Insulin Users Research Articles

Weather VBG Analysis can Replace ABG Analysis in DKA Patients

Introduction: Endocrinological emergencies such as DKA are known for hyperglycemia, ketone bodies, and metabolic acidosis in the blood and urine. It rarely occurs in type 2 DM patients. ABG and VBG are biochemical parameters used in its research. Objective: To evaluate the efficacy of VBG against ABG in DKA patients. Methodology: Details on DM type, duration, antidiabetic drug and insulin usage, and past DKA hospitalizations were collected. A complete blood count, ESR, RFT, electrolyte levels (sodium, potassium, calcium, and phosphate), LFT, RBS, UT, ABG, VBGA, microscopy, chest X-ray, ECG, abdominal and pelvic ultrasound are recommended. Result and Conclusion: We discovered that the majority of patients pH levels were in the 7.00-7.25 range in both AB and VB (48.7% and 46.1%, respectively) and that the majority of patients' levels were above 15 in both AB and VB (56.6% and 64.5%, respectively). Thus, we found that VBG analysis parameters were similar to ABG analysis parameters. The blood gas analysis parameters pH and exhibited the strongest linear correlation when comparing arterial and venous samples.

Smart Insulin Pen: Managing Insulin Therapy for People with Diabetes in the Digital Era

The number of insulin users in Korea has doubled over the past 20 years. Numerous studies have shown the benefits of continuous glucose monitoring (CGM) on glycemic outcomes in people with diabetes receiving insulin therapy. However, patients often failed to reach the target even with the CGM. Advanced technology, such as automated insulin delivery (AID), can potentially reduce patient burden and improve glycemic status in people on insulin therapy. However, wearing a CGM all day and complex device operation could also burden users. Additionally, since insulin users are often elderly with type 2 diabetes, there is an urgent need for new devices that are more efficient and simpler than AID. In that sense, the smart insulin pen (SIP) is the expected future technology that does not need to be worn all day and helps to calculate insulin doses with a built-in bolus calculator integrated with CGM. In this context, we discuss efficient use of SIP as an educational tool.

Evaluation of a hybrid protocol using continuous glucose monitoring and point-of-care testing in non-critically ill patients in a community hospital.

Inpatient glycemic management typically involves use of point-of-care (POC) glucose measurements to inform insulin dosing decisions. This study evaluated a hybrid monitoring protocol using real-time continuous glucose monitoring (rtCGM) supplemented with POC testing at a community hospital. Adult inpatients receiving POC glucose testing were monitored using rtCGM in a telemetry unit. The hybrid monitoring protocol required a once-daily POC test but otherwise primarily relied on rtCGM values for insulin dosing decisions. Outcomes assessment included surveillance error grid (SEG) and Clarke Error Grid (CEG) analysis results, the mean absolute relative difference (MARD) for available rtCGM-POC value pairs before and after study protocol application, the number of POC tests avoided, and the number of hypoglycemic events involving a blood glucose value of <70 mg/dL identified by rtCGM and POC values. Data were collected from 30 inpatients (the mean age was 69.4 years, 77% were female, 80% had type 2 diabetes, and 37% were at-home insulin users). With the protocol applied, a total of 202 rtCGM-POC pairs produced a MARD of 12.5%. SEG analysis showed 2 pairs in the "moderate" risk category, with all other pairs in the "none" or "slight" risk categories. CEG analysis showed 99% of paired values to be in the clinically acceptable range. Six hypoglycemic events in 5 patients were resolved without incident. Three hundred three POC tests were avoided, a 60% reduction for the study duration. Use of a hybrid monitoring protocol of rtCGM and POC testing in a community hospital demonstrated sustained rtCGM accuracy and was found to reduce the frequency of POC testing to manage inpatient glycemia.

Sociodemographic and spending characteristics of Medicare beneficiaries taking prescription drugs subject to price negotiations.

The 2022 Inflation Reduction Act authorizes Medicare to negotiate the prices of 10 drugs in 2026 and additional drugs thereafter. Understanding the sociodemographic and spending characteristics of beneficiaries taking these specific drugs could be important describing the impact of the legislation. To describe sociodemographic and spending characteristics of Medicare beneficiaries who use the 10 prescription drugs ("negotiated drugs") that will face Medicare drug price negotiations in 2026. A 20% sample of Medicare Part D beneficiaries from 2020 (n = 10,224,642) was used. Sociodemographic and spending characteristics were descriptively reported for beneficiaries taking the negotiated drugs, including subgroups by low-income subsidy (LIS) status and by drug, and for Part D beneficiaries not taking negotiated drugs. Part D beneficiaries taking a negotiated drug compared with Part D beneficiaries not taking a negotiated drug overall had similar sociodemographic characteristics, more comorbidities (3.9 vs 2.2) and higher mean [median] Medicare ($33,882 [$18,251] vs $12,366 [$3,429]) and out-of-pocket (OOP) spending ($813 [$307] vs $441 [$160]). There was variation in characteristics by LIS status. The mean age was highest among non-LIS beneficiaries taking a negotiated drug compared with LIS beneficiaries taking a negotiated drug and beneficiaries not taking a negotiated drug (76.2 vs 69.9 vs 71.4). Among beneficiaries using negotiated drugs, a higher percentage of LIS beneficiaries compared with non-LIS was female (59.7% vs 48.0%), was Black (20.9% vs 6.6%), and resided in lower-income areas (39.1% vs 20.3%). Mean [median] annual Part D OOP spending for negotiated drugs was $115 [$59] for beneficiaries with LIS and $1,475 [$1,204] for beneficiaries without LIS. There were also differences depending on which negotiated drug was used. Drugs for cancer and blood clots had the highest proportions of White users, whereas type 2 diabetes and heart failure drugs had the highest proportions of Black users and beneficiaries residing in lower-income areas. Annual Part D OOP costs were lowest for sitagliptin (LIS: $104 [$60], non-LIS: $1,391 [$1,153]) and highest for ibrutinib (LIS: $649 [$649], non-LIS: $6,449 [$6,867]). Among non-LIS beneficiaries, 24% (22% to 76%) had more than $2,000 in OOP costs. Inflation Reduction Act OOP spending caps and LIS expansion will lower prescription drug costs for beneficiaries with OOP costs exceeding $2,000 who are mostly White and live in higher-income areas, insulin users who are disproportionately Black with multiple chronic conditions, and beneficiaries with low incomes. However, these provisions will not impact the 76% of non-LIS beneficiaries using negotiated drugs who have OOP costs that are still substantial but below $2,000. Negotiations could reduce OOP costs through reduced coinsurance payments for this group, which is older and has more chronic conditions compared with beneficiaries not taking negotiated drugs. Part D plan design, spending, and utilization changes should be monitored after negotiation to determine if further solutions are needed to lower OOP costs for this group.

A retrospective electronic medical record-based study of insulin usage and outcomes in insulin-naive Indian adults with T2DM: The REALITY study

ObjectiveThis retrospective longitudinal study analyzed the demographic profile, insulin usage pattern, and outcomes of insulin-naive adults with type 2 diabetes mellitus (T2DM) who initiated insulin glargine.MethodsThe study included 1006 insulin naive T2DM individuals aged ≥ 18 years, treated with any insulin type between January 2016 and December 2018, using electronic medical records.ResultsMajority of participants were men (55.8%) with a mean age of 59.8 ± 11.9 years and average T2DM duration of 12.0 ± 6.6 years. Insulin glargine was the most commonly used insulin (66.9%), followed by insulin aspart (16.4%), insulin degludec (15.1%), human insulin (11.1%), and insulin isophane (9.2%). At baseline, the mean glycated hemoglobin (HbA1c) was 8.9 ± 1.9%, mean fasting plasma glucose (FPG) was 190 ± 59 mg/dL, and mean post-prandial plasma glucose (PPG) was 264 ± 78 mg/dL. In the insulin glargine group, baseline HbA1c was 9.0 ± 1.7%, FPG was 196 ± 62 mg/dL, and PPG was 283 ± 81 mg/dL. Throughout the study, there was an improvement in HbA1c, FPG, and PPG levels in the insulin glargine group. Body weight remained relatively stable, and the number of hypoglycemic events was minimal and non-life-threatening.ConclusionThe REALITY study in India demonstrated that initiating basal insulin treatment in insulin-naive individuals with T2DM led to improved glycemic parameters over a 12-month period.

Effect of early enteral nutrition on short-term outcomes and survival in patients in the cardiothoracic intensive care unit: An inverse probability weighted retrospective study

ObjectivesThe merits of early enteral nutrition (EEN) in patients in the cardiothoracic intensive care unit (CTICU) remain unclear. This retrospective study aimed to address this issue. MethodsWe analyzed data from the MIMIC IV v2.0 database, including patients with a CTICU stay of ≥4 d. Patients were divided into early and delayed enteral nutrition (EN) groups. Differences in baseline data were corrected using an inverse probability weighting (IPW) approach. Generalized linear models (GLMs) were used to compare trends over time between groups, and survival effects were evaluated with weighted logistic and Cox regression, supplemented by weighted Kaplan–Meier curves. Subgroup analysis facilitated the exploration of potential interactions. ResultsThe study included 720 CTICU patients. Following IPW, all baseline variables were balanced. EEN led to shorter hospital and CTICU stays, lower incidence of respiratory and blood infections, and reduced total insulin usage in the first week of CTICU admission, albeit with an increased total gastric residual volume. Mortality risk between the groups did not significantly differ at 28 d or at 1 y. Excessive early energy and protein intake elevated the risk of 28-d mortality, but the relationship may not be linear. Overweight patients or those with fewer comorbidities had a higher mortality risk with EEN. ConclusionsEEN may improve short-term outcomes in CTICU patients without a clear survival benefit. Early high caloric and protein intake could lead to adverse outcomes, suggesting a careful evaluation for initiating EN in specific patients.

Knowledge, attitude and practice of self-administered insulin by diabetes mellitus patients: A cross sectional study

Diabetes mellitus is a heterogeneous clinical syndrome secondary to defects in insulin secretion, action, or both. India is emerging as the world's diabetic capital. Inadequate awareness about the use of insulin is likely to influence its acceptance and adherence. To assess the knowledge, attitude, and practice (KAP) of self-administered insulin by patients of diabetes mellitus. It was a cross-sectional study conducted by the department of pharmacology at a tertiary care teaching hospital over a period of six months at the medicine outpatient department. A prevalidated questionnaire was used to assess the KAP of insulin use. Informed consent was obtained from the patients prior to giving them a questionnaire. Among the 151 responses, 58 were male and 93 were female. Among them, 66% knew about different types of insulin, and 32% knew about different insulin delivery devices. Around 40% of patients were not aware of HbA1c as a monitoring tool. Nearly 48% patients knew the complications of diabetes. Half of the patients were confident about the self-administration of insulin. About 54% patients took insulin for treatment. Among current insulin users, 75% injected insulin at the upper arm, 83% missed insulin doses, 74% had never used a glucometer, and 32% failed to rotate the site. Knowledge and attitude were good in the majority of patients, but practice regarding the use of insulin was poor. Skilled health care providers could educate diabetes mellitus patients on self-care management and insulin self-therapy and bridge this gap.

Ambient Heat and Risk of Serious Hypoglycemia in Older Adults With Diabetes Using Insulin in the U.S. and Taiwan: A Cross-National Case-Crossover Study.

To measure the association between ambient heat and hypoglycemia-related emergency department visit or hospitalization in insulin users. We identified cases of serious hypoglycemia among adults using insulin aged ≥65 in the U.S. (via Medicare Part A/B/D-eligible beneficiaries) and Taiwan (via National Health Insurance Database) from June to September, 2016-2019. We then estimated odds of hypoglycemia by heat index (HI) percentile categories using conditional logistic regression with a time-stratified case-crossover design. Among ∼2 million insulin users in the U.S. (32,461 hypoglycemia case subjects), odds ratios of hypoglycemia for HI >99th, 95-98th, 85-94th, and 75-84th percentiles compared with the 25-74th percentile were 1.38 (95% CI, 1.28-1.48), 1.14 (1.08-1.20), 1.12 (1.08-1.17), and 1.09 (1.04-1.13) respectively. Overall patterns of associations were similar for insulin users in the Taiwan sample (∼283,000 insulin users, 10,162 hypoglycemia case subjects). In two national samples of older insulin users, higher ambient temperature was associated with increased hypoglycemia risk.

Durability of Effectiveness Between Users of Once-Weekly Semaglutide and Dipeptidyl Peptidase4 Inhibitors (DPP-4i) in US Adults with Type2 Diabetes.

Long-term effectiveness and durability of glucose-lowering medications are important considerations in managing type2 diabetes (T2D). This study aimed to compare durability of treatment efficacy of once-weekly (OW) semaglutide for T2D with that of the dipeptidyl peptidase4 inhibitor (DPP-4i) class. This observational cohort study used 2017-2022 data from the Optum® Clinformatics® Data Mart to compare long-term clinical outcomes associated with semaglutide or DPP-4i in US adults with T2D. The primary outcomes were HbA1c at 2-year follow-up, change in HbA1c from baseline, and the odds of achieving HbA1c targets. BMI at 2-year follow-up, change in BMI from baseline, odds of reducing BMI category, and the need for treatment augmentation were exploratory outcomes. Bivariate and multivariate analyses were conducted using inverse probability of treatment weighting (IPTW) weighted descriptive statistics. Weighted HbA1c and BMI cohorts included 865 and 642 semaglutide users and 779 and 537 DPP-4i users, respectively. In the weighted HbA1c cohort, semaglutide and DPP-4i users had an average age of 60years and similar baseline characteristics including HbA1c level and comorbidity status. Two-year follow-up HbA1c with semaglutide was 0.56% lower than with DPP-4i; reduction in HbA1c from baseline was 0.61% greater. Odds of achieving HbA1c level < 7% were 2.16 times greater after covariate adjustment (all, p < 0.001). Semaglutide was associated with 1.03kg/m2 greater reduction in BMI and 2.27 times greater odds of reducing BMI category vs DPP-4i (p < 0.001). Semaglutide users were less likely to add new glucose-lowering treatment (hazard ratio [HR] 0.57; p < 0.001) or initiate insulin (HR 0.49; p < 0.001) vs DPP-4i users. Compared with DPP-4i, semaglutide was associated with lower follow-up HbA1c and BMI, greater reduction in HbA1c and BMI from baseline, and reduced likelihood of requiring treatment augmentation or insulin initiation to manage T2D in US adults, suggesting better durability of semaglutide vs DPP-4i. INFOGRAPHIC.

Machine learning-based prediction of medication refill adherence among first-time insulin users with type 2 diabetes

AimsThe prevalence of Type 2 Diabetes Mellitus (T2DM) is projected to be 7 % in 2030. Despite its need for long-term diabetes care, the adherence rate of injectable medications such as insulin is around 60 %, lower than the acceptable threshold of 80 %. This study aims to create classification models to predict insulin adherence among adult T2DM naïve insulin users. MethodsClinical data were extracted from Taipei Medical University Clinical Research Database (TMUCRD) from January 1st, 2004 to December 30th, 2020. A patient was regarded as adherent if his/her medication possession ratio (MPR) was at least 80 %. Seven domains of predictors were created, including demographics, baseline medications, baseline comorbidities, baseline laboratory data, healthcare resource utilization, index insulins, and the concomitant non-insulin T2DM medications. We built two Xgboost models for internal and external testing respectively. ResultsUsing a cohort of 4134 patients from Taiwan, our model achieved the Area Under the curve of the Receiver Operating Characteristic (AUROC) of the internal test was 0.782 and the AUROC of the external test was 0.771. the SHAP (SHapley Additive exPlanations) value showed that the number of prescribed medications, the number of outpatient visits, and laboratory data were predictive of future insulin adherence. ConclusionsThis is the first study to predict adherence among adult naïve insulin users. The developed model is a potential clinical decision support tool to identify possible non-adherent patients for healthcare providers to design individualized education plans.

Clinical Utility of Spectral-Domain Optical Coherence Tomography Marker Disorganization of Retinal Inner Layers in Diabetic Retinopathy.

Disorganization of retinal inner layers (DRIL) is a potential spectral-domain optical coherence tomography (SD-OCT) imaging biomarker with clinical utility in diabetic retinopathy (DR). A cross-sectional study was conducted at a large academic center. The cohort was composed of 1,175 patients with type 2 diabetes with and without retinopathy on initial examination between September 2009 and January 2019 (n = 2,083 eyes). DR risk and progression factors were obtained from the medical record. Trained graders masked to patients' clinical histories evaluated SD-OCT scans for DRIL. Of 2,083 eyes, 28.1% (n = 585) demonstrated presence of DRIL with high interrater reliability (K = 0.88, 95% CI 0.86-0.90). DRIL was associated with worse visual acuity (VA) (P < 0.001) and DR severity (P < 0.0001). Insulin users had more severe DR (P < 0.0001). DR-related factors, race (Black, White) and sex (male) were significantly associated with DRIL (P < 0.05). DRIL was strongly associated with DR severity and worse VA, supporting its utility as an unfavorable prognostic indicator. [Ophthalmic Surg Lasers Imaging Retina 2023;54:692-700.].

Decline in HbA1c during the first year of elexacaftor/tezacaftor/ivacaftor treatment in the Danish cystic fibrosis cohort: Short title: Decline in HbA1c after elexacaftor/tezacaftor/ivacaftor treatment

BackgroundElexacaftor/tezacaftor/ivacaftor (ETI) has improved the clinical status of individuals with cystic fibrosis (CF), however, whether ETI impacts glucose tolerance remains unknown. We aimed to study the change in glycated hemoglobin (HbA1c) and CF related diabetes (CFRD) status after initiation of ETI. MethodsWe included individuals ≥12 years treated with ETI in Denmark in a longitudinal observational study. HbA1c was measured at baseline, 3, 6, 9 and 12 months after treatment initiation. Change in HbA1c was assessed in mixed models adjusted for age, sex, glucose tolerance and prior CFTR modulator treatment. In a sub-population with CFRD, we assessed the change in insulin usage, hypoglycemic events and the 30-day continuous glucose monitoring (CGM) parameters (i.e., average blood glucose, time below (≤3.9 mM) and above (>10.0 mM) normal range, and the variation in glucose) after 12 months of treatment. ResultsAmong 321 individuals with CF, HbA1c declined by 2.1 mmol/mol [95 % confidence interval (CI): -2.6; -1.5 mmol/mol] after 3 months and by 2.3 mmol/mol [95 %CI: -2.8; -1.9 mmol/mol] after 12 months of ETI treatment. The decline was independent of glucose tolerance status at baseline. In 26 individuals with CFRD at baseline, the mean decline in HbA1c was 3.6 mmol/mol [95 %CI: -6.9; -0.4 mmol/mol] after 12 months, but we did not observe any change in insulin usage, weekly number of hypoglycemic events or CGM parameters. ConclusionIn the Danish CF cohort, HbA1c declined over 12 months of ETI treatment, however, among a subset with CFRD, we observed no change in insulin usage and CGM glucose levels.

Incidence and risk factors of prostate cancer among the Northern and Eastern parts of the United Arab Emirates population.

Prostate cancer (PCa) is a prevalent disease worldwide. However, the incidence and patient-specific risk factors of PCa in the Middle East, specifically in the United Arab Emirates,have not been previously reported. We conducted a retrospective cohort study on 2377 men diagnosed with either benign prostatic hyperplasia (BPH) or PCa in the Northern and Eastern regions of the United Arab Emirates, excluding the Western part, which includes Abu Dhabi. The study spanned from January 2012 and December 2021. To calculate the PCa incidence rate, we utilized the world age-standardized incidence rates (W-ASIR) categorized by age groups. Patient-specific risk factors of PCa were identified through a multivariate logistic regression analysis of clinical data. A total of 247 cases of PCa and 2130 cases of BPH were included in the study. In our cohort, the W-ASIR for PCa was 21.3 per 100,000 men. The incidence of PCa showed an increasing trend with age, with the highest incidence observed among men aged 70 years and older. Accordingly, multivariate analysis revealed that age over 70 was associated with an increased risk of PCa (OR: 2.546, 95% confidence interval [CI]: 1.892-3.425, p < 0.01). On the other hand, preexisting conditions such as hypertensionand diabetes mellituswere found to lower the risk of PCa (OR: 0.222, 95% CI: 0.163-0.302, p < 0.001) and (OR: 0.364, 95% CI: 0.205-0.648, p < 0.001), respectively. Additionally, metformin intake was associated with a reduced risk of PCa (OR: 0.385, 95% CI: 0.190-0.782, p = 0.008); while insulin usage increased the risk of PCa (OR: 2.586, 95% CI: 1.539-4.344, p < 0.001). Anti-BPH medications such as phosphodiesteraseinhibitors (OR: 0.223, 95% CI: 0.069-0.723, p = 0.012) or 5-α reductase (OR: 0.206, 95% CI: 0.110-0.389, p < 0.000), were found to lower the risk of PCa. The findings underscore the high incidence of PCa in the United Arab Emirates, with age being a significant factor. Furthermore, the study highlights the influence of certain comorbidities and medications on the risk of developing PCa within the United Arab Emiratespopulation.

Effect of exercise in incident atrial fibrillation among diabetes mellitus with different diabetes duration

Abstract Background/Introduction In previous studies, level of exercise and AF risk seems to have nonlinear relationship. Vigorous physical activities have been considered as a risk factor of atrial fibrillation (AF). However, other studies have shown regular exercise to be associated with reduced incidence, symptoms, recurrence, and burden of AF. Conversely, a sedentary lifestyle is an important risk factor for the development of AF. Currently, the effect of exercise amount on the risk of AF among patients with diabetes mellitus (DM) according to diabetes duration has not been examined. Purpose This study aimed to evaluate the effect of exercise amount on incident AF among patients with DM using a nationwide population cohort. Methods The subjects with type 2 DM who underwent the Korean National Health Insurance Service health examination during 2015 and 2016 were identified. The study population was divided into four groups according to DM duration (new onset, less than 5 years, 5 to 10 years, and more than 10 years). Also, they were categorized into four groups according to the amount of exercise (0, &amp;lt;500, 500 to 1000, 1000-1500, and ≥1500 METs-Min per week). The study outcome was incident AF. Results A total of 2,392,486 subjects with a mean follow-up duration of 3.9 ± 0.9 years were enrolled (mean age 59.3 ± 12.0, female 39.8%). The mean DM duration was 5.3 ± 5.1 years, and the mean exercise amount was 643.0 ± 638.0 METs-min/week. 704,732 subjects were new-onset DM, 649,811 subjects had less than 5 years of DM duration, 464,870 subjects had DM duration between 5 to 10 years, and 573,073 subjects had more than 10 years of DM. As the DM duration became longer, age, the prevalence of comorbidities (hypertension, chronic kidney disease, chronic heart failure, prior myocardial infarction, prior stroke, and prior peripheral artery disease), the prevalence of more than three oral anti-diabetes medications, and insulin usage increased sequentially (all p&amp;lt;0.0001). In each DM duration group, the exercise amount of AF risk showed slightly different relationship. The new-onset DM group and DM duration 5 to 10 years groups showed the most reduced AF risk in exercise amounts 1000 -1500 METs-Min/week (adjusted hazard ratio [HR] 0.98, 95% confidence interval [CI] 0.82-0.96 p=0.0016 and adjusted HR 0.83, 95% CI 0.77-0.89, p=0.0098, respectively). The DM duration less than 5 years and more than 10 years groups both showed the lowest risk in exercise ≥1500 METs-Min/week (adjusted HR 0.91, 95% CI 0.85-0.97; adjusted HR 0.85, 95% CI 0.81-0.90, both p&amp;lt;0.001). Conclusions Regular exercise of more than ≥1500 METs-Min/week did not increase the risk of AF risk in DM patients. It was associated with reduced AF risk in all DM patients except new-onset DM. Further study is needed to assess the biophysiological change regarding DM duration that could affect the AF risk.

Abstract 15190: Association of Initiating SGLT2i and GLP1Ra Therapeutics on Insulin Utilization and MACE Outcomes Among Patients With Diabetes in an Integrated Healthcare System

Background: Nearly 10% of US adults diagnosed with diabetes (DM) begin using insulin within 1 year (yr) of the diagnosis. A third of all patients (pts) with DM experience an atherosclerotic cardiovascular (CV) event. SGLT2is and GLP1Ras, have been shown to reduce major adverse CV events (MACE). Meta-analyses show a reduction in insulin utilization when these medications are initiated individually or concurrently. This study evaluated the real-world impact on MACE and insulin usage among pts with DM initiating SGLT2is and GLP1Ras. Methods: Intermountain pts (n=6,476) ≥18 years of age with ≥3 encounters and on insulin at time of initiation of SGLT2i, GLP1-RA, or combined therapy from January 1, 2012 to November 30, 2021 were studied. Pts were stratified by whether they stopped-insulin (st-in) within 90 days of having started SGLT2i, GLP1Ra, or both or continued-insulin (co-in). MACE was defined as death, MI, CVA, or HF hospitalization and was assessed at 1- and 3-yrs. Results: Of 6,476 pts, 93.3% (n=6,039) st-in and 6.7% (n=437) co-in. St-in pts had less comorbidities, but were older (58.2 vs. 55.0 years), male (55% vs. 48.5%), weighed less (105.5 vs. 110.7 kg), and included fewer pts with DM I (18.5% vs 38.4%). Renal function and hemoglobin A1C were similar. Compared to co-in, pts with st-in were prescribed SGLT2i (30.0% vs 20.4%) or combination (SGLT2i/GLP1Ra) (16.2% vs 11.2%) more often. St-in vs co-in had a higher frequency of MACE, which persisted after adjustment by risk factors, comorbidities, and medications (Table). Conclusion: In pts with DM on insulin, adding SGLT2i, GLP1Ra, or both led to a change in insulin utilization, with &gt;90% of pts stopping insulin entirely. However, we observed an increase in 1-yr and 3-yr MACE for st-in vs co-in pts. This suggests a need for caution when initiating these medications in those already on insulin with regards to insulin management, including a decision to discontinue insulin. More data are needed to further understand our observations.

Perception and attitude of type 2 diabetic patients toward insulin therapy in the primary care of National Guard for Health Affairs (NGHA) in Jeddah, Saudi Arabia.

Our study explores and determines the perception toward insulin among patients with diabetes in the National Guard for Health Affairs (NGHA), Jeddah, the Kingdom of Saudi Arabia (KSA), and aims to gain insight into the causes of refusal. Patients with type 2 diabetes (T2D) are likely to need the use of insulin to keep blood glucose levels within normal range and delay the onset of diabetes-related problems. Individuals with diabetes may be hesitant to begin insulin therapy if they have a negative attitude toward it, which might add to the delay in beginning treatment. A cross-sectional study was conducted in the primary healthcare centers of the NGHA in Jeddah, Saudi Arabia. Data were collected through a validated self-administered questionnaire that was divided into three sections, with a total of 32 questions. The first section concerned demographic data, the second part was directed toward insulin users, and the last section was directed toward non-insulin patients. Our study collected 314 responses. Males constituted 54.8% of participants and insulin users resembled 45.7%. According to our study, important deterrents to starting insulin therapy among non-insulin users included the following: the cost of insulin, the pain associated with injections, the difficulty in maintaining food control while on insulin treatment, scarring at the injection site, and the weight gain impact. Factors that were found to influence compliance to insulin therapy among insulin users included fear of weight gain and self-administration of insulin.

Metformin Cessation and Dementia Incidence.

Prior studies suggested that metformin may be associated with reduced dementia incidence, but associations may be confounded by disease severity and prescribing trends. Cessation of metformin therapy in people with diabetes typically occurs due to signs of kidney dysfunction but sometimes is due to less serious adverse effects associated with metformin. To investigate the association of terminating metformin treatment for reasons unrelated to kidney dysfunction with dementia incidence. This cohort study was conducted at Kaiser Permanente Northern California, a large integrated health care delivery system, among a cohort of metformin users born prior to 1955 without history of diagnosed kidney disease at metformin initiation. Dementia follow-up began with the implementation of electronic health records in 1996 and continued to 2020. Data were analyzed from November 2021 through September 2023. A total of 12 220 early terminators, individuals who stopped metformin with normal estimated glomerular filtration rate (eGFR), were compared with routine metformin users, who had not yet terminated metformin treatment or had terminated (with or without restarting) after their first abnormal eGFR measurement. Early terminators were matched with routine users of the same age and gender who had diabetes for the same duration. The outcome of interest was all-cause incident dementia. Follow-up for early terminators and their matched routine users was started at age of termination for the early terminator. Survival models adjusted for sociodemographic characteristics and comorbidities at the time of metformin termination (or matched age). Mediation models with HbA1c level and insulin usage 1 and 5 years after termination tested whether changes in blood glucose or insulin usage explained associations between early termination of metformin and dementia incidence. The final analytic sample consisted of 12 220 early terminators (5640 women [46.2%]; mean [SD] age at start of first metformin prescription, 59.4 [9.0] years) and 29 126 routine users (13 582 women [46.6%]; mean [SD] age at start of first metformin prescription, 61.1 [8.9] years). Early terminators had 1.21 times the hazard of dementia diagnosis compared with routine users (hazard ratio, 1.21; 95% CI, 1.12 to 1.30). In mediation analysis, contributions to this association by changes in HbA1c level or insulin use ranged from no contribution (0.00 years; 95% CI, -0.02 to 0.02 years) for insulin use at 5 years after termination to 0.07 years (95% CI, 0.02 to 0.13 years) for HbA1c level at 1 year after termination, suggesting that the association was largely independent of changes in HbA1c level and insulin usage. In this study, terminating metformin treatment was associated with increased dementia incidence. This finding may have important implications for clinical treatment of adults with diabetes and provides additional evidence that metformin is associated with reduced dementia risk.

THU266 Lowered HbA1c In Individuals With Long-term Type 1 Diabetes Undergoing BCG Bladder Cancer Therapy

Abstract Disclosure: H. Dias: None. W. Kühtreiber: None. D.L. Faustman: None. Originally developed for the prevention of tuberculosis, the bacillus Calmette-Guérin (BCG) vaccine has shown benefit in diverse human diseases, including infection resistance, allergies, multiple sclerosis and autoimmune diabetes. BCG has also been approved in the United States and Europe since 1972 for early-stage bladder cancer, where it is administered commonly as 6 doses via intravesical therapy for 6 weeks (“high-dose intravesical BCG”). We analyzed three large databases-the Management Science Associates database (with Quest Diagnostics data) (N=263 million adults), the Research Patient Data Registry (RPDR) from the Massachusetts General Brigham (MGB) system (N=6.5 million), and data from Optum Labs (OL)(N=45 million) -for a correlation between high-dose intravesical BCG and HbA1c levels in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D). We identified subjects with documented T1D (N=19) or T2D (N=106) undergoing BCG therapy for bladder cancer, and then retrospectively assessed BCG’s subsequent year-by-year impact on blood sugar trends. T1D records were identified by searching for T1D diagnosis and insulin usage; records showing any history of oral hypoglycemic agents (e.g., metformin) were excluded. T2D records were searched for using T2D diagnosis and exclusion of any T1D diagnosis. No patients had a history of BCG treatment/vaccination other than for bladder cancer. Patients with T1D in the datasets showed downward trends in HbA1c values after high-dose intravesical BCG, but not patients with T2D. The data suggests that high-dose intravesical BCG therapy may contribute towards a drop in HbA1c values in T1D, but not T2D. This is consistent with earlier interventional trials of the BCG vaccine in longstanding T1D. Presentation: Thursday, June 15, 2023

THU247 Characterizing Inpatient Cases Of DKA Precipitated By SGLT2 Inhibitor Use

Abstract Disclosure: A. Aslamy: None. R. Nazemi: Speaker; Self; Eli Lilly &amp; Company, AstraZeneca. C. Tseng: None. S. Kim: None. R. Gianchandani: None. Background: SGLT2 inhibitors are a unique class of anti-hyperglycemic medications that can increase the risk of DKA in patients with diabetes (1). The overall incidence of DKA precipitated by SGLT2 inhibitor use is estimated to be 0.1%, however, this is likely higher in practice with increasing usage of these medications for treatment of heart failure and renal dysfunction. Herein, we characterize inpatient admissions with SGLT2 inhibitor induced DKA to further understand associated risk factors. Clinical Case: Euglycemic and hyperglycemic DKA cases (n=7) over a four-month period were identified, all of whom had been on SGLT2 inhibitors for an average of 8.5 (± 5.4) months prior to presentation. Six patients had T2D and one patient had known T1D. The average patient age was 69 (±8) years. The average A1c was 9.2% (±1.9%). Patients on dapagliflozin (n=3) had significantly higher A1c on admission compared to those on empagliflozin (n=4) (p=0.017). Average glucose on presentation of the six T2D patients was 206.5 (± 55.61) mg/dL (euglycemic DKA range) while the T1D patient presented with glucose of 605 mg/dL. All seven patients had elevated anion gap (mean 25.5 ± 7.2mEq/L), low bicarbonate (mean 8.9 ± 4.1 mmol/L), pH less than 7.4, and evidence of either ketonemia or ketonuria. Five out of the seven cases had a concurrent infection, and the remaining two cases were readmissions after recent cardiac surgery. All patients were treated with intravenous/subcutaneous insulin and intravenous dextrose with resolution of DKA within 24 hours. SGLT2 inhibitors were immediately discontinued. Average length of stay was 9 (±6) days, and was higher in the postcardiac surgery patients. Notably, the type of SGLT2 inhibitor (dapagliflozin vs. empagliflozin), age, sex, A1c on presentation, number of comorbidities, presence of infection, prior insulin usage, duration of diabetes, and duration of SGLT2 use had no significant effect on length of stay. Conclusion: Clinical characteristics of SGLT2 inhibitor induced DKA cohort were older age, uncontrolled diabetes (A1c &amp;gt;7), and concurrent infections or recent major surgery. Resolution of DKA was quick and length of stay longer for major surgery. When placed on SGLT2 inhibitors, diabetes patients should be warned of these potential clinical scenarios that can increase their risk of DKA. Reference: (1) Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: Analysis of FAERS data. Diabetes Metab Res Rev. 2017 Nov; 33 Presentation: Thursday, June 15, 2023

SAT161 The Impact Of A Very Low-calorie Diet On Reversal Of Metabolic Disorders Among Indian Subjects: A Real World Clinic-based Study

Abstract Disclosure: N. Deshpande: None. N. Kapoor: None. Introduction: Reversal/remission of diabetes has been tested and well proven in the Caucasians. However, the Asian Indian phenotype is genetically and clinically distinct and there is a lack of robust data on this subject. Also, hitherto, the benefits of such an intervention have been reported only in a tightly monitored trial-based environment, but its efficacy from real-world data in busy clinical practices is lacking from the Indian subcontinent. In this study we aimed to study the impact of marked reduction of calorie intake on obesity indicators and diabetes related comorbidities in subjects of Indian ethnicity in a clinic-based cohort. Material and Methods: A 3-month structured Reversal Diet of 800-830 calories/day, comprising an inhouse packed commercially available meal replacement liquid formula, along with non-starchy veggies/soups/ diluted buttermilk, and fat replaced all 3 major meals. Clinical and biochemical metabolic parameters were assessed at baseline and at 3 months. Only those subjects who completed the 3-month assessment were included. Body composition was analyzed using bioimpedance with the INBODY 230 Analyser. Statistical analysis was undertaken using the SPSS 16·0 software package. This study was approved by the Institutional Review Board. Results: 374 subjects were included of which 117(31.2%) had type 2 Diabetes (T2DM). At baseline the mean (SD) age of the participants was 40.1(12.4) years and 333/374(89.1%) participants were women. There was significant improvement in body weight (85.4 Vs 77.7 Kg), BMI (32.6 Vs 29.8 kg/m2), Waist circumference (103.6 Vs 98.3 cm) and hip circumference (109.2 Vs 103.8 cm) at 3 months, compared to baseline. Body fat % changed from 41.9 to 37.6 and other anthropometric indicators (neck circumference, thigh circumference and arm circumference) were also significantly better after the intervention (P&amp;lt; .001). Among subjects with T2DM (31.2%), 40% had remission in diabetes, 28% of insulin users stopped insulin and about 30% stopped oral anti diabetic agents. Even among those who did not go into diabetes remission, Insulin was stopped in 29% and reduced in 38%, Oral Anti Diabetic agents reduced in 22%, blood pressure was normalized without medicines in 14% and NAFLD remission was attained in 41% of patients. Conclusion: A significant impact towards reversal of metabolic disorders was observed following a structured very low-calorie diet intervention, in this clinic-based cohort. Further follow-up studies are currently needed to provide long term evidence on the sustainability and long-term efficacy of such an intervention in the metabolically unique Indian population. Presentation: Saturday, June 17, 2023