Rate Of Hypoglycemia Research Articles

Neurodevelopmental Outcomes After Late Preterm Antenatal Corticosteroids

The Antenatal Late Preterm Steroids (ALPS) trial changed clinical practice in the United States by finding that antenatal betamethasone at 34 to 36 weeks decreased short-term neonatal respiratory morbidity. However, the trial also found increased risk of neonatal hypoglycemia after betamethasone. This follow-up study focused on long-term neurodevelopmental outcomes after late preterm steroids. To evaluate whether administration of late preterm (34-36 completed weeks) corticosteroids affected childhood neurodevelopmental outcomes. Prospective follow-up study of children aged 6 years or older whose birthing parent had enrolled in the multicenter randomized clinical trial, conducted at 13 centers that participated in the Maternal-Fetal Medicine Units (MFMU) Network cycle from 2011-2016. Follow-up was from 2017-2022. Twelve milligrams of intramuscular betamethasone administered twice 24 hours apart. The primary outcome of this follow-up study was a General Conceptual Ability score less than 85 (-1 SD) on the Differential Ability Scales, 2nd Edition (DAS-II). Secondary outcomes included the Gross Motor Function Classification System level and Social Responsiveness Scale and Child Behavior Checklist scores. Multivariable analyses adjusted for prespecified variables known to be associated with the primary outcome. Sensitivity analyses used inverse probability weighting and also modeled the outcome for those lost to follow-up. Of 2831 children, 1026 enrolled and 949 (479 betamethasone, 470 placebo) completed the DAS-II at a median age of 7 years (IQR, 6.6-7.6 years). Maternal, neonatal, and childhood characteristics were similar between groups except that neonatal hypoglycemia was more common in the betamethasone group. There were no differences in the primary outcome, a general conceptual ability score less than 85, which occurred in 82 (17.1%) of the betamethasone vs 87 (18.5%) of the placebo group (adjusted relative risk, 0.94; 95% CI, 0.73-1.22). No differences in secondary outcomes were observed. Sensitivity analyses using inverse probability weighting or assigning outcomes to children lost to follow-up also found no differences between groups. In this follow-up study of a randomized clinical trial, administration of antenatal corticosteroids to persons at risk of late preterm delivery, originally shown to improve short-term neonatal respiratory outcomes but with an increased rate of hypoglycemia, was not associated with adverse childhood neurodevelopmental outcomes at age 6 years or older.

The Relationship between All-Cause Dementia and Acute Diabetes Complications among American Indian and Alaska Native Peoples.

American Indian and Alaska Native people (AI/AN) bear a disproportionate burden of diabetes. Growing evidence shows significant associations between several acute diabetes complications and dementia among diabetes patients. However, little is known about these relationships among AI/AN adults. Here, we aim to investigate these associations among AI/AN adults. This cross-sectional study extracted data from the Indian Health Service's (IHS) National Data Warehouse and related administrative databases. A total of 29,337 IHS actual users with diabetes who were 45+ years old during fiscal year 2013 were included. All-cause dementia and diabetes complications were identified using ICD-9 diagnostic codes. Negative binomial regression models were used to evaluate the associations of interest. Nearly 3% of AI/AN diabetes patients had a dementia diagnosis. After controlling for covariates, dementia was associated with a 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). AI/AN diabetes patients with dementia suffered from considerably higher rates of acute diabetes complications than their counterparts without dementia. The clinical management of patients with comorbid diabetes and dementia is particularly challenging and may require individualized treatment approaches.

The Canadian Hypoglycemia During Hospitalization Score Is Externally Valid in the Australian Diabetes IN-hospital: Glucose & Outcomes (DINGO) Cohort

ObjectivesThe Hypoglycemia During Hospitalization (HyDHo) score predicts hypoglycemia in a population of Canadian inpatients by assigning various weightings to 5 key clinical criteria known at the time of admission, in particular age, recent presentation to an emergency department, insulin use, use of oral hypoglycemic agents, and chronic kidney disease. Our aim in this study was to externally validate the HyDHo score by applying this risk calculator to an Australian population of inpatients with diabetes. MethodsThis study was a retrospective data analysis of a subset of the Diabetes IN-hospital: Glucose & Outcomes (DINGO) cohort. The HyDHo score was applied based on clinical information known at the time of admission to stratify risk of inpatient hypoglycemia. ResultsThe HyDHo score was applied to 1,015 patients, generating a receiver-operating characteristic c-statistic of 0.607. A threshold of ≥9, as per the original study, generated a sensitivity of 83% and a specificity of 20%. A threshold of ≥10, to better suit this Australian population, generated a sensitivity of 90% and a specificity of 34%. The HyDHo score has been externally valid in a geographically different population; in fact, it outperformed the original study after accounting for local hypoglycemia rates. ConclusionsOur findings support the external validity of the HyDHo score in a geographically different population. Application of this simple and accessible tool can serve as an adjunct to predict an inpatient’s risk of hypoglycemia and guide more appropriate glucose monitoring and diabetes management.

Ongoing burden and recent trends in severe hospitalised hypoglycaemia events in people with type 1 and type 2 diabetes in Scotland: A nationwide cohort study 2016–2022

AimsWe examined severe hospitalised hypoglycaemia (SHH) rates in people with type 1 and type 2 diabetes in Scotland during 2016–2022, stratifying by sociodemographics. MethodsUsing the Scottish National diabetes register (SCI-Diabetes), we identified people with type 1 and type 2 diabetes alive anytime during 2016–2022. SHH events were determined through linkage to hospital admission and death registry data. We calculated annual SHH rates overall and by age, sex, and socioeconomic status. Summary estimates of time and stratum effects were obtained by fitting adjusted generalised additive models using R package mgcv. ResultsRates for those under 20 with type 1 diabetes reached their minimum at the 2020–2021 transition, 30% below the study period average. A gradual decline over time also occurred among 20–49-year-olds with type 1 diabetes. Overall, females had 15% higher rates than males with type 2 diabetes (rate ratio 1.15, 95% CI 1.08–1.22). People in the most versus least deprived quintile experienced 2.58 times higher rates (95% CI 2.27–2.93) in type 1 diabetes and 2.33 times higher (95% CI 2.08–2.62) in type 2 diabetes. ConclusionsDespite advances in care, SHH remains a significant problem in diabetes. Future efforts must address the large socioeconomic disparities in SHH risks.

Cost-Effectiveness of Closed-Loop Automated Insulin Delivery Using the Cambridge Hybrid Algorithm in Children and Adolescents with Type 1 Diabetes: Results from a Multicenter 6-Month Randomized Trial.

The main objective of this study is to evaluate the incremental cost-effectiveness (ICER) of the Cambridge hybrid closed-loop automated insulin delivery (AID) algorithm versus usual care for children and adolescents with type 1 diabetes (T1D). This multicenter, binational, parallel-controlled trial randomized 133 insulin pump using participants aged 6 to 18 years to either AID (n = 65) or usual care (n = 68) for 6 months. Both within-trial and lifetime cost-effectiveness were analyzed. Analysis focused on the treatment subgroup (n = 21) who received the much more reliable CamAPS FX hardware iteration and their contemporaneous control group (n = 24). Lifetime complications and costs were simulated via an updated Sheffield T1D policy model. Within-trial, both groups had indistinguishable and statistically unchanged health-related quality of life, and statistically similar hypoglycemia, severe hypoglycemia, and diabetic ketoacidosis (DKA) event rates. Total health care utilization was higher in the treatment group. Both the overall treatment group and CamAPS FX subgroup exhibited improved HbA1C (-0.32%, 95% CI: -0.59 to -0.04; P = .02, and -1.05%, 95% CI: -1.43 to -0.67; P < .001, respectively). Modeling projected increased expected lifespan of 5.36 years and discounted quality-adjusted life years (QALYs) of 1.16 (U.K. tariffs) and 1.52 (U.S. tariffs) in the CamAPS FX subgroup. Estimated ICERs for the subgroup were £19 324/QALY (United Kingdom) and -$3917/QALY (United States). For subgroup patients already using continuous glucose monitors (CGM), ICERs were £10 096/QALY (United Kingdom) and -$33 616/QALY (United States). Probabilistic sensitivity analysis generated mean ICERs of £19 342/QALY (95% CI: £15 903/QALY to £22 929/QALY) (United Kingdom) and -$28 283/QALY (95% CI: -$59 607/QALY to $1858/QALY) (United States). For children and adolescents with T1D on insulin pump therapy, AID using the Cambridge algorithm appears cost-effective below a £20 000/QALY threshold (United Kingdom) and cost saving (United States).

Continuous Glucose Monitoring in Older Adults: What We Know and What We Have Yet to Learn.

To assess the growing use of continuous glucose monitoring (CGM) systems by older adults and explore additional areas integration that could benefit adults with frailty. The use of CGM devices has expanded rapidly in the last decade. This has been supported by substantial data showing significant benefit in glycemic metrics: hemoglobin A1c improvements, less hypoglycemia, and improved quality of life. However, sub-populations, such as older persons, exist where available data are limited. Furthermore, frail older adults represent a heterogeneous population with their own unique challenges to the management of diabetes. This group has some of the poorest outcomes related to the sequela of diabetes. For example, hypoglycemia resulting in significant morbidity and mortality is more frequent in older person with diabetes than in younger persons with diabetes. We present a concise literature review on CGM use in the older adult as well as expand upon glycemic and nonglycemic benefits of CGM for patients, caregivers, and providers. Retrospective analysis of inpatient glycemic data of 16,935 older adults with Type 2 diabetes mellitus at Atrium Health Wake Forest Baptist indicated those with fraility managed with insulin or sulfonylurea had the highest rates of delirium (4.8%), hypoglycemia (3.5%), cardiovascular complications (20.2%) and ED visits/hospitalizatoins (49%). In addition, we address special consideration of specific situations including inpatient, palliative and long term care settings. This review article summarizes the available data for CGM use in older adults, discusses the benefits and obstacles with CGM use in this population, and identifies areas of future research needed for improved delivery of care to older persons with diabetes.

Single Center Evaluation of Long-Term Results of Glargin U-300 in Insulin Naive Patients In a Real-World Setting

Objective: Insulin therapy stands as one of the most effective and well-established therapeutic options for managing glycemic control in Diabetes Mellitus (DM). Glargine 300 U/mL (Gla-300) represents a new long-acting insulin analog, which has demonstrated a decrease in the risk of hypoglycemia and a reduction in the total number of injections due to prolonged insulin absorption. In this study, we investigated the long-term effects of Gla-300 on Fasting Plasma Glucose (FPG) and HbA1c levels, as well as the incidence of hypoglycemia in insulin-naive patients admitted to the Internal Medicine outpatient clinic, over a period of 0, 3, 6, 12, and 24 months.. Material and Methods: Between January 2018 and June 2022, insulin-naive patients diagnosed with Type 2 Diabetes Mellitus (T2DM) who initiated treatment with Gla-300 and sought care at the Internal Medicine outpatient clinic were subjected to retrospective analysis. Results: The study included 49 insulin-naive patients. A statistically significant decrease was observed in Fasting Plasma Glucose (FPG) (p = 0.03) and HbA1c (p = 0.02) levels during the 24-month follow-up period of Glargine U-300. Additionally, a significant reduction in both FPG (p &lt; 0.01) and HbA1c (p &lt; 0.01) values was achieved at the time of diagnosis and at 3 months. Hypoglycemia was reported in only 1 patient (2%) during our study, indicating a very low hypoglycemia rate. Conclusion: Diabetes mellitus (DM) poses a significant public health challenge, resulting in economic burden and diminished quality of life. Developed to address these challenges, Gla-300 serves as a long-acting basal insulin that effectively reduces the risk of hypoglycemia while offering targeted glycemic control, as evidenced by our study findings. In Turkey, there is a pressing need for multicenter, prospective real-world studies that incorporate parameters such as insulin dosage and weight monitoring.

Insulin Degludec in People with Type2 Diabetes in China: A Non-interventional, Retrospective Chart Review Study (CN-TREAT).

Insulin degludec (degludec), an ultra-long-acting basal insulin analogue, provides equivalent glycemic control to other basal insulin analogues, with lower risk of hypoglycemia and flexible dosing. Chinese TREsiba AudiT (CN-TREAT) investigated outcomes with degludec in people with type2 diabetes (T2D) in routine clinical practice in China. This was a retrospective chart review study in adults with T2D initiating or switching to degludec at 50 sites in China between January 2020 and July 2021. The primary endpoint was change in glycated hemoglobin (HbA1c) from baseline to end of study (EOS; week20). Secondary endpoints included change from baseline to EOS in fasting plasma glucose (FPG), self-measured plasma glucose (SMPG), daily insulin dose, and rate of hypoglycemia. Data from 936 participants were included (499 insulin-naïve; 437 insulin-experienced). Mean (95% confidence interval [CI]) HbA1c change from baseline to EOS was - 1.48%-points (- 1.57; - 1.38; P < 0.0001) overall: - 1.95%-points (- 2.08; - 1.81; P < 0.0001) in insulin-naïve participants and - 0.95%-points (- 1.08; - 0.82; P < 0.0001) in insulin-experienced participants. Mean (95%CI) changes in FPG and SMPG were - 2.27mmol/L (- 2.69; - 1.85; P < 0.0001) and - 2.89mmol/L (- 3.52; - 2.25; P < 0.0001), respectively, with similar reductions in insulin-naïve and insulin-experienced subgroups. Rate of hypoglycemia did not change statistically significantly from baseline to EOS overall, or in insulin-experienced participants, except when adjusted for baseline hypoglycemia. Basal insulin dose did not change statistically significantly in insulin-experienced participants. In routine clinical practice in China, initiation or switching to degludec was associated with improvements in glycemic control in people with T2D, with no increased risk of hypoglycemia. ClinialTrials.gov, NCT04227431.

Efficacy and Safety of IDegAsp in a Real-World Korean Population with Type 2 Diabetes Mellitus.

This study investigated the real-world efficacy and safety of insulin degludec/insulin aspart (IDegAsp) in Korean adults with type 2 diabetes mellitus (T2DM), whose insulin treatment was switched to IDegAsp. This was a multicenter, retrospective, observational study comprising two 26-week treatment periods, before and after switching to IDegAsp, respectively. Korean adults with uncontrolled T2DM treated with basal or premix insulin (±oral antidiabetic drugs) were enrolled. The primary objective was to compare the degree of glycosylated hemoglobin (HbA1c) change in each 26-week observation period. The analyses included changes in HbA1c, fasting plasma glucose (FPG), body weight, proportion of participants achieving HbA1c <7.0%, hypoglycemic events, and total daily insulin dose (ClinicalTrials.gov, number NCT04656106). In total, 196 adults (mean age, 65.95 years; mean T2DM duration, 18.99 years) were analyzed. The change in both HbA1c and FPG were significantly different between the pre-switching and the post-switching period (0.28% vs. -0.51%, P<0.001; 5.21 mg/dL vs. -23.10 mg/dL, P=0.005), respectively. After switching, the rate of achieving HbA1c <7.0% was significantly improved (5.10% at baseline vs. 11.22% with IDegAsp, P=0.012). No significant differences (before vs. after switching) were observed in body weight change, and total daily insulin dose. The rates of overall and severe hypoglycemia were similar in the two periods. In real-world clinical practice in Korea, the change of insulin regimen to IDegAsp was associated with an improvement in glycemic control without increase of hypoglycemia, supporting the use of IDegAsp for patients with T2DM uncontrolled with basal or premix insulin.

Medical education on hospital hyperglycemia improving knowledge and outcomes.

To evaluate the effects of medical education on hospital hyperglycemia on physician's technical knowledge and the quality of medical prescriptions, patient care, and clinical outcomes. The intervention included online classes and practical consultations provided by an endocrinologist to medical preceptors and residents of the Department of Internal Medicine. A pretest and a post-test (0 to 10 points) were applied before and after the intervention and patients medical records were reviewed before and after the intervention. The outcomes were improvement in medical knowledge, in the quality of prescriptions for patients in the clinical area, and clinical outcomes. The global mean of correct answers improved with the intervention [before: 6.9 points (±1.7) versus after the intervention: 8.8 points (±1.5) (p < 0.001)]. The number of patients who did not have at least one blood glucose assessment during the entire hospitalization for acute illness decreased from 12.6% before to 2.6% (p < 0.001) after the intervention. There was also a significant reduction in hospital hypoglycemia rates (p < 0.026). The use of sliding-scale insulin as the main treatment was quite low before and after the intervention (2.2% and 0%). After 6 months, medical knowledge did not show significant reduction. Medical education on hospital hyperglycemia can improve medical knowledge and clinical outcomes for patients. The improvement in medical knowledge was maintained after 6 months.

Real-World Study on Effectiveness of Insulin Glargine U300 After Oral Antidiabetic Drug Failure in Patients with Type 2 Diabetes in the Gulf Region.

The effectiveness and safety of long-acting insulin glargine U300 (Gla-300), in patients with type2 diabetes mellitus (T2DM) requiring insulin, has not been reported in the Gulf region. Insulin-naïve patients with T2DM, uncontrolled on OADs, and prescribed Gla-300 were followed up in a 12-month prospective observational study. Gla-300 was titrated to glycemic targets. The primary endpoint (achieving glycemic targets) was evaluated at month 6 of treatment. The need for treatment intensification, safety, and patient-reported outcomes (PRO) were also reported. The study included 412 patients (61.7% men; age 52.2 ± 11.1years and T2DM duration 10.7 ± 6.8years). Almost 50% were on more than 3 OADs, mostly biguanides, sulfonylureas, and dipeptidyl-peptidase-4 inhibitors. Baseline HbA1c level was 9.2% ± 1.1% and targets were set at 6.9% ± 0.4%. Baseline fasting plasma glucose was 11.5 ± 3.8mmol/l. Fifty-seven patients (13.8%) achieved glycemic targets at month 6, hindered by baseline HbA1c ≥ 10%, frequent co-morbidities, older age, suburban/rural residence, and full-time employment. Levels of HbA1c dropped progressively by 0.96% ± 0.07% (month 3), 1.29% ± 0.08% (month 6), and 1.76% ± 0.06% (month 12). Gla-300 dose was 17.0 ± 9.0IU/day at baseline, 24.6 ± 9.6 IU/day at month 3, 28.5 ± 9.9IU/day at month 6, and 30.7 ± 10.7IU/day at month 12. Three patients experienced non-severe hypoglycemia and a slight decrease in body weight and PROs improved. In the Gulf, Gla-300 in patients with T2DM uncontrolled on OADs improved glycemic control, with low rates of hypoglycemia and improved PROs. Gla-300 dose up-titration from baseline to month 6 did not, however, result in a vast proportion of patients achieving their pre-determined HbA1c targets. ClinicalTrials.gov identifier: NCT03703869.

Home Insulin Pump Use in Hospitalized Children With Type 1 Diabetes

Pediatric data on inpatient home insulin pumps are absent in the literature. Understanding safety of home insulin pumps, managed by patients or caregivers, during times of illness will help diabetes technology securely move into pediatric hospitals. To examine whether insulin can be safely and accurately delivered to hospitalized children through home insulin pumps when managed by patients or caregivers. This single-center, retrospective, observational cohort study included children with insulin-dependent diabetes admitted to a tertiary children's hospital from January 1, 2016, to December 31, 2021. In all these patients, diabetes was the primary or secondary diagnosis on admission. Insulin delivery via home insulin pump, hospital insulin pump, or subcutaneous injection. Hyperglycemia (glucose, >250 mg/dL) and hypoglycemia (glucose, <45 mg/dL) rates (quantified as the proportion of total insulin-days), glucose variability, and diabetic ketoacidosis (DKA) recurrences were compared for hospital pumps (manual mode), home pumps (manual mode), and subcutaneous injections using bivariate tests. There were 18 096 insulin-days among 2738 patients aged 0.5 to 25 years (median age, 15.8 years [IQR, 12.3-18.3 years]). Overall, 990 (5.5%) of insulin-days involved hospital insulin pumps, and 775 (4.3%) involved home pumps. A total of 155 insulin-days (15.7%) involving hospital pumps were hyperglycemic, compared with 209 (27.0%) involving home pumps and 7374 (45.2%) involving injections (P < .001). Moderate hypoglycemia days comprised 31 insulin-days (3.1%) involving hospital pumps compared with 35 (4.5%) involving home pumps and 830 (5.1%) involving injections (P = .02). Severe hypoglycemia did not differ significantly according to insulin delivery method. Two patients using injections (0.01%) developed DKA; no patients using hospital or home pumps developed DKA. In this cohort study, home insulin pump use was found to be safe in a children's hospital regarding hyperglycemia and hypoglycemia. These data support use of home insulin pumps during pediatric admissions in patients who do not require intensive care and without active DKA.

Safety and Efficacy of Insulins in Critically Ill Patients Receiving Continuous Enteral Nutrition

ObjectiveThere is a relative lack of consensus regarding the optimal management of hyperglycemia in patients receiving continuous enteral nutrition (EN), with or without a diagnosis of diabetes. MethodsThis retrospective study examined 475 patients (303 with known diabetes) hospitalized in critical care setting units in 2019 in a single center who received continuous EN. Rates of hypoglycemia, hyperglycemia, and glucose levels within the target range (70-180 mg/dL) were compared between patients with and without diabetes, and among patients treated with intermediate-acting (IA) biphasic neutral protamine Hagedorn 70/30, long-acting (LA) insulin, or rapid-acting insulin only. ResultsAmong those with type 2 diabetes mellitus, IA and LA insulin regimens were associated with a significantly higher proportion of patient-days in the target glucose range and fewer hyperglycemic days. Level 1 (<70 mg/dL) and level 2 (<54 mg/dL) hypoglycemia occurred rarely, and there were no significant differences in level 2 hypoglycemia frequency across the different insulin regimens. ConclusionAdministration of IA and LA insulin can be safe and effective for those receiving insulin doses for EN-related hyperglycemia.

Breaking through diabetes management barriers: Assessing the accuracy of Freestyle Libre Pro flash continuous glucose monitoring in diabetes patients with myocardial infarction.

The objective of this study was to assess the accuracy of FreeStyle Libre Pro (FSL-Pro) flash continuous glucose monitoring (CGM) in patients with type 2 diabetes mellitus (T2DM) and acute myocardial infarction (AMI). A single-arm, single-center prospective study was conducted in the cardiac care unit from January 2021 to September 2023. Patients underwent finger-prick blood glucose (FPBG) testing before breakfast (6:00 am) and after meals (at 9:00, 13:00, 19:00 pm), along with CGM during their hospitalization. Statistical analyses included mean differences (MDs), mean absolute relative difference (MARDs) of blood glucose levels, and hypoglycemia occurrences. A Bland-Altman plot analysis and Pearson correlation were performed. Ninety-seven T2DM and AMI patients underwent CGM for up to 72 h (1142 monitoring point). Mean daily BG, Fasting plasma glucose (FPG) and mean postprandial plasma glucose (PPG) were significantly lower by CGM than by FPBG with an estimated MD of -0.89 mmol/L in BG, -0.88 mmol/L in FPG, and -0.90 mmol/L in PPG, respectively. The maximum effect was mainly in the first day and then the difference was gradually declined (falling range, Day1, -1.24; Day 2, -0.70; Day 3, -0.68, mmol/L, respectively). The incidence rates of hypoglycemia and potential hypoglycemia was 1.57% and 8.5% higher, respectively, in CGM than in FBPG. A Bland-Altman Plot revealed some variability and bias between the two methods of measurement of glucose monitoring (p < .001). Pearson's correlation coefficient demonstrated a significant correlation between the mean BG, FPG, and PPG of CGM and FBPG (Pearson's coefficient: 0.92, 0.87, 0.92, respectively, p < .001). Compared with FPBG, FSL Pro-CGM showed lower mean glucose and higher hypoglycemia detection in T2DM and AMI patients, especially in the first 24 h.

Reducing or Discontinuing Insulin or Sulfonylurea When Initiating a Glucagon-like Peptide-1 Agonist.

Hypoglycemia and weight gain are well-known adverse effects of insulin and sulfonylureas in patients with type 2 diabetes. Glucagon-like peptide-1 (GLP-1) agonist monotherapy has a low incidence of hypoglycemia, but when combined with insulin or sulfonylureas, patients have higher rates of hypoglycemia. The primary study outcome was to determine the percentage of patients with dose reductions or discontinuation of insulin or a sulfonylurea at baseline, 3, 6, and 12 months. Secondary outcomes included changes in hemoglobin A1c and body weight measured. This was a single-center, quality assurance, quality improvement, retrospective chart review of patients prescribed a GLP-1 agonist while on insulin and/or a sulfonylurea between January 1, 2019, and September 30, 2022, at a pharmacist-led patient aligned care team (PACT) clinic at the Wilkes-Barre Veterans Affairs Medical Center. This retrospective chart review included 136 patients. Throughout 12 months of following the pharmacist-led PACT clinic, 55 patients (57.3%) had ≥ 1 insulin dose reduction, 16 patients (29.6%) had ≥ 1 dose reduction of a sulfonylurea, 14 patients (14.6%) discontinued insulin, and 21 patients (38.9%) discontinued their sulfonylurea. Patients taking insulin and/or sulfonylurea in combination with a GLP-1 agonist may require a dose reduction or discontinuation of the diabetic agents. Patients on both insulin and sulfonylurea may need closer monitoring due to the higher incidences of discontinuations compared with patients on only 1 of these agents. Dose reductions or discontinuations of these diabetic agents can promote positive patient outcomes, such as preventing hypoglycemia, minimizing weight gain, increasing weight loss, and reducing hemoglobin A1c.

Efficacy and safety of insulin glargine 300 units/mL vs insulin degludec in patients with type 1 and type 2 diabetes: a systematic review and meta-analysis.

Ultra-long-acting insulin analogs [insulin degludec (IDeg) and insulin glargine 300 units/mL (IGla-300)] offer a longer duration of action with less risk of hypoglycemia compared to other long-acting insulins. However, data about the comparative efficacy and safety are inconsistent. We searched CENTRAL, PubMed, Embase, ICTRP Search Portal, and ClinicalTrials.gov on 7 October 2022. Randomized controlled trials (RCTs) comparing the safety and efficacy of IDeg (100 or 200 units/mL) and IGla-300 in patients with type 1 or type 2 diabetes were included. Three review authors independently selected trials, assessed the risk of bias, extracted data, and evaluated the overall certainty of the evidence using GRADE. The primary outcomes were the change in glycated hemoglobin (HbA1c) and any hypoglycemia; the secondary outcomes were the change in fasting plasma glucose (FPG) and severe and nocturnal hypoglycemia. Four open-label RCTs were included (2727 participants), 3 parallel and 1 cross-over. Overall, the risk of bias assessment yielded some concern or high risk. There was a comparable change in HbA1c from baseline to the end of treatment, a mean difference of 0.07% (95% confidence interval (CI) 0.06 - 0.19; p = 0.29; 3 trials; 2652 patients; very low-certainty evidence), and a comparable rate of any hypoglycemia, rate ratio 1.02 (95% CI 0.8 - 1.3; p = 0.87; 3 trials; 2881 patients; very low-certainty evidence). IDeg resulted in more reduction in FPG compared to IGla-300, mean difference of 10.27 mg/dL (95% CI 7.25 - 13.29; p < 0.001; 3 trials; 2668 patients; low-certainty evidence). Similar rates of nocturnal and severe hypoglycemia were observed, rate ratio of 1.13 (95% CI 0.72 - 1.78; p = 0.54; 3 trials; 2668 patients; very low-certainty evidence) and 1.4 (95% CI 0.41 - 4.73; p = 0.59; 2 trials; 1952 patients; very low-certainty evidence), respectively. There is no evidence of a difference between IDeg and IGla-300 in the mean change in HbA1c and the risk of anytime, nocturnal, and severe hypoglycemia. IDeg appeared to cause a higher reduction in FPG compared to IGla-300. However, this finding should be interpreted with caution due to the small number of trials included and their high risk of bias. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022364891, identifier CRD42022364891.

Factors affecting the prolongation of glycemic time in range among children with type 1 diabetes using continuous glucose monitoring systems: A case control study

BackgroundTime in range is a reliable measure of the risk of diabetes complications. High percentage of patients with diabetes fail to achieve the recommended time in range (TIR) target of 70–180 mg/dl (3.9–10 mmol/l) >70%.ObjectiveThis study aimed to identify factors influencing TIR prolongation.MethodsChildren aged 1–17 years with >1-year type 1 diabetes (T1D) duration, treated with continuous subcutaneous insulin infusion (CSII) ≥3 months, using continuous glucose monitoring (CGM) or intermittently scanned CGM (is-CGM) ≥1 month, and with a registration time >70% were included. Data were collected during routine diabetology visits at an outpatient clinic. Insulin pump and CGM or is-CGM reports in the most recent 14 days were recorded using a dedicated software. Legal caregivers were also asked to complete a questionnaire on how the patients use the insulin pump functions and eating habits.ResultsA sample of 110 patients was categorized into two groups: those with TIR >70% and TIR ≤70%. TIR ≤70% group presented with repeated hyperglycemia and a high glycemic variability coefficient of variation. We noted an acceptable hypoglycemia rate (3%), regardless of the TIR value. Patients with TIR >70% predominantly used predictive low glucose suspend system, maintained adequate intervals between insulin delivery and meal consumption, used the “bolus calculator” function, and more frequently created electronic reports.ConclusionsHyperglycemia and high glycemic variability prevent patients from achieving the target TIR. Advanced features in the CGM systems, premeal insulin bolus, and patients’ involvement in diabetes treatment are the main factors contributing to TIR prolongation.

Glycemic Management in Insulin-Naive Patients in the Inpatient Setting.

The ideal inpatient insulin regimen efficiently attains the target blood glucose range, effectively treats hyperglycemia, and minimizes the risk of hypoglycemia. The objective of this study was to compare glycemic targets achieved by using correctional monotherapy (CM) and basal-bolus therapy (BBT) in insulin-naive patients in the inpatient setting to determine optimal blood glucose management for these patients. This was a retrospective observational cohort study of 792 patients with diabetes not on home insulin therapy who were admitted to an academic hospital over a 5.5-month period. The percentages of hyperglycemic and hypoglycemic values in each group were compared. Among the 3,112 measured blood glucose values obtained from 792 patients within the first 24 hours of insulin administration, 28.5% were hyperglycemic in the BBT group compared with 23.5% in the CM group. When adjusted for covariates, there was a 23% decrease in hyperglycemia in the BBT group (incidence rate ratio = 0.77, 95% CI 0.64-0.95, P = 0.006). Increases in A1C and admission blood glucose, as well as decreases in admission creatinine and inpatient steroid use, were independently associated with higher rates of hyperglycemia, adjusted for all other covariates. There was no significant difference between the groups in the rate of hypoglycemia in the first 24 hours, which was 1.9% in the BBT group and 1.4% in the CM group (P = 0.301). Utilizing BBT in insulin-naive patients admitted to the hospital within the first 24 hours of insulin administration results in lower rates of hyperglycemia without higher rates of hypoglycemia when compared with CM.

Effects of a 2-Week Kinect-Based Mixed-Reality Exercise Program on Prediabetes: A Pilot Trial during COVID-19.

Pre-diabetes can develop into type 2 diabetes mellitus, but can prevented by regular exercise. However, the outcomes when combining unsupervised Kinect-based mixed-reality (KMR) exercise with continuous glucose monitoring (CGM) remain unclear. Therefore, this single-arm pilot trial examined changes in blood glucose (BG) concentrations over 672 hours (4 weeks), including a 2-week period of KMR exercise and CGM in individuals with pre-diabetes. This was a pre-and post-treatment case-control study with nine participants. General questionnaires were administered and body composition, fasting BG concentrations, and 2-hour oral glucose tolerance test (2-OGTT) results were measured pre-and post-treatment. Weekly average glucose concentrations, hyperglycemia rate, hypoglycemia rate, average glucose concentration over time, amount of physical activity, amount of food intake, and pre- and postprandial BG (immediately and 30, 60, 90, and 120 minutes after lunch) were measured over 4 weeks (pre-test, exercise, and post -test weeks). Glucose concentrations were measured before exercising, between sets, and 30 and 60 minutes after exercise during the 2 weeks of unsupervised exercise (3 days/week). In all participants, body mass index (27.16±2.92 kg/m2), fasting BG (108.00±7.19 mg/dL), 2-OGTT (162.56±18.12 mg/dL), hyperglycemia rate (P=0.040), and 90-minute postprandial BG (P=0.035) were significantly reduced during the 2 exercise weeks, and the 2-OGTT result (P=0.044) and diastolic blood pressure (DBP) (P=0.046) were significantly reduced at the post -test as compared with the pre-test. This study found that 2 weeks of unsupervised KMR exercise reduced 2-OGTT, DBP, hyperglycemia rate, and 90-minute postprandial BG concentration. We believed this effect could be identified more clearly in studies involving a larger number of participants and longer durations of exercise.

Evaluation of Insulin and Glucagon-like peptide-1 Receptor Agonists Combination for Type 2 Diabetes Mellitus: An Updated Meta-analysis

Glucagon-like peptide-1 receptor agonists (GLP-1RA) increase glucose-stimulated insulin secretion, suppress glucagon production, increase satiety, reduce food intake, improve insulin sensitivity, and reduce visceral fat. This study aims to compare the GLP-1RA and insulin combination or GLP-1RA added to background insulin therapy with other injectable therapies in patients with type-2 diabetes mellitus (T2DM). We searched for studies that compared GLP-1RA and insulin combination with other injectable therapies in T2DM patients for HbA1c (%) change, achieving HbA1c &lt;7% at study end, hypoglycemia incidence, and weight change. The following intervention groups were analyzed: the combination of basal insulin and GLP-1RA, basal-plus/basal-bolus, and placebo/insulin intensification (insulin uptitration)/GLP-1RA. A total of 48 studies were included. Insulin and GLP-1RA combination therapy reduced HbA1c more than placebo/insulin intensification (insulin up-titration)/GLP-1RA (WMD -0.693, p &lt;0.001) and basal-plus/basal-bolus (WMD -0.105, p =0.027). Insulin and GLP-1RA combination therapy significantly reduced body weight more than placebo/insulin intensification (insulin up-titration)/GLP-1RA (WMD -1.894, p &lt;0.001) and basal-plus/basal-bolus (WMD -3.6, p =0.001). Patients on insulin and GLP-1RA combination therapy had a higher chance of achieving the HbA1c target than placebo/insulin intensification (insulin up-titration)/GLP-1RA arm (RR 1.964, p &lt;0.001), but not than basal-plus/basal-bolus arm (RR 1.037, 95% CI 0.971 to 1.103). Hypoglycemia rates were comparable between combination therapy and placebo/insulin intensification (insulin up-titration)/GLP-1RA (RR 0.94, 95% 0.84 - 1.04), but statistically significant when compared to combination therapy and basal-plus/basal-bolus (RR 0.63, p &lt;0.001). Our findings support using GLP-1RA in combination with insulin as a useful intensification approach for producing therapeutic improvement in T2DM therapy for individuals who have not reached their HbA1c goal.