Glycemic Management In Patients Research Articles

A Mobile-Based Intervention for Glycemic Control in Patients With Type 2 Diabetes: Retrospective, Propensity Score-Matched Cohort Study.

BackgroundMobile-based interventions appear to be promising in ameliorating huge burdens experienced by patients with type 2 diabetes. However, it is unclear how effective mobile-based interventions are in glycemic management of patients with type 2 diabetes based on real-world evidence.ObjectiveThis study aimed to evaluate the effectiveness of a mobile-based intervention on glycemic control in patients with type 2 diabetes based on real-world population data.MethodsThis retrospective, propensity score-matched cohort study analyzed longitudinal data from a clinical electronic health database. The study population included 37,913 patients with type 2 diabetes at cohort entry between October 1, 2016, and July 31, 2018. A total of 2400 patients were matched 1:1, using propensity score matching, into the usual care and mobile health (mHealth) groups. The primary outcomes of glycemic control included control rates of glycated hemoglobin (HbA1c), fasting blood glucose (FBG), and postprandial 2-hour blood glucose (P2BG). Mean values and variation trends of difference with 95% CI were the secondary outcomes. The general linear model was used to calculate repeated-measures analyses of variance to examine the differences between the two groups. Subgroup and sensitivity analyses were performed.ResultsOf the 2400 patients included in the analysis, 1440 (60.00%) were male and the mean age was 52.24 years (SD 11.56). At baseline, the control rates of HbA1c, FBG, and P2BG in the mHealth and usual care groups were 45.75% versus 47.00% (P=.57), 38.03% versus 32.76% (P=.07), and 47.32% versus 47.89% (P=.83), respectively. At the 3-, 6-, 9-, and 12-month follow-ups, the mHealth group reported higher control rates of HbA1c than did the usual care group: 69.97% versus 46.06% (P<.001), 71.89% versus 61.24% (P=.004), 75.38% versus 53.44% (P<.001), and 72.31% versus 46.70% (P<.001), respectively. At the four follow-up sessions, the control rates of FBG in the mHealth and usual care groups were statistically different: 59.24% versus 34.21% (P<.001), 56.61% versus 35.14% (P<.001), 59.54% versus 34.99% (P<.001), and 59.77% versus 32.83% (P<.001), respectively. At the four follow-up sessions, the control rates of P2BG in the mHealth group were statistically higher than in the usual care group: 79.72% versus 48.75% (P<.001), 80.20% versus 57.45% (P<.001), 81.97% versus 54.07% (P<.001), and 76.19% versus 54.21% (P=.001), respectively. At the four follow-up sessions, the percentages of HbA1c reduction in the mHealth group were 8.66% (95% CI 6.69-10.63), 10.60% (95% CI 8.66-12.54), 10.64% (95% CI 8.70-12.58), and 8.11% (95% CI 6.08-10.14), respectively. At the four follow-up sessions, the percentages of P2BG reduction in the mHealth group were 8.44% (95% CI 7.41-10.73), 17.77% (95% CI 14.98-20.23), 16.23% (95% CI 13.05-19.35), and 16.91% (95% CI 13.17-19.84), respectively. Starting from the sixth month, the mean HbA1c and P2BG values in the two groups increased slightly.ConclusionsThis mobile-based intervention delivered by a multidisciplinary team can better improve glycemic control rates of patients with type 2 diabetes than usual care. These effects were best sustained within the first 6 months. Starting from the sixth month, intensive management needs to be conducted to maintain long-term effectiveness of the mobile-based intervention.

Evidence-based treatment of hyperglycaemia with incretin therapies in patients with type 2 diabetes and advanced chronic kidney disease.

Type 2 diabetes is the leading cause of chronic kidney disease (CKD). The prevalence of CKD is growing in parallel with the rising number of patients with type 2 diabetes globally. At present, the optimal approach to glycaemic control in patients with type 2 diabetes and advanced CKD (categories 4 and 5) remains uncertain, as these patients were largely excluded from clinical trials of glucose‐lowering therapies. Nonetheless, clinical trial data are available for the use of incretin therapies, dipeptidyl peptidase‐4 inhibitors and glucagon‐like peptide‐1 receptor agonists, for patients with type 2 diabetes and advanced CKD. This review discusses the role of incretin therapies in the management of these patients. Because the presence of advanced CKD in patients with type 2 diabetes is associated with a markedly elevated risk of cardiovascular disease (CVD), treatment strategies must include the reduction of both CKD and CVD risks because death, particularly from cardiovascular causes, is more probable than progression to end‐stage kidney disease. The management of hyperglycaemia is essential for good diabetes care even in advanced CKD. Current evidence supports an individualized approach to glycaemic management in patients with type 2 diabetes and advanced CKD, taking account of the needs of each patient, including the presence of co‐morbidities and concomitant therapies. Although additional studies are needed to establish optimal strategies for glycaemic control in patients with type 2 diabetes and advanced CKD, treatment regimens with currently available pharmacotherapy can be individually tailored to meet the needs of this growing patient population.

2407-PUB: Glycemic Patterns Derived from Masked Continuous Glucose Monitoring in Adolescents with Type 1 Diabetes on Contemporary Management

Background: There has been a change in the management of type 1 diabetes (T1D) with the availability of continuous glucose monitoring (CGM) systems. In Australia, subsidized CGM is available to patients below the age of 21. A randomized controlled trial (RCT) evaluating hybrid closed loop therapy is currently underway and the baseline data provided an opportunity to analyze the glycemic patterns in patients on contemporary management. Methods: Adolescents and young adults with T1D and HbA1c &amp;lt;10.5% were eligible. All participants wore masked CGM (Enlite® Sensor 3, Medtronic) for 3 weeks during the run-in period. Glucose data from masked CGM were evaluated for glycemic patterns including sensor glucose (SG), glucose variability, percentage time in range, time in hypoglycemia and hyperglycemia. Results: Data were analyzed from 100 participants (47M, 53F; pump 80, MDI 20) with (mean±SD) age 14.9±2.7 years, diabetes duration 7.6±0.9 years, HbA1c 7.9±0.9% of which 55% participants were on real-time CGM. The (mean±SD) SG was 9.6±1.6mmol/l with fasting SG of 8.8±1.9mmol/l. The SG coefficient of variation was 41.3±6.04%. The median [IQR] %time in range (3.9 to 10mmol/l) was 55.9 [44.1,62.3]. The %time in hypoglycemia (&amp;lt;3.0 and &amp;lt; 3.9mmol/l) were 1.1[0.3,2.2] and 4.4[2.2,8.6] respectively. The %time in hyperglycemia (&amp;gt;10 and &amp;gt;13.9mmol/l) were 35.5[24.7,45.7] and 14.1[8.1,18.8] respectively. Conclusion: Majority of adolescents in the trial were on insulin pump therapy with half of them on CGM. The baseline CGM data of these participants provide a snapshot of the glycemic management in patients with T1D on current therapy; especially highlighting the reduced time in hypoglycemia compared to earlier trials. The data can further inform the conduct of future trials. Disclosure M.B. Abraham: None. G.J. Smith: None. M. de Bock: None. B.R. King: None. J. Fairchild: None. G. Ambler: None. F. Cameron: None. E.A. Davis: None. D.N. ONeal: None. T. Jones: Research Support; Self; Dexcom, Inc., Medtronic MiniMed, Inc. Speaker's Bureau; Self; Eli Lilly and Company, Roche Diabetes Care.

952-P: Improving Glycemic Management of Patients with Type 2 Diabetes in Acute Geriatric Care by Using a Basal Insulin Algorithm Incorporated into a Workflow and Decision Support System

Introduction: Glycemic management can be complex in elderly patients despite of multimorbidity and polypharmacy. International guidelines recommend individualizing therapy goals by using easy to handle basal insulin regimen with low hypoglycemia risk. An algorithm for basal insulin therapy (including basal-plus) based on the individual’s health status was developed and incorporated into GlucoTab®. This tablet-based workflow and decision support system provides suggestions for insulin therapy, blood glucose (BG) management and offers workflow support by visualization of open tasks. The study objective was to investigate efficacy and safety of the GlucoTab® system in patients at an acute geriatric hospital. Methods: A randomized controlled trial was performed in 58 patients with type 2 diabetes aged ≥ 65 years. Patients in the intervention group (IG) (n=31) were treated according to GlucoTab® basal insulin algorithm, patients in the control group (CG) (n=27) received diabetes therapy according to physician’s prescription electronically documented in GlucoTab®. Results: Patients of both groups (sex: IG=65% vs. CG=63% females, age: 78±6 vs. 76±6 years, BMI: 29±6 vs. 30±6 kg/m2 and HbA1c: 56±10 vs. 61±13 mmol/mol) were attributed an individual health status: 74% moderate and 26% good health. The percentage of fasting BG (FBG) values within health-dependent FBG target range was 59±33% vs. 51±31%. BG values below, within, and above health dependent target range occurred in 4%, 75% and 22% vs. 1%, 75% and 25%, respectively. In both groups no severe hypoglycemic event &amp;lt;40 mg/dl was observed. The number of BG values in the ranges 40 to 69 mg/dl was 3 vs. 2, respectively. Mean FBG was 142±49 vs. 150±38 mg/dl and mean daily BG was 195±74 vs. 201±46 mg/dl. Conclusion: The GlucoTab® basal insulin algorithm supported an efficacious and safe glycemic management in patients with type 2 diabetes in acute geriatric care. Disclosure A. Libiseller: None. K.M. Lichtenegger: None. J. Kopanz: None. A. de Campo: Advisory Panel; Self; Sanofi-Aventis. T. Wiesinger: Other Relationship; Self; Bristol-Myers Squibb Company. L. Weidinger: None. L. Laubreiter: None. W. Schippinger: None. T. Truskaller: None. B.C. Lackner: None. P. Beck: Employee; Self; decide Clinical Software GmbH. Stock/Shareholder; Self; decide Clinical Software GmbH. B. Höll: Employee; Self; decide Clinical Software GmbH. T.R. Pieber: Advisory Panel; Self; ADOCIA, Arecor Limited, AstraZeneca, Novo Nordisk A/S, Sanofi. Speaker's Bureau; Self; Novo Nordisk A/S. Funding Austrian Research Promotion Agency (FFG844737)

An audit of the adherence to blood-glucose monitoring and overall glycaemic management in patients requiring parenteral nutrition

Parenteral Nutrition (PN) delivers artificial nutrients intravenously. National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) reported deficiencies in care of hospital patients.2 Recommendations were made which are backed by NICE and BAPEN; highlighting clinical parameters such as glucose measurements taken ≥1/day until stable then weekly. Weekly measures are employed in home PN patients who are considered stable. It is important hyperglycaemia is avoided in hospitalised patients as it is associated with a higher mortality risk.1 Hyperglycaemia is associated with poorer outcomes with increased rate of infections and sepsis, cardiac associated complications, acute kidney injury and greater mortality.2 Literature draws upon blood glucose ranges of 8–10 mmol/L is acceptable for critically ill hospitalised patients and PN-patients .1,3

Current therapeutic approaches in the management of hyperglycemia in chronic renal disease.

Diabetes mellitus (DM) and chronic kidney disease (CKD) are intricately intertwined. DM is the most common cause of CKD. Adequate control of DM is necessary for prevention of progression of CKD, while careful management of the metabolic abnormalities in CKD will assist in achieving better control of DM. Two of the key organs involved in glucose production are the kidney and the liver. Furthermore, the kidney also plays a role in glucose filtration and reabsorption. In CKD, monitoring of glycemic control using traditional methods such as Hemoglobin A1c (Hba1c) must be done with caution secondary to associated hematological abnormalities in CKD. With regard to medication management in the care of patients with DM, CKD has significant effects. For example, the dosages of oral and non-insulin anti-hyperglycemic agents often need to be modified according to renal function. Insulin metabolism is altered in CKD, and a reduction in insulin dose is almost always needed. Dialysis also affects various aspects of glucose homeostasis, necessitating appropriate changes in therapy. Due to the aforementioned factors glycemic management in patients with DM and CKD can be quiet challenging.

Linagliptin monotherapy compared with voglibose monotherapy in patients with type 2 diabetes undergoing hemodialysis: a 12-week randomized trial

ObjectiveFocusing on efficacy and tolerability, we compared linagliptin monotherapy with voglibose monotherapy in patients with type 2 diabetes undergoing hemodialysis (HD).Research design and methodsIn this multicenter, randomized, open-label, parallel-group, active-controlled...

Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes and moderate or severe renal impairment: observations from the SAVOR-TIMI 53 Trial.

The glycemic management of patients with type 2 diabetes mellitus (T2DM) and renal impairment is challenging, with few treatment options. We investigated the effect of saxagliptin in the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR)-Thrombolysis in Myocardial Infarction (TIMI) 53 trial according to baseline renal function. Patients with T2DM at risk for cardiovascular events were stratified as having normal or mildly impaired renal function (estimated glomerular filtration rate [eGFR] >50 mL/min/1.73 m(2); n = 13,916), moderate renal impairment (eGFR 30-50 mL/min/1.73 m(2); n = 2,240), or severe renal impairment (eGFR <30 mL/min/1.73 m(2); n = 336) and randomized to receive saxagliptin or placebo. The primary end point was cardiovascular death, myocardial infarction, or ischemic stroke. After a median duration of 2 years, saxagliptin neither increased nor decreased the risk of the primary and secondary composite end points compared with placebo, irrespective of renal function (all P for interactions ≥ 0.19). Overall, the risk of hospitalization for heart failure among the three eGFR groups of patients was 2.2% (referent), 7.4% (adjusted hazard ratio [HR] 2.38 [95% CI 1.95-2.91], P < 0.001), and 13.0% (adjusted HR 4.59 [95% CI 3.28-6.28], P < 0.001), respectively. The relative risk of hospitalization for heart failure with saxagliptin was similar (P for interaction = 0.43) in patients with eGFR >50 mL/min/1.73 m(2) (HR 1.23 [95% CI 0.99-1.55]), eGFR 30-50 mL/min/1.73 m(2) (HR 1.46 [95% CI 1.07-2.00]), and in patients with eGFR <30 (HR 0.94 [95% CI 0.52-1.71]). Patients with renal impairment achieved reductions in microalbuminuria with saxagliptin (P = 0.041) that were similar to those of the overall trial population. Saxagliptin did not affect the risk of ischemic cardiovascular events, increased the risk of heart failure hospitalization, and reduced progressive albuminuria, irrespective of baseline renal function.

Clinical inertia—a barrier to effective management of T2DM

In routine primary care, clinicians are slow to intensify glycaemic management in patients with type 2 diabetes mellitus (T2DM), despite access to an increasing number of therapeutic resources. This so-called clinical inertia is troubling and could explain why we are failing to meet targets for diabetes control in many patients.

Diabetes and pancreatic cancer

Pancreatic cancer is the fourth leading cause of cancer-related death in the United States with a 5-year survival rate of less than 5%. There are substantial evidences that smoking, male gender, alcohol use, African American race, type 2 diabetes, family history, obesity, and pancreatitis increase the risk of pancreatic cancer. The prevalence of diabetes in individuals with pancreatic cancer is reported to range between 5% and 20%. Pancreatic cancer and diabetes have a bidirectional and complex relationship. Although preexisting diabetes may be an etiological factor in the development of pancreatic cancer, it has also been proposed that, as pancreatic cancer destroys pancreatic parenchyma, it can lead to diabetes, though a relatively large degree of pancreatic tissue needs to be destroyed for this to occur. Pancreatic cancer typically progresses without early detection because of a lack of overt symptoms. Cohort and case-control studies indicate that 25%-50% of patients with pancreatic cancer develop diabetes mellitus within the 3 years before the cancer diagnosis, and given the close temporal association, it was speculated this new-onset diabetes may be directly linked to the malignancy. However, studies have failed to identify reliable imaging protocols as a means to detect early pancreatic cancer in patients with new-onset diabetes mellitus. Moreover, the partial pancreatectomy (ie, Whipple) classically performed to treat early pancreatic cancer commonly leads to the development of diabetes postoperatively. Total pancreatectomy results in total insulin deficiency and near-absent glucagon production. All of these patients develop diabetes and require treatment with insulin. In this review, we focus on 3 areas: (1) type 2 diabetes, obesity, and the risk of developing pancreatic cancer; (2) association of metformin, insulin use, and the risk of pancreatic cancer; and (3) glycemic management in patients who have undergone partial or total pancreatectomy.

Metabolic surgery for type 2 diabetes: efficacy and risks.

Bariatric surgery has emerged as a highly effective treatment for obesity and is increasingly recognized to have benefits for glycemic management in patients with pre-existing type 2 diabetes mellitus (T2DM), and for diabetes prevention. This article will review the efficacy and mechanisms of metabolic surgery for the treatment of T2DM. Recent small randomized studies with 1-2 years of follow-up begin to provide level 1 data of the effects of surgical procedures compared to medical management on glycemic control. Physiology studies using sophisticated metabolic techniques to evaluate insulin secretion, action, and entero-endocrine changes in patients preoperatively and postoperatively have shed light on the mechanisms that lead to changes in glycemia observed after bariatric surgery. Understanding the efficacy and physiologic effects of bariatric surgery on metabolism will help guide patient management in the context of a growing epidemic of obesity and T2DM, and may also ultimately enable us to develop less invasive but equally effective therapeutic strategies for weight loss and metabolic control.

Glycemic Management in Patients Presenting with Acute Coronary Syndromes: Survey of Care by Canadian Endocrinologists and Cardiologists

Cardiac care often occurs in subspecialty units where diabetes (DM) care may not be a primary focus. We performed a survey to ascertain physician awareness and local practice protocols with respect to glycemic management in ACS patients.

Comparison of Insulin Pump Therapy (Continuous Subcutaneous Insulin Infusion) to Alternative Methods for Perioperative Glycemic Management in Patients with Planned Postoperative Admissions

Patients with diabetes who use insulin pumps [continuous subcutaneous insulin infusion (CSII)] undergo surgeries that require postoperative hospital admission. There are no defined guidelines for CSII perioperative use. This retrospective single-institution study identified type 1 and type 2 diabetes subjects by electronically searching 2005-2010 anesthesia preoperative assessments for "pump." Surgical cases (n = 92) were grouped according to intraoperative insulin delivery method: (a) CSII continuation of basal rate with/without correctional insulin bolus(es) (n = 53); (b) conversion to intravenous insulin infusion (n = 20); and (c) CSII suspension with/without correctional insulin bolus(es) (n = 19). These groups were compared on mean intraoperative blood glucose (BG) and category of most extreme intraoperative BG. Differences were found on baseline characteristics of diabetes duration (p = .010), anesthesia time (p = .011), proportions receiving general anesthesia (p = .013), and preoperative BG (p = .033). The conversion group had the longest diabetes duration and anesthesia time; it had a higher proportion of general anesthesia recipients and a higher mean preoperative BG than the continuation group. There was no significant difference in mean BG/surgical case between continuation (163.5 ± 58.5 mg/dl), conversion (152.3 ± 28.9 mg/dl), and suspension groups (188.3 ± 44.9 mg/dl; p = .128). The suspension group experienced a greater percentage of cases (84.2%) with one or more intraoperative BG > 179 mg/dl than continuation (45.3%) and conversion (40%) groups Figure 1 groupings (p = .034). In this limited sample, preliminary findings are consistent with similar intraoperative glycemic control between CSII continuation and CSII conversion to intravenous insulin infusions. Continuous subcutaneous insulin infusion suspension had a greater rate of hyperglycemia. Preoperative differences between insulin delivery groups complicate interpretations of findings.

Glucagon-like peptide-1 (GLP-1) receptor agonists: Differentiating the new medications.

IntroductionGlucagon-like peptide-1 (GLP-1) has been the focus of considerable research activity in the treatment of type 2 diabetes mellitus (T2DM) because the incretin effect is significantly reduced or absent in individuals with T2DM. Thus, pharmacologic efforts to develop medications that mimic the actions of GLP-1 have become a target for improving or reversing chronic hyperglycemia. Two GLP-1 receptor agonists are commercially available: exenatide twice daily (b.i.d.) and liraglutide once daily (q.d.). Targeted and individualized intensification of diabetes management can best be accomplished with a thorough understanding of these new medications.MethodsInformation was gathered through a search of MEDLINE and PubMed for GLP-1 and glycemic management in patients with type 2 diabetes.ResultsActivation of the GLP-1 receptors on the β-cells results in enhanced levels of insulin biosynthesis, β-cell proliferation, resistance to β-cell apoptosis, and enhanced β-cell survival in both humans and rodents; yet, the risk of hypoglycemia is minimized because insulin production and exocytosis occurs in a glucose-dependent manner. The efficacy and safety of the two commercially available GLP-1 receptor agonists, liraglutide and exenatide, in managing postprandial glycemia have been well documented in numerous clinical trials, in which reductions in glycosylated hemoglobin (HbA1c) levels of −0.79% to −1.12% have been demonstrated. Weight reduction/maintenance and improvements in blood pressure and lipidemia have also been reported.ConclusionBecause GLP-1 receptor agonists work in a glucose-dependent manner, they are likely to reduce hyperglycemia safely, without a marked fluctuation toward hypoglycemia. In the process of acutely restoring β-cell function, GLP-1 agonists may allow patients to achieve HbA1c <7% without experiencing weight gain or hypoglycemia. The ability of GLP-1 receptor agonists to improve blood pressure and postprandial lipidemia in the context of weight neutrality or weight loss may have the potential to ameliorate some of the cardiovascular risks observed in patients with T2DM.

Intraoperative and Postoperative Glycemic Management in Patients with Diabetes

Intraoperative and Postoperative Glycemic Management in Patients with Diabetes

Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery

Optimal evidence-based perioperative blood glucose control in patients undergoing ambulatory surgical procedures remains controversial. Therefore, the Society for Ambulatory Anesthesia has developed a consensus statement on perioperative glycemic management in patients undergoing ambulatory surgery. A systematic review of the literature was conducted according the protocol recommended by the Cochrane Collaboration. The consensus panel used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for providing suggestions. It was revealed that there is insufficient evidence to provide strong recommendations for the posed clinical questions. In the absence of high-quality evidence, recommendations were based on general principles of blood glucose control in diabetics, drug pharmacology, and data from inpatient surgical population, as well as clinical experience and judgment. In addition, areas of further research were also identified.

Implications of UKPDS evidence

Ram Kela and Melanie J Davies discuss the evidence from the UKPDS and other recently published trials about intensity of glycaemic management in patients with type 2 diabetes

Review: Optimal dosing strategies for maximising the clinical response to metformin in type 2 diabetes

Recently revised consensus targets for glycaemic management in patients with type 2 diabetes are challenging and require optimisation of dosing strategies for oral antidiabetic therapies. The demonstration of significant cardiovascular outcome benefits in metformin-treated type 2 diabetic patients enrolled in the United Kingdom Prospective Diabetes Study has established this agent as the first line oral therapy after diet failure in newly presenting overweight people with type 2 diabetes mellitus. The antihyperglycaemic efficacy of metformin increases with increasing daily doses between 500 mg and the upper limits of the recommended daily dosage ( ≥ 2000 mg/day). Although metformin is associated with gastrointestinal side-effects in up to 20% of patients, this is not generally dose related. Transient dose reduction, slower titration and taking the dose with meals may ameliorate the problem. Risk of lactic acidosis due to metformin is negligible when this agent is prescribed correctly, and is unrelated to the plasma metformin concentration. Intensification of metformin therapy within the dose range represents a rational and practical therapeutic strategy for optimising glycaemic control in patients who are suitable for, and tolerant of, metformin treatment. The recently introduced 1000 mg metformin tablet should facilitate the use of higher doses and may help treatment compliance.