Hospitalization For Hypoglycemia Research Articles

Trends in Incidence of Hospitalization for Hypoglycemia and Diabetic Ketoacidosis in Individuals With Type 1 or Type 2 Diabetes With and Without Severe Mental Illness in Denmark From 1996 to 2020: A Nationwide Study.

To examine trends in incidence of acute diabetes complications in individuals with type 1 or type 2 diabetes with and without severe mental illness (SMI) in Denmark by age and calendar year. We conducted a cohort study using nationwide registers from 1996 to 2020 to identify individuals with diabetes, ascertain SMI status (namely, schizophrenia, bipolar disorder, or major depression) and identify the outcomes: hospitalization for hypoglycemia and diabetic ketoacidosis (DKA). We used Poisson regression to estimate incidence rates (IRs) and incidence rate ratios (IRRs) of recurrent hypoglycemia and DKA events by SMI, age, and calendar year, accounting for sex, diabetes duration, education, and country of origin. Among 433,609 individuals with diabetes, 8% had SMI. Risk of (first and subsequent) hypoglycemia events was higher for individuals with SMI than for those without SMI (for first hypoglycemia event, IRR: type 1 diabetes, 1.77 [95% CI 1.56-2.00]; type 2 diabetes, 1.64 [95% CI 1.55-1.74]). Individuals with schizophrenia were particularly at risk for recurrent hypoglycemia events. The risk of first DKA event was higher in individuals with SMI (for first DKA event, IRR: type 1 diabetes, 1.78 [95% CI 1.50-2.11]; type 2 diabetes, 1.85 [95% CI 1.64-2.09]). Except for DKA in the type 2 diabetes group, IR differences between individuals with and without SMI were highest in younger individuals (<50 years old) but stable across the calendar year. SMI is an important risk factor for acute diabetes complication and effective prevention is needed in this population, especially among the younger population and those with schizophrenia.

Continuous Glucose Monitor Metrics Are Associated with Emergency Department Visits and Hospitalizations for Hypoglycemia and Hyperglycemia, but Have Low Predictive Value.

Objective: Determine whether continuous glucose monitor (CGM) metrics can provide actionable advance warning of an emergency department (ED) visit or hospitalization for hypoglycemic or hyperglycemic (dysglycemic) events. Research Design and Methods: Two nested case-control studies were conducted among insulin-treated diabetes patients at Kaiser Permanente, who shared their CGM data with their providers. Cases included dysglycemic events identified from ED and hospital records (2016-2021). Controls were selected using incidence density sampling. Multiple CGM metrics were calculated among patients using CGM >70% of the time, using CGM data from two lookback periods (0-7 and 8-14 days) before each event. Generalized estimating equations were specified to estimate odds ratios and C-statistics. Results: Among 3626 CGM users, 108 patients had 154 hypoglycemic events and 165 patients had 335 hyperglycemic events. Approximately 25% of patients had no CGM data during either lookback; these patients had >2 × the odds of a hypoglycemic event and 3-4 × the odds of a hyperglycemic event. While several metrics were strongly associated with a dysglycemic event, none had good discrimination. Conclusion: Several CGM metrics were strongly associated with risk of dysglycemic events, and these can be used to identify higher risk patients. Also, patients who are not using their CGM device may be at elevated risk of adverse outcomes. However, no CGM metric or absence of CGM data had adequate discrimination to reliably provide actionable advance warning of an event and thus justify a rapid intervention.

Continuous Glucose Monitoring and Reduced Diabetes-Related Hospitalizations in Patients with Type 2 Diabetes and CKD.

There is a heightened risk of glycemic variability in patients with diabetes and chronic kidney disease (CKD). This glycemic variability could lead to hypoglycemic or hyperglycemic crises. We hypothesized that initiation of continuous glucose monitoring (CGM), which provides a glucose measurement every 1-5 minutes, could reduce the incidence of hospitalizations for patients with type 2 diabetes (T2D) and CKD. A retrospective analysis of US administrative claims data from the Optum Clinformatics© Database was conducted. People with T2D, using insulin, not receiving dialysis, and living with stage 3-5 CKD who initiated CGM between 1/1/2016 and 3/31/2022 were identified. NDC and HCPCS codes were used to identify CGM device use and ICD-10 codes were used to identify CKD diagnosis and categorize healthcare encounters. Rates of diabetes-related hospitalizations were obtained, and multivariable logistic regression analyses revealed predictors of hypoglycemic and hyperglycemic encounters. A total of 8,959insulin-using patients with T2D and CKD were identified. Most were White (72.3%), had Medicare insurance coverage (82.2%), were using intensive insulin (91.3%), and had Stage 3 CKD (86.0%). After CGM initiation, rates of hospitalizations for hyperglycemia or hypoglycemia decreased by 18.2% and 17.0%, respectively (p<0.0001 for both). The proportion hospitalized with at least one hypoglycemic or hyperglycemic event also significantly decreased after CGM initiation. Significant predictors of both hypoglycemic and hyperglycemic encounters included a previous encounter of that type, age 30-59 years and depression (for hypoglycemia), and age 30-49 and neuropathy (for hyperglycemia). Use of CGM or glucagon-like peptide-1 receptor agonists was significantly protective against hypoglycemic encounters. Initiation of CGM was associated with significant reductions in diabetes-related hospitalizations among insulin-using individuals with T2D and moderate-to-severe CKD. CGM could help patients with T2D and CKD control their glucose and avoid potentially dangerous glycemic events.

Preventing severe hypoglycemia in adults with type 2 diabetes (PHT2): Design, delivery and evaluation framework for a randomized controlled trial

BackgroundSevere hypoglycemia is a common and feared complication of medications used to lower blood glucose levels in individuals with diabetes. Psychoeducational interventions can prevent severe hypoglycemia in individuals with type 1 diabetes (T1D). We aim to determine the effectiveness of this approach among adults with type 2 diabetes (T2D) at elevated risk for severe hypoglycemia. MethodsPreventing Hypoglycemia in Type 2 diabetes (PHT2) is a two-arm, parallel, randomized controlled trial. Participants are eligible if they are adults with T2D receiving care at an integrated group practice in Washington state and have experienced one or more episodes of severe hypoglycemia in the prior 12 months or have impaired awareness of hypoglycemia (Gold score ≥ 4). Participants are randomized to proactive nurse care management with or without my hypo compass, an evidence-based, psychoeducational intervention combining group and individual self-management training. For this study, my hypo compass was adapted to be suitable for adults with T2D and from an in-person to a virtual intervention over videoconference and telephone. The primary outcome is any self-reported severe hypoglycemia in the 12 months following the start of the intervention. Secondary outcomes include biochemical measures of hypoglycemia, self-reported hypoglycemia awareness, fear of hypoglycemia, and emergency department visits and hospitalizations for severe hypoglycemia. The study includes a process evaluation to assess implementation fidelity and clarify the causal pathway. ConclusionThe PHT2 trial will compare the effectiveness of two approaches for reducing severe hypoglycemia in adults with T2D.Trial registration: clinicaltrials.gov, # NCT04863872

Change in hbA1c following treatment with and the short-term risk of major adverse cardiovascular outcomes

Abstract Background Post-hoc analyses from glucagon-like peptide-1 receptor agonist (GLP1-RA) trial populations have shown a benefit on cardiovascular outcomes from reduction in glycated hemoglobin (HbA1c). It is of interest to see if this finding translates into a cohort of real-world GLP1-RA users. Purpose To study among new GLP1-RA users, how reaching a Hba1c below 53 mmol/mol six months after initiation affects the risk of major adverse cardiovascular outcomes (MACE), compared with a HbA1c above 53 mmol/mol. Methods We included new GLP1-RA users six months after initiation of treatment, with an available HbA1c value 0-6 months before and 0-6 months after GLP1-RA initiation, from the Danish registries between 2010-2022. HbA1c levels pre- and post-treatment were categorized as above 53 mmol/mol or below 53mmol/mol. The primary outcome was defined as a composite of myocardial infarction, stroke, and all-cause death. Patients were followed from index (6 months after GLP1-RA initiation) until the outcome, a total of 1 years, or end-of-study (31.12.21), whichever comes first. Crude 1-year risks were compared using the Kaplan Meier estimator, or the Aalen Johansen estimator if competing risk was present. The effect of HbA1c below 53 mmol/mol versus a HbA1c above 53 mmol/mol on MACE was estimated using a Cox regression model adjusted for age, sex, educational level, baseline comorbidities, type 2 diabetes duration, and baseline cardiovascular disease including heart failure. Hospitalization for hyperglycemia was also evaluated using a Cox regression. Results A total of 4,081 new GLP1-RA users (median age: 58y [IQR:50;66], 52% males) were included, 3,090 had a post-treatment HbA1c below 53 mmol/mol and 991 had a post-treatment Hba1c above 53 mmol/mol. During a median follow-up of 1 year (IQR:1.0,1.0), the crude 1-year risk of MACE in persons with a HbA1c below 53 mmol/mol was 6.4% (95% confidence interval [CI]: 5.5;7.2) and 9.5% (7.7;11.3) in persons with HbA1c above 53 mmol/mol, yielding a hazard rate of 0.69 (0.54;0.88). No interaction between pre-and post HbA1c was found (p=0.59). The hazard rate of hospitalization for hypoglycemia was 0.76 (0.45:1.23) for persons reaching HbA1c level below 53 mmol/mol compared to patients with a HbA1c above 53 mmol/mol, with no interaction between pre- and post HbA1c observed (p =0.052). Conclusion A HbA1c level below 53 mmol/mol, among GLP1-RA users reduced the 1-year rate of MACE and did not significantly increase the 1-year rate of hospitalization for hypoglycemia.

SAT169 Sugar Crash: A Case Of Recurrent Hypoglycemia

Abstract Disclosure: C.T. Malvar: None. P. Patel: None. H. Moran: None. D. Bleich: None. Introduction: Post-prandial hypoglycemia is a rare complication following Roux-en-Y gastric bypass surgery (RYGB). Some theories suggest that post-operative beta cell expansion and altered beta cell function may lead to increased secretion of insulin, thereby causing hypoglycemia. We report a 39-year-old female with multiple episodes of recurrent post-prandial hypoglycemia following RYGB. Case Report: A 39-year-old female with a past medical history of type 2 diabetes managed with insulin, hypertension, hyperlipidemia, and obesity underwent RYGB and developed multiple episodes of fatigue, diaphoresis, palpitations, and tremulousness a year later. The patient continued to have worsening symptoms, leading to multiple hospitalizations for hypoglycemia. During her initial presentation to the emergency department, she was found to be afebrile, tachycardic with stable blood pressure. Work up revealed a glucose of 34 mg/dl (70 - 109 mg/dl), insulin of 40.1 (2.6 - 24.9 uIU/mL), C-peptide of 3.8 (1.1 - 4.4 ng/mL), potassium of 3.2 (3.5 - 4.8 meq/l), negative sulfonylurea screen, normal renal function, and a mild leukocytosis of 12.6 (4.0 - 11.0 x 10*3/µL). CT abdomen/pelvis, chest x-ray, and urinalysis were normal and did not reveal any infection. The patient denied taking any hypoglycemic agents and reported consuming high glycemic index meals. During her hospitalization, she received a bolus of dextrose followed by a continuous dextrose drip; however, she continued to experience recurrent hypoglycemic events requiring glucagon and dextrose tablets. Subsequent morning labs showed elevated insulin levels at 34.6 (2.6 - 24.9 uIU/mL) and a normal IGF-1 level. Her 8AM cortisol level was 2.3 (6.0 - 18.4 ug/dl). Due to high suspicion of adrenal insufficiency, she was started on Hydrocortisone. Pituitary MRI was negative for any adenoma. Hydrocortisone was held and a cosyntropin stimulation test established appropriate adrenal response. Hydrocortisone and dextrose tablets were discontinued. She was educated on eating low glycemic index meals to prevent future hypoglycemic episodes. She was started on acarbose as it delays carbohydrate degradation, thereby preventing reactive hypoglycemia. Conclusion: This case highlights the importance of having a thorough differential diagnosis in patients with a history of bariatric surgery and hypoglycemic episodes including adrenal insufficiency, which in this case was ruled out. RYGB increases stimulation of islet β-cells by enteral signals and enhances GLP-1 sensitivity and insulin secretion, predisposing some individuals to hypoglycemic episodes. Patients may have remission of diabetes and no longer need medications post-operatively. Dietary modification is fundamental in the management of hypogylcemia after RYGB. Pharmacotherapy is an adjunctive treatment if symptoms persist. Presentation: Saturday, June 17, 2023

SAT105 Frequent Monitoring Of Blood Glucose Levels Via A Remote Patient Monitoring System Helps Improve Glycemic Control

Abstract Disclosure: I. Sachmechi: None. M. Amini: None. S. Salam: None. R. Khan: None. A. Spitznogle: None. T. Belen: None. Objective: This study aims to evaluate the effectiveness of the Vivovitals telehealth platform on improving glycemic control and reducing A1C in patients with uncontrolled type II diabetes mellitus by providing more accessible and frequent patient care under the monitoring by their physician. Methods: This 12-week, prospective, pragmatic, single-center, double-arm study assessed the impact of the Vivovitals diabetes platform on glycemic control among 78 adults ≥ 18 years of age, with A1C ≥ 7.5% (58 mmol/mol) at baseline. The participants were randomized into two groups. The control group received standard care, while the intervention group was assisted to install the application on their smartphones and connect it to a Bluetooth Glucometer, and access to an online data portal. Blood glucose measurements were transmitted to the provider daily. Patients were contacted twice weekly regardless of their blood sugar measurements and additional call was made if blood glucose levels were &amp;lt;70 mg/dL or &amp;gt;180 mg/dL and modifications were made to diet and medication. The control group was allowed to call the provider if they have questions regarding their blood sugar levels or their medications. The two groups were compared at baseline and 12 weeks using nonparametric tests with p&amp;lt;0.05 considered statistically significant. Results: The mean A1C in the intervention group (n=39) was 9.53 (81 mmol/mol) +1.68 at baseline. Post-trial, mean A1C decreased to 7.99 (64 mmol/mol) + 1.40 (p &amp;lt; 0.001). In comparison, the mean A1C in the control group (n=39) was 9.63 (64 mmol/mol) + 1.47 at baseline with little change in post-trial mean A1C averaging 9.16 (77 mmol/mol) + 1.51 (p = 0.87). Discussion: In this study, patients who utilized the Vivovitals platform saw a significant decrease in A1C at an average of 1.56% compared to the non-significant 0.47% A1C reduction in the control group participants. We believe the A1C-reducing effect in the intervention group was due to the more frequent interactions with the physician and subsequent medication adjustments based on the data provided. The Vivovitals platform allows an affordable closer monitoring of blood glucose levels, identification of the direction of glycemic trends, and earlier intervention. While not explored in this study, it is reasonable to believe that the use of the Vivovitals diabetes platform could reduce Emergency Department visits and inpatient hospitalizations for hypoglycemia or hyperglycemia as the clinician can intervene before a patient becomes symptomatic. Conclusion: We conclude that the Vivovitals platform may help to reduce A1C in adults with uncontrolled type 2 diabetes mellitus in conjunction with lifestyle modifications and anti-diabetic medications. Presentation: Saturday, June 17, 2023

Glycaemic control, risk of hypoglycaemia and all-cause mortality in new users of second-generation basal insulin with type 2 diabetes and chronic kidney disease: a nationwide register-based cohort study.

The aim of this study was to compare the performance of the second-generation basal insulins, insulin degludec 100 U/ml (Deg-100) and insulin glargine 300 U/ml (Gla-300), in terms of change in HbA1c, hospitalisation for hypoglycaemia and all-cause mortality among individuals with type 2 diabetes and concurrent chronic kidney disease. This register-based cohort study, based on the entire Danish diabetes population, included 6519 new users of Deg-100 and Gla-300 with type 2 diabetes and moderate to end-stage chronic kidney disease. HbA1c trajectories, from initiation of either Deg-100 (2013) or Gla-300 (2015) to end of follow-up (2020), were modelled with mixed-effect models while rates of hospitalisation for hypoglycaemia and all-cause mortality were modelled in separate models using Poisson likelihood. Of the 6519 (44% women) individuals included in the study, 3747 were exposed to Deg-100 and 2772 to Gla-300. Both mean (SD) type 2 diabetes duration (14.4 [6.6] years vs 15.2 [6.7] years) and median (IQR) chronic kidney disease duration (2.3 [1.3, 3.9] years vs 2.8 [1.6, 4.6] years) were significantly shorter in the Gla-300 group. The median (IQR) follow-up time was similar between groups: 1.0 (0.5-1.6) year for Gla-300 and 1.0 (0.3-1.5) year for Deg-100. In both groups mean HbA1c levels were reduced by 13-14 mmol/mol (1.2-1.3%) from initiation to end of follow-up, with the largest reduction (of 8-9 mmol/mol [0.7-0.8%]) occurring during the first year. There was no significant difference in HbA1c reduction between Deg-100 and Gla-300. Both the rate of hospitalisation for hypoglycaemia (rate ratio 1.02 [95% CI 0.70, 1.49], Deg-100 vs Gla-300) and the rate of all-cause mortality (rate ratio 0.98 [95% CI 0.84, 1.15], Deg-100 vs Gla-300) were similar between the groups. We found no difference in HbA1c reduction, hospitalisation for hypoglycaemia or all-cause mortality between Gla-300 and Deg-100 in a real-world population of new users with type 2 diabetes and moderate to end-stage chronic kidney disease. Therefore, we conclude that these two treatment options are equally effective and safe in this vulnerable population.

Severe hypoglycemia and falls in older adults with diabetes: The Diabetes & Aging Study

ObjectiveTo estimate rates of severe hypoglycemia and falls among older adults with diabetes and evaluate their association. Research Design and MethodsSurvey in an age-stratified, random sample adults with diabetes age 65–100 years; respondents were asked about severe hypoglycemia (requiring assistance) and falls in the past 12 months. Prevalence ratios (adjusted for age, sex, race/ethnicity) estimated the increased risk of falls associated with severe hypoglycemia. ResultsAmong 2,158 survey respondents, 79 (3.7%) reported severe hypoglycemia, of whom 68 (86.1%) had no ED visit or hospitalization for hypoglycemia. Falls were reported by 847 (39.2%), of whom 745 (88.0%) had no fall documented in outpatient or inpatient records. Severe hypoglycemia was associated with a 70% greater prevalence of falls (adjusted prevalence ratio = 1.7 (95% CI, 1.3–2.2)). ConclusionWhile clinical documentation of events likely reflects severity or care-seeking behavior, severe hypoglycemia and falls are common, under-reported life-threatening events.

Glucagon prescribing and prevention of hospitalization for hypoglycemia in a large health system

AimsTo examine glucagon prescribing trends among patients at high risk of severe hypoglycemia and assess if a glucagon prescription is associated with lower rates of severe hypoglycemia requiring hospital care. MethodsRetrospective analysis of electronic health records from a large integrated healthcare system between May 2019 and August 2021. We included adults (≥18 years) with type 1 diabetes or with type 2 diabetes treated with short-acting insulin and/or recent history of hypoglycemia-related emergency department visit or hospitalization. We calculated rates of glucagon prescribing overall and by patient characteristics. We then matched 1:1 those who were and were not prescribed glucagon and assessed subsequent hypoglycemia-related hospitalization. ResultsOf 9,200 high risk adults, 2063 (22.4%) were prescribed glucagon. Among patients more likely to be prescribed glucagon were those younger, female, White, living in urban areas, with prior severe hypoglycemia, and with a recent endocrinology specialist visit. In the matched cohort (N = 1707 per arm), 62 prescribed glucagon and 33 not prescribed glucagon were hospitalized for hypoglycemia (adjusted incidence rate ratio 1.71, 95% CI 1.10–2.66; P = 0.018). ConclusionGlucagon prescribing was infrequent with significant racial and rural disparities. Patients with glucagon prescriptions did not have lower rates of hospitalization for hypoglycemia.

818-P: Glycemic Control in Naïve Users of Second-Generation Basal Insulins with T2D and CKD—A Nationwide Register-Based Cohort Study

Objective: We aimed to compare the effectiveness and safety of second-generation basal insulins, insulin glargine 300 U/mL (Gla-300) and insulin degludec 100 U/mL (Deg-100), in terms of change in HbA1c, hospitalization for hypoglycemia and all-cause mortality. Methods: In this register-based cohort study, using real-word data on the entire Danish diabetes population in the period 2013-2020, we included 6519 naïve users of Gla-300 or Deg-100 with T2D and chronic kidney disease (CKD). Change in HbA1c, from initiation of either study drugs to end of follow-up, was modeled with mixed-effect models while rates of hospitalization for hypoglycemia and all-cause mortality were modeled in separate Poisson models. Results: Mean HbA1c levels were reduced by 13-14 mmol/mol over a four-year period in both groups with no significant difference (Figure). The rate of hospitalization for hypoglycemia was slightly but not significantly higher in the Deg-100 group (rate-ratio 1.03 (CI 95%: 0.71, 1.49) while the all-cause mortality rate was slightly but not significantly lower in the Deg-100 group (0.97 (0.83, 1.14)). Conclusion: We found no difference in HbA1c reduction, hospitalization for hypoglycemia or all-cause mortality between Gla-300 and Deg-100, in a real-world population of naïve users with T2D and CKD. Disclosure V.Kosjerina: Research Support; Sanofi-Aventis Deutschland GmbH. B.Carstensen: Stock/Shareholder; Novo Nordisk. H.Amadid: Employee; Novo Nordisk A/S. D.Vistisen: Research Support; Bayer Inc., Sanofi, Boehringer-Ingelheim, Stock/Shareholder; Novo Nordisk A/S. Funding Sanofi-Aventis Deutschland GmbH

Impact of Race and Ethnicity on Severe Hypoglycemia Associated with Sulfonylurea Use for Type 2 Diabetes among Veterans.

Sulfonylureas are associated with hypoglycemia. Whether a racial/ethnic disparity in this safety outcome exists is unknown. We sought to assess the impact of race/ethnicity on severe hypoglycemia associated with sulfonylurea use for type 2 diabetes (T2D). Using Veterans Affairs and Medicare data, Veterans initially receiving metformin monotherapy for T2D between 2004 and 2006 were identified. Sulfonylurea use (either alone or via the addition of a prescription for a sulfonylurea to metformin) was captured and compared to remaining on metformin alone during the follow-up period (2007-2016). Hazard ratios (HR) and 95% confidence intervals (CI) from longitudinal competing risk Cox models were used to measure the association between sulfonylurea use and severe hypoglycemia defined as hospitalization for hypoglycemia. A total of 113,668 Veterans with T2D were included. A higher risk of severe hypoglycemia was associated with the receipt of sulfonylurea prescriptions versus remaining on metformin alone across all groups. The effect was largest among Hispanic Veterans (HR: 7.59, 95%CI:4.32-13.33), followed by Veterans in the other race/ethnicity cohort (HR: 4.57, 95%CI:2.50-8.36) and Non-Hispanic Black Veterans (HR: 3.67, 95%CI:2.78-4.85). The effect was smallest among Non-Hispanic White Veterans (HR: 3.11, 95%CI:2.77-3.48). In conclusion, a higher risk of severe hypoglycemia associated with sulfonylurea prescriptions was observed across all analyses. The relationship was most pronounced for Hispanic Veterans, who had nearly 8 times the risk of severe hypoglycemia with sulfonylureas versus remaining on metformin alone.

Marked reduction in the hospital admission rate of a man with nonislet cell tumor hypoglycemia after starting steroids: a case report.

The authors present the case of a man with metastatic lung cancer who had multiple hospitalizations for hypoglycemia and associated anorexia, weight loss, and depression. After receiving steroids, the patient's hospital admission rate due to hypoglycemia reduced, depression improved, and weight loss reversed. Steroids, diazoxide, octreotide, glucagon infusion, and recombinant growth hormone have shown good results in treating NICTH. Steroids have many advantages: they are easy to administer and relatively inexpensive. In our patient, steroids had the added benefit of improving the appetite with subsequent weight gain and controlling depression. They also significantly reduced the readmission rate. NICTH is a rare cause of hypoglycemia. Glucocorticoids show better palliative effects than other medical treatments. In our patient, steroids dramatically reduced the number of hospitalizations due to hypoglycemia while improving the appetite, weight, and depression.

Respiratory Outcomes of Insulin Use in Patients with COPD: A Nationwide Population-Based Cohort Study.

Acute exacerbations of chronic obstructive pulmonary disease (COPD) with severe hyperglycemia may require insulin to lower glucose levels in people with coexisting type 2 diabetes (T2D) and COPD. We conducted this study to examine the risk of hospitalization for COPD, pneumonia, ventilator use, lung cancer, hypoglycemia, and mortality with and without insulin use in people with T2D and COPD. We adopted propensity-score-matching to identify 2370 paired insulin users and non-users from Taiwan's National Health Insurance Research Database between 1 January 2000 and 31 December 2018. Cox proportional hazards models and the Kaplan-Meier method were utilized to compare the risk of outcomes between study and control groups. The mean follow-up for insulin users and non-users was 6.65 and 6.37 years. Compared with no insulin use, insulin use was associated with a significantly increased risk of hospitalization for COPD (aHR 1.7), bacterial pneumonia (aHR 2.42), non-invasive positive pressure ventilation (aHR 5.05), invasive mechanical ventilation (aHR 2.72), and severe hypoglycemia (aHR 4.71), but with no significant difference in the risk of death. This nationwide cohort study showed that patients with T2D and COPD requiring insulin therapy may have an increased risk of acute COPD exacerbations, pneumonia, ventilator use, and severe hypoglycemia without a significant increase in the risk of death.

Reduced acute diabetes events after FreeStyle Libre® system initiation in people 65 years or older with type 2 diabetes on intensive insulin therapy in France.

Background and aims Older people with type 2 diabetes (T2DM) on insulin are at increased risk of hypoglycemia and associated morbidity. Management of T2DM in older people must optimize glycemic control while minimizing risks for hypoglycemia and diabetic ketoacidosis (DKA). In France, the FreeStyle Libre® system (FSL) has been reimbursed since June 2017 for T2DM on intensive insulin therapy. We assessed the impact of starting FSL on hospitalizations for acute diabetes events (ADEs) in people ≥65 years old, with T2DM on intensive insulin therapy. Materials and methods A retrospective study on the French SNDS claims database was conducted on people ≥65 years old with T2DM, treated with MDI or insulin pump and starting FSL between 01/08/2017 to 31/12/2018. The analysis covered claims data for 12 months before, and up to 24 months after FSL initiation. Hospitalizations for severe hypoglycemia (SH), DKA, comas and hyperglycemia were identified using ICD-10 codes. Results We identified 38,312 people with T2DM ≥65 years old on intensive insulin therapy initiating FSL during the selection period. Hospitalizations for ADEs were observed in 1.6% of subjects in the 12 months before FSL initiation, compared to 1.05% after 12 months and 0.96% after 24 months, a 34% and 40% reduction, driven by fewer DKA admissions after 12 months and by fewer SH admissions at 24 months. Conclusions These results indicate that FSL can reduce hospitalization for ADEs in this vulnerable older population of adults aged 65 years and older with T2DM on intensive insulin therapy, in whom optimal glycemic control must be achieved while minimizing risk of hypoglycemia and other ADEs.

Virtual Clinics for Diabetes Care.

Virtual Clinics for Diabetes Care.

The Relationship between All‐cause Dementia and Acute Diabetes Complications among American Indian and Alaska Native Peoples

AbstractBackgroundAmerican Indian and Alaska Native people (AI/ANs) bear a disproportionate burden of diabetes. Growing evidence has shown significant associations between several acute diabetes complications and dementia among diabetes patients in the general population. However, little is known about these relationships among AI/ANs.MethodsThis cross‐sectional study extracted patient registration and health service utilization data from the Indian Health Service’s National Data Warehouse and related administrative databases. A total of 29,337 AI/AN adults with diabetes who were 45+ years old and used IHS or tribal health services during fiscal year 2013 were included. All‐cause dementia and acute diabetes complications were identified using ICD‐9 diagnostic codes in the utilization data. Negative binomial regression models were used to evaluate the associations of interest after adjusting for potential confounders.ResultsNearly 3% (n = 843) of AI/AN diabetes patients had a dementia diagnosis. Among AI/ANs with diabetes, similar proportions of patients had a history of hospitalization or ED visits for hypoglycemia only (3.6%) or hyperglycemia only (4.1%). About 0.8% had both types of acute diabetes complications. As shown in Fig1, after controlling for demographics, health care coverage, and comorbidities, dementia diagnosis was associated with 94% higher rate of severe hypoglycemia (Incidence Rate Ratio [IRR = 1.94, 95% CI:1.50‐2.51), 52% higher rate of severe hyperglycemia (IRR = 1.52, 95% CI, 1.11‐2.08), and 92% higher rate of any acute complication (IRR = 1.92, 95% CI:1.53‐2.41). Dementia was not significantly associated with diabetic ketoacidosis (DKA) in the adjusted model (IRR = 1.82, 95% CI:0.83‐4.01). Further adjustments on clinical measurements and medications did not substantially change the estimated IRRs for hypoglycemia and hyperglycemia.ConclusionsAI/AN diabetes patients with dementia suffered from considerably higher rates of severe hypoglycemia and hyperglycemia than their counterparts without dementia. Clinical management of patients with comorbid diabetes and dementia is particularly challenging and requires individualized treatment approaches.

ODP202 Geriatric Type 1 Diabetes- unique management challenge

Abstract Case Presentation A 87 year old female with a past medical history of Type 1 Diabetes Mellitus (DM), Parkinson's disease and osteoporosis was sent from an assisted living facility to the emergency department for evaluation of elevated blood glucose levels. She had a long standing history of type 1 DM and further review revealed that she had extremely labile (brittle) blood sugars, with multiple prior hospitalizations for both hypoglycemia and hyperglycemia. Assisted living facility staff reported that her blood sugars were persistently elevated despite receiving scheduled insulin doses. On presentation, she did not have any specific complaints except for polydipsia and polyuria. She was hemodynamically stable, alert and oriented to time, place and person. Initial lab work included serum glucose 754 (70-79 mg/dL), bicarbonate 25 (21-31 mmol/L), anion gap 10 (6-14 mmol/L), ketone 0.9 (&amp;lt; 0.6 mmol/L), leukocyte count 4.7 (4-11 k/mm u) and creatinine 1. 06 (0.6-1.2 mg/dL). Urinalysis showed glycosuria and proteinuria but no evidence of infection. IVF and insulin were started. Extensive infectious work-up was negative. Her blood glucose levels stabilized with basal-bolus regimen and correctional doses of insulin. Tight glycemic control was avoided due to her history of hypoglycemic unawareness and multiple previous episodes for severe and recurrent hypoglycemia. Discussion Brittle diabetes is a disorder commonly seen in patients with Type 1 DM and is characterized by extreme swings in blood glucose levels (severe recurrent hypoglycemic and hyperglycemic episodes) without a clear cut precipitating cause requiring hospitalizations. It has been linked to autonomic dysfunction, hormonal imbalance, psychological issues, nutrient malabsorption and autoimmune conditions. Geriatric Type 1 DM presents great challenges in management as it combines micro and macro vascular complications of long standing DM with geriatric syndrome - concurrent comorbidities, cognitive losses of various degrees, vision and hearing loss, loss autonomic and hormonal counter-regulation, and progressive frailty leading to severe glycemic instability makes self management of DM near impossible. Our patient was an elderly female with osteoporosis, Parkinson's and hypoglycemic unawareness. Great care was taken to maintain her blood glucose levels in the optimal range both during and after hospitalization. Daily insulin was being administered by staff after checking blood glucose levels, avoiding the possibility of dose omission or errors. Detailed instructions on administration of the correct dose of insulin according to caloric consumption and physical activity were provided. With this case, we wish to highlight the unique challenge Brittle Diabetes in geriatric presents, and as this sector of population is growing owing to better treatment options for diabetics and longer life expectancy, there is a growing need to recognize this entity, adopt a multi-disciplinary patient centered approach and prioritize prevention of both hypoglycemia and extreme hyperglycemia over tight glycemic control. Presentation: No date and time listed

Effect of nationwide reimbursement of real-time continuous glucose monitoring on HbA1c, hypoglycemia and quality of life in a pediatric type 1 diabetes population: The RESCUE-pediatrics study.

ObjectiveReal-time continuous glucose monitoring (RT-CGM) can improve metabolic control and quality of life (QoL), but long-term real-world data in children with type 1 diabetes (T1D) are scarce. Over a period of 24 months, we assessed the impact of RT-CGM reimbursement on glycemic control and QoL in children/adolescents with T1D treated with insulin pumps.Research design and methodsWe conducted a multicenter prospective observational study. Primary endpoint was the change in HbA1c. Secondary endpoints included change in time in hypoglycemia, QoL, hospitalizations for hypoglycemia and/or ketoacidosis and absenteeism (school for children, work for parents).ResultsBetween December 2014 and February 2019, 75 children/adolescents were followed for 12 (n = 62) and 24 months (n = 50). Baseline HbA1c was 7.2 ± 0.7% (55 ± 8mmol/mol) compared to 7.1 ± 0.8% (54 ± 9mmol/mol) at 24 months (p = 1.0). Participants with a baseline HbA1c ≥ 7.5% (n = 27, mean 8.0 ± 0.3%; 64 ± 3mmol/mol) showed an improvement at 4 months (7.6 ± 0.7%; 60 ± 8mmol/mol; p = 0.009) and at 8 months (7.5 ± 0.6%; 58 ± 7mmol/mol; p = 0.006), but not anymore thereafter (endpoint 24 months: 7.7 ± 0.9%; 61 ± 10mmol/mol; p = 0.2). Time in hypoglycemia did not change over time. QoL for parents and children remained stable. Need for assistance by ambulance due to hypoglycemia reduced from 8 to zero times per 100 patient-years (p = 0.02) and work absenteeism for parents decreased from 411 to 214 days per 100 patient-years (p = 0.03), after 24 months.ConclusionRT-CGM in pump-treated children/adolescents with T1D showed a temporary improvement in HbA1c in participants with a baseline HbA1c ≥ 7.5%, without increasing time in hypoglycemia. QoL was not affected. Importantly, RT-CGM reduced the need for assistance by ambulance due to hypoglycemia and reduced work absenteeism for parents after 24 months.Clinical trial registration[ClinicalTrials.gov], identifier [NCT02601729].

Association between heat exposure and hospitalization for diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia in Japan.

An increase in extreme heat events has been reported along with global warming. Heat exposure in ambient temperature is associated with all-cause diabetes mortality and all-cause hospitalization in diabetic patients. However, the association between heat exposure and hospitalization for hyperglycemic emergencies, such as diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), and hypoglycemia is unclear. The objective of our study is to clarify the impact of heat exposure on the hospitalization for DKA, HHS, and hypoglycemia. Data of daily hospitalizations for hyperglycemic emergencies (i.e., DKA or HHS) and hypoglycemia was extracted from a nationwide administrative database in Japan and linked with temperature in each prefecture in Japan during 2012-2019. We applied distributed lag non-linear model to evaluate the non-linear and lagged effects of heat exposure on hospitalization for hyperglycemic emergencies. The pooled relative risk for hyperglycemic emergencies of heat effect (the 90th percentile of temperature with reference to the 75th percentile of temperature) and extreme heat effect (the 99th percentile of temperature with reference to the 75th percentile of temperature) over 0-3 lag days was 1.27 (95%CI: 1.16-1.39) and 1.64 (95%CI: 1.38-1.93), respectively. The pooled relative risk for heat effect on hospitalization for hypoglycemia and extreme heat effect over 0-3 lag days was 1.33 (95%CI: 1.17-1.52) and 1.65 (95%CI: 1.29-2.10), respectively. These associations were consistent by type of hyperglycemic emergencies and type of diabetes and were generally consistent by regions. Heat exposure was associated with hospitalizations for DKA, HHS and hypoglycemia. These results may be useful to guide preventive actions for the risk of fatal hyperglycemic emergencies and hypoglycemia.