Intensive Insulin Regimens Research Articles

The IDEAL (Insulin therapy DE-intensificAtion with iglarLixi) Randomised Controlled Trial-Study Design and Protocol.

Multiple daily injection insulin regimen (MDI) represents the most intensive insulin regimen used in the management of people with type 2 diabetes (PwT2D). Its efficacy regarding glycaemic control is counterbalanced by the increased risk of hypoglycaemia, frequently observed tendency to weight gain and necessity for frequent glucose monitoring. Recent introduction of novel antidiabetic medications with pleiotropic effects reaching far beyond the reduction of glycaemia (HbA1c), such as the glucagon-like peptide 1 receptor agonist (GLP-1 RA), has significantly widened the therapeutic options available for management of T2D. Consequently, there is currently asubstantial number of PwT2D for whom the MDI regimen was initiated at a time when no other options were available. Yet, in present times, these individuals could benefit from simplified insulin regimens ideally taking advantage of the beneficial effects of the novel classes of antidiabetic medications. iGlarLixi (Suliqua®) is a once-daily fixed-ratio combination of basal insulin analogue glargine 100U/ml and a GLP-1 RA lixisenatide. Insulin therapy DE-intensificAtion with iglarLixi (IDEAL) is a six-centre, open-label, parallel-group, active comparator, phase IV randomised controlled trial with a 24-week active treatment period examining the efficacy and safety of MDI regimen de-intensification with once-daily administration of iGlarLixi versus MDI regimen continuation in PwT2D on a backgroud therapy with metformin ± sodium-glucose cotransporter 2 inhibitor. The primary objective is to compare the effects of MDI therapy de-intensification with iGlarLixi versus MDI regimen continuation regarding glycaemic control (HbA1c). Secondary objectives include detailed evaluation of the effects of MDI regimen de-intensification with iGlarLixi on glycaemic control using standardised continuous glucose monitoring (CGM) metrics and self-monitoring of plasma glucose. Furthermore, body weight and body composition analysis, quality of life and safety profile are evaluated. ClinicalTrials.gov, identifier NCT04945070.

Effectiveness of Faster Aspart versus Insulin Aspart in Children with Type 1 Diabetes: A Meta-Analysis.

Intensive insulin regimens are recommended to achieve glycemic goals in children and adolescents with type 1 diabetes. Fast-acting insulin aspart (faster aspart) is a new formulation of insulin aspart (IAsp) in which L-arginine and niacinamide are added to assure formulation stability, early absorption, and ultra-fast action. This meta-analysis compares faster aspart with IAsp for blood sugar control in children with type 1 diabetes. This study suggested treating diabetes with insulin, especially in children with type 1 diabetes. PubMed, MEDLINE, Embase, Cochrane Library, Web of Science, and Google Scholar were searched from 2000 to 2023 without language restrictions. Blood glucose monitoring, HbA1c, care model, insulin aspart, IAsp, faster aspart, type 1 diabetes, and pediatrics are Mesh keywords. Cochrane Q statistics and index tested heterogeneity. To account for heterogeneity, Q=145.99 (P-value < 0.001) and =97.26%, and the random-effect model was used to aggregate primary study results. The meta-analysis of randomized-controlled trials was conducted in accordance with PRISMA standards. The overall estimate measure i.e. mean difference was found to be 5.44 [0.45, 10.44] and 7.71 [7.16, 8.26] which indicate significant reduction in the HbA1C level in the fast acting insulin aspart group as compared to the IAsp in T1D. However, the mean difference with respect to BMI was found to be -0.06 [-0.60, 0.48] which indicate non-significant reduction. Faster aspart had faster onset and more early exposure than IAsp in children and adolescents with greater and more variable anti-insulin antibody levels than adults did. Hence fast-acting insulin aspart may provide better glucose control than IAsp in T1D.

Evaluating Pharmacists' Time Collecting Self-Monitoring Blood Glucose Data.

Patients on intensive insulin regimens are encouraged to self-monitor blood glucose (SMBG) to optimize their therapy. Clinical pharmacist practitioners (CPPs) use SMBG data to adjust diabetes medications; however, collecting SMBG data from patients is seen anecdotally as time intensive. CPPs involved in diabetes management on primary care teams at the Boise Veterans Affairs Medical Center in Idaho were asked to estimate and record the following: SMBG data collection method, time spent collecting data, extra time spent documenting or formatting SMBG readings, total patient visit time, and visit type. For total patient visit time, pharmacists were asked to estimate only time spent discussing diabetes care and collecting SMBG data. Data were collected for 1 week using a standardized spreadsheet distributed to 24 CPPs. Eight pharmacists provided data from 120 patient encounters. For all encounters, the mean time spent collecting SMBG data was 3.3 minutes, and completing additional documentation/formatting was 1.3 minutes for a total of 4.6 minutes. Patient visits lasted a mean 20.1 minutes; 16% was spent on data collection and 6% on documentation and formatting. At the Boise Veterans Affairs Medical Center, CPPs spend relatively little time per patient collecting SMBG data for clinical use. However, this time can be substantial when multiplied over several patient encounters. Opportunities exist to increase efficiency in SMBG data collection and documentation.

A retrospective comparison between intensive and nonintensive insulin regimens in type 2 diabetes mellitus.

This study compared the outcomes between intensive and nonintensive insulin regimens and assessed the predictive factors for failing to achieve the glycated hemoglobin (A1C) goals in type-2-diabetes-mellitus (T2DM) patients requiring insulin therapy. A single-center, retrospective assessment of the medical records of 125 T2DM patients undergoing intensive (46 patients) and nonintensive insulin therapy (79 patients) were conducted. No significant differences were found when the intensive and nonintensive insulin therapy groups were compared in terms of the percentage decreases of glucose and A1C levels. The mean A1C levels of the nonintensive and intensive groups declined from 11.15% and 11.30% to 7.97% and 8.06%, respectively. Both intensive and nonintensive insulin therapies improved the baseline glycemic parameters but being overweight or obese and/or being reluctant to dietary recommendations led to treatment failures regardless of the insulin regimen.

Advantages and disadvantages of connected insulin pens in diabetes management.

Insulin administration remains vital to the treatment of diabetes and although there have been advances in insulin delivery, evidence suggests that many people with diabetes on insulin therapy have suboptimal glycemic management. Recent advancements in insulin administration techniques include connected insulin devices, such as connected insulin pens and pen caps. In this review, we provide an overview of the literature on the use of connected insulin pens and pen caps to further elucidate the clinical benefits and drawbacks of these devices. We discuss the development of these devices, outlining the characteristics of insulin pens and pen caps with regulatory approvals. These devices have different features that can ease the burden of diabetes management, including automatic recording of insulin dose information, tracking of insulin-on-board, bolus calculators, and missed dose alerts. Despite the advantages of connected pens and pen caps, a small percentage of insulin users are currently using these devices, due to many factors, including lack of health-care professional awareness, initial training for prescribers, and setup of the device. Overcoming these barriers and publishing more data demonstrating the glycemic outcomes associated with these systems could improve diabetes management for people living with diabetes. As health-care systems become increasingly digital, connected insulin pens have the potential to allow a data-driven approach to diabetes management for people who are not interested in, cannot afford, or do not have intensive insulin regimens that might warrant use of insulin pumps or automated insulin delivery systems.

Long-Term Benefits of an Integrated Continuous Glucose Monitoring and Insulin Pump System for Emergency Admissions, Hospitalization, and Metabolic Control in a Cohort of People With Diabetes: Retrospective Cohort Study.

There is evidence in the literature that the use of sensor-augmented insulin pumps in patients with high-complexity diabetes improves metabolic control. However, there is no long-term information on clinical outcomes such as hospitalization or admission to the emergency room. This study describes outcomes for metabolic control, incidence of hospitalizations, and emergency room visits in a specific population using this technology. We aimed to assess long-term glycemic and clinical outcomes after the use of continuous subcutaneous insulin infusion and continuous glucose monitoring in people with diabetes. A retrospective cohort study was carried out in patients with diabetes previously treated with an intensive insulin regimen at a specialized diabetes treatment center who required a sensor-augmented insulin pump due to nonoptimal glycemic control. Glycated hemoglobin, severe hypoglycemic episodes, nonsevere hypoglycemic episodes, perception of hypoglycemia, and the incidence of emergency room visits and hospitalizations before and after treatment were evaluated. Between January 2013 and August 2020, 74 patients with a median age of 36 (IQR 27-46) years were included in the study with a median 4 (IQR 2-7) years of follow-up. We found a statistically significant reduction in glycated hemoglobin (8.35% vs 7%; P<.001), nonsevere hypoglycemic episodes (71/74, 96% vs 62/74, 84%; P=.01), emergency room visits (42/73, 58% vs 4/62, 6%; P<.001), and hospitalizations (36/72, 50% vs 10/72, 14%; P<.001) after use of continuous subcutaneous insulin infusion. The use of a sensor-augmented insulin pump associated with a strict follow-up program for patients with high-complexity diabetes led to a significant and sustained reduction in glycated hemoglobin and hypoglycemic episodes, as well as in the rate of emergency room visits and hospitalizations. These results encourage the adoption of this technology in patients who do not achieve metabolic control with optimal management of diabetes.

Coverage for Continuous Glucose Monitoring for Individuals with Type 2 Diabetes Treated with Nonintensive Therapies: An Evidence-Based Approach to Policymaking.

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and public insurers. Moreover, recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. However, despite increasing evidence supporting CGM use for individuals treated with less-intensive insulin therapy or noninsulin medications, insurance coverage is limited or nonexistent. This narrative review reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in T2D individuals treated with basal insulin only and/or noninsulin therapies and presents an evidence-based rationale for expanding access to CGM within this population.

Rates and Correlates of Uptake of Continuous Glucose Monitors Among Adults with Type 2 Diabetes in Primary Care and Endocrinology Settings.

Clinical trials indicate continuous glucose monitor (CGM) use may benefit adults with type 2 diabetes, but CGM rates and correlates in real-world care settings are unknown. We sought to ascertain prevalence and correlates of CGM use and to examine rates of new CGM prescriptions across clinic types and medication regimens. Retrospective cohort using electronic health records in a large academic medical center in the Southeastern US. Adults with type 2 diabetes and a primary care or endocrinology visit during 2021. Age, gender, race, ethnicity, insurance, clinic type, insulin regimen, hemoglobin A1c values, CGM prescriptions, and prescribing clinic type. Among 30,585 adults with type 2 diabetes, 13% had used a CGM. CGM users were younger and more had private health insurance (p < .05) as compared to non-users; 72% of CGM users had an intensive insulin regimen, but 12% were not taking insulin. CGM users had higher hemoglobin A1c values (both most recent and most proximal to the first CGM prescription) than non-users. CGM users were more likely to receive endocrinology care than non-users, but 23% had only primary care visits in 2021. For each month in 2021, a mean of 90.5 (SD 12.5) people started using CGM. From 2020 to 2021, monthly rates of CGM prescriptions to new users grew 36% overall, but 125% in primary care. Most starting CGM in endocrinology had an intensive insulin regimen (82% vs. 49% starting in primary care), whereas 28% starting CGM in primary care were not using insulin (vs. 5% in endocrinology). CGM uptake for type 2 diabetes is increasing rapidly, with most growth in primary care. These trends present opportunities for healthcare system adaptations to support CGM use and related workflows in primary care to support growth in uptake.

Use of Flash Glucose Monitoring and Glycemic Control in Patients with Type2 Diabetes Mellitus Not Treated with an Intensive Insulin Regimen: 1-Year Real-Life Retrospective Cohort Study.

Estimation of laboratory-derived glycated hemoglobin (HbA1c) cannot be individually used to monitor clinically significant trends in glucose variability. Hence, clinicians advise use of continuous glucose monitoring (CGM) devices such as the Freestyle Libre™ flash glucose monitoring system (FLASH) to optimize glycemic control by estimating glucose monitoring index (GMI) values, which convert mean glucose into an estimate of simultaneously measured laboratory HbA1c. This study aimed to investigate the sustainability of intermittently scanned continuous glucose monitoring (isCGM) in patients with type2 diabetes mellitus (T2DM) not on intensive insulin regimen, and correlations between GMI values obtained from isCGM and laboratory-derived HbA1c values. A retrospective review of 93 patients with T2DM not on intensive insulin regimen, using FLASH device, was conducted at a major tertiary hospital in Saudi Arabia, over 1year of continuous device use. To determine the sustainability of isCGM, various glycemic markers such as average glucose and time in range were evaluated. Paired ttest or Wilcoxon signed-rank test was used to assess differences in markers of glycemic control, and Pearson's correlation was used to determine correlations between HbA1c and GMI values. Descriptive analysis shows the mean HbA1c value significantly decreased following continued use of isCGM. Pre-isCGM mean HbA1c value of 8.3% improved to 8.1% (p < 0.001) and 7.9% (p < 0.001) in the first 90 and last 90days of device use, respectively. For both 90-day time periods, correlation analysis revealed a statistically significant positive correlation and linear regression between laboratory-derived HbA1c and GMI values (first 90days r = 0.7999, p < 0.001; last 90days r = 0.6651, p < 0.001). Continuous use of isCGM demonstrated reductions in HbA1c levels for patients with T2DM not on an intensive insulin regimen. The GMI values showed high levels of agreement with measured HbA1c, indicating their accuracy in glucose management.

Twice-daily injections and multiple daily injections of insulin in toddlers with type 1 diabetes: a retrospective cohort study.

Twice-daily injections and multiple daily injections of insulin in toddlers with type 1 diabetes: a retrospective cohort study.

Use of insulin degludec/aspart after resolution of euglycemic diabetic ketoacidosis associated with dapagliflozin in a female patient with newly diagnosed maturity onset diabetes of the young type 3

Abstract Introduction Maturity-onset diabetes of the young (MODY) is a monogenic disorder characterized by beta cell dysfunction. MODY presents generally at a young onset, and usually does not prone to ketosis. MODY should be distinguished from type 1(T1D) or type 2 diabetes(T2D), because the treatment modalities may be different. In this case, we aimed to emphasize the successful use of insulin degludec/aspart (IDegAsp) after resolution euglycemic diabetic ketoacidosis (euDKA) in a patient latterly diagnosed with MODY. Clinical Case A 39-year-old female patient was referred to our clinic with severe hyperglycemia. SMBG results revealed that blood glucose levels were about 300–400 mg/dL indicating severe hyperglycemia. She has been followed up for T2D 15 years and had been taking oral antidiabetic regimen until 6 months ago. Insulin glargine was prescribed 6 months ago, but she gave up insulin and had been taking linagliptin 5 mg/day and dapagliflozin 10 mg/day. The previous history was remarkable for arrhythmia which was treated with ablation 15 years ago. Maternal history of T2D was present. On physical examination, heart rate was 100/min, and systemic examination findings were in normal range except for central obesity. Laboratory evaluation revealed that fasting blood glucose was 212 mg/dL, HbA1c 10.2%, creatinine 1.1 mg/dL, and ketone 3+ in urinalysis. Arterial blood gas analysis revealed mild acidosis (pH 7.25, HCO3 18 mmol/L). The patient was hospitalized with a diagnosis of euDKA. Intravenous hydration with 0.9% NaCL and regular insulin was administered, and oral antidiabetic medications were stopped. In the follow-up, intensive insulin regimen (preprandial insulin glulisine 3×5 unit and basal insulin glargine 1×15 unit) was given after the resolution of euDKA. Although dose adjustments, two attacks of near-hypoglycemia (71 and 77 mg/dL) were detected in the first week after resolution of euDKA. IDegAsp (premeal 2×12 unit) was substituted for glargine and glulisine. Due to the maintenance of glycemic regulation by oral antidiabetic regimen for a long period, and the existence of maternal history of T2D, genetic analysis was performed with a pre-diagnosis of MODY. To exclude T1D, we demonstrated that autoantibodies (islet cell antibody 5.01 U/mL, and Anti-GAD antibody 7.74 IU/mL) for T1D were negative. HNF1A heterozygous mutation was detected, and MODY type 3 was diagnosed. HbA1c level was gradually regressed to 8.8%, and then to 6.3%. By the diagnosis of MODY type 3, gliclazide treatment was considered. Basal fasting C-peptide level was measured as 1.22 ng/mL. The antidiabetic regimen was revised as linagliptin 5 mg/day and gliclazide 30 mg/day, and insulin was stopped. Conclusion Some types of MODY is associated with mild hyperglycemia, however some others necessitate insulin treatment. The number of reports regarding the use of IDegAsp in MODY is limited. We reached HbA1c target with IDegAsp in a patient with MODY type 3 after resolution of euDKA.

PSUN264 Insulin Edema: A rare side effect of Intensive Insulin Therapy

Abstract Insulin therapy associated generalized edema is a rare entity. The true incidence is unknown. It has been reported mostly in patients with poorly controlled diabetes mellitus started on intensive insulin regimens. The severity ranges from mild lower extremity swelling to anasarca. Management is primarily supportive with salt restrictions, diuretics and if possible, reduction of insulin doses. We present a case of a 39-year-old African American woman who developed generalized edema after initiation of insulin. She had history of gestational diabetes and presented to the endocrinology clinic to establish care after being hospitalized with Diabetic Ketoacidosis (DKA). She was diagnosed with diabetes mellitus initially during her pregnancy two years prior and was treated with insulin. After pregnancy, she was lost to follow up. She was then admitted to the hospital with severe DKA and was discharged on multiple daily injections of insulin. On the initial encounter in clinic, the patient endorsed developing abdominal distension and lower extremity swelling with insulin use previously so she was not using insulin consistently. Her physical examination was unremarkable. Lab work was significant for hemoglobin A1C of &amp;gt;15%, C-peptide 0.9 ng/mL (1.1-4.4 ng/mL), islet cell antibody 0.09 nmol/L (&amp;lt;0.02 nmol/L), glutamic acid decarboxylase antibody 0.40 nmol/L (&amp;lt;0.02 nmol/L). Her kidney and liver function were normal. She had normal thyroid function and cortisol levels. Her echocardiogram revealed normal cardiac function and she had non proliferative diabetic retinopathy on retinal exam. The patient was started on insulin and a continuous glucose monitor was placed to assess her glycemic patterns. Three days after starting insulin, she developed generalized body swelling involving face, abdomen, and lower extremities. The patient was advised to cut back on salt and started on low dose furosemide. On follow up one month later, her abdominal swelling had improved however she still had pitting lower extremity edema. On follow up two months later the edema completely resolved. Clinicians should be aware of the presentation and management of insulin induced edema. In most of the cases in literature, insulin induced edema started after starting insulin in newly diagnosed Type 1 diabetes or uncontrolled Type 2 diabetes. The pathophysiology is unclear. There is some evidence that insulin deficiency causes a catabolic state and hyperglycemia increases tissue capillary permeability. Re-introduction of insulin causes free water retention and renal excretion of sodium. This along with increased capillary permeability can lead to insulin edema. Water retention caused by the effect of counter regulatory hormones can also play a role. Insulin edema needs to be differentiated from other causes of diffuse edema. Management is generally supportive including temporarily decreasing insulin doses, salt restriction and diuretics as needed. Patient reassurance is important as well to aid in adherence to the prescribed insulin regimen. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

ODP604 | LBSUN287 Ketosis-prone Type 2 Diabetes (Flatbush Diabetes) In Remission: Report Of Two Cases

Abstract Diabetic ketoacidosis (DKA) is a triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration1. Diabetic ketoacidosis (DKA) is a well-known manifestation of Type 1 diabetes2; however, there has been an increase in the incidence of DKA as the first presentation in Type 2 diabetes. This subtype of diabetes is typically seen in non-Caucasian middle-aged obese males due to non-autoimmune disruption of glucose metabolism, which requires an initial intensive insulin regimen. After initial insulin treatment for several weeks to several months, a significant percentage of people can become insulin independent with an oral hypoglycemic agent(OHA) and /or just lifestyle modification, and in remission for many years3. This hybrid form of diabetes sharing the characteristics of T1DM and T2DM is called "Flatbush diabetes", also known as "ketosis-prone T2DM4 5. This article aims to emphasize the importance of early recognition of this heterogeneous syndrome through the two representative case reports of Ketosis-prone T2DM. Case presentation We describe two cases of African American men (elderly and young adult) with no past medical histories, who presented to the Emergency Department with a few days history of polyphagia, polydipsia, polyuria and fatigue. New onset of Type 2 diabetes and unprovoked DKA were diagnosed. Both of them received standard treatment with intravenous fluid and insulin drip, recovered uneventfully and discharged with insulin. Both of them followed up closely in our endocrinology clinic, their GAD antibodies were 0. 00(n&amp;lt;=0. 02nmol/L), Islet cell antibody&amp;lt;1: 4(n&amp;lt;1: 4) and C-peptide were 2.6ng/mL and 6ng/mL(1.1-4.4ng/mL) respectively. Their insulin was gradually withdrawn with the addition of an oral hypoglycemic agent. Both the patients are currently insulin independent for more than 15 months. Conclusion This is an important clinical entity to recognize ketosis-prone T2DM as insulin independence positively impacts quality of life and decreases economic burden on the health care system. For patients with suspected ketosis-prone T2DM, B-cell autoantibodies and C-peptide level should be obtained 1-3 weeks at the first outpatient visit, as it can predict patients’ prognosis. These patients should also be referred to an endocrinologist and need careful follow-up. Among all ketosis-prone T2DM patients, those with preserved B-cell function are more likely to be insulin independent and go into remission phase. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

970-P: Management of Diabetes after Hospitalization for COVID-Infection

COVID-infection and its treatment can markedly worsen hyperglycemia. Conversely, patients with diabetes who contract SARS CoV-2 are at increased risk of morbidity and mortality, and their management post-hospital stay can be challenging. The aim of this study was to describe a comprehensive and effective approach for monitoring and treating glucose levels in COVID-patients after hospitalization. Over a period of nine months, 37 patients (13 females and 24 males, average age 64 years) were treated, with 18 having a previously known history of diabetes. All patients received therapy with multiple daily injections of insulin and started on personal continuous glucose monitoring (CGM) for use at home. The patients were evaluated every 2-4 weeks via in-person and telehealth visits. During and in between these visits, the outpatient insulin regimen was adjusted by electronic portal communication and remote data upload via software and individual CGM accounts. Ten patients were on basal insulin, while 27 were on multiple daily insulin injections. At a mean follow-up of 4 months post-discharge, the average hemoglobin A1c decreased from 10.3% to 6.9%, an impressive change of 3.4% (p&amp;lt;0.05) . The average time-in-range (TIR) , a key metric used with CGM, increased from 53% at first post-hospital visit, to 74% at 4 months. In conclusion, patients requiring hospital care after being diagnosed with acute COVID-infection manifest with significant exacerbation of hyperglycemia, and in many cases, new-onset diabetes. Most patients require intensive insulin regimens for diabetes control, often in concert with CGM use; this approach can effectively lower A1c and TIR. It is imperative that patients be provided close follow-up and support by maintaining contact on an ongoing basis. Disclosure A.A.Rizvi: None.

Deprescribing in type 2 diabetes and cardiovascular disease: Recommendations for safe and effective initiation of glucagon-like peptide-1 receptor agonists in patients on insulin therapy

Select glucagon-like peptide-1 (GLP-1) receptor agonists have demonstrated cardiovascular benefits in both primary and secondary prevention populations and are recommended in multiple guidelines for cardiovascular risk reduction in people with type 2 diabetes (T2D). Despite this, uptake of GLP-1 receptor agonists in clinical practice has been lagging. While the etiology of their underuse is multifactorial, lack of comfortability in adding a GLP-1 receptor agonist to established insulin regimens is a common barrier. Adjustments to basal and bolus insulin doses upon initiation of GLP-1 receptor agonists in trials have varied. When recommending empiric dose adjustments during initiation of GLP-1 receptors agonists, the most recent A1C and the current blood glucose levels, if available, should be taken into consideration. When initiating in a person being managed with basal-only insulin regimens, an empiric 20 % dose reduction is recommended if the baseline A1C is ≤8 %. For individuals using intensive insulin regimens, empiric dose reductions of up to 25 % in basal and 50 % in bolus therapy were implemented and summarized further in this review. Overall, initiation of GLP-1 receptor agonists can decrease insulin requirements and may permit deintensification of antihyperglycemic therapy through the reduction or discontinuation of bolus insulin therapy. As a result, this simplified regimen promotes increased adherence, reduces glycemic variability and hypoglycemia, and improves overall glycemic management and quality of life. This review aims to serve as a guide for clinicians to facilitate the initiation of GLP-1 receptor agonists and deintensification of insulin by providing suggested dose adjustments based on available literature.

Effects of dapagliflozin on postprandial lipid metabolism in type 2 diabetes mellitus.

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) modulate lipid metabolism and improve cardiovascular morbidity and mortality in patients with type 2 diabetes mellitus (T2DM). The exact cardioprotective mechanism of SGLT2i is unclear. We evaluated the effects of SGLT2i on postprandial lipids, lipoprotein concentrations, glucose and fatty acids. A placebo-controlled randomized, proof-of-concept study. Fourteen male patients with T2DM on intensive insulin regimen were randomly and double-blind allocated to 12 weeks dapagliflozin (10 mg) or placebo. Postprandial effects were assessed with an 8-h standardized oral fat loading test. Mean glycated A1c did not change by dapagliflozin, but the mean daily insulin dose was significantly reduced. Although dapagliflozin did not affect fasting or postprandial levels of glucose and insulin, it increased the postprandial levels of glucagon. While fasting levels of free fatty acids and beta-hydroxybutyrate (bHBA) were unchanged, dapagliflozin significantly increased the postprandial bHBA response. This was seen in the context of increased postprandial glucagon levels by dapagliflozin, without influencing postprandial insulin or glucose levels. Dapagliflozin did not affect fasting or postprandial plasma cholesterol and triglycerides nor postprandial inflammatory markers. Fasting apolipoprotein B48 was decreased without affecting the postprandial response. Markers of inflammation and vascular function did not change. Treatment with dapagliflozin of patients with T2DM led to a reduction of fasting chylomicron remnants and increased postprandial ketone bodies compared to placebo suggesting enhanced hepatic fatty acid oxidation. The latter may have been caused by decreasing the insulin-glucagon ratio. The beneficial clinical effects seen in the trials using dapagliflozin most likely are not due to effects on postprandial inflammation nor postprandial lipemia.

Management of Type 1 Diabetes in Children in the Outpatient Setting.

Management of Type 1 Diabetes in Children in the Outpatient Setting.

Health Care Disparities in Use of Continuous Glucose Monitoring.

Numerous studies have demonstrated that use of continuous glucose monitoring (CGM) improves glycemic control and reduces diabetes-related hospitalizations and emergency room service utilization in individuals with diabetes who are treated with intensive insulin regimens. Recent studies have revealed disparities in use of CGM within racially and ethnically diverse and lower socioeconomic populations, leading to underutilization of CGM in these populations. This article reviews the scope and impact of these disparities on utilization of CGM and explores the factors that may be contributing to this issue.

77-LB: A Retrospective Analysis of the Association between HbA1c and Continuous Glucose Monitor Use for U.S. Patients with Type 2 Diabetes

Background: Use of real-time continuous glucose monitoring (rtCGM) reduces HbA1c in individuals with type 2 diabetes (T2D) treated with intensive insulin regimens in randomized clinical trials. However, the effects of CGM use on glycemia in T2D patients in real world settings, particularly those treated with less intensive therapies, has not been well studied. Materials and Methods: This large retrospective, observational analysis utilized data from the Optum Research Database (ORD) to assess the glycemic effects of CGM use (any CGM or real-time CGM [rtCGM]) compared with self-monitoring of blood glucoses (SMBG) within a large T2D population treated with intensive insulin therapy (IIT) and non-intensive therapies (NIT), including basal insulin only, and non-insulin medications. Outcomes were changes from baseline in HbA1c up to 6 months post index date in all patients and by treatment regimen. The percentage of patients who achieved ≥1.0 HbA1c reductions was also assessed. Results: Data from 82,983 eligible patients were assessed (Any CGM, n=1,406; rtCGM, n=148; SMBG, n=81,575). Significant HbA1c reductions were observed with Any CGM (-0.46) and rtCGM (-0.72) vs. SMBG (-0.09), ps &amp;lt; 0.001. HbA1c reductions were significant in CGM vs. SMBG users in the ITT (Any CGM, -0.38%; rtCGM, -0.68%, ps&amp;lt;0.001) and NIT groups (Any CGM, -0.67%, p&amp;lt;0.001, and rtCGM, -0.87, p=0.008). Significantly higher percentages of Any CGM and rtCGM vs. SMBG users achieved ≥1.0 HbA1c reductions in the IIT and NIT groups. Effects of Any CGM and rtCGM were attenuated but remained statistically significant in multivariate adjusted models for the overall T2D cohort. Conclusions: Use of CGM (Any CGM or rtCGM) confers notable benefits in improving glycemic control regardless of therapy regimen. These findings support expanding CGM access to the broader T2D population. Disclosure G. J. Norman: Employee; Self; Dexcom, Inc. M. L. Paudel: None. T. Bancroft: None. P. M. Lynch: Employee; Self; Dexcom, Inc.

Bone Breaking Triglycerides

A 40 yo African American female with pmhx of T2DM, DLD was admitted for worsening leg and arm pain that started a year prior but had worsened in the last 6 months. Pain started in the right arm and progressed to include the right leg and left leg. She had presented to the ER 3 times in the last 3 weeks with no diagnosis and prescribed anti-inflammatories. On ROS she had unintended weight loss of 50 lbs. Pain was not relieved with anti-inflammatories or narcotics. She was diagnosed with diabetes in the previous 5 years and had not been compliant with her medications. Plain x-rays showed OA of the hip. An osseus survey showed multiple expansile, bubbly, and lucent intramedullary lesions consistent with polyostotic fibrous dysplasia versus multiple myeloma. CT showed a radiolucent lesion of the left femur with absence of normal bone trabeculae. Her labs showed normal calcium, phosphorous, renal function, PTH and no evidence of monoclonal gammopathy. Vitamin D was low at 8.2 ng/ml (6.6–49 ng/ml). CT CAP showed no concern for malignancy in other organs. A lipid profile was done and showed elevated fasting triglycerides of 2617 mg/dL (<150 mg/dl) and LDL direct 54 mg/dl (<100 mg/dl). A1c was 11.2% on admission. She denied any use of alcohol, estrogens, SSRI’s. No history of pancreatitis. On physical exam she did not have tendinous xanthomas, eruptive xanthomas, palmar xanthomas, or lipemia retinalis. Family history not significant for lipid disorders. Patient was fasted for 24 hours and then started on intensive insulin regimen as well as fenofibrate for hypertriglyceridemia. Triglycerides came down to less than 500 over 7 days. She was evaluated by ortho for her bone lesions and underwent bone lesion biopsy as well as prophylactic IMN of her bilateral femurs for prevention of impending fragility fractures. Bone biopsy was significant for xanthoma of the bone. Following discharge, she remained on fenofibrate and fish oil as well as a basal/bolus insulin regimen. Triglycerides remained controlled. She has not followed up outpatient for further workup. This case highlights an atypical presentation of triglyceride deposition in the setting of hypertriglyceridemia. It shows that hypertriglyceridemia should be included in the differential for lytic lesions when preliminary workup is negative. It also highlights that complications other than pancreatitis and cardiovascular disease can significantly alter a patient’s life if triglycerides go untreated.