collateral history and a high index of suspicion. The gold standard of diagnosis is supervised 72-hour fasting test with plasma glucose, insulin, C-peptide, and proinsulin level measurements. Medical management of insulinoma includes the use of diazoxide, calcium channel blockers, propranolol, and glucocorticoids. Surgery is definitive treatment for insulinomas, with cure rates ranging from 77 to 100%. Conclusion: Insulinomas are benign and curable in most cases but can be fatal if misdiagnosed. Incidental findings of hypoglycemia should warrant thorough diagnostic workup to facilitate timely diagnosis and management.

12420 Effects Of A Continuous Glucose Monitoring (CGM) Optimization Program On Prescribing Behavior And Glycemic Outcomes

Abstract Disclosure: A. Sterbenz: None. J. Fuentes Rosales: None. S. Abraham: None. P. Siroya: None. R. Middelbeek: None. J. Mitri: None. F. Rossitto: None. E. Cabana: None. A. Gharse: None. L. Collins: None. L. Aliaga: None. A. Millan Ferro: None. J. Cifuni: None. A. Schwartz: None. E. Kelley: None. C. Gomez: None. M. Aballay: None. Introduction: Continuous glucose monitoring (CGM) improves glucose control in patients with diabetes, as demonstrated in clinical trials. There is limited information available on the real-world application of CGM adoption in a resource-limited setting or safety net outpatient hospital setting. This intervention's aim was to assess the impact of a multifaceted approach on improving CGM utilization and on glycemic control among patients with diabetes. Methods: Wyckoff Heights Medical Center, located in Brooklyn, NY is a resource-limited setting that in partnership with the Joslin Diabetes Center, Boston, MA launched a CGM Clinical Care Optimization Program. This quality improvement (QI) initiative included establishing a diabetes technology team (DTT) which met weekly (n=24 sessions) to establish a highly specialized interprofessional group. The DTT activities included: 1) Establishing a CGM workflow; 2) Expanding Medical Assistant responsibilities related to diabetes technology and training; 3) Creating five bilingual (English-Spanish) patient handouts; 4) Building CGM vendor relationships; 5) Developing a CGM manual for data download, billing and coding, and education to increase CGM knowledge across the system. Data were collected prior to CGM initiation and at most recent visit. Results: The intervention occurred between February and November 2023. Prior to this intervention, 49 patients had a CGM prescription. After 9 months, CGM prescriptions were written for 333 patients (680% increase) with the following baseline characteristics (mean ± SD): age (61.2 ± 14.7 yrs.); 56% female; 44% male; 71% Latino; Race: 67% Other (63% Hispanic or Latino), 25% Black or African American, 4% White, Asian 2%, American Indian or Alaska Native 2%; 38% Spanish-speaking, 59% English-Speaking, 3% Other; 81% government insurance (63% Medicaid, 18% Medicare), 19% commercial insurance. The majority of patients had been diagnosed with type 2 diabetes (91%) and 9% had type 1 diabetes. Baseline HbA1C was 9.7 ± 1.5%. Of note, prior to CGM, 34% of patients had A1C>9%. The impact of CGM use was evaluated on 116 patients that met the following criteria: baseline A1C value within 60 days before or up-to 30 days after prescription, and a A1C >90 days after. After an average duration of 154 days of CGM use, HbA1c decreased significantly by -0.51% (p=0.001), demonstrating improved glycemic control post-CGM use. In those with A1c >9%, HbA1c decreased from 10.5% to 8.8% (p<0.01). Conclusion: Creating a CGM optimization program in a resource-limited setting is critical in improving patient self-awareness and provider insight in glycemic control in patients diagnosed with type 1 and type 2 diabetes. These data demonstrate the feasibility of implementing a CGM optimization program in a resource-limited setting, which is critically important in improving clinical care for people with diabetes. Presentation: 6/2/2024

6971 Effects of the Hybrid Closed-loop System in Pediatric-Onset Type 1 Diabetes

Abstract Disclosure: H. Woo: None. J. Yoo: None. S. Shin: None. Y. Lee: None. H. Kim: None. M. Gu: None. J. Kim: None. J. Kim: None. C. Shin: None. Y. Lee: None. Purpose: We evaluated the effectiveness and limitations of the MiniMedTM 770G, a hybrid closed-loop (HCL) system which adjusts basal insulin every five minutes using continuous glucose monitoring (CGM) data, for glycemic control in pediatric-onset type 1 diabetes (T1D) in South Korea. Methods: We enrolled 20 patients (10 boys and 10 girls) who had been using the 770G pump for over three months, initiating its use between February 2022 and May 2023. Prior to this, they were CGM users and were followed for over a year post T1D diagnosis. Clinical and biochemical data, along with CGM metrics such as time in range (TIR), time below range (TBR), time above range (TAR), and coefficient of variation (CV), were analyzed. Additionally, the percentage of SmartGuard Auto Mode system usage was collected. Results: The median age at the start of 770G was 13.97 years (IQR 11.24–17.86), with a median of 6.5 years of duration of type 1 diabetes. After utilizing the 770G pump (n=20), TIR, TAR, and CV improved over the year (P<0.05). Patients utilizing Auto Mode over 85% of the time exhibited significant improvements in HbA1c (P=0.02), TIR (P=0.04), CV (P<0.01), and TAR 250 (P=0.02), in contrast to those who used Auto Mode 85% or less. Hyperglycemia and lack of calibration contributed to over 50% of the exits from Auto Mode. Conclusions: The implementation of HCL in adolescents and young adults with T1D enhanced glycemic control over one year. Educating patients on sustained Auto Mode use without interruptions is crucial. Presentation: 6/2/2024

8070 Atypical New Onset Diabetes Mellitus in a Young Male: Is this LADA vs Type 1 or Type 2?

Abstract Disclosure: S.K. Devineni: None. S. Shaik: None. J.L. Gilden: None. Background: Recent literature suggests that autoantibody seropositivity is common in new onset autoimmune Diabetes Mellitus (DM), especially in younger patients. Latent autoimmune diabetes of adults (LADA), a form of adult-onset autoimmune DM. is considered a mix of type 1 and type 2 DM, sharing similar immune cell characteristics to both subtypes. Unlike type 1, LADA patients do not require insulin for glycemic control for the first six months after diagnosis. Unlike type 2, LADA patients are positive for single islet autoantibody, glutamic acid decarboxylase (GAD), and anti-gliadin antibodies. Patients with LADA often present with symptoms (polyuria, polydipsia, nocturia, fatigue, and visual changes). We present a case of new onset Diabetes Mellitus in a young male, autoantibody seronegative, at the time of diagnosis. Case report: A 19-year-old Caucasian male was sent to the Emergency Department with a serum blood glucose (BG) level of 579 mg% after routine blood tests. He denied any clinical symptoms and serum levels showed no elevation in ketones, nor bicarbonate levels, ruling out ketoacidosis. His hemoglobin A1c at that time was 14.7%. He denied prior knowledge of personal or family history of DM. or other autoimmune disorders. However, it was discovered that routine labs done 1 ½ months earlier on a Health Screen revealed BG=295 mg% with urine positive for ketones (80 mg/dl) and glucose (>1000 mg/dL). Physical Exam: (HT=178 cm; WT=79 Kg) was unremarkable. Autoantibodies for GAD 65, islet-cell, Zinc transporter 8, and Islet Antigen 2 were all negative. He was hospitalized for 9 days. BG levels were difficult to control and required increasing doses of both long acting and short acting insulin. He was discharged with insulin therapy (30 units of glargine at nighttime and 12 units of premeal aspart). One week later, the patient ate several gummy bears as a nighttime snack and subsequently woke up in the middle of the night feeling shaky and having blurry vision. BG was greater than 300 mg%. In the emergency room, he. received intravenous fluids. No insulin was given as his BG normalized and he was discharged. Later, a continuous glucose monitor revealed multiple hypoglycemic episodes. The patient was living in a situation where he only had limited access to certain foods, and thus his insulin regimen was decreased (28 units glargine and 10 units aspart for meals) Conclusion: We present the case of new onset atypical DM in a young patient whose insulin sensitivity and risk factors seem to resemble a pattern of type 1 DM; despite seronegative autoantibodies We predict that he may eventually seroconvert to type 1 DM. It is also possible that he may have an unusual presentation of LADA or type 2 DM, although he had no hyperglycemic symptoms. Presentation: 6/3/2024

7507 Early Detection of Hyperglycemia Using CGM Despite Reduced Dosing of Teprotumumab

Abstract Disclosure: L. Needleman: None. S.H. Kim: None. A.L. Kossler: None. C. Dosiou: None. Background: In a previous longitudinal observation study, we showed that patients with prediabetes increased HbA1c by a mean of 0.7% and 30% progressed to type 2 diabetes after treatment with teprotumumab for 3 months, or after 4 infusions [1]. However, temporal effects of hyperglycemia and the impact of lower doses of teprotumumab on hyperglycemia are unknown. Clinical case: An 86-year-old woman was diagnosed with Graves’ disease after evaluation for palpitations showed undetectable TSH, free T4 2.31 ng/dL (ref. 0.8-1.8 ng/dL), total T3 252 ng/dL (ref. 76-181 ng/dL), and elevated TSI (5.0, ref. <1.3). Thyroxine levels normalized four weeks after starting methimazole. Nine weeks after the initial presentation she developed diplopia and bilateral proptosis. She was diagnosed with active moderate-to-severe thyroid eye disease (CAS 4/7) and was started on teprotumumab 10 mg/kg intravenously every three weeks. The dose was not increased to 20 mg/kg due to concern for adverse effects given the patient’s age and underlying hearing impairment. At baseline, she had prediabetes based on a HbA1c of 6.0%. Additional risk factors for type 2 diabetes included older age and Asian race [1]. Continuous glucose monitoring (CGM, Dexcom G7) before starting teprotumumab showed 71% time in tight range (TITR, 70-140 mg/dL) with average fasting glucose of 115 mg/dL. Prior to starting teprotumumab, she received counseling for lifestyle modification including carbohydrate moderation. Ten days following her first teprotumumab dose, her TITR reduced to 66%. After three doses of teprotumumab, her proptosis improved by 2 mm, CAS decreased to 1/7, and diplopia resolved. However, the TITR was 59% and average fasting glucose increased to 128 mg/dL. HbA1c also increased to 7.4% and the patient was started on metformin. Conclusion: In this case, teprotumumab increased glucose as early as after the first infusion. Glucose tolerance continued to worsen with subsequent doses, with development of type 2 diabetes, even with reduced dosage of teprotumumab. This case demonstrates that monitoring for teprotumumab-related hyperglycemia can be optimized with use of CGM and that lower doses of teprotumumab do not eliminate the risk of worsening glucose tolerance. Whether hyperglycemia would have been more severe with full dose teprotumumab remains uncertain. Reference: [1] Amarikwa L, Mohamed A, Kim SH, Kossler AL, Dosiou C. Teprotumumab-Related Hyperglycemia. J Clin Endocrinol Metab. 2023 Mar 10;108(4):858-864. Presentation: 6/3/2024

5180 Atypical Presentation of Type 2 Diabetes Mellitus in a 72Year Old Caucasian Male with Hemoglobin J-Baltimore Variant: A Case Report

Abstract Disclosure: C. Muojieje: None. M. Luzuriaga: None. Objective: This case report discusses the unusual manifestation of Type 2 Diabetes Mellitus (T2DM) in a 72-year-old Caucasian male possessing a rare Hemoglobin variant, Hemoglobin J-Baltimore. It emphasizes the importance of recognizing how hemoglobin variants can impact HbA1c measurements. Alternative markers, such as fructosamine and HbA1c measurement using turbidimetric inhibition immunoassay (TINIA), are discussed as potential tools for a more precise assessment of glycemic control. Furthermore, it accentuates the effectiveness of tailored treatment strategies in such cases. Methods: A 72-year-old Caucasian male with a history of T2DM was referred to an endocrinology clinic due to substantial discordance between the blood glucose (BG) values when self-monitoring and HbA1c. The patient was diagnosed with T2DM a decade ago due to fasting hyperglycemia. His HbA1c levels had remained within normal range. He exhibited signs of diabetic nephropathy with moderately increased albuminuria. He was never prescribed an oral hypoglycemic agent. He reported polyuria, weight loss, and fatigue, prompting him to monitor his BG at home twice daily, revealing readings > 200 mg/dl. HbA1c measurement using high-performance liquid chromatography (HPLC) was 4.8%. His fasting plasma glucose was 190 mg/dl, and fructosamine levels were 292 umol/L (205 - 285 umol/L). An HbA1c level via TINIA was 6.4%. Hemoglobin electrophoresis unveiled the presence of Hemoglobin J-Baltimore. We started metformin, resulting in an improvement in HbA1c from 6.4% to 5.8%. Fructosamine levels improved from 292 umol/L to 210 umol/L. Fasting blood glucose remained > 150 mg/dl. Dulaglutide was introduced. Follow-up analysis showed an improvement in FBS to < 120 mg/dl. HbA1c remained unchanged at 5.9%. Conclusion: The significance of hemoglobin variants, exemplified by Hemoglobin J-Baltimore, cannot be overstated in the context of patients with T2DM, especially within populations where these variants are uncommon. This case underscores the need for a nuanced approach to glycemic control assessment in such individuals. The utilization of alternative markers, such as HbA1c values obtained through TINIA, emerges as a valuable strategy. The role of continuous glucose monitoring (CGM) is crucial, providing real-time and comprehensive data, which enhances the quality of care and contributes to more tailored and effective treatment strategies. Presentation: 6/1/2024

8193 Mauriac Syndrome Uncovered, The Insulin Access Impact in Type 1 Diabetes Mellitus

Abstract Disclosure: D.H. Sacoto: None. R. Belokovskaya: None. K. Gebran: None. K. Madani: None. A. De Rosairo: None. D. Patel: None. A.A. Franco-Akel: None. Introduction: Mauriac syndrome is a rare complication of poorly controlled type 1 diabetes mellitus (T1DM). It is reversible with appropriate glycemic control; however, factors affecting healthcare access to insulin are leading to its re-emergence. We present a case of Mauriac syndrome as a complication of uncontrolled T1DM due to insulin access. Case: A 22-year-old Hispanic female with a history of T1DM presented to the emergency department with a two-day history of abdominal pain. She was diagnosed with diabetic ketoacidosis (DKA) (blood glucose: 802 mg/dL; pH 7.14; bicarbonate: 7 mmol/L; anion gap: 34; positive serum ketones). Incidental transaminitis was noted. R factor showed a cholestatic pattern of 0.6 (AST: 136 U/L, ALT: 49 U/L, alkaline phosphatase:286 U/L). US liver revealed an enlarged liver (craniocaudal: 16.5 cm) without biliary obstruction. Her phenotype consisted of short stature (4.8 feet) with a moon face and a protuberant abdomen. Her records revealed a normal karyotype 46 XX, with a bone age of 4 years, pubertal delay, low insulin-like growth factor-1 levels (58 ng/mL), and long-standing hyperlipidemia. Over the years, she experienced multiple DKA episodes in the context of uncontrolled T1DM (hemoglobin A1c:11-13 %). The main problem identified included difficulty with insulin access, specifically related to insurance coverage as well as managing her disease. Glycemic control has significantly improved with continuous glucose monitoring and updated insurance status. Discussion: Mauriac syndrome is characterized by hepatomegaly, transaminitis, delayed pubertal maturation, growth failure, and cushingoid features. Hyperglycemia leads to intrahepatic glycogen deposition and the lack of insulin to lipolysis and ketosis, leading to high cortisol levels and growth delay. Factors leading to uncontrolled T1DM include lack of insulin access. The high cost is considered a major barrier, with an average price per millimeter of insulin tripled from 231 to 736 US dollars. Even patients with insurance tend to have high co-pays and deductibles, with a 61% chance of delay or denial due to pre-approval requirements. Lower socioeconomic status, lack of access to devices such as insulin pumps, migratory status, social support, and ethnic background are other factors related to glycemic control. Our patient belongs to a family of immigrants with low socioeconomic status, which might have contributed to the development of Mauriac syndrome. Since clinical and laboratory abnormalities are reversible with appropriate glycemic control, advocating for policies that facilitate better insulin access is paramount. Presentation: 6/2/2024

6538 Find me if you can! A Case of a "Well Placed Solitary Insulinoma" in "The Center" of an SACST

Abstract Disclosure: R. Kennedy: None. D.A. D'Alessio: None. A.V. Vella: None. Introduction: Selective arterial calcium stimulation testing (SACST) can be utilized in patients to localize solitary insulinomas when imaging is non diagnostic. While a heterogenous stimulation pattern suggests NIPHS, or multiple insulinomas this case uniquely demonstrates such a pattern with a solitary insulinoma. Clinical Case: The patient is a 48 year old female who presented to the emergency department (ED) for bizarre behavior which resolved with a sweetened drink. Serum glucose was 62 mg/dL, she was treated with IV dextrose and was discharged from the ED. She was referred to outpatient endocrinology for further evaluation where continuous glucose monitoring confirmed predominantly fasting hypoglycemia. Adrenal insufficiency was excluded. She was admitted for a 72 hour inpatient fast where the patient achieved hypoglycemia within 24 hours, with glucose 46 mg/dL (associated with neuroglycopenic symptoms), beta hydroxybutyrate < 0.18 mmol/L, insulin 3.9 mcIU/mL, proinsulin 157pmol/L, c-peptide 1.4 ng/mL and a glucose rise greater than 25mg/dL after glucagon administration. Sulfonylurea screen and insulin antibodies were negative; IGF1 within normal limits. These labs were consistent with hyperinsulinemic hypoglycemia. An MRI pancreas however did not reveal an insulinoma. The patient therefore underwent a SACST, demonstrating a 10 fold response in the territory of the gastroduodenal artery and splenic artery, as well as a 3 fold response in the superior mesenteric artery. This heterogenous pattern in addition to the marked response in each arterial territory raised the possibility of multiple insulinomas. However as there were no tumors present on imaging, medical management was initiated with close follow up. She was trialed with months of somatostatin analogs and diazoxide with minimal improvement in the frequency and severity of her hypoglycemia. About a year after her initial diagnosis, repeat abdominal imaging (CT and MRI) revealed an 8 mm arterial hyper-enhancing lesion in the body of the pancreas concerning for neuroendocrine tumor. Repeat SACST was performed, this time showing a greater than 10 fold response in all three arterial territories. Angiography showed a tumor blush that was visible when each of the three major arteries were injected sequentially. She underwent laparoscopic pancreatic enucleation. The lesion was located on the body of the pancreas, with histology confirming an insulinoma. The patient responded promptly post operatively; her symptoms resolved without further need of medical management. Conclusion: Our case shows that the interpretation of an SACST should take into account the arterial anatomy before ascribing a non-focal response to multiple territories of insulin hypersecretion. Presentation: 6/1/2024

6894 Disparities in Continuous Glucose Monitor Utilization and Real-Time Remote Sharing in Patients with Type 2 Diabetes Treated with Insulin on Medicare

Abstract Disclosure: K.L. Flint: None. T. Ting: None. K. Rivera: None. P. Tamang: None. C.A. Colling: None. J.H. Li: None. M.S. Putman: Consulting Fee; Self; Synspira Therapeutics. Research Investigator; Self; Dexcom. Other; Self; Vertex Pharmaceuticals Incorporated. Introduction: Continuous glucose monitors (CGM) are FDA-approved for the management of diabetes and have been shown to improve glycemic control. For optimal utilization, CGM can be connected to cloud-based clinic portals for real-time sharing of glycemic data with clinicians to guide clinical care. Although studies have previously identified disparities in access to CGM for patients who receive Medicare, limited data are available examining disparities in CGM utilization and data sharing. Hypothesis: We hypothesized that racial and socioeconomic disparities in CGM access exist both in utilization and in real-time remote sharing of CGM data. Methods: This was a retrospective cohort study examining patients with type 2 diabetes on insulin using Medicare as primary or secondary insurance in a single diabetes clinic affiliated with a tertiary care medical center. Clinical data extracted from the electronic health record (EHR) included age, self-reported race and ethnicity, sex, preferred language, education level, ZIP code-based median household income, and enrollment in the EHR-patient portal. The most recent diabetes clinic note for each patient as of October 2023 was reviewed to assess whether each patient was using CGM at the time of the visit. The clinic’s CGM portal accounts were reviewed to assess whether the patient was connected to and actively sharing CGM data with the clinic. Two sample t-tests and chi-square tests were used to evaluate continuous and categorical predictors of CGM use and real-time remote sharing, respectively. Results: Of the 847 patients who qualified for inclusion, 420 (49.6%) were using CGM and 213 (25.1%) were sharing CGM data in real-time. Compared to patients not using CGM (n=427), patients using CGM were younger (70.8 years vs 73.5 years, p<0.001) and more often enrolled in the EHR-based patient portal (91.9% vs 84.1%, p<0.001); however, there were no differences in racial, ethnic, or socioeconomic factors between the groups (p>0.05 for all). Of the patients using CGM, remote sharing of data was associated with younger age (69.5 years vs 72.3 years, p<0.01), identifying as White (74.2% vs 65.0%, p=0.04), using English as preferred language (92.5% vs 84.2%, p=0.02), higher levels of education (p=0.01), and using the EHR-based patient portal (97.2% vs 86.7%, p<0.001). Conclusions: In this cohort of patients with type 2 diabetes on insulin receiving Medicare, there were no significant socioeconomic disparities in CGM utilization. However, racial and socioeconomic disparities were pronounced in real-time remote sharing of CGM data, suggesting that patients from minoritized racial backgrounds, patients who do not use English as their preferred language, and patients with less education may benefit from additional support and training to connect and share their CGM with their providers. Presentation: 6/2/2024

9337 Postprandial And “Fasting” Hypoglycemia In A Patient With A History Of Gastric Bypass Surgery And Carcinoid Syndrome

Abstract Disclosure: S. Ntelis: None. M. Pennant: None. Background: Hypoglycemia is an increasingly recognized complication of bariatric surgery that can occur years after the procedure. Episodes most commonly occur 1-3 hours after meals. Fasting hypoglycemia is not typical and raises concerns for other etiologies, including adrenal insufficiency and other causes of endogenous hyperinsulinism. Clinical Case: A 51-year-old woman with a history of carcinoid tumor of unknown origin with liver metastases, treated with monthly octreotide injections, and history of Roux-en-Y gastric bypass presented with multiple episodes of symptomatic hypoglycemia up to 24 mg/dl. Symptoms included tremor and diaphoresis and improved with juice. Morning cortisol was 22.7 mcg/dL (n > 19.4 mc/dL), ruling out adrenal insufficiency. A continuous glucose monitor (CGM) was placed, and she was advised to have frequent low-carbohydrate meals mixed with healthy fats and protein. She was also advised to add cornstarch to meals, until mixed-meal testing could be performed. She was hospitalized for a seizure provoked by hypoglycemia after a heavy high-carbohydrate meal, and treatment with acarbose 25 mg three times daily was started. Mixed-meal testing was consistent with post-prandial hyper-insulinemic hypoglycemia, with elevated insulin (58 mcIU/ml, n: 2.6-24.9 mcIU/ml) and c-peptide (11.2 ng/ml, n: 1.1-4.4 ng/ml) levels during an episode of symptomatic hypoglycemia (glucose 22 mg/dL) 2.5 hours after the patient’s meal. CGM showed hypoglycemia mostly occurring after meals and some episodes of hypoglycemia early in the morning, that occurred after late-night snacks. Clinical picture and laboratory testing were suggestive of post-bariatric surgery hypoglycemia. Poor hepatic glycogen reserve, secondary to the liver metastases, was considered a contributing factor. Interestingly, although hypoglycemia was mediated by hyperinsulinemia, treatment with a somatostatin analogue provided no benefit. The frequency of hypoglycemia decreased with adherence to a low-carbohydrate diet, and episodes mostly occurred when acarbose use was delayed. Octreotide was transitioned to lantreotide. Due to persistence of early-morning low glucose values on follow-up, further work-up was pursued to rule out etiologies of fasting hypoglycemia. Glucose values remained >70 mg/dl during 72 hours of fasting. IGF-I (115 ng/ml, n: 53-287 ng/ml) and IGF-II (608 ng/ml, n: 267-616 ng/ml) levels were normal, and insulin antibodies were undetectable. Post-bariatric surgery hypoglycemia was confirmed and acarbose dose was increased to 50 mg three times daily. Conclusion: Postprandial hypoglycemia is a late complication of bariatric surgery. Early-morning hypoglycemia can also be seen after bariatric surgery in patients who have late-night meals and snacks. Presentation: 6/1/2024

7378 Glargine Induced Neuroglycopenia in Patients with End-Stage Renal Disease: Importance of Insulin Regimen Optimization in Haemodialysis Patients

Abstract Disclosure: M. Shrivastava: None. L. Kaur: None. B. Armendariz: None. R. Kaur: None. A. Shetty: None. In patients with end stage renal disease (ESRD), hypoglycemia accounts for up to 3.6% of all the admissions with mortality rates of up to 30%. A combination of impaired insulin clearance, changes in glucose metabolism and dialysis process makes the patients with end stage renal disease vulnerable to neuroglycopenia.Case description:53 year old female with past medical history of insulin dependent type 2 diabetes mellitus, ESRD secondary to diabetes, on hemodialysis(HD) thrice weekly since two years, presented to the emergency with altered mental status, respiratory distress, tachycardia. Lab work revealed blood glucose(BG) of 23 mg/dl, HbA1c of 8.4%, eGFR of 6, and arterial blood gas showed hypercapnic respiratory acidosis. Patient received dextrose, with no improvement of symptoms. Eventually she developed acute hypercapnic respiratory failure requiring endotracheal intubation with mechanical ventilation, and was transferred to the ICU. As per family, a night prior to presentation, last recorded BG after dinner was 253 mg/dl, she took her night time glargine, which was recently increased by her primary care for poorly controlled HbA1c levels. Brain MRI and long term EEG monitoring findings were consistent with underlying extensive brain injury secondary to prolonged hypoglycemia. Unfortunately, the patient's condition did not improve despite HD and BG correction, eventually she underwent compassionate extubation. Case Discussion:The insulin requirements in ESRD patients are reduced by approximately 50%, regardless of residual insulin secretion. Malnutrition and acidosis reduce hepatic glycogen stores and availability of gluconeogenic precursor, expected compensatory renal gluconeogenesis is compromised by decreased renal function causing hypoglycemia, which is further worsened by inappropriately high plasma insulin levels caused by reduced renal insulin breakdown. Diabetes mellitus patients with ESRD are frequently managed with basal-bolus insulin regimen, and HD up to thrice weekly, leaving them without HD for up to 3 days especially over the weekend. This can result in accumulation of insulin metabolites causing delayed insulin clearance as seen in our patient. In such cases even long acting insulin, such as glargine, can have compounding effects, which could possibly cause fatal complications such as neuroglycopenia. In such patients continuous glucose monitor use with tapering dose glargine regimen may help eliminate this compounding effect. Conclusion: Neuroglycopenia is a rare manifestation of diabetes mellitus with ESRD. Compromised renal gluconeogenesis and impaired insulin clearance can cause inappropriately high plasma levels of insulin. In such patients continuous glucose monitoring along with tapering dose of long acting insulin should be utilized for proper glycemic control to limit compounded effect of insulin metabolite accumulation. Presentation: 6/3/2024

6774 Recurrent Hypoglycemia In Malignant Insulinoma With Multiple Liver Metastases Successfully Managed With Octreotide

Abstract Disclosure: K. Kim: None. S. Mascarell: None. Introduction: Insulinoma is a rare functional pancreatic neuroendocrine tumor (pNET) with the incidence of 1-4/million person-years. Malignant insulinomas with locoregional invasion or metastases consist 10% among insulinomas. While the treatment of a single insulinoma is surgical resection, treatment of malignant insulinoma requires a comprehensive approach. Due to the low prevalence of the disease, data on therapeutic modalities of malignant insulinomas are limited. We hereby present a case of malignant insulinoma in which recurrent hypoglycemia was successfully managed with octreotide. Case: A 36 year old female diagnosed with grade III well differentiated pNET with multiple metastases to the liver and abdominal lymph nodes 1 year ago was admitted for recurrent hypoglycemic episodes. She reported progressively worsening hypoglycemia for the past 1 month. She was eating every 2 hours including her sleeping hours to prevent hypoglycemia. Due to recurrent hypoglycemia she required hospitalization with IV dextrose. After 13 hours of fasting in the ICU, hypoglycemia due to insulin hypersecretion was confirmed with blood glucose 51 mg/dL and elevated serum insulin 51.11 uIU/mL (1.9-23uIU/mL). She underwent the short octreotide test which showed suppressed insulin (5.25 uIU/mL) 6 hours after receiving 100 mcg of octreotide. She was started on octreotide 50 mcg every 12 hours and monitored for further hypoglycemic episodes. She tolerated octreotide without any side effects including hypoglycemia. She was discharged home with a continuous glucose monitor (CGM) and transitioned to intramuscular lanreotide 20mg injections every 4 weeks as an outpatient. No further hypoglycemic episodes occurred. Discussion: Few cases report treatment of hypoglycemia in malignant insulinoma with octreotide. Octreotide has the dual effect of suppressing insulin secretion and tumor growth on insulinomas that express SSTR2 receptors. However, because somatostatin agonists also inhibit the secretion of glucagon, in insulinomas without SSTR2 expression, octreotide can aggravate hypoglycemia. This was especially a concern for our patient with a large tumor burden. Thus the short octreotide test was conducted. We suggest that the octreotide test of 100 mcg SQ octreotide injection followed by hourly measurements of glucose and insulin levels is a useful and convenient test to predict efficacy while monitoring for octreotide induced hypoglycemia. Finally the use of CGM in the outpatient setting enabled successful transition to octreotide LAR which improved the patient’s quality of life greatly by enabling once a month injections. Presentation: 6/3/2024

6870 Cardiac Imaging And Metabolomics Studies Suggest Differential Risk And Protective Biomarkers For Cardiovascular Disease In Renoprotected, Long-Duration Type 1 Diabetes

Abstract Disclosure: M. Yu: None. S. Jangolla: None. N. Ziemniak: None. E. Viebranz: None. T. Chokshi: None. K. Park: None. I. Wu: None. H. Shah: None. G.L. King: None. Cardiovascular disease (CVD) is a major cause of mortality in people with Type 1 diabetes (T1D), especially in those with nephropathy (DN). However, in long-duration T1D, a substantial proportion of individuals without DN still exhibit excessive CVD risks. The Joslin 50-Year “Medalist” Study (n=1043), composed of people with T1D≥50 years, are ideal for studying CVD in a renoprotected T1D cohort, as only 13% have DN, and yet 40% have CVD, despite excellent control of lipids and blood pressure. Stratifying the Medalists by DN revealed that exercise was cardioprotective in the group with DN (OR 0.60, p=0.04); while age at T1D diagnosis (OR 1.03, p=0.01), HbA1c (OR 1.25, p=0.01), C-reactive protein (OR 1.14, p=0.01), and interleukin-6 (OR 1.13, p=0.01) all increased CVD risk in Medalists without DN. A subset of Medalists also underwent coronary artery calcification scans (CAC; n=153) and cardiac magnetic resonance imaging of left ventricular (LV) structure and function (CMR; n=111). The majority of these Medalists (97.8%) had detectable CAC>0; furthermore, the median CAC score of 1000 was higher at any cutoff compared to similar age-matched T1D and Type 2 diabetes (T2D) populations with higher DN prevalence. In contrast, mean CMR values in this Medalist subset were comparable to other cohorts. Continuous glucose monitoring (CGM) metrics for hyperglycemia (mean glucose, β=0.002, p=0.03; glucose management indicator, β=0.09, p=0.03; and time above range>180 mg/dL, β=0.003, p=0.02), but not glucose variability or hypoglycemia, were associated with LV remodeling in the Medalists, even after adjusting for eGFR. Likewise, plasma levels of advanced glycation end-products (AGEs) N-carboxyethyl-lysine (CEL), N-carboxymethyl-lysine (CML), and methylglyoxal-derived hydroimidazolone (MGH1) were associated with CAC (β=16.22, p=0.05; β=15.21, p=0.01; and β=10.18, p=0.01, respectively) and LV remodeling (β=0.001, p=0.09; β=0.001, p=0.05; and β=0.001, p=0.04, respectively) in the Medalists. The association of CEL with CVD replicated in a separate Medalist subset (n=311) with self-reported CVD data (OR 1.26, p=0.01). Plasma global metabolomics studies (n=140) revealed that amino acid activation pathways, with lower levels of branched chain amino acids, were associated with CAC (FDR=0.002); while amino acid metabolism pathways were associated with less favorable LV volumes (FDR=0.03). In this comprehensive study of aging T1D people with no substantial DN, hyperlipidemia, or hypertension, cardiac imaging and metabolomics studies suggest disproportionate advanced CAC, as compared to subclinical LV remodeling or dysfunction, and highlight the importance of targeting hyperglycemia for CVD risk reduction. Plasma metabolites associated with CVD in T1D are different from those in T2D, and may provide novel information on potential therapeutic targets for CVD in T1D. Presentation: 6/1/2024

8145 Type 2 Diabetes In A Patient With IMAGe Syndrome

Abstract Disclosure: N. Mulpuri: None. S. Mirfakhraee: None. J. Abramowitz: None. Background: Individuals with mutations that lead to deficiency of POLE1 (a catalytic subunit of polymerase epsilon) may have clinical features of IMAGe syndrome (intrauterine growth restriction, metaphyseal dysplasia, adrenal hypoplasia congenital, and genitourinary anomalies) in addition to distinctive facial features and variable immunodeficiency. Of 15 reported cases in the literature, none were previously characterized with type 2 diabetes mellitus (T2DM). Clinical case: This is a 25-year-old woman with a history of IMAGe syndrome (confirmed mutation in the POLE gene). With regards to IMAGe syndrome history, during the prenatal period, she had growth restriction in the third trimester with delivery at 38 weeks. At 4 years-old, she presented with adrenal crisis and was started on glucocorticoid and mineralocorticoid therapy, now taking hydrocortisone 2.5mg three times daily (8.6 mg/m2/day) and fludrocortisone 0.05mg daily. Initial labs in the adult endocrine clinic were notable for serum glucose 339 mg/dL (65-99 mg/dL), undetectable estradiol (< 15 pg/ml) with FSH 6.8 mIU[JA1] /mL and LH 2.0 mIU/mL, TSH 1.25 mIU/L (0.40-4.50 mIU/dL), FT4 0.7 ng/dL (0.8-1.8 ng/dL). The patient denied any history of T2DM. She also denied polyuria, polydipsia, or weight loss. There was no stigmata of peripheral insulin resistance on exam. Subsequent labs included HbA1c 8.9%, fructosamine 417 mcmol/L (200-285 mcmol/L), insulin 18.4 mcIU/mL (2.6-24.9 mcIU/mL), and C-peptide 3.9 ng/dL (1.1-4.4 ng/dL) with serum glucose 164 mg/dL. Islet cell, insulin, and GAD-65 antibodies were undetectable. CT abdomen/pelvis did not show any pancreatic mass or anomalies. Initially, prandial insulin (lispro 3 units prior to each meal) was initiated given post-prandial hyperglycemia noted on continuous glucose monitoring. Low-dose levothyroxine, 25 mcg daily, was initiated given concern for secondary hypothyroidism, with subsequent normalization of serum thyroxine. HbA1c improved to 7.4% six months later. Ultimately, she transitioned to sitagliptin 25 mg daily and her latest HbA1c was 6.2% three years after initial diagnosis of T2DM. Conclusion: Of the 15 cases of IMAGe syndrome with mutations in POLE described in Logan et al, none were noted to have diabetes. The patient described above was diagnosed with new-onset diabetes at age 21, presumably T2DM in the context of undetectable antibodies and high-normal C-peptide. Interestingly, she did not have any typical stigmata of peripheral insulin resistance. Glucocorticoids used for the treatment of adrenal insufficiency in patients with IMAGe syndrome can contribute to development of T2DM. Patients with IMAGe syndrome on chronic glucocorticoids should be monitored for hyperglycemia and diabetes. Additionally, glucocorticoid doses should be optimized to balance mitigating side effects such as hyperglycemia and osteoporosis while preventing adrenal crisis. Presentation: 6/3/2024

8000 Intestinimonas Butyriciproducens As A New Preventive Therapy For Type 2 Diabetes: a Proof Of Concept Randomized Controlled Trial

Abstract Disclosure: V. Antoniotti: None. M. Caputo: None. E. Mollero: None. A. Antonioli: None. S. Tini: None. M. Manfredi: None. S. Gul: None. N. Bui: None. J. Seegers: None. W. De Vos: None. G. Aimaretti: None. F. Prodam: None. Background. The incidence of type 2 Diabetes Mellitus (T2D) is increasing worldwide. Prevention is possible by changing lifestyle but it’s not effective alone in real life, due to poor compliance over time. New strategies are necessary, mostly for high-risk individuals. Therapeutic microbiology is a further proposed target, and butyrate-producing bacteria can improve metabolic parameters in obese patients. Our study aims to evaluate the effect of Intestinimonas butyriciproducens as a preventive therapy for T2D in prediabetes thanks to its effects in decreasing Advanced Glycation End Products (AGEs), converting sugars and proteins in butyrate, and increasing insulin sensitivity.Methods. The trial is a double-blind, randomized, placebo-controlled (phase 1) and open-label pilot study with two different doses (phase 2) of 26 weeks. I. butyriciproducens (105 CFU/day) or placebo were given for 12 weeks, then subjects in placebo will start the treatment (105 CFU/day), and the other group will increase the dose (108 CFU/day) for 14 weeks. Overweight or obese patients with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) were included. Patients were assessed for clinical, biochemical, and microbiota parameters at the time of recruitment (V1), after phase 1 (V7) and phase 2 (V10), during which the eating and lifestyle habits were also evaluated. No dietary advice was given. Results. Nineteen have completed the study. Treated patients during the first phase had a significant improvement in glucose-insulin metabolism demonstrated through the HOMA Disposition Index (p= 0.0075). Lipid profile also ameliorates in patients treated at a low dose and then at a high dose, particularly decreasing triglycerides (phase 1: p= 0.0212; phase 2: p= 0.0261). The weight and BMI of patients were stable throughout the period of study. Data from Flash glucose Monitoring (FGM) show a more stable glucose, mainly at the end of the study. Serum AGE concentrations showed a trend towards a decrease in treated patients, whereas IL-10 slowly increased without changes in IL-6 and IL-17.Lastly, 10 out of 19 patients after 26 weeks of treatment had a remission in IFG or IGT (52.6%). Conclusions. Intestinimonas butyriciproducens seems to improve insulin sensitivity and triglycerides in treated patients. Intestinimonas butyriciproducens could be a new strategy in the work-up of T2D prevention. Presentation: 6/1/2024

12553 Severe Hyperglycemia After Initiation Of Bictegravir Antiretroviral Therapy With Resolution Upon Discontinuation

Abstract Disclosure: S. Hudson: None. J. Aurora: None. K. Grossman: None. L. Kogelman: None. A.G. Pittas: None. Background: Antiretroviral therapy (ART) containing bictegravir (BIC), a second-generation integrase strand transfer inhibitor (INSTI), is a first-line treatment for HIV. There are mixed reports of INSTIs causing adverse metabolic effects, such as weight gain and hyperglycemia. There are cases of BIC causing hyperglycemia and diabetic ketoacidosis (DKA) within weeks to months following initiation; however, this has not been reported in clinical trials (1). It is unclear whether discontinuing BIC resolves hyperglycemia. We report a case of a patient with prediabetes who developed severe hyperglycemia after switching to a BIC-containing ART. The discontinuation of BIC resulted in significant improvement in glycemia, leading to the de-escalation of diabetes pharmacotherapy. Clinical Case: A 36-year-old woman with obesity was diagnosed with HIV during pregnancy, which was complicated by gestational diabetes mellitus. After pregnancy, she had prediabetes. Her initial ART was darunavir/cobicistat/emtricitabine/tenofovir alafenamide. Due to intolerable GI side effects, six years later, she was switched to bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF). Laboratory tests four months before starting BIC/FTC/TAF were consistent with prediabetes (HbA1c 6.4%, non-fasting blood glucose of 118 mg/dL). After one month, she was started on metformin when her HbA1c increased to 9.1% with a non-fasting blood glucose of 332 mg/dL. Another month later, HbA1c increased to 12.8% with a non-fasting blood glucose of 685 mg/dL without DKA. She was hospitalized for diabetes management. There were no significant changes in weight, viral load, or CD4 count. A search for secondary causes of hyperglycemia (diabetogenic medications, hypercortisolism, and autoimmune diabetes) was not revealing. She was discharged on metformin and insulin glargine. Her HIV regimen was switched to FTC/TAF and doravirine due to suspicion of BIC-induced hyperglycemia. After five months, she developed symptoms of hypoglycemia, and her estimated HbA1c by continuous glucose monitoring was 6.3%. Insulin glargine was discontinued. While on metformin, HbA1c three months later was 6.3%. Two years later on metformin and linagliptin: HbA1c was 6.1% and beta-cell function did not reveal insulin deficiency or resistance (non-fasting blood glucose 96 mg/dL, insulin 13.5 uIU/mL [RR 2.6-24.9 mIU/mL], C-peptide 3.7 ng/mL [RR 1.1-4.4 ng/mL]). Conclusion: Patients with HIV and a history of obesity and/or dysglycemia who are switched to a BIC-containing ART regimen should be educated and monitored for acute hyperglycemia. This may be due to impaired beta-cell function and/or insulin resistance; however, further research is needed to understand the mechanism. An alternative ART regimen should be considered if hyperglycemia develops. Reference: 1. Nolan NS, et al. Open Forum Infect Dis. 2021;16;8(5): ofab077. Presentation: 6/3/2024

Continuous glucose monitoring-based metrics and the duration of hypoglycaemia events with once-weekly insulin icodec versus once-daily insulin glargine U100 in insulin-naive type 2 diabetes: an exploratory analysis of ONWARDS 1

Continuous glucose monitoring (CGM) can provide a comprehensive assessment of glycaemic control. This exploratory analysis of the ONWARDS 1 trial assessed CGM-based metrics and CGM-derived hypoglycaemia duration in insulin-naive individuals with type 2 diabetes treated with subcutaneous once-weekly insulin icodec (icodec) versus once-daily insulin glargine U100 (glargine U100). ONWARDS 1 was a 78-week (52-week main treatment phase and a 26-week treatment extension phase plus a 5-week follow-up), randomised, open-label, treat-to-target, phase 3a trial done at 143 sites (outpatient clinics and hospital departments) across 12 countries. Adults (aged ≥18 years) with type 2 diabetes (HbA1c: 7·0-11·0%) who had not previously received insulin were randomly assigned (1:1) via an interactive web-response system to once-weekly icodec or once-daily glargine U100. Double-masked CGM data were collected during treatment initiation (weeks 0-4), midtrial (weeks 22-26), end of main phase (weeks 48-52), end of extension phase (weeks 74-78), and follow-up (weeks 78-83). Secondary and exploratory outcomes were CGM-based metrics, including the mean percentages of time in glycaemic range (TIR; sensor glucose 3·9-10·0 mmol/L [70-180 mg/dL]), time in tight range (TITR; 3·9-7·8 mmol/L [70-140 mg/dL]), time above range (TAR; >10·0 mmol/L [>180 mg/dL]), and time below range (TBR; <3·9 mmol/L [<70 mg/dL] and <3·0 mmol/L [<54 mg/dL]), and CGM-derived hypoglycaemic episode durations (episodes defined by sensor glucose <3·9 mmol/L [<70 mg/dL for ≥15 consecutive minutes]). Analyses were done in the full analysis set (all randomly assigned participants). The ONWARDS 1 trial is registered with ClinicalTrials.gov, NCT04460885, and is complete. Participants were enrolled and randomly assigned in ONWARDS 1 between Nov 25, 2020, and Dec 1, 2022 (n=492 in each treatment group). During treatment initiation, we observed no statistically significant differences in the mean percentages of TIR, TITR, TAR, and TBR with icodec versus glargine U100. During the midtrial, end of main phase, and end of extension phase periods, the mean percentages of TIR and TITR were statistically significantly greater and the mean percentages of TAR statistically significantly lower with icodec versus glargine U100. The mean percentages of TIR met the internationally recommended CGM target (>70%) with icodec but not with glargine U100 during the three periods. TBR (<3·9 mmol/L [<70 mg/dL] and <3·0 mmol/L [<54 mg/dL]) was low and below recommended targets (<4% and <1%, respectively) across all study periods in both treatment groups, with no statistically significant differences between treatment groups for the lower threshold (<3·0 mmol/L [<54 mg/dL]). During the follow-up period, mean percentages of TIR, TITR, TAR, and TBR did not statistically significantly differ with icodec versus glargine U100. The duration of overall hypoglycaemic episodes was similar between treatment groups throughout the trial (median duration ≤35 min). These CGM data support the long-term efficacy and safety of icodec versus glargine U100 during treatment and indicated no increase in the duration of individual hypoglycaemic episodes with icodec versus glargine U100 in insulin-naive individuals with type 2 diabetes. Novo Nordisk.

A reduced carbohydrate diet improves glycemic regulation in hyperglycemic older people in a retirement home: The SAGE study.

Poor glucose regulation associated with gradual insulin resistance is a significant risk factor in several age-related chronic diseases. An eating plan that promotes a lower carbohydrate intake may have a beneficial effect on glucose metabolism. This study aimed to evaluate how a diet reduced carbohydrate by 32% (RCHO) over a 2-month period would influence the metabolic profile of older individuals (N = 24) living in a retirement home (RH). A continuous glucose monitor was used to measure blood glucose during four periods: the standard diet before (baseline) and after (washout) the intervention, during the 4 initial days of the RCHO diet (RCHO-early), and the final days of the 2-month intervention (RCHO-end). The blood metabolic profile was also measured (glucose, ketones, insulin, triglycerides and cholesterol). RCHO intake decreased average blood glucose compared to the standard diet in hyperglycemic participants: RCHO-early 7.8 ± 1.0 vs 7.5 ± 1.1 mM (p = 0.012) and RCHO-end 7.8 ± 1.0 vs 7.0 ± 0.9 mM (p = 0.050). In the hyperglycemic participants, the percentage of time spent in hyperglycemia (> 10.0 mM) decreased by 50% during the RCHO-early (p = 0.012) and by 66% at RCHO-end (p = 0.021) compared to baseline. Glycated hemoglobin was significantly lower at RCHO-end in both hyperglycemic and normoglycemic participants compared to baseline (p < 0.008). Plasma ketones increased 3-fold in hyperglycemic participants at RCHO-end compared to baseline (p < 0.028). This study shows that an RCHO diet has metabolic health benefits in an older population and confirms its safety, tolerability, and acceptability in a RH. (NCT06022094).

Differential effects of oral versus intravenous hydrocortisone and dexamethasone on capillary blood glucose levels in adult inpatients – a single centre study

BackgroundCorticosteroids raise blood glucose concentrations; however, it remains unknown which form of administration, oral or intravenous, is associated with the greatest degree of blood glucose rise in hospitalised patients. Furthermore, whether the pattern of the associated hyperglycaemia throughout the day differs depending on the route of administration. MethodsThis was a single centre retrospective study of 384 adult inpatients receiving oral or intravenous hydrocortisone and dexamethasone. Data on capillary glucose concentrations and time taken over seven days were collected. A mixed model for repeated measures was applied to compare changes in glucose concentration over time for oral and intravenous corticosteroids. An auto-regressive covariance structure was employed to model correlations between repeated measurements. This was adjusted for age, sex, pre-admission diabetes, and/or pre-admission corticosteroid status. ResultsNo significant difference was found between oral and intravenous hydrocortisone on day one or across all seven days (Mean Difference 0.17mmol/l (-1.39, 1.75), p=0.827, and Mean Difference 0.20mmol/l (-0.61, 1.01), p=0.639 respectively). There were no differences in mean glucose concentrations between those on oral or intravenous dexamethasone on day one or across all seven days (Mean Difference 0.41mmol/l (-0.55,1.38), p=0.404 and Mean Difference -0.09mmol/l (-1.05,0.87), p=0.855respectively). ConclusionThis study found that oral and intravenous administration of hydrocortisone and dexamethasone, do not have a significantly differing impact on blood glucose levels. Capillary glucose monitoring is strongly recommended in all individuals who are on either oral or intravenous corticosteroids.