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Kensara RE, Ismail S, Aseeri M, Hasan H, Al Rahimi J, Zarif H, El Khansa S. The impact of the implementation of computerized insulin order sets for the control of hyperglycemia in hospitalized cardiac patients. Cardiovasc Endocrinol Metab 2024; 13:e02961. [PMID: 38116231 PMCID: PMC10727652 DOI: 10.1097/xce.0000000000000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/23/2023] [Indexed: 12/21/2023]
Abstract
Background Glycemic control is crucial in managing hospitalized patients with type II diabetes (T2DM), and it presents as a clinical challenge in the cardiac population. Therefore, we aimed to evaluate the impact of computerized insulin order sets in T2DM hospitalized cardiac patients. Methods A quasi-experimental, pre- and post-study design. We included T2DM patients who were hospitalized for at least 3 days. Patients undergoing cardiac surgery were excluded. The primary endpoint was the mean difference in random blood glucose level (BGL) before and after the implementation of insulin order sets. While the secondary endpoints were to compare the median differences in fasting BGLs and the number of hyperglycemic and hypoglycemic episodes during the first 7 days. The study consisted of three phases: pre-implementation, intervention and post-phase. In the intervention phase, insulin order sets were integrated into the electronic prescribing system, and education was provided to the cardiology department. The post-phase included the patient's post-implementations. Results A total of 194 patients were enrolled during the study period. The mean random BGL was 11.17 mmol/L, 95% CI, 10.6-11.7 in the pre-phase and 9.5 mmol/L, 95% CI, 9-1 -9.9 mmol/L in the post-phase (P < 0.001). The median fasting BGL was 9.2 mmol/L (7.4-11.8, IQR) in the pre-phase and 8.5 mmol/L (6.6-10.3, IQR) in the post-phase (P = 0.027). The number of hypoglycemic episodes was 24 in pre-phase and 33 in post-phase (P = 0.13). Conclusion The use of computerized insulin order sets was associated with potential improvements in random and fasting glycemic control without increasing the risk of hyperglycemia or hypoglycemia.
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Affiliation(s)
- Raed Ehsan Kensara
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
| | - Sherin Ismail
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA
| | - Mohammed Aseeri
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
| | - Hani Hasan
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
| | - Jamilah Al Rahimi
- King Abdullah International Medical Research Center, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
- Department of Cardiac Sciences, Ministry of National Guard-Health Affairs
| | - Hawazen Zarif
- King Abdullah International Medical Research Center, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences
- Department of Medicine, Ministry of National Guard-Health Affairs, Jeddah, Saudi Arabia
| | - Sara El Khansa
- Pharmaceutical Care Department, Ministry of the National Guard-Health Affairs, Jeddah
- King Abdullah International Medical Research Center, Saudi Arabia
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Wang SH, Shao W, Jiang QH, Zheng XL, Shen QB, Lin XY, Zhang QQ, Zhang LL, Shi XL, Wang WG, Li XJ. Risk Factors for Glycemic Control in Hospitalized Patients with Type 2 Diabetes Receiving Continuous Subcutaneous Insulin Infusion Therapy. Diabetes Ther 2023; 14:167-178. [PMID: 36454378 PMCID: PMC9880112 DOI: 10.1007/s13300-022-01342-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Patients with diabetes are confronted with numerous obstacles to achieve adequate glycemic control during hospitalization. The aim of this study was to explore the risk factors associated with glycemic control in hospitalized patients with type 2 diabetes mellitus (T2DM) treated with continuous subcutaneous insulin infusion (CSII). METHODS This cross-sectional study included 5223 patients hospitalized with T2DM in a tertiary hospital in Xiamen (China) between January 2017 and December 2019. All patients were managed according to established protocols for glycemic monitoring and insulin pump treatment regimens. Demographic information and clinical profiles were collected from electronic health records. Multiple linear regression analysis was used to identify the risk factors associated with glycemic control. RESULTS Among the 5223 hospitalized patients with T2DM receiving CSII therapy, 55.2% achieved their ideal blood glucose level (3.9-10.0 mmol/L), 44.5% experienced hyperglycemia (> 10.0 mmol/L), and 0.3% experienced hypoglycemia (< 3.9 mmol/L) during their hospitalization. Multivariate analyses showed that among inpatients with T2DM, older age, male gender, higher low-density lipoprotein-cholesterol (LDL-C) level, lower C-peptide (C-P) level, lower body mass index (BMI), longer duration of diabetes, previous insulin prescriptions, nephropathy, and retinopathy were factors more likely to be associated with a blood glucose level in the hyperglycemic range (P < 0.05). We also observed that among hospitalized patients with T2DM, those with lower BMI, lower C-P, lower LDL-C, longer disease duration, and previous insulin prescriptions were more likely to correlate with a higher proportion of hypoglycemia range (all P < 0.05). CONCLUSION Older age, male gender, lower BMI, lower C-P, higher LDL-C, previous insulin prescriptions, longer duration of diabetes, nephropathy, and retinopathy may be risk factors for a higher proportion of hyperglycemic events in hospitalized patients with T2DM under CSII therapy. Furthermore, lower BMI, lower C-P, lower LDL-C, longer duration of diabetes, and previous insulin prescriptions were found to be important factors for a higher proportion of hypoglycemic events. Evaluating the clinical features, comorbidities, and complications of hospitalized patients is essential to achieve reasonable glycemic control.
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Affiliation(s)
- Shun-Hua Wang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Wei Shao
- Xinglin Branch, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Qiu-Hui Jiang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
- The Third Clinical Medical College of Fujian Medical University, Fujian, China
| | - Xuan-Ling Zheng
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Qing-Bao Shen
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Xiao-Yan Lin
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Qiao-Qing Zhang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Lu-Lu Zhang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Xiu-Lin Shi
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Wen-Gui Wang
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China.
| | - Xue-Jun Li
- Department of Endocrinology and Diabetes, Xiamen Diabetes Institute, Xiamen Clinical Medical Center for Endocrine and Metabolic Diseases, Xiamen Diabetes Prevention and Treatment Center, Fujian Key Laboratory of Diabetes Translational Medicine, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China.
- The Third Clinical Medical College of Fujian Medical University, Fujian, China.
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Wendt A, Eliasson L. Pancreatic alpha cells and glucagon secretion: Novel functions and targets in glucose homeostasis. Curr Opin Pharmacol 2022; 63:102199. [PMID: 35245797 DOI: 10.1016/j.coph.2022.102199] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/25/2022] [Accepted: 01/31/2022] [Indexed: 11/16/2022]
Abstract
Diabetes is the result of dysregulation of both insulin and glucagon. Still, insulin has attracted much more attention than glucagon. Glucagon is released from alpha cells in the islets of Langerhans in response to low glucose and certain amino acids. Drugs with the primary aim of targeting glucagon signalling are scarce. However, glucagon is often administered to counteract severe hypoglycaemia, and commonly used diabetes medications such as GLP-1 analogues, sulfonylureas and SGLT2-inhibitors also affect alpha cells. Indeed, there are physiological and developmental similarities between the alpha cell and the insulin-secreting beta cell and new data confirm that alpha cells can be converted into insulin-secreting cells. These aspects and attributes, the need to find novel therapies targeting the alpha cell and more are considered in this review.
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Affiliation(s)
- Anna Wendt
- Islet Cell Exocytosis, Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Clinical Research Centre, SUS, Malmö, Sweden
| | - Lena Eliasson
- Islet Cell Exocytosis, Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Clinical Research Centre, SUS, Malmö, Sweden.
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Kant R, Yadav P, Pratti M, Barnwal S. Hypoglycemia: Elucidating its circadian propensity and recovery time based on clinical parameters. CASPIAN JOURNAL OF INTERNAL MEDICINE 2022; 13:29-37. [PMID: 35178205 PMCID: PMC8797821 DOI: 10.22088/cjim.13.1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 10/31/2022]
Abstract
BACKGROUND Hypoglycemia is frequently associated with insulin therapy in diabetic patients; it leads to many short and long-term complications and even death if not addressed in time. This study was undertaken to observe the circadian propensity of hypoglycemia and its recovery time based on type 2 diabetes mellitus patients' clinical parameters. METHODS We included type 2 diabetes mellitus (DM) hospitalized patients with the exclusion of patients suffering from critical illness. Data were collected for a period of three months (September to November 2019). RESULTS A total of 120 patients were included, comprising 60% males and 40% females. Approximately 55% of patients had hypoglycemic episodes at around 12 am- 6 am. The most common comorbidity present in these patients was hypertension (43.3%, P=0.931). Anemia (OR-3.765, CI-1.350-5.500, P=0.011), retinopathy (OR 6.066, CI-2.031-8.113, P=0.001), and duration of DM (OR-6.266, CI-2.209-7.774, P=0.001) were significantly associated with the recovery time of hypoglycemia, around 50±14.14min in the elderly population of age 60-70. People with BMI 22.5- 27.5 Kg/m2 took around 45.66 ± 19.37 min to recover after treatment. CONCLUSION Time taken to recover from hypoglycemic episodes vary with age and BMI. Associated comorbidities such as anemia, retinopathy, and DM duration had a significant bearing on the time taken to recover from hypoglycemia. Recovery time was directly proportional to BMI, a new finding that needs further molecular level evaluation. Circadian propensity of hypoglycemia in these patients have been identified in the early morning hours of the day.
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Affiliation(s)
- Ravi Kant
- Department of Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Poonam Yadav
- Center of Excellence in Nursing Education and Research, All India Institute of Medical Sciences, Rishikesh, India
| | - Madhuri Pratti
- Department of Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Shruti Barnwal
- Department of Dermatology, Govt. Doon Medical College, Dehradun, India
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Boeder S, Kulasa K. Hospital care: improving outcomes in type 1 diabetes. Curr Opin Endocrinol Diabetes Obes 2021; 28:14-20. [PMID: 33315629 DOI: 10.1097/med.0000000000000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Caring for patients with type 1 diabetes (T1D) in the hospital presents unique challenges. This review provides an update on significant issues relevant to the inpatient management of T1D. Topics include trends in diabetic ketoacidosis (DKA), hypoglycemia, and adapting ambulatory technologies for inpatient use. RECENT FINDINGS Rates of DKA in the United States are rising. Although socioeconomic status, health insurance coverage, and hemoglobin A1c are persistently associated with DKA in individuals with T1D, newer risk factors have also emerged. These include the off-label use of sodium-glucose cotransporter inhibitor medications, immune checkpoint inhibitor-induced diabetes, and infection with severe acute respiratory syndrome coronavirus 2. Hypoglycemia is common among hospitalized patients with T1D. Use of validated hypoglycemia risk prediction models and multidisciplinary care initiatives can reduce the risk of inpatient hypoglycemia. Finally, continuous glucose monitoring is being adapted for use in the hospital setting and has shown promise during the coronavirus disease 2019 (COVID-19) pandemic. SUMMARY Evidence-based treatment algorithms, risk prediction calculators, multidisciplinary interventions, and wearable technology hold promise for improved outcomes in hospitalized patients with T1D.
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Affiliation(s)
- Schafer Boeder
- Department of Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, La Jolla, California, USA
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Zhang Q, Dou H, Rorsman P. 'Resistance is futile?' - paradoxical inhibitory effects of K ATP channel closure in glucagon-secreting α-cells. J Physiol 2020; 598:4765-4780. [PMID: 32716554 PMCID: PMC7689873 DOI: 10.1113/jp279775] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
By secreting insulin and glucagon, the β- and α-cells of the pancreatic islets play a central role in the regulation of systemic metabolism. Both cells are equipped with ATP-regulated potassium (KATP ) channels that are regulated by the intracellular ATP/ADP ratio. In β-cells, KATP channels are active at low (non-insulin-releasing) glucose concentrations. An increase in glucose leads to KATP channel closure, membrane depolarization and electrical activity that culminates in elevation of [Ca2+ ]i and initiation of exocytosis of the insulin-containing secretory granules. The α-cells are also equipped with KATP channels but they are under strong tonic inhibition at low glucose, explaining why α-cells are electrically active under hypoglycaemic conditions and generate large Na+ - and Ca2+ -dependent action potentials. Closure of residual KATP channel activity leads to membrane depolarization and an increase in action potential firing but this stimulation of electrical activity is associated with inhibition rather than acceleration of glucagon secretion. This paradox arises because membrane depolarization reduces the amplitude of the action potentials by voltage-dependent inactivation of the Na+ channels involved in action potential generation. Exocytosis in α-cells is tightly linked to the opening of voltage-gated P/Q-type Ca2+ channels, the activation of which is steeply voltage-dependent. Accordingly, the inhibitory effect of the reduced action potential amplitude exceeds the stimulatory effect resulting from the increased action potential frequency. These observations highlight a previously unrecognised role of the action potential amplitude as a key regulator of pancreatic islet hormone secretion.
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Affiliation(s)
- Quan Zhang
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Oxford, OX3 7LE, UK
| | - Haiqiang Dou
- Metabolic Physiology Unit, Institute of Neuroscience and Physiology, University of Göteborg, PO Box 430, Göteborg, SE-405 30, Sweden
| | - Patrik Rorsman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Churchill Hospital, Oxford, OX3 7LE, UK.,Metabolic Physiology Unit, Institute of Neuroscience and Physiology, University of Göteborg, PO Box 430, Göteborg, SE-405 30, Sweden
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