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Visser MM, Vangoitsenhoven R, Gillard P, Mathieu C. Review Article - Diabetes Technology in the Hospital: An Update. Curr Diab Rep 2024:10.1007/s11892-024-01545-3. [PMID: 38842632 DOI: 10.1007/s11892-024-01545-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW There have been many developments in diabetes technology in recent years, with continuous glucose monitoring (CGM), insulin pump therapy (CSII) and automated insulin delivery (AID) becoming progressively accepted in outpatient diabetes care. However, the use of such advanced diabetes technology in the inpatient setting is still limited for several reasons, including logistical challenges and staff training needs. On the other hand, hospital settings with altered diet and stress-induced hyperglycemia often pose challenges to tight glycemic control using conventional treatment tools. Integrating smarter glucose monitoring and insulin delivery devices into the increasingly technical hospital environment could reduce diabetes-related morbidity and mortality. This narrative review describes the most recent literature on the use of diabetes technology in the hospital and suggests avenues for further research. RECENT FINDINGS Advanced diabetes technology has the potential to improve glycemic control in hospitalized people with and without diabetes, and could add particular value in certain conditions, such as nutrition therapy or perioperative management. Taken together, CGM allows for more accurate and patient-friendly follow-up and ad hoc titration of therapy. AID may also provide benefits, including improved glycemic control and reduced nursing workload. Before advanced diabetes technology can be used on a large scale in the hospital, further research is needed on efficacy, accuracy and safety, while implementation factors such as cost and staff training must also be overcome.
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Affiliation(s)
| | | | - Pieter Gillard
- Department of Endocrinology, University Hospitals Leuven, Louvain, Belgium
| | - Chantal Mathieu
- Department of Endocrinology, University Hospitals Leuven, Louvain, Belgium.
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2
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Idrees T, Castro-Revoredo IA, Oh HD, Gavaller MD, Zabala Z, Moreno E, Moazzami B, Galindo RJ, Vellanki P, Cabb E, Johnson TM, Peng L, Umpierrez GE. Continuous Glucose Monitoring-Guided Insulin Administration in Long-Term Care Facilities: A Randomized Clinical Trial. J Am Med Dir Assoc 2024; 25:884-888. [PMID: 38460943 DOI: 10.1016/j.jamda.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES To evaluate the efficacy of real-time continuous glucose monitoring (rt-CGM) in adjusting insulin therapy in long-term care facilities (LTCF). DESIGN Prospective randomized clinical trial. SETTINGS AND PARTICIPANTS Insulin-treated patients with type 2 diabetes (T2D) admitted to LTCF. METHODS Participants in the standard of care wore a blinded CGM with treatment adjusted based on point-of-care capillary glucose results before meals and bedtime (POC group). Participants in the intervention (CGM group) wore a Dexcom G6 CGM with treatment adjusted based on daily CGM profile. Treatment adjustment was performed by the LTCF medical team, with a duration of intervention up to 60 days. The primary endpoint was difference in time in range (TIR 70-180 mg/dL) between treatment groups. RESULTS Among 100 participants (age 74.73 ± 11 years, 80% admitted for subacute rehabilitation and 20% for nursing home care), there were no significant differences in baseline clinical characteristics between groups, and CGM data were compared for a median of 17 days. There were no differences in TIR (53.38% ± 30.16% vs 48.81% ± 28.03%, P = .40), mean daily mean CGM glucose (184.10 ± 43.4 mg/dL vs 190.0 ± 45.82 mg/dL, P = .71), or the percentage of time below range (TBR) <70 mg/dL (0.83% ± 2.59% vs 1.18% ± 3.54%, P = .51), or TBR <54 mg/dL (0.23% ± 0.85% vs 0.56% ± 2.24%, P = .88) between rt-CGM and POC groups. CONCLUSIONS AND IMPLICATIONS The use of rtCGM is safe and effective in guiding insulin therapy in patients with T2D in LTCF resulting in a similar improvement in glycemic control compared to POC-guided insulin adjustment.
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Affiliation(s)
- Thaer Idrees
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | | | - Hyungseok D Oh
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Monica D Gavaller
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Zohyra Zabala
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Emmelin Moreno
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Bobak Moazzami
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Elena Cabb
- Division of Geriatrics, and Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Theodore M Johnson
- Division of General Internal Medicine, Department of Medicine, Emory University, Atlanta, GA, USA; Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Limin Peng
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University, Atlanta, GA, USA.
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3
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Ang L, Lin YK, Schroeder LF, Huang Y, DeGeorge CA, Arnold P, Akanbi F, Knotts S, DuBois E, Desbrough N, Qu Y, Freeman R, Esfandiari NH, Pop-Busui R, Gianchandani R. Feasibility and Performance of Continuous Glucose Monitoring to Guide Computerized Insulin Infusion Therapy in Cardiovascular Intensive Care Unit. J Diabetes Sci Technol 2024; 18:562-569. [PMID: 38563491 PMCID: PMC11089859 DOI: 10.1177/19322968241241005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND We evaluated the feasibility of real-time continuous glucose monitoring (CGM) for titrating continuous intravenous insulin infusion (CII) to manage hyperglycemia in postoperative individuals in the cardiovascular intensive care unit and assessed their accuracy, nursing acceptance, and postoperative individual satisfaction. METHODS Dexcom G6 CGM devices were applied to 59 postsurgical patients with hyperglycemia receiving CII. A hybrid approach combining CGM with periodic point-of-care blood glucose (POC-BG) tests with two phases (initial-ongoing) of validation was used to determine CGM accuracy. Mean and median absolute relative differences and Clarke Error Grid were plotted to evaluate the CGM accuracy. Surveys of nurses and patients on the use of CGMs experience were conducted and results were analyzed. RESULTS In this cohort (mean age 64, 32% female, 32% with diabetes) with 864 paired POC-BG and CGM values analyzed, mean and median absolute relative difference between POC-BG and CGM values were 13.2% and 9.8%, respectively. 99.7% of paired CGM and POC-BG were in Zones A and B of the Clarke Error Grid. Responses from nurses reported CGMs being very or quite convenient (n = 28; 93%) and it was favored over POC-BG testing (n = 28; 93%). Majority of patients (n = 42; 93%) reported their care process using CGM as being good or very good. CONCLUSION This pilot study demonstrates the feasibility, accuracy, and nursing convenience of adopting CGM via a hybrid approach for insulin titration in postoperative settings. These findings provide robust rationale for larger confirmatory studies to evaluate the benefit of CGM in postoperative care to improve workflow, enhance health outcomes, and cost-effectiveness.
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Affiliation(s)
- Lynn Ang
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Yu Kuei Lin
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Lee F. Schroeder
- Department of Pathology, University of
Michigan, Ann Arbor, MI, USA
| | - Yiyuan Huang
- Department of Biostatistics, University
of Michigan, Ann Arbor, MI, USA
| | - Christina A. DeGeorge
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Patrick Arnold
- Department of Pharmacy, University of
Michigan, Ann Arbor, MI, USA
| | - Folake Akanbi
- Division of Endocrinology and
Metabolism, Department of Medicine, Michigan State University, East Lansing, MI,
USA
| | - Sharon Knotts
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Elizabeth DuBois
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Nicole Desbrough
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Yunyan Qu
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Regi Freeman
- Michigan Department of Nursing,
University of Michigan, Ann Arbor, MI, USA
| | - Nazanene H. Esfandiari
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
| | - Roma Gianchandani
- Division of Metabolism, Endocrinology
& Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor,
MI, USA
- Department of Medicine, Division of
Endocrinology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Baker M, Lauterwasser S, Valenti C, Kallenberger M, Stolte H. Evaluation of a hybrid protocol using continuous glucose monitoring and point-of-care testing in non-critically ill patients in a community hospital. Am J Health Syst Pharm 2024; 81:e261-e267. [PMID: 38146957 DOI: 10.1093/ajhp/zxad332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Indexed: 12/27/2023] Open
Abstract
PURPOSE 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Matt Baker
- North Kansas City Hospital, North Kansas City, MO, USA
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5
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Irace C, Coluzzi S, Di Cianni G, Forte E, Landi F, Rizzo MR, Sesti G, Succurro E, Consoli A. Continuous glucose monitoring (CGM) in a non-Icu hospital setting: The patient's journey. Nutr Metab Cardiovasc Dis 2023; 33:2107-2118. [PMID: 37574433 DOI: 10.1016/j.numecd.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/28/2023] [Indexed: 08/15/2023]
Abstract
AIMS Although consistent data support the outpatient use of continuous glucose monitoring (CGM) to improve glycemic control and reduce hypoglycemic burden, and clinical outcomes, there are limited data regarding its use in the hospital setting, particularly in the non-intensive care unit (non-ICU) setting. The emerging use of CGM in the non-critical care setting may be useful in increasing the efficiency of hospital care and reducing the length of stay for patients with diabetes while improving glycemic control. DATA SYNTHESIS The purpose of this Expert Opinion paper was to evaluate the state of the art and provide a practical model of how CGM can be implemented in the hospital. SETTING A patient's CGM journey from admission to the ward to the application of the sensor, from patient education on the device during hospitalization until discharge of the patient to maintain remote control. CONCLUSIONS This practical approach for the implementation and management of CGM in patients with diabetes admitted to non-ICUs could guide hospitals in their diabetes management initiatives using CGM, helping to identify patients most likely to benefit and suggesting how this technology can be implemented to maximize clinical benefits.
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Affiliation(s)
- Concetta Irace
- Department of Health Science, University Magna Graecia of Catanzaro, Catanzaro, Italy.
| | - Sara Coluzzi
- Endocrinology and Metabolism Unit, ASL, Pescara, Italy
| | - Graziano Di Cianni
- ASL Tuscany Northwest, Diabetes and Metabolic Disease, Livorno Hospital, Livorno, Italy
| | | | - Francesco Landi
- Department of Geriatrics and Orthopedics, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Rosaria Rizzo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Elena Succurro
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Agostino Consoli
- Endocrinology and Metabolism Unit, ASL, Pescara, Italy; Department of Medicine and Aging Sciences DMSI and Center for Advanced Studies and Technology CAST, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
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6
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Zelada H, Perez-Guzman MC, Chernavvsky DR, Galindo RJ. Continuous glucose monitoring for inpatient diabetes management: an update on current evidence and practice. Endocr Connect 2023; 12:e230180. [PMID: 37578799 PMCID: PMC10563639 DOI: 10.1530/ec-23-0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/14/2023] [Indexed: 08/15/2023]
Abstract
Over the last few years, several exciting changes in continuous glucose monitoring (CGM) technology have expanded its use and made CGM the standard of care for patients with type 1 and type 2 diabetes using insulin therapy. Consequently, hospitals started to notice increased use of these devices in their hospitalized patients. Furthermore during the coronavirus disease 2019 (COVID) pandemic, there was a critical need for innovative approaches to glycemic monitoring, and several hospitals started to implement CGM protocols in their daily practice. Subsequently, a plethora of studies have demonstrated the efficacy and safety of CGM use in the hospital, leading to clinical practice guideline recommendations. Several studies have also suggested that CGM has the potential to become the standard of care for some hospitalized patients, overcoming the limitations of current capillary glucose testing. Albeit, there is a need for more studies and particularly regulatory approval. In this review, we provide a historical overview of the evolution of glycemic monitoring in the hospital and review the current evidence, implementation protocols, and guidance for the use of CGM in hospitalized patients.
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Affiliation(s)
- Henry Zelada
- Division of Endocrinology, Diabetes and Metabolism, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | | | - Daniel R Chernavvsky
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Diabetes and Metabolism, University of Miami Miller School of Medicine. Miami, Florida, USA
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Spierling Bagsic SR, Fortmann AL, Belasco R, Bastian A, Lohnes S, Ritko A, Sandoval H, Chichmarenko M, Soriano EC, Talavera L, Philis-Tsimikas A. Real-Time Continuous Glucose Monitoring in the Hospital: A Real-World Experience. J Diabetes Sci Technol 2023; 17:656-666. [PMID: 37056168 PMCID: PMC10210125 DOI: 10.1177/19322968231165982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Glycemic control in the hospital setting is imperative for improving outcomes among patients with diabetes. Bedside point-of-care (POC) glucose monitoring has remained the gold standard for decades, while only providing momentary glimpses into a patient's glycemic control. Continuous glucose monitoring (CGM) has been shown to improve glycemic control in the ambulatory setting. However, a paucity of inpatient experience and data remains a barrier to US Food and Drug Administration (FDA) approval and expanded/non-research use in the hospital setting. METHOD Amid the COVID-19 pandemic, the FDA exercised its enforcement discretion to not object to the use of CGM systems for the treatment of patients in hospital settings to support COVID-19 health care-related efforts to reduce viral exposure of health care workers. Following this announcement, Scripps Health, a large not-for-profit health care system in San Diego, California, implemented CGM as the new "standard of care" (CGM as SOC) for glucose monitoring and management in the hospital. RESULTS The present report serves to (1) detail the implementation procedures for employing this new SOC; (2) describe the patients receiving CGM as SOC, their glycemic control, and hospital outcomes; and (3) share lessons learned over two years and nearly 900 hospital encounters involving CGM. CONCLUSIONS Here, we conclude that CGM is feasible in the hospital setting by using a dedicated diabetes care team and the CGM technology with remote monitoring.
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Affiliation(s)
| | - Addie L. Fortmann
- Scripps Whittier Diabetes Institute,
Scripps Health, San Diego, CA, USA
| | - Rebekah Belasco
- Scripps Whittier Diabetes Institute,
Scripps Health, San Diego, CA, USA
| | | | - Suzanne Lohnes
- Scripps Whittier Diabetes Institute,
Scripps Health, San Diego, CA, USA
| | | | - Haley Sandoval
- Scripps Whittier Diabetes Institute,
Scripps Health, San Diego, CA, USA
| | | | - Emily C. Soriano
- Scripps Whittier Diabetes Institute,
Scripps Health, San Diego, CA, USA
| | - Laura Talavera
- Scripps Whittier Diabetes Institute,
Scripps Health, San Diego, CA, USA
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Carlsson CJ, Nørgaard K, Oxbøll AB, Søgaard MIV, Achiam MP, Jørgensen LN, Eiberg JP, Palm H, Sørensen HBD, Meyhof CS, Aasvang EK. Continuous Glucose Monitoring Reveals Perioperative Hypoglycemia in Most Patients With Diabetes Undergoing Major Surgery: A Prospective Cohort Study. Ann Surg 2023; 277:603-611. [PMID: 35129526 DOI: 10.1097/sla.0000000000005246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the frequency and duration of hypo- and hyperglycemia, assessed by continuous glucose monitoring (CGM) during and after major surgery, in departments with implemented diabetes care protocols. SUMMARY BACKGROUND DATA Inadequate glycemic control in the perioperative period is associated with serious adverse events, but monitoring currently relies on point blood glucose measurements, which may underreport glucose excursions. METHODS Adult patients without (A) or with diabetes [non-insulin-treated type 2 (B), insulin-treated type 2 (C) or type 1 (D)] undergoing major surgery were monitored using CGM (Dexcom G6), with an electrochemical sensor in the interstitial fluid, during surgery and for up to 10 days postoperatively. Patients and health care staff were blinded to CGM values, and glucose management adhered to the standard diabetes care protocol. Thirty-day postoperative serious adverse events were recorded. The primary outcome was duration of hypoglycemia (glucose <70 mg/dL). Clinicaltrials.gov: NCT04473001. RESULTS Seventy patients were included, with a median observation time of 4.0 days. CGM was recorded in median 96% of the observation time. The median daily duration of hypoglycemia was 2.5 minutes without significant difference between the 4 groups (A-D). Hypoglycemic events lasting ≥15 minutes occurred in 43% of all patients and 70% of patients with type 1 diabetes. Patients with type 1 diabetes spent a median of 40% of the monitoring time in the normoglycemic range 70 to 180 mg/dL and 27% in the hyperglycemic range >250 mg/dL. Duration of preceding hypo- and hyperglycemia tended to be longer in patients with serious adverse events, compared with patients without events, but these were exploratory analyses. CONCLUSIONS Significant duration of both hypo- and hyperglycemia was detected in high proportions of patients, particularly in patients with diabetes, despite protocolized perioperative diabetes management.
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Affiliation(s)
- Christian J Carlsson
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Center for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Britt Oxbøll
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Center for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mette I V Søgaard
- Department of Surgery & Transplantation, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael P Achiam
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthe-siology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars N Jørgensen
- Digestive Disease Center, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jonas P Eiberg
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Vascular Surgery, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Academy for Medical Education and Simulation (CAMES), The Capital Region of Denmark, Copenhagen, Denmark
| | - Henrik Palm
- Department of Orthopaedic Surgery, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Helge B D Sørensen
- Department of Health Technology, Technical University of Denmark, Lyngby, Denmark
| | - Christian S Meyhof
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Center for Translational Research, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Eske K Aasvang
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthe-siology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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9
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Clubbs Coldron B, Coates V, Khamis A, MacRury S. Use of Continuous Glucose Monitoring in Non-ICU Hospital Settings for People With Diabetes: A Scoping Review of Emerging Benefits and Issues. J Diabetes Sci Technol 2023; 17:467-473. [PMID: 34696622 PMCID: PMC10012381 DOI: 10.1177/19322968211053652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Evidence indicates that poor glycemic control is associated with increased morbidity and length of stay in hospital. There are a wide range of guidelines published, which seek to ensure safe and effective inpatient glycemic control in the hospital setting. However, the implementation of these protocols is limited in practice. In particular, the feasibility of "flash" and continuous glucose monitoring (CGM) remains untested on general wards. METHOD Scoping Review. RESULTS If used in the general ward hospital settings, CGM and flash glucose monitoring (FGM) systems could lead to improved glycemic control, decreased length of stay, and reduced risk of severe hypoglycemia or hyperglycemia. Potential problems include lack of experience with this technology and costs of sensors. Rapid analysis of glucose measurements can facilitate clinical decision making and therapy adjustment in the hospital setting. In addition, people with diabetes may be empowered to better self-manage their condition in hospital as they have direct access to their glucose data. CONCLUSIONS More studies are required in which the feasibility, benefits and limitations of FGM and CGM in non-intensive care unit hospital settings are elucidated. We need evidence on which types of hospital wards might benefit from the introduction of this technology and the contexts in which they are less useful. We also need to identify the types of people who are most likely to find FGM and CGM useful for self-management and for which populations they have the most benefit in terms of clinical outcomes and length of stay.
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Affiliation(s)
- Benjamin Clubbs Coldron
- Division of Rural Health and
Wellbeing, Centre for Health Science, University of Highlands and Islands,
Inverness, UK
| | - Vivien Coates
- School of Nursing, Ulster
University, Derry, UK
- Western Health and Social Care
Trust, Altnagelvin Area Hospital, Londonderry, UK
| | - Amjed Khamis
- Letterkenny University Hospital,
Letterkenny, Ireland
| | - Sandra MacRury
- Division of Rural Health and
Wellbeing, Centre for Health Science, University of Highlands and Islands,
Inverness, UK
- Raigmore Hospital, Inverness,
UK
- Sandra MacRury, MBChB, FRCP, MD,
Division of Rural Health and Wellbeing, Centre for Health Science,
University of Highlands and Islands, Old Perth Road, Inverness IV2
3JH, UK.
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10
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McCall AL, Lieb DC, Gianchandani R, MacMaster H, Maynard GA, Murad MH, Seaquist E, Wolfsdorf JI, Wright RF, Wiercioch W. Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2023; 108:529-562. [PMID: 36477488 DOI: 10.1210/clinem/dgac596] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality. OBJECTIVE To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia. METHODS A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. RESULTS The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia. CONCLUSION The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.
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Affiliation(s)
- Anthony L McCall
- University of Virginia Medical School, Department of Medicine, Division of Endocrinology and Metabolism, Charlottesville, VA 22901, USA
| | - David C Lieb
- Eastern Virginia Medical School, Division of Endocrine and Metabolic Disorders, Department of Medicine, Norfolk, VA 23510, USA
| | | | | | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55905, USA
| | - Elizabeth Seaquist
- Diabetes Center and the Division of Endocrinology & Metabolism, Minneapolis, MN 55455, USA
| | - Joseph I Wolfsdorf
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | | | - Wojtek Wiercioch
- McMaster University GRADE Centre and Michael G. DeGroote Cochrane Canada Centre Department of Health Research Methods, Evidence, and Impact, Hamilton, ON, L8S 4L8, Canada
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11
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Torres Roldan VD, Urtecho M, Nayfeh T, Firwana M, Muthusamy K, Hasan B, Abd-Rabu R, Maraboto A, Qoubaitary A, Prokop L, Lieb DC, McCall AL, Wang Z, Murad MH. A Systematic Review Supporting the Endocrine Society Guidelines: Management of Diabetes and High Risk of Hypoglycemia. J Clin Endocrinol Metab 2023; 108:592-603. [PMID: 36477885 DOI: 10.1210/clinem/dgac601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Indexed: 12/12/2022]
Abstract
CONTEXT Interventions targeting hypoglycemia in people with diabetes are important for improving quality of life and reducing morbidity and mortality. OBJECTIVE To support development of the Endocrine Society Clinical Practice Guideline for management of individuals with diabetes at high risk for hypoglycemia. METHODS We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence. RESULTS We included 149 studies reporting on 43 344 patients. Continuous glucose monitoring (CGM) reduced episodes of severe hypoglycemia in patients with type 1 diabetes (T1D) and reduced the proportion of patients with hypoglycemia (blood glucose [BG] levels <54 mg/dL). There were no data on use of real-time CGM with algorithm-driven insulin pumps vs multiple daily injections with BG testing in people with T1D. CGM in outpatients with type 2 diabetes taking insulin and/or sulfonylureas reduced time spent with BG levels under 70 mg/dL. Initiation of CGM in hospitalized patients at high risk for hypoglycemia reduced episodes of hypoglycemia with BG levels lower than 54 mg/dL and time spent under 54 mg/dL. The proportion of patients with hypoglycemia with BG levels lower than 70 mg/dL and lower than 54 mg/dL detected by CGM was significantly higher than point-of-care BG testing. We found no data evaluating continuation of personal CGM in the hospital. Use of an inpatient computerized glycemic management program utilizing electronic health record data was associated with fewer patients with and episodes of hypoglycemia with BG levels lower than 70 mg/dL and fewer patients with severe hypoglycemia compared with standard care. Long-acting basal insulin analogs were associated with less hypoglycemia. Rapid-acting insulin analogs were associated with reduced severe hypoglycemia, though there were more patients with mild to moderate hypoglycemia. Structured diabetes education programs reduced episodes of severe hypoglycemia and time below 54 mg/dL in outpatients taking insulin. Glucagon formulations not requiring reconstitution were associated with longer times to recovery from hypoglycemia, although the proportion of patients who recovered completely from hypoglycemia was not different between the 2 groups. CONCLUSION This systematic review summarized the best available evidence about several interventions addressing hypoglycemia in people with diabetes. This evidence base will facilitate development of clinical practice guidelines by the Endocrine Society.
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Affiliation(s)
| | - Meritxell Urtecho
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Mohammed Firwana
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | | | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Rami Abd-Rabu
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
| | - Andrea Maraboto
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Amjad Qoubaitary
- College of Arts and Science, University of San Francisco, San Francisco, CA 94117, USA
| | - Larry Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN 55902, USA
| | - David C Lieb
- Division of Endocrine and Metabolic Disorders, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA 23501-1980, USA
| | - Anthony L McCall
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
| | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN 55902, USA
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12
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Huang W, Li S, Lu J, Shen Y, Wang Y, Wang Y, Feng K, Huang X, Zou Y, Hu L, Lu Y, Zhou J, Li Y. Accuracy of the intermittently scanned continuous glucose monitoring system in critically ill patients: a prospective, multicenter, observational study. Endocrine 2022; 78:470-475. [PMID: 36227509 PMCID: PMC9559122 DOI: 10.1007/s12020-022-03216-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/30/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Continuous glucose monitoring (CGM) has the potential to improve glucose control in the intensive care unit (ICU) setting. We sought to evaluate the accuracy of the intermittently scanned CGM (isCGM) system in critically ill patients. RESEARCH DESIGN AND METHODS Adult patients were consecutively enrolled from three ICUs from August 2020 to January 2021. The performance of FreeStyle Libre Pro was evaluated against the venous blood glucose samples as a reference. Numerical accuracy was examined by the mean absolute relative difference (MARD), the Bland-Altman analysis, and the International Organization for Standardization criteria. Clinical accuracy was assessed by performing the Clarke and consensus error grid analysis. RESULTS A total of 122 patients were included and 3416 matched glucose pairs were analyzed. The overall MARD was 18.0%, and the highest MARD (33.1%) was observed in the hypoglycemic range (<70 mg/dL). The Bland-Altman analysis revealed a mean bias of -11.7 mg/dL, with the 95% limits of agreement of -73.0 to 49.5 mg/dL. The percentages of isCGM glucose values within ±15%/15, ±20%/20, and ±30%/30 mg/dL were 49.8%, 64.7%, and 84.5%, respectively. The Clarke and consensus error grid analysis showed acceptable clinical accuracy with 98.5% and 98.8% of glucose values falling into zones A and B. CONCLUSIONS Our study demonstrated suboptimal overall accuracy of isCGM for critically ill patients. Whether the adjunctive use of isCGM could improve glucose management and health outcomes in the critically ill needs further investigation. CLINICAL TRIAL REGISTRATION ChiCTR2100042036, Chinese Clinical Trial Registry.
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Affiliation(s)
- Weifeng Huang
- Department of Critical Care Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Siwan Li
- Department of Critical Care Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyi Lu
- Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yun Shen
- Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yaxin Wang
- Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yufei Wang
- Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kaixuan Feng
- Department of Critical Care Medicine, Jinshan Branch of Shanghai Sixth People's Hospital, Shanghai, China
| | - Xiaoli Huang
- Department of Critical Care Medicine, Jinshan Branch of Shanghai Sixth People's Hospital, Shanghai, China
| | - Yan Zou
- Department of Critical Care Medicine, Lingang Campus of Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Linjie Hu
- Department of Epidemiology, Ministry of Education Key Laboratory of Public Health Safety, School of Public Health, Fudan University, Shanghai, China
| | - Yihan Lu
- Department of Epidemiology, Ministry of Education Key Laboratory of Public Health Safety, School of Public Health, Fudan University, Shanghai, China
| | - Jian Zhou
- Department of Endocrinology and Metabolism, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yingchuan Li
- Department of Critical Care Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of Critical Care Medicine, Tongji University Affiliated Shanghai Tenth People's Hospital, Shanghai, China.
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13
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Avari P, Lumb A, Flanagan D, Rayman G, Misra S, Dhatariya K, Choudhary P. Continuous Glucose Monitoring Within Hospital: A Scoping Review and Summary of Guidelines From the Joint British Diabetes Societies for Inpatient Care. J Diabetes Sci Technol 2022; 17:611-624. [PMID: 36444418 DOI: 10.1177/19322968221137338] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Increasing numbers of people, particularly with type 1 diabetes (T1D), are using wearable technologies. That is, continuous subcutaneous insulin infusion (CSII) pumps, continuous glucose monitoring (CGM) systems, and hybrid closed-loop systems, which combine both these elements. Given over a quarter of all people admitted to hospital have diabetes, there is a need for clinical guidelines for when people using them are admitted to hospital. The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) provide a scoping review and summary of guidelines on the use of diabetes technology in people with diabetes admitted to hospital.JBDS-IP advocates enabling people who can self-manage and use their own diabetes technology to continue doing so as they would do out of hospital. Whilst people with diabetes are recommended to achieve a target of 70% time within range (3.9-10.0 mmol/L [70-180 mg/dL]), this can be very difficult to achieve whilst unwell. We therefore recommend targeting hypoglycemia prevention as a priority, keeping time below 3.9 mmol/L (70 mg/dL) at < 1%, being aware of looming hypoglycemia if glucose is between 4.0 and 5.9 mmol/L (72-106 mg/dL), and consider intervening, particularly if there is a downward CGM trend arrow.Health care organizations need clear local policies and guidance to support individuals using diabetes technologies, and ensure the relevant workforce is capable and skilled enough to ensure their safe use within the hospital setting. The current set of guidelines is divided into two parts. Part 1, which follows below, outlines the guidance for use of CGM in hospital. The second part outlines guidance for use of CSII and hybrid closed-loop in hospital.
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Affiliation(s)
- Parizad Avari
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Alistair Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Daniel Flanagan
- Department of Endocrinology, University Hospital Plymouth, Plymouth, UK
| | - Gerry Rayman
- Ipswich Diabetes Centre, East Suffolk and North East Essex Foundation Trust, Ipswich, UK
| | - Shivani Misra
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, UK
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14
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Longo RR, Joshi R. The Devil Is in the Details: Use, Limitations, and Implementation of Continuous Glucose Monitoring in the Inpatient Setting. Diabetes Spectr 2022; 35:405-419. [PMID: 36561647 PMCID: PMC9668728 DOI: 10.2337/dsi22-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Until recently, continuous glucose monitoring (CGM) systems were reserved for use in the outpatient setting or for investigational purposes in hospitalized patients. However, during the coronavirus disease 2019 pandemic, use of CGM in the inpatient setting has grown rapidly. This review outlines important details related to the accuracy, limitations, and implementation of, as well as necessary staff education for, inpatient CGM use and offers a glimpse into the future of CGM in the inpatient setting.
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Affiliation(s)
- Rebecca Rick Longo
- Lahey Hospital and Medical Center–Beth Israel Lahey Health, Burlington, MA
| | - Renu Joshi
- University of Pittsburgh Medical Center, Harrisburg, PA
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15
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Molitch ME. Hyperglycaemia management in non-critical care settings: guidelines in focus. Lancet Diabetes Endocrinol 2022; 10:614-616. [PMID: 35870477 DOI: 10.1016/s2213-8587(22)00214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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16
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Longo RR, Elias H, Khan M, Seley JJ. Use and Accuracy of Inpatient CGM During the COVID-19 Pandemic: An Observational Study of General Medicine and ICU Patients. J Diabetes Sci Technol 2022; 16:1136-1143. [PMID: 33971753 PMCID: PMC9445343 DOI: 10.1177/19322968211008446] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Continuous glucose monitoring (CGM) is widely used in the outpatient setting for people with diabetes and has been limited to investigational use only for the inpatient population. In April 2020, the US FDA exercised enforcement discretion for the temporary use of inpatient CGM during the pandemic, thus hospitals were presented the opportunity to implement this technology. METHODS We sought to investigate the accuracy of CGM in hospitalized patients on general care floors and the intensive care unit (ICU) in attempts to decrease healthcare professional exposure to COVID-19 and ultimately improve glycemic management of patients affected by COVID-19. Point of care (POC) and laboratory (Lab) glucose values were matched with simultaneous CGM glucose values and measures of accuracy were performed to evaluate the safety and usability of CGM in this population. Our data are presented drawing a distinction between POC and Lab as reference glucose sources. RESULTS In 808 paired samples obtained from 28 patients (10 ICU, 18 general floor), overall mean absolute relative difference (MARD) for all patients using either POC or Lab as reference was 13.2%. When using POC as the reference glucose MARD was 13.9% and using Lab glucose as reference 10.9%. Using both POC and Lab reference glucose pairs the overall MARD for critical care patients was 12.1% and for general floor patients 14%. CONCLUSION We determined, with proper protocols and safeguards in place, use of CGM in the hospitalized patient is a reasonable alternative to standard of care to achieve the goal of reducing healthcare professional exposure. Further study is necessary to validate safety, accuracy, and efficacy of this technology. Investigation and analysis are necessary for the development of protocols to utilize CGM trend arrows, alerts, and alarms.
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Affiliation(s)
- Rebecca Rick Longo
- Lahey Hospital and Medical Center, Burlington, MA, USA
- Rebecca Rick Longo, ACNP-BC, MSN, CDCES, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | - Heather Elias
- Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Mehvish Khan
- Lahey Hospital and Medical Center, Burlington, MA, USA
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17
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Buschur EO, Faulds E, Dungan K. CGM in the Hospital: Is It Ready for Prime Time? Curr Diab Rep 2022; 22:451-460. [PMID: 35796882 PMCID: PMC9261155 DOI: 10.1007/s11892-022-01484-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW The use of continuous glucose monitoring (CGM) in the hospital setting is growing with more patients using these devices at home and when admitted to the hospital, especially during the COVID-19 pandemic. RECENT FINDINGS Historically, most evidence for CGM use in the inpatient setting was limited to small studies utilizing outdated CGM technology and analyzing accuracy of sensor measurements. Previous studies have shown reduced sensor accuracy during extreme hypo- or hyperglycemia, rapid fluctuations of glucose, compression of the sensor itself, and in those who are critically ill. Studies that are more recent have shown CGM to have adequate accuracy and may be effective in reducing hypoglycemia in hospitalized patients; some studies have also showed improvement in time in target glycemic range. Furthermore, CGM may reduce nursing workload, cost of inpatient care, and use of personal protective equipment and face-to-face patient care especially for patients during the COVID-19 pandemic. This review will describe the evidence for use of CGM in hospitalized critically ill or non-critically ill patients, address accuracy and safety considerations, and outline paths for future implementation.
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Affiliation(s)
- Elizabeth O. Buschur
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
| | - Eileen Faulds
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
- grid.261331.40000 0001 2285 7943The Ohio State University College of Nursing, Columbus, OH USA
| | - Kathleen Dungan
- grid.261331.40000 0001 2285 7943Division of Endocrinology, Diabetes & Metabolism, The Ohio State University College of Medicine, 5th Floor McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210-1296 USA
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18
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Samigullin A, Humpert PM, Östman E. Continuous glucose monitoring as a close to real life alternative to meal studies – a pilot study with a functional drink containing amino acids and chromium. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:931837. [PMID: 36062264 PMCID: PMC9433800 DOI: 10.3389/fmedt.2022.931837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
This pilot study aimed to evaluate a continuous glucose monitoring (CGM) based approach to study the effects of a functional drink containing specific amino acids and chromium picolinate (FD) and a combination of FD with a juice (FDJ) on postprandial glucose in a close to real life setting. The predefined primary endpoint for this study was the 120-min incremental area under the glucose curve (iAUC0−120min) after meals. It was estimated that using CGM and repeated meals in 6 participants could be sufficient to match the power of the previous study in regards to the quantity of meals. Participants followed a pre-specified meal schedule over 9 days and consumed the drinks three times daily with main meals. Differences between drinks were analyzed by analysis of covariances (ANCOVA) with subject number and activity as random factors and nutrient composition as covariates. In 156 meals available for analysis, a significant 34% reduction of glucose iAUC0−120min was shown for FDJ (p < 0.001). FD did not show a significant effect on its own, but a significant reduction of 17.6% (p = 0.007) was shown in pooled data for FD and FDJ. While the differences between the two functional drinks used were not the primary focus of this study, it was sufficiently powered to detect previously described effects in 60 participants in a cross-over design under laboratory settings. The design presented defines a novel and cost-effective approach using CGM devices and app-based lifestyle tracking for studying nutritional effects on glucose at home in a close to real-life setting.
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Affiliation(s)
- Azat Samigullin
- starScience GmbH, Heidelberg, Germany
- Stoffwechselzentrum Rhein Pfalz, Mannheim, Germany
- *Correspondence: Azat Samigullin
| | - Per M. Humpert
- starScience GmbH, Heidelberg, Germany
- Stoffwechselzentrum Rhein Pfalz, Mannheim, Germany
- Department of Internal Medicine, Endocrinology and Diabetes, Heidelberg University Hospital, Heidelberg, Germany
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19
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Korytkowski MT, Muniyappa R, Antinori-Lent K, Donihi AC, Drincic AT, Hirsch IB, Luger A, McDonnell ME, Murad MH, Nielsen C, Pegg C, Rushakoff RJ, Santesso N, Umpierrez GE. Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2022; 107:2101-2128. [PMID: 35690958 PMCID: PMC9653018 DOI: 10.1210/clinem/dgac278] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management. OBJECTIVE To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia. METHODS A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. RESULTS The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition-associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes. CONCLUSION The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.
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Affiliation(s)
- Mary T Korytkowski
- University of Pittsburgh, Division of Endocrinology, Department of Medicine, Pittsburgh, PA, USA
| | - Ranganath Muniyappa
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Amy C Donihi
- University of Pittsburgh School of Pharmacy, Department of Pharmacy and Therapeutics, Pittsburgh, PA, USA
| | - Andjela T Drincic
- University of Nebraska Medical Center, Endocrinology & Metabolism, Omaha, NE, USA
| | - Irl B Hirsch
- University of Washington Diabetes Institute, Seattle, WA, USA
| | - Anton Luger
- Medical University and General Hospital of Vienna, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Marie E McDonnell
- Brigham and Women’s Hospital and Harvard Medical School, Division of Endocrinology Diabetes and Hypertension, Boston, MA, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | | | - Claire Pegg
- Diabetes Patient Advocacy Coalition, Tampa, FL, USA
| | - Robert J Rushakoff
- University of California, San Francisco, Department of Medicine, Division of Endocrinology and Metabolism, San Francisco, CA, USA
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20
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Seisa MO, Saadi S, Nayfeh T, Muthusamy K, Shah SH, Firwana M, Hasan B, Jawaid T, Abd-Rabu R, Korytkowski MT, Muniyappa R, Antinori-Lent K, Donihi AC, Drincic AT, Luger A, Torres Roldan VD, Urtecho M, Wang Z, Murad MH. A Systematic Review Supporting the Endocrine Society Clinical Practice Guideline for the Management of Hyperglycemia in Adults Hospitalized for Noncritical Illness or Undergoing Elective Surgical Procedures. J Clin Endocrinol Metab 2022; 107:2139-2147. [PMID: 35690929 PMCID: PMC9653020 DOI: 10.1210/clinem/dgac277] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 12/21/2022]
Abstract
CONTEXT Individuals with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. Management of hyperglycemia in these patients is challenging. OBJECTIVE To support development of the Endocrine Society Clinical Practice Guideline for management of hyperglycemia in adults hospitalized for noncritical illness or undergoing elective surgical procedures. METHODS We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence. RESULTS We included 94 studies reporting on 135 553 patients. Compared with capillary blood glucose, continuous glucose monitoring increased the number of patients identified with hypoglycemia and decreased mean daily blood glucose (BG) (very low certainty). Data on continuation of insulin pump therapy in hospitalized adults were sparse. In hospitalized patients receiving glucocorticoids, combination neutral protamine hagedorn (NPH) and basal-bolus insulin was associated with lower mean BG compared to basal-bolus insulin alone (very low certainty). Data on NPH insulin vs basal-bolus insulin in hospitalized adults receiving enteral nutrition were inconclusive. Inpatient diabetes education was associated with lower HbA1c at 3 and 6 months after discharge (moderate certainty) and reduced hospital readmissions (very low certainty). Preoperative HbA1c level < 7% was associated with shorter length of stay, lower postoperative BG and a lower number of neurological complications and infections, but a higher number of reoperations (very low certainty). Treatment with glucagon-like peptide-1 agonists or dipeptidyl peptidase-4 inhibitors in hospitalized patients with type 2 diabetes and mild hyperglycemia was associated with lower frequency of hypoglycemic events than insulin therapy (low certainty). Caloric oral fluids before surgery in adults with diabetes undergoing surgical procedures did not affect outcomes (very low certainty). Counting carbohydrates for prandial insulin dosing did not affect outcomes (very low certainty). Compared with scheduled insulin (basal-bolus or basal insulin + correctional insulin), correctional insulin was associated with higher mean daily BG and fewer hypoglycemic events (low certainty). CONCLUSION The certainty of evidence supporting many hyperglycemia management decisions is low, emphasizing importance of shared decision-making and consideration of other decisional factors.
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Affiliation(s)
- Mohamed O Seisa
- Correspondence: Mohamed Seisa, M.D., Mayo Clinic Rochester, Rochester, MN 55902, USA.
| | - Samer Saadi
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | | | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | | | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Tabinda Jawaid
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Rami Abd-Rabu
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | | | - Ranganath Muniyappa
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA
| | | | - Amy C Donihi
- University of Pittsburgh School of Pharmacy,Pittsburgh, PA 15261, USA
| | | | - Anton Luger
- Medical University and General Hospital of Vienna, Austria
| | | | | | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
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21
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Dillmann C, Amoura L, Fall Mostaine F, Coste A, Bounyar L, Kessler L. Feasibility of Real-Time Continuous Glucose Monitoring Telemetry System in an Inpatient Diabetes Unit: A Pilot Study. J Diabetes Sci Technol 2022; 16:955-961. [PMID: 33660531 PMCID: PMC9264424 DOI: 10.1177/1932296821994586] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hospitalization of persons with diabetes in an inpatient diabetes unit is challenging, notably for patients having different profiles. We aimed to evaluate the feasibility and the benefit of a continuous glucose monitoring (CGM) telemetry system to control glucose excursions in hospitalized patients with diabetes, according to their diabetes type and the reasons for their hospitalization. METHOD A prospective pilot study was conducted in 53 insulin-requiring diabetes patients hospitalized in the general ward. Glucose was monitored using Guardian Connect (GC, Medtronic) to adopt insulin therapy. The time in range (TIR, target 70-180 mg/dL), the time below range (TBR), and the time above range (TAR) were recorded by GC between the start of hospitalization (SH) and end of hospitalization (EH), and analyzed according to the diabetes type (type 1 diabetes n = 28, type 2 diabetes n = 25) and the reasons for hospitalization (acute complications n = 35, therapeutic education n = 18). Patient and caregiver satisfaction was also assessed. RESULTS In patients with type 2 diabetes and those hospitalized for acute complications, TIR significantly increased between the SH and EH, from 75.7% (95%CI 48.5-84.6) to 82.2% (95%CI 63.2-91.8) P = 0.043 and from 58.3% (95%CI 46.3-69.7) to 66.4% (95%CI 55.6-75.5) P = 0.031, respectively, and TAR significantly decreased, with no change in TBR. In patients with diabetes hospitalized for therapeutic education, TBR significantly decreased from 3.4% (95%CI 0-9.4) to 0% (95%CI 0-3.8) P = 0.037. Finally, 94% of patients and caregivers deemed the GC system useful. CONCLUSIONS CGM telemetry system use is feasible and well accepted in patients hospitalized in diabetes care unit and could be useful to improve therapeutic education and metabolic control, especially for specific homogenous populations with diabetes.
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Affiliation(s)
| | - Lamia Amoura
- Department of Diabetology, University
Hospital of Strasbourg, France
| | | | - Adrien Coste
- Department of Diabetology, University
Hospital of Strasbourg, France
| | - Leila Bounyar
- Department of Diabetology, University
Hospital of Strasbourg, France
| | - Laurence Kessler
- Department of Diabetology, University
Hospital of Strasbourg, France
- Inserm UMR 1260, Regenerative
Nanomedicine, University of Strasbourg, France
- Laurence Kessler, MD, PhD, Service
d’Endocrinologie-Diabète-Nutrition, Hôpital Civil, 1 Place de l’Hôpital,
Strasbourg Cedex 67 091, France.
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22
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Idrees T, Castro-Revoredo IA, Migdal AL, Moreno EM, Umpierrez GE. Update on the management of diabetes in long-term care facilities. BMJ Open Diabetes Res Care 2022; 10:10/4/e002705. [PMID: 35858714 PMCID: PMC9305812 DOI: 10.1136/bmjdrc-2021-002705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.
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Affiliation(s)
- Thaer Idrees
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Iris A Castro-Revoredo
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Alexandra L Migdal
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Emmelin Marie Moreno
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Emory University, Atlanta, Georgia, USA
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23
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Sweeney AT, Pena S, Sandeep J, Hernandez B, Chen Y, Breeze JL, Bulut A, Feghali K, Abdelrehim M, Abdelazeem M, Srivoleti P, Salvucci L, Cann SB, Norman C. Use of a Continuous Glucose Monitoring System in High Risk Hospitalized Non-critically ill Patients with Diabetes after Cardiac Surgery and during their Transition of Care from the Intensive Care Unit during Covid-19-A Pilot Study. Endocr Pract 2022; 28:615-621. [PMID: 35276324 PMCID: PMC8902897 DOI: 10.1016/j.eprac.2022.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/02/2022] [Accepted: 03/02/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Continuous glucose monitoring (CGM) has demonstrated benefits in managing inpatient diabetes. We initiated this single-arm pilot feasibility study during the COVID-19 pandemic in 11 patients to determine the feasibility and accuracy of real-time CGM in cardiac surgery patients with diabetes after their transition of care from the intensive care unit(ICU). METHODS Clarke Error Grid(CEG) analysis was used to compare CGM and point-of-care(POC) measurements. Mean absolute relative difference(MARD) of the paired measurements was calculated to assess the accuracy of the CGM for glucose measurements during the first 24 hours on CGM, the remainder of time on the CGM as well as for different chronic kidney disease(CKD) strata. RESULTS Overall MARD between POC and CGM measurements was 14.80%. MARD for patients without CKD IV and V with eGFR < 20 ml/min/1.73m2 was 12.13%. Overall, 97% of the CGM values were within the no-risk zone of the CEG analysis. For the first 24 hours, a sensitivity analysis of the overall MARD for all subjects and for those with eGFR > 20 ml/min/1.73m2 was 15.42% (+/- 14.44) and 12.80% (+/- 7.85) respectively. Beyond the first 24 hours, overall MARD for all subjects and for those with eGFR > 20 ml/min/1.73m2 was 14.54% (+/- 13.21) and 11.86% (+/- 7.64) respectively. CONCLUSIONS CGM has great promise to optimize inpatient diabetes management in the noncritical care setting and after the transition of care from the ICU with high clinical reliability, and accuracy. More studies are needed to further assess CGM in patients with advanced CKD.
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Affiliation(s)
- Ann T Sweeney
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA.
| | - Samara Pena
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Jeena Sandeep
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Bryan Hernandez
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Ye Chen
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Janis L Breeze
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Aysegul Bulut
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Karen Feghali
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Moaz Abdelrehim
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Mohamed Abdelazeem
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Padmavathi Srivoleti
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Linda Salvucci
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Susan Berry Cann
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Catalina Norman
- Department of Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
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24
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Concurrent Validity of a Continuous Glucose-Monitoring System at Rest and During and Following a High-Intensity Interval Training Session. Int J Sports Physiol Perform 2022; 17:627-633. [DOI: 10.1123/ijspp.2021-0222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022]
Abstract
Purpose: To assess the concurrent validity of a continuous blood-glucose-monitoring system (CGM) postbreakfast, preexercise, exercise, and postexercise, while assessing the impact of 2 different breakfasts on the observed level of validity. Methods: Eight nondiabetic recreational athletes (age = 30.8 [9.5] y; height = 173.6 [6.6] cm; body mass = 70.3 [8.1] kg) took part in the study. Blood glucose concentration was monitored every 10 minutes using both a CGM (FreeStyle Libre, Abbott, France) and finger-prick blood glucose measurements (FreeStyle Optimum) over 4 different periods (postbreakfast, preexercise, exercise, and postexercise). Two different breakfasts (carbohydrates [CHO] and protein oriented) over 2 days (2 × 2 d in total) were used. Statistical analyses included the Bland–Altman method, standardized mean bias (expressed in standardized units), median absolute relative difference, and the Clarke error grid analysis. Results: Overall, mean bias was trivial to small at postbreakfast (effect size ± 90% confidence limits: −0.12 ± 0.08), preexercise (−0.08 ± 0.08), and postexercise (0.25 ± 0.14), while moderate during exercise (0.66 ± 0.09). A higher median absolute relative difference was observed during exercise (13.6% vs 7%–9.5% for the other conditions). While there was no effect of the breakfast type on the median absolute relative difference results, error grid analysis revealed a higher value in zone D (ie, clinically unsafe zone) during exercise for CHO (10.5%) compared with protein (1.6%). Conclusion: The CGM device examined in this study can only be validly used at rest, after both a CHO and protein-rich breakfast. Using CGM to monitor blood glucose concentration during exercise is not recommended. Moreover, the accuracy decreased when CHO were consumed before exercise.
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25
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Wang S, Tan Z, Wu T, Shen Q, Huang P, Wang L, Liu W, Song H, Lin M, Shi X, Li X. Largest Amplitude of Glycemic Excursion Calculating from Self-Monitoring Blood Glucose Predicted the Episodes of Nocturnal Asymptomatic Hypoglycemia Detecting by Continuous Glucose Monitoring in Outpatients with Type 2 Diabetes. Front Endocrinol (Lausanne) 2022; 13:858912. [PMID: 35498416 PMCID: PMC9047895 DOI: 10.3389/fendo.2022.858912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/15/2022] [Indexed: 12/03/2022] Open
Abstract
AIMS Nocturnal asymptomatic hypoglycemia (NAH) is a serious complication of diabetes, but it is difficult to be detected clinically. This study was conducted to determine the largest amplitude of glycemic excursion (LAGE) to predict the episodes of NAH in outpatients with type 2 diabetes. METHODS Data were obtained from 313 outpatients with type 2 diabetes. All subjects received continuous glucose monitoring (CGM) for consecutive 72 hours. The episodes of NAH and glycemic variability indices (glucose standard deviation [SD], mean amplitude of plasma glucose excursion [MAGE], mean blood glucose [MBG]) were accessed via CGM. LAGE was calculated from self-monitoring blood glucose (SMBG). RESULTS A total of 76 people (24.3%) had NAH. Compared to patients without NAH, patients with NAH showed higher levels of glucose SD (2.4 ± 0.9 mmol/L vs 1.7 ± 0.9 mmol/L, p <0.001), MAGE (5.2 ± 2.1 mmol/L vs 3.7 ± 2.0, p<0.001) and LAGE (4.6 ± 2.3 mmol/L vs 3.8 ± 1.9 mmol/L, p=0.007), and lower level of MBG (7.5 ± 1.5 mmol/L vs 8.4 ± 2.2 mmol/L, p=0.002). LAGE was significantly associated with the incidence of NAH and time below rang (TBR) in model 1 [NAH: 1.189 (1.027-1.378), p=0.021; TBR: 0.008 (0.002-0.014), p=0.013] with adjustment for age, BMI, sex, work, hyperlipidemia, complication and medication, and in model 2 [NAH: 1.177 (1.013-1.367), p=0.033; TBR: 0.008 (0.002-0.014), p=0.012] after adjusting for diabetes duration based on model 1, as well as in model 3 [NAH: 1.244 (1.057-1.464), p=0.009; TBR: 0.009 (0.002-0.016), p=0.007] with further adjustment for HbA1c based on model 2. In addition, no significant interactions were found between LAGE and sex, age, HbA1c, duration of diabetes, BMI and insulin therapy on the risk of NAH. The receiver operator characteristic (ROC) curve shows the ideal cutoff value of LAGE for the prediction of NAH was 3.48 mmol/L with 66.7% sensitivity, 50% specificity and 0.587 (95% CI: 0.509-0.665) of area under the ROC curve. CONCLUSIONS High glycemic variability is strongly associated with the risk of NAH. The LAGE based on SMBG could be an independent predictor of NAH for outpatients with type 2 diabetes, and LAGE greater than 3.48 mmol/L could act as a warning alarm for high risk of NAH in daily life.
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Affiliation(s)
- Shoubi 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Eye Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Zhenhua Tan
- Xiahe Branch of the Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Ting Wu
- The School of Clinical of Medicine, Fujian Medical University, Fuzhou, China
| | - Qingbao 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Peiying Huang
- 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Liying 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Wei Liu
- 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Haiqu Song
- 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Mingzhu 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Xiulin 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- *Correspondence: Xuejun Li, ; Xiulin Shi,
| | - Xuejun 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, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- *Correspondence: Xuejun Li, ; Xiulin Shi,
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26
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Bouillet B, Tscherter P, Vaillard L, Nonciaux C, Hourdain P, Ravier A, Rouland A, Petit JM, Vergès B, Quilot E. Frequent and severe hypoglycaemia detected with continuous glucose monitoring in older institutionalised patients with diabetes. Age Ageing 2021; 50:2088-2093. [PMID: 34324624 DOI: 10.1093/ageing/afab128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Little is known about the prevalence of hypoglycaemia in older people with diabetes. However, the HbA1c goal is ≥8% for institutionalised patients with treatments that can cause hypoglycaemia. PURPOSE We aimed to assess the prevalence of hypoglycaemia with continuous glucose monitoring and to evaluate the link with HbA1C in older institutionalised patients with diabetes taking potentially hypoglycaemia-inducing drugs. DESIGN Prospective, multicentre study carried out in six geriatric care centres in the Côte d'Or region of France between January 2019 and July 2020. SETTINGS, SUBJECTS AND METHODS A FreeStyle Libre Pro® (FSLP) was worn for up to 14 days in blinded mode in 42 patients taking at least one potentially hypoglycaemia-inducing antidiabetic drug. RESULTS Two hundred and forty-two hypoglycaemic events were detected in 79% (n = 33) of patients wearing the FSLP. One or more hypoglycaemic event was detected in 100% of patients with HbA1C < 7% and in 79% of patients with HbA1C ≥ 8% (P = 0.02). The time spent in hypoglycaemia was higher in patients with HbA1C < 7% than those with HbA1C ≥ 8% (P = 0.015). Time spent <54 mg/dl was detected in 45% of patients. CONCLUSIONS We report a very high prevalence of hypoglycaemia, with a significant proportion of severe hypoglycaemia, in older institutionalised patients with diabetes taking potentially hypoglycaemia-inducing drugs. Having HbA1C < 7% exposes patients to a higher risk of hypoglycaemia, but this risk remains also high in patients with HbA1C ≥ 8%. In this population, continuous glucose monitoring could be considered an effective tool to detect hypoglycemia, which is associated with increased risk of cardiovascular events, falling, fractures, cognitive impairment and mortality.
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Affiliation(s)
- Benjamin Bouillet
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, France
- INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
| | - Pauline Tscherter
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, France
| | | | | | | | | | - Alexia Rouland
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, France
- INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
| | - Jean Michel Petit
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, France
- INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
| | - Bruno Vergès
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, France
- INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
| | - Emilienne Quilot
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, France
- INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
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27
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Criner KE, Kim HN, Ali H, Kumar SJ, Kanter JE, Wang L, Korytkowski MT. Hypoglycemia symptoms are reduced in hospitalized patients with diabetes. J Diabetes Complications 2021; 35:107976. [PMID: 34364780 PMCID: PMC8434970 DOI: 10.1016/j.jdiacomp.2021.107976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 01/02/2023]
Abstract
AIMS Hospitalized patients with diabetes are have an impaired ability to detect hypoglycemia events. The purpose of this study was to compare hypoglycemia symptom scores (HSS) in hospitalized patients with diabetes after a documented blood glucose (BG) <70mg/dl with recalled HSS with outpatient hypoglycemia events. METHODS Non-critically ill hospitalized patients with diabetes grouped as symptomatic (n=23) or asymptomatic (n=32) at time of index hypoglycemia completed a standardized HSS-Questionnaires (HSS-Q) related to the inpatient event and to recall of symptoms with outpatient hypoglycemia. RESULTS After controlling for BG at time of index hypoglycemia (49.8±11.4 vs. 57.4±6.8mg/dl, p=0.02), symptomatic patients reported higher HSS than asymptomatic patients with the inpatient event (11.6±7.3 vs. 1.5±3.4, p<0.001) and in the outpatient setting (13.9±8.6 vs. 10.1±10.6, p<0.01). Recurrent hypoglycemia was more frequent in asymptomatic patients (13% vs. 44%, p=0.015) during the hospitalization. CONCLUSIONS Compared to symptomatic patients, asymptomatic patients had lower inpatient and outpatient HSS and more frequent recurrent hypoglycemia events. These results suggest modification of glycemic management strategies in high risk patients to reduce risk for hypoglycemia events.
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Affiliation(s)
- Kristin E Criner
- University of Pittsburgh Medical Center, United States of America
| | - Han Na Kim
- University of Pittsburgh Medical Center, United States of America
| | - Hira Ali
- University of Pittsburgh Medical Center, United States of America
| | - Smita J Kumar
- University of Pittsburgh Medical Center, United States of America
| | - Justin E Kanter
- University of Pittsburgh Medical Center, United States of America
| | - Li Wang
- University of Pittsburgh, Clinical and Translational Science Institute, United States of America
| | - Mary T Korytkowski
- University of Pittsburgh, Division of Endocrinology and Metabolism, United States of America.
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Wen X, Ou T, Zeng N, Li X, Luo A, Xu X, Li W, Du T. Clinical interpretation of the flash continuous glucose monitoring data out of range in type 2 diabetes: A real-world study. Diabetes Res Clin Pract 2021; 178:108989. [PMID: 34331978 DOI: 10.1016/j.diabres.2021.108989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/30/2021] [Accepted: 07/24/2021] [Indexed: 10/20/2022]
Abstract
AIMS Flash continuous glucose monitoring system (FCGM) reports nocturnal hypoglycemia with low accuracy in low blood glucose. In our study, we aimed to evaluate the accuracy and clinic profile of FCGM data out of range in T2DM. METHODS FCGM data out of range were measured in T2DM patients at eight-time points of a day and compared with fingertip capillary blood glucose levels (REFs) as reference values. RESULTS A total of 307 out-of-range cases from 25,886 paired FCGM/REF data from 742 T2DM patients were evaluated. The distribution of "LO" and "HI" cases displayed the significant difference between eight-time points (P < 0.001) with the highest frequency (6.52%) of the "LO" value at 3 AM. The consistency rate between FCGM "LO" readings and REF < 40 mg/dl was far lower than that of FCGM "HI" readings with REF > 500 mg/dl (0.84% vs. 52.2%). In addition, the frequency of some clinical characteristics, including diabetes duration, hypoglycemia, hypertension, HbA1c, and Hb, were higher in patients with FCGM "LO" readings compared to those with "HI" readings. CONCLUSIONS These findings suggest the results and treatment regarding FCGM "LO" data should be interpreted with strong caution in the light of the emerging possible adverse measurement in patients.
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Affiliation(s)
- Xiaofang Wen
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510250, China
| | - Tingting Ou
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510250, China
| | - Nan Zeng
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510250, China
| | - Xiaowei Li
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510250, China
| | - Ai Luo
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510250, China
| | - Xiaojia Xu
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510250, China
| | - Wangen Li
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510250, China
| | - Tao Du
- Department of Endocrinology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510250, China.
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Davis GM, Spanakis EK, Migdal AL, Singh LG, Albury B, Urrutia MA, Zamudio-Coronado KW, Scott WH, Doerfler R, Lizama S, Satyarengga M, Munir K, Galindo RJ, Vellanki P, Cardona S, Pasquel FJ, Peng L, Umpierrez GE. Accuracy of Dexcom G6 Continuous Glucose Monitoring in Non-Critically Ill Hospitalized Patients With Diabetes. Diabetes Care 2021; 44:1641-1646. [PMID: 34099515 PMCID: PMC8323182 DOI: 10.2337/dc20-2856] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 04/18/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Advances in continuous glucose monitoring (CGM) have transformed ambulatory diabetes management. Until recently, inpatient use of CGM has remained investigational, with limited data on its accuracy in the hospital setting. RESEARCH DESIGN AND METHODS To analyze the accuracy of Dexcom G6, we compared retrospective matched-pair CGM and capillary point-of-care (POC) glucose data from three inpatient CGM studies (two interventional and one observational) in general medicine and surgery patients with diabetes treated with insulin. Analysis of accuracy metrics included mean absolute relative difference (MARD), median absolute relative difference (ARD), and proportion of CGM values within 15, 20, and 30% or 15, 20, and 30 mg/dL of POC reference values for blood glucose >100 mg/dL or ≤100 mg/dL, respectively (% 15/15, % 20/20, % 30/30). Clinical reliability was assessed with Clarke error grid (CEG) analyses. RESULTS A total of 218 patients were included (96% with type 2 diabetes) with a mean age of 60.6 ± 12 years. The overall MARD (n = 4,067 matched glucose pairs) was 12.8%, and median ARD was 10.1% (interquartile range 4.6, 17.6]. The proportions of readings meeting % 15/15, % 20/20, and % 30/30 criteria were 68.7, 81.7, and 93.8%, respectively. CEG analysis showed 98.7% of all values in zones A and B. MARD and median ARD were higher in the case of hypoglycemia (<70 mg/dL) and severe anemia (hemoglobin <7 g/dL). CONCLUSIONS Our results indicate that CGM technology is a reliable tool for hospital use and may help improve glucose monitoring in non-critically ill hospitalized patients with diabetes.
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Affiliation(s)
- Georgia M Davis
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Elias K Spanakis
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD.,Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD
| | - Alexandra L Migdal
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Lakshmi G Singh
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Bonnie Albury
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Maria Agustina Urrutia
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - K Walkiria Zamudio-Coronado
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - William H Scott
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Rebecca Doerfler
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD
| | - Sergio Lizama
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD
| | - Medha Satyarengga
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD
| | - Kashif Munir
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD
| | - Rodolfo J Galindo
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Priyathama Vellanki
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Saumeth Cardona
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Francisco J Pasquel
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Limin Peng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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30
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Perez-Guzman MC, Shang T, Zhang JY, Jornsay D, Klonoff DC. Continuous Glucose Monitoring in the Hospital. Endocrinol Metab (Seoul) 2021; 36:240-255. [PMID: 33789033 PMCID: PMC8090458 DOI: 10.3803/enm.2021.201] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 12/14/2022] Open
Abstract
Continuous glucose monitors (CGMs) have suddenly become part of routine care in many hospitals. The coronavirus disease 2019 (COVID-19) pandemic has necessitated the use of new technologies and new processes to care for hospitalized patients, including diabetes patients. The use of CGMs to automatically and remotely supplement or replace assisted monitoring of blood glucose by bedside nurses can decrease: the amount of necessary nursing exposure to COVID-19 patients with diabetes; the amount of time required for obtaining blood glucose measurements, and the amount of personal protective equipment necessary for interacting with patients during the blood glucose testing. The United States Food and Drug Administration (FDA) is now exercising enforcement discretion and not objecting to certain factory-calibrated CGMs being used in a hospital setting, both to facilitate patient care and to obtain performance data that can be used for future regulatory submissions. CGMs can be used in the hospital to decrease the frequency of fingerstick point of care capillary blood glucose testing, decrease hyperglycemic episodes, and decrease hypoglycemic episodes. Most of the research on CGMs in the hospital has focused on their accuracy and only recently outcomes data has been reported. A hospital CGM program requires cooperation of physicians, bedside nurses, diabetes educators, and hospital administrators to appropriately select and manage patients. Processes for collecting, reviewing, storing, and responding to CGM data must be established for such a program to be successful. CGM technology is advancing and we expect that CGMs will be increasingly used in the hospital for patients with diabetes.
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Affiliation(s)
- M. Citlalli Perez-Guzman
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University, Atlanta, GA,
USA
| | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA,
USA
| | | | - Donna Jornsay
- Diabetes Program, Mills-Peninsula Medical Center, Burlingame, CA,
USA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA,
USA
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Kalra S, Shaikh S, Priya G, Baruah MP, Verma A, Das AK, Shah M, Das S, Khandelwal D, Sanyal D, Ghosh S, Saboo B, Bantwal G, Ayyagari U, Gardner D, Jimeno C, Barbary NE, Hafidh KA, Bhattarai J, Minulj TT, Zufry H, Bulugahapitiya U, Murad M, Tan A, Shahjada S, Bello MB, Katulanda P, Podgorski G, AbuHelaiqa WI, Tan R, Latheef A, Govender S, Assaad-Khalil SH, Kootin-Sanwu C, Joshi A, Pathan F, Nkansah DA. Individualizing Time-in-Range Goals in Management of Diabetes Mellitus and Role of Insulin: Clinical Insights From a Multinational Panel. Diabetes Ther 2021; 12:465-485. [PMID: 33367983 PMCID: PMC7846622 DOI: 10.1007/s13300-020-00973-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023] Open
Abstract
Diabetes mellitus is a global health concern associated with significant morbidity and mortality. Inadequate control of diabetes leads to chronic complications and higher mortality rates, which emphasizes the importance of achieving glycemic targets. Although glycated hemoglobin (HbA1c) is the gold standard for measuring glycemic control, it has several limitations. Therefore, in recent years, along with the emergence of continuous glucose monitoring (CGM) technology, glycemic control modalities have moved beyond HbA1c. They encompass modern glucometrics, such as glycemic variability (GV) and time-in-range (TIR). The key advantage of these newer metrics over HbA1c is that they allow personalized diabetes management with person-centric glycemic control. Basal insulin analogues, especially second-generation basal insulins with properties such as longer duration of action and low risk of hypoglycemia, have demonstrated clinical benefits by reducing GV and improving TIR. Therefore, for more effective and accurate diabetes management, the development of an integrated approach with second-generation basal insulin and glucometrics involving GV and TIR is the need of the hour. With this objective, a multinational group of endocrinologists and diabetologists reviewed the existing recommendations on TIR, provided their clinical insights into the individualization of TIR targets, and elucidated on the role of the second-generation basal insulin analogues in addressing TIR.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India.
| | - Shehla Shaikh
- Department of Endocrinology, KGN Institute of Diabetes and Endocrinology, Mumbai, Maharashtra, India
| | - Gagan Priya
- Department of Endocrinology, Fortis Hospital, Chandigarh, Punjab, India
| | - Manas P Baruah
- Department of Endocrinology, Excel Hospital, Guwahati, Assam, India
| | - Abhyudaya Verma
- Endocrine Division, Index Medical College, Indore, Madhya Pradesh, India
| | - Ashok K Das
- Department of Endocrinology and Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Mona Shah
- HARMONY Endocrine Diabetes and Metabolic Clinic, Vadodara, Gujarat, India
| | - Sambit Das
- Department of Endocrinology, Apollo Hospitals, Bhubaneswar, Odisha, India
| | - Deepak Khandelwal
- Department of Endocrinology and Diabetes, Maharaja Agrasen Hospital, New Delhi, India
| | - Debmalya Sanyal
- Department of Endocrinology, KPC Medical College, Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department of Endocrinology and Metabolism, IPGMER, Kolkata, West Bengal, India
| | - Banshi Saboo
- Dia Care, Diabetes Care and Hormone Clinic, Ahmedabad, Gujarat, India
| | - Ganapathi Bantwal
- Department of Endocrinology, St. John's Medical College and Hospital, Bangalore, Karnataka, India
| | - Usha Ayyagari
- Department of Endocrinology, Apollo Sugar Clinics, Chennai, Tamil Nadu, India
| | - Daphne Gardner
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Cecilia Jimeno
- Department of Endocrinology, Philippine Society of Endocrinology, Diabetes and Metabolism, Manila, Philippines
| | - Nancy E Barbary
- Department of Endocrinology, Ain Shams University, Cairo, Egypt
| | - Khadijah A Hafidh
- Department of Endocrinology, Rashid Hospital-Dubai Health Authority, Dubai, UAE
| | - Jyoti Bhattarai
- Department of Endocrinology, Metro Kathmandu Hospital, Kathmandu, Nepal
| | - Tania T Minulj
- Department of Endocrinology, General Hospital Karyadi, Semarang, Indonesia
| | - Hendra Zufry
- Department of Endocrinology, General Hospital Zainoel Abidin, Aceh, Indonesia
| | | | - Moosa Murad
- Department of Internal Medicine, Indira Gandhi Memorial Hospital, Malé, Maldives
| | - Alexander Tan
- Department of Endocrinology, Sunway Medical Centre, Kuala Lumpur, Malaysia
| | - Selim Shahjada
- Department of Endocrinology, BSMMU (Bangabandhu Sheikh Mujib Medical University Hospital), Dhaka, Bangladesh
| | - Mijinyawa B Bello
- Department of Endocrinology, Gwarinpa District Hospital, Abuja, Nigeria
| | - Prasad Katulanda
- Department of Endocrinology, University of Colombo, Colombo, Sri Lanka
| | - Gracjan Podgorski
- Department of Endocrinology, Greenacres Hospital, Port Elizabeth, South Africa
| | | | - Rima Tan
- Department of Endocrinology, FEU-NRMF Medical Center, Quezon City, Philippines
| | - Ali Latheef
- Department of Endocrinology, Indira Gandhi Memorial Hospital, Malé, Maldives
| | | | | | | | - Ansumali Joshi
- Department of Endocrinology, Kathmandu Diabetes and Thyroid Center, Kathmandu, Nepal
| | - Faruque Pathan
- Department of Endocrinology, Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh
| | - Diana A Nkansah
- Department of Endocrinology, 37 Military Hospital Accra, Accra, Ghana
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Yeh T, Yeung M, Mendelsohn Curanaj FA. Managing Patients with Insulin Pumps and Continuous Glucose Monitors in the Hospital: to Wear or Not to Wear. Curr Diab Rep 2021; 21:7. [PMID: 33449214 PMCID: PMC7810103 DOI: 10.1007/s11892-021-01375-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW As the prevalence of diabetes mellitus in the USA continues to rise, so does the popularity of diabetes management devices such as continuous glucose monitors (CGMs) and insulin pumps. The use of this technology has been shown to improve outpatient glycemic outcomes and quality of life and oftentimes may be continued in the hospital setting. Our aim is to review the current guidelines and available evidence on the continuation of insulin pumps and CGMs in the inpatient setting. RECENT FINDINGS Patients with diabetes are at higher risk for hospitalizations and complications due to hyper- or hypoglycemia, metabolic co-morbidities, or as seen recently, more severe illness from infections such as SARS-CoV-2. The maintenance of euglycemia is important to decrease both morbidity and mortality in the hospital setting. There is consensus among experts and medical societies that inpatient use of diabetes technology in carefully selected patients with proper institutional protocols is safe and can improve inpatient glycemic outcomes and reduce hypoglycemia. During the COVID-19 pandemic, CGMs played a vital role in managing hyperglycemia in some hospitalized patients. Insulin pumps and CGMs have the potential to transform glycemic management in hospitalized patients. In order for institutions to safely and effectively incorporate these technologies on their inpatient units, hospital-based providers will need to be able to understand how to manage and utilize these devices in their practice in conjunction with diabetes experts.
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Affiliation(s)
- Tiffany Yeh
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA.
| | - Michele Yeung
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Felicia A Mendelsohn Curanaj
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
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Galindo RJ, Migdal AL, Davis GM, Urrutia MA, Albury B, Zambrano C, Vellanki P, Pasquel FJ, Fayfman M, Peng L, Umpierrez GE. Comparison of the FreeStyle Libre Pro Flash Continuous Glucose Monitoring (CGM) System and Point-of-Care Capillary Glucose Testing in Hospitalized Patients With Type 2 Diabetes Treated With Basal-Bolus Insulin Regimen. Diabetes Care 2020; 43:2730-2735. [PMID: 32641372 PMCID: PMC7809713 DOI: 10.2337/dc19-2073] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 05/10/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We compared the performance of the FreeStyle Libre Pro continuous glucose monitoring (CGM) and point-of-care capillary glucose testing (POC) among insulin-treated hospitalized patients with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS This was a prospective study in adult patients with T2D admitted to general medicine and surgery wards. Patients were monitored with POC before meals and bedtime and with CGM during the hospital stay. Study end points included differences between POC and CGM in mean daily blood glucose (BG), hypoglycemia <70 and <54 mg/dL, and nocturnal hypoglycemia. We also calculated the mean absolute relative difference (MARD), ±15%/15 mg/dL, ±20%/20 mg/dL, and ±30%/30 mg/dL and error grid analysis between matched glucose pairs. RESULTS Mean daily glucose was significantly higher by POC (188.9 ± 37.3 vs. 176.1 ± 46.9 mg/dL) with an estimated mean difference of 12.8 mg/dL (95% CI 8.3-17.2 mg/dL), and proportions of patients with glucose readings <70 mg/dL (14% vs. 56%) and <54 mg/dL (4.1% vs. 36%) detected by POC BG were significantly lower compared with CGM (all P < 0.001). Nocturnal and prolonged CGM hypoglycemia <54 mg/dL were 26% and 12%, respectively. The overall MARD was 14.8%, ranging between 11.4% and 16.7% for glucose values between 70 and 250 mg/dL and higher for 51-69 mg/dL (MARD 28.0%). The percentages of glucose readings within ±15%/15 mg/dL, ±20%/20 mg/dL, and ±30%/30 mg/dL were 62%, 76%, and 91%, respectively. Error grid analysis showed 98.8% of glucose pairs within zones A and B. CONCLUSIONS Compared with POC, FreeStyle Libre CGM showed lower mean daily glucose and higher detection of hypoglycemic events, particularly nocturnal and prolonged hypoglycemia in hospitalized patients with T2D. CGM's accuracy was lower in the hypoglycemic range.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Alexandra L Migdal
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Georgia M Davis
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Maria A Urrutia
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Bonnie Albury
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Cesar Zambrano
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Priyathama Vellanki
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Francisco J Pasquel
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Maya Fayfman
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
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Fortmann AL, Spierling Bagsic SR, Talavera L, Garcia IM, Sandoval H, Hottinger A, Philis-Tsimikas A. Glucose as the Fifth Vital Sign: A Randomized Controlled Trial of Continuous Glucose Monitoring in a Non-ICU Hospital Setting. Diabetes Care 2020; 43:2873-2877. [PMID: 32855160 PMCID: PMC7576427 DOI: 10.2337/dc20-1016] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/15/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The current standard for hospital glucose management is point-of-care (POC) testing. We conducted a randomized controlled trial of real-time continuous glucose monitoring (RT-CGM) compared with POC in a non-intensive care unit (ICU) hospital setting. RESEARCH DESIGN AND METHODS A total of 110 adults with type 2 diabetes on a non-ICU floor received RT-CGM with Dexcom G6 versus usual care (UC). RT-CGM data were wirelessly transmitted from the bedside. Hospital telemetry monitored RT-CGM data and notified bedside nursing of glucose alerts and trends. Standardized protocols were used for interventions. RESULTS The RT-CGM group demonstrated significantly lower mean glucose (M∆ = -18.5 mg/dL) and percentage of time in hyperglycemia >250 mg/dL (-11.41%) and higher time in range 70-250 mg/dL (+11.26%) compared with UC (P values <0.05). Percentage of time in hypoglycemia was very low. CONCLUSIONS RT-CGM can be used successfully in community-based hospital non-ICU settings to improve glucose management. Continuously streaming glucose readings may truly be the fifth vital sign.
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Galindo RJ, Umpierrez GE, Rushakoff RJ, Basu A, Lohnes S, Nichols JH, Spanakis EK, Espinoza J, Palermo NE, Awadjie DG, Bak L, Buckingham B, Cook CB, Freckmann G, Heinemann L, Hovorka R, Mathioudakis N, Newman T, O’Neal DN, Rickert M, Sacks DB, Seley JJ, Wallia A, Shang T, Zhang JY, Han J, Klonoff DC. Continuous Glucose Monitors and Automated Insulin Dosing Systems in the Hospital Consensus Guideline. J Diabetes Sci Technol 2020; 14:1035-1064. [PMID: 32985262 PMCID: PMC7645140 DOI: 10.1177/1932296820954163] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article is the work product of the Continuous Glucose Monitor and Automated Insulin Dosing Systems in the Hospital Consensus Guideline Panel, which was organized by Diabetes Technology Society and met virtually on April 23, 2020. The guideline panel consisted of 24 international experts in the use of continuous glucose monitors (CGMs) and automated insulin dosing (AID) systems representing adult endocrinology, pediatric endocrinology, obstetrics and gynecology, advanced practice nursing, diabetes care and education, clinical chemistry, bioengineering, and product liability law. The panelists reviewed the medical literature pertaining to five topics: (1) continuation of home CGMs after hospitalization, (2) initiation of CGMs in the hospital, (3) continuation of AID systems in the hospital, (4) logistics and hands-on care of hospitalized patients using CGMs and AID systems, and (5) data management of CGMs and AID systems in the hospital. The panelists then developed three types of recommendations for each topic, including clinical practice (to use the technology optimally), research (to improve the safety and effectiveness of the technology), and hospital policies (to build an environment for facilitating use of these devices) for each of the five topics. The panelists voted on 78 proposed recommendations. Based on the panel vote, 77 recommendations were classified as either strong or mild. One recommendation failed to reach consensus. Additional research is needed on CGMs and AID systems in the hospital setting regarding device accuracy, practices for deployment, data management, and achievable outcomes. This guideline is intended to support these technologies for the management of hospitalized patients with diabetes.
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Affiliation(s)
| | | | | | - Ananda Basu
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Suzanne Lohnes
- University of California San Diego Medical Center, La Jolla, CA, USA
| | | | - Elias K. Spanakis
- University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, MD, USA
| | | | - Nadine E. Palermo
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Tonya Newman
- Neal, Gerber and Eisenberg LLP, Chicago, IL, USA
| | - David N. O’Neal
- University of Melbourne Department of Medicine, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
| | | | | | | | - Amisha Wallia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | | | - Julia Han
- Diabetes Technology Society, Burlingame, CA, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Drive Room 5147, San Mateo, CA 94401, USA.
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Singh LG, Satyarengga M, Marcano I, Scott WH, Pinault LF, Feng Z, Sorkin JD, Umpierrez GE, Spanakis EK. Reducing Inpatient Hypoglycemia in the General Wards Using Real-time Continuous Glucose Monitoring: The Glucose Telemetry System, a Randomized Clinical Trial. Diabetes Care 2020; 43:2736-2743. [PMID: 32759361 PMCID: PMC7576426 DOI: 10.2337/dc20-0840] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/01/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Use of real-time continuous glucose monitoring (RT-CGM) systems in the inpatient setting is considered investigational. The objective of this study was to evaluate whether RT-CGM, using the glucose telemetry system (GTS), can prevent hypoglycemia in the general wards. RESEARCH DESIGN AND METHODS In a randomized clinical trial, insulin-treated patients with type 2 diabetes at high risk for hypoglycemia were recruited. Participants were randomized to RT-CGM/GTS or point-of-care (POC) blood glucose testing. The primary outcome was difference in inpatient hypoglycemia. RESULTS Seventy-two participants were included in this interim analysis, 36 in the RT-CGM/GTS group and 36 in the POC group. The RT-CGM/GTS group experienced fewer hypoglycemic events (<70 mg/dL) per patient (0.67 [95% CI 0.34-1.30] vs. 1.69 [1.11-2.58], P = 0.024), fewer clinically significant hypoglycemic events (<54 mg/dL) per patient (0.08 [0.03-0.26] vs. 0.75 [0.51-1.09], P = 0.003), and a lower percentage of time spent below range <70 mg/dL (0.40% [0.18-0.92%] vs. 1.88% [1.26-2.81%], P = 0.002) and <54 mg/dL (0.05% [0.01-0.43%] vs. 0.82% [0.47-1.43%], P = 0.017) compared with the POC group. No differences in nocturnal hypoglycemia, time in range 70-180 mg/dL, and time above range >180-250 mg/dL and >250 mg/dL were found between the groups. The RT-CGM/GTS group had no prolonged hypoglycemia compared with 0.20 episodes <54 mg/dL and 0.40 episodes <70 mg/dL per patient in the POC group. CONCLUSIONS RT-CGM/GTS can decrease hypoglycemia among hospitalized high-risk insulin-treated patients with type 2 diabetes.
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Affiliation(s)
- Lakshmi G Singh
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Medha Satyarengga
- Center for Diabetes and Endocrinology, University of Maryland Shore Regional Health, Easton, MD
| | - Isabel Marcano
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD
| | - William H Scott
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Lillian F Pinault
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Zhaoyong Feng
- Pharmaceutical Research Computing, Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - John D Sorkin
- Baltimore Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center, Baltimore, MD
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Elias K Spanakis
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD .,Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD
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Reutrakul S, Genco M, Salinas H, Sargis RM, Paul C, Eisenberg Y, Fang J, Caskey RN, Henkle S, Fatoorehchi S, Osta A, Srivastava P, Johnson A, Messmer SE, Barnes M, Pratuangtham S, Layden BT. Feasibility of Inpatient Continuous Glucose Monitoring During the COVID-19 Pandemic: Early Experience. Diabetes Care 2020; 43:e137-e138. [PMID: 32769129 PMCID: PMC7876554 DOI: 10.2337/dc20-1503] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Sirimon Reutrakul
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Matthew Genco
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Harley Salinas
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Robert M Sargis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Carlie Paul
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Yuval Eisenberg
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Jiali Fang
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Rachel N Caskey
- Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Sarah Henkle
- Department of Family Medicine, University of Illinois at Chicago, Chicago, IL
| | - Sam Fatoorehchi
- Department of Family Medicine, University of Illinois at Chicago, Chicago, IL
| | - Amanda Osta
- Department of Medicine, University of Illinois at Chicago, Chicago, IL.,Department of Pediatrics, University of Illinois at Chicago, Chicago, IL
| | - Pavan Srivastava
- Department of Medicine, University of Illinois at Chicago, Chicago, IL.,Department of Pediatrics, University of Illinois at Chicago, Chicago, IL
| | - Alexia Johnson
- University of Illinois Hospital & Health Sciences System, Chicago, IL
| | - Sarah E Messmer
- Department of Medicine, University of Illinois at Chicago, Chicago, IL.,Department of Pediatrics, University of Illinois at Chicago, Chicago, IL
| | - Michelle Barnes
- Department of Medicine, University of Illinois at Chicago, Chicago, IL.,Department of Pediatrics, University of Illinois at Chicago, Chicago, IL
| | | | - Brian T Layden
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, IL
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38
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Galindo RJ, Aleppo G, Klonoff DC, Spanakis EK, Agarwal S, Vellanki P, Olson DE, Umpierrez GE, Davis GM, Pasquel FJ. Implementation of Continuous Glucose Monitoring in the Hospital: Emergent Considerations for Remote Glucose Monitoring During the COVID-19 Pandemic. J Diabetes Sci Technol 2020; 14:822-832. [PMID: 32536205 PMCID: PMC7673156 DOI: 10.1177/1932296820932903] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Continuous glucose monitoring (CGM) has become a widely used tool in the ambulatory setting for monitoring glucose levels, as well as detecting uncontrolled hyperglycemia, hypoglycemia, and glycemic variability. The accuracy of some CGM systems has recently improved to the point of manufacture with factory calibration and Food and Drug Administration clearance for nonadjunctive use to dose insulin. In this commentary, we analyze the answers to six questions about what is needed to bring CGM into the hospital as a reliable, safe, and effective tool. The evidence to date indicates that CGM offers promise as an effective tool for monitoring hospitalized patients. During the current coronavirus disease 2019 crisis, we hope to provide guidance to healthcare professionals, who are seeking to reduce exposure to SARS-Cov-2, as well as preserve invaluable personal protective equipment. In this commentary, we address who, what, where, when, why, and how CGM can be adopted for inpatient use.
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Affiliation(s)
- Rodolfo J. Galindo
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Elias K. Spanakis
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, MD, USA
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, USA
| | - Shivani Agarwal
- Fleischer Institute for Diabetes and Metabolism, NY-Regional Center for Diabetes Translational Research, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Priya Vellanki
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Darin E. Olson
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Division of Endocrinology, Atlanta Veterans Affairs Medical Center, GA, USA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Georgia M. Davis
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Francisco J. Pasquel
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Accuracy and stability of an arterial sensor for glucose monitoring in a porcine model using glucose clamp technique. Sci Rep 2020; 10:6604. [PMID: 32313062 PMCID: PMC7170864 DOI: 10.1038/s41598-020-63659-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/03/2020] [Indexed: 01/08/2023] Open
Abstract
Intravascular glucose sensors have the potential to improve and facilitate glycemic control in critically ill patients and might overcome measurement delay and accuracy issues. This study investigated the accuracy and stability of a biosensor for arterial glucose monitoring tested in a hypo- and hyperglycemic clamp experiment in pigs. 12 sensors were tested over 5 consecutive days in 6 different pigs. Samples of sensor and reference measurement pairs were obtained every 15 minutes. 1337 pairs of glucose values (range 37–458 mg/dl) were available for analysis. The systems met ISO 15197:2013 criteria in 99.2% in total, 100% for glucose <100 mg/dl (n = 414) and 98.8% for glucose ≥100 mg/dl (n = 923). The mean absolute relative difference (MARD) during the entire glycemic range of all sensors was 4.3%. The MARDs within the hypoglycemic (<70 mg/dl), euglycemic (≥70–180 mg/dl) and hyperglycemic glucose ranges (≥180 mg/dl) were 6.1%, 3.6% and 4.7%, respectively. Sensors indicated comparable performance on all days investigated (day 1, 3 and 5). None of the systems showed premature failures. In a porcine model, the performance of the biosensor revealed a promising performance. The transfer of these results into a human setting is the logical next step.
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40
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Gómez AM, Imitola Madero A, Henao Carrillo DC, Rondón M, Muñoz OM, Robledo MA, Rebolledo M, García Jaramillo M, León Vargas F, Umpierrez G. Hypoglycemia Incidence and Factors Associated in a Cohort of Patients With Type 2 Diabetes Hospitalized in General Ward Treated With Basal Bolus Insulin Regimen Assessed by Continuous Glucose Monitoring. J Diabetes Sci Technol 2020; 14:233-239. [PMID: 30678495 PMCID: PMC7196858 DOI: 10.1177/1932296818823720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Continuous glucose monitoring (CGM) is a better tool to detect hyper and hypoglycemia than capillary point of care in insulin-treated patients during hospitalization. We evaluated the incidence of hypoglycemia in patients with type 2 diabetes (T2D) treated with basal bolus insulin regimen using CGM and factors associated with hypoglycemia. METHODS Post hoc analysis of a prospective cohort study. Hypoglycemia was documented in terms of incidence rate and percentage of time <54 mg/dL (3.0 mmol/L) and <70 mg/dL (3.9 mmol/L). Factors evaluated included glycemic variability analyzed during the first 6 days of basal bolus therapy. RESULTS A total of 34 hospitalized patients with T2D in general ward were included, with admission A1c of 9.26 ± 2.62% (76.8 ± 13 mmol/mol) and mean blood glucose of 254 ± 153 mg/dL. There were two events of hypoglycemia below 54 mg/dL (3.0 mmol/L) and 11 events below 70 mg/dL (3.9 mmol/L) with an incidence of hypoglycemic events of 0.059 and 0.323 per patient, respectively. From second to fifth day of treatment the percentage of time in range (140-180 mg/dL, 7.8-10.0 mmol/L) increased from 72.1% to 89.4%. Factors related to hypoglycemic events <70 mg/dL (3.9 mmol/L) were admission mean glucose (IRR 0.86, 95% CI 0.79, 0.95, P < .01), glycemic variability measured as CV (IRR 3.12, 95% CI 1.33, 7.61, P < .01) and SD, and duration of stay. CONCLUSIONS Basal bolus insulin regimen is effective and the overall incidence of hypoglycemia detected by CGM is low in hospitalized patients with T2D. Increased glycemic variability as well as the decrease in mean glucose were associated with events <70 mg/dL (3.9 mmol/L).
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Affiliation(s)
- Ana María Gómez
- Pontificia Universidad Javeriana,
Bogotá, Colombia
- Hospital Universitario San Ignacio,
Endocrinology Unit, Bogotá, Colombia
- Ana María Gómez, MD, Endocrinology Unit,
Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Carrera 7
No. 40-62, Bogotá, Colombia.
| | - Angélica Imitola Madero
- Pontificia Universidad Javeriana,
Bogotá, Colombia
- Hospital Universitario San Ignacio,
Endocrinology Unit, Bogotá, Colombia
| | - Diana Cristina Henao Carrillo
- Pontificia Universidad Javeriana,
Bogotá, Colombia
- Hospital Universitario San Ignacio,
Endocrinology Unit, Bogotá, Colombia
| | - Martín Rondón
- Department of Clinical Epidemiology and
Biostatistics, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Oscar Mauricio Muñoz
- Hospital Universitario San Ignacio,
Department of Internal Medicine, Bogotá, Colombia
| | | | | | | | | | - Guillermo Umpierrez
- Department of Medicine, Emory
University, Atlanta, GA, USA
- Division of Endocrinology, Metabolism
and Lipids, Emory University, Atlanta, GA, USA
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41
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Davis GM, Galindo RJ, Migdal AL, Umpierrez GE. Diabetes Technology in the Inpatient Setting for Management of Hyperglycemia. Endocrinol Metab Clin North Am 2020; 49:79-93. [PMID: 31980123 PMCID: PMC7453786 DOI: 10.1016/j.ecl.2019.11.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In past decades, a rapid evolution of diabetes technology led to increased popularity and use of continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) in the ambulatory setting for diabetes management, and recently, the artificial pancreas became available. Efforts to translate this technology to the hospital setting have shown accuracy and reliability of CGM, safety of CSII in appropriate populations, improvement of inpatient glycemic control with computerized glycemic management systems, and feasibility of inpatient CGM-CSII closed-loop systems. Several ongoing studies are focusing on continued translation of this technology to improve glycemic control and outcomes in hospitalized patients.
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Affiliation(s)
- Georgia M Davis
- Department of Medicine, Emory University, 69 Jesse Hill Jr Drive Southeast, Glenn Memorial Building, Suite 200, Atlanta, GA 30303, USA
| | - Rodolfo J Galindo
- Department of Medicine, Emory University, 69 Jesse Hill Jr Drive Southeast, Glenn Memorial Building, Suite 200, Atlanta, GA 30303, USA
| | - Alexandra L Migdal
- Department of Medicine, Emory University, 69 Jesse Hill Jr Drive Southeast, Glenn Memorial Building, Suite 200, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Emory University, 69 Jesse Hill Jr Drive Southeast, Glenn Memorial Building, Suite 200, Atlanta, GA 30303, USA.
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42
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Montero AR, Dubin JS, Sack P, Magee MF. Future technology-enabled care for diabetes and hyperglycemia in the hospital setting. World J Diabetes 2019; 10:473-480. [PMID: 31558981 PMCID: PMC6748879 DOI: 10.4239/wjd.v10.i9.473] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/13/2019] [Accepted: 08/27/2019] [Indexed: 02/05/2023] Open
Abstract
Patients with diabetes are increasingly common in hospital settings where optimal glycemic control remains challenging. Inpatient technology-enabled support systems are being designed, adapted and evaluated to meet this challenge. Insulin pump use, increasingly common in outpatients, has been shown to be safe among select inpatients. Dedicated pump protocols and provider training are needed to optimize pump use in the hospital. Continuous glucose monitoring (CGM) has been shown to be comparable to usual care for blood glucose surveillance in intensive care unit (ICU) settings but data on cost effectiveness is lacking. CGM use in non-ICU settings remains investigational and patient use of home CGM in inpatient settings is not recommended due to safety concerns. Compared to unstructured insulin prescription, a continuum of effective electronic medical record-based support for insulin prescription exists from passive order sets to clinical decision support to fully automated electronic Glycemic Management Systems. Relative efficacy and cost among these systems remains unanswered. An array of novel platforms are being evaluated to engage patients in technology-enabled diabetes education in the hospital. These hold tremendous promise in affording universal access to hospitalized patients with diabetes to effective self-management education and its attendant short/long term clinical benefits.
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Affiliation(s)
- Alex Renato Montero
- MedStar Diabetes Institute, Washington, DC 20010, United States
- Department of Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Jeffrey S Dubin
- MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Paul Sack
- MedStar Diabetes Institute, Washington, DC 20010, United States
- MedStar Union Memorial Hospital, Baltimore, MD 21218, United States
| | - Michelle F Magee
- MedStar Diabetes Institute, Washington, DC 20010, United States
- MedStar Health Research Institute, Washington, DC 20010, United States
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43
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Aleppo G, Webb K. Continuous Glucose Monitoring Integration in Clinical Practice: A Stepped Guide to Data Review and Interpretation. J Diabetes Sci Technol 2019; 13:664-673. [PMID: 30453772 PMCID: PMC6610596 DOI: 10.1177/1932296818813581] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The advent of continuous glucose monitoring (CGM) technology has transformed the approach to diabetes care. Multiple CGM systems are commercially available and increased accuracy has allowed development of hybrid and automated insulin delivery systems. Evidence of CGM clinical benefits has also increased exponentially in the last decade. METHODS Literature search, review of professional guidelines, and consensus statements were used to guide the preparation of this article. The clinical benefits of both professional and personal CGM in clinical practice as well as barriers to wider adotpion were explored. A stepped approach to review and interpretation of CGM data is suggested for use in the clinician's office regardless of the software used. RESULTS Although increasing, the use of CGM in patients with diabetes is still not widespread; multiple barriers are still in place, despite the approval of CGM systems for patients above the age of 2 years old, the extension of coverage for Medicare beneficiaries and the integration of CGM with multiple insulin pump systems. Integration of CGM technology in clinical practice presents various challenges, from concerns relative to time constraints during office visits to lack of systematic approach to interpretation of the data. CONCLUSIONS Understanding the usefulness of personal and professional CGM, appropriate patient selection as well as patient and provider training are crucial for the expansion of CGM therapy use in clinical practice. Utilizing the proposed stepped approach to CGM review and interpretation may allow wider adoption of CGM with more effective and efficient office visits.
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Affiliation(s)
- Grazia Aleppo
- Division of Endocrinology, Metabolism
and Molecular Medicine, Feinberg School of Medicine, Northwestern University,
Chicago, IL, USA
- Northwestern Medicine Diabetes Training
and Education Program, Division of Endocrinology, Metabolism and Molecular Medicine,
Northwestern Medical Group, Chicago, IL, USA
- Grazia Aleppo, MD, FACE, FACP, Division of
Endocrinology, Northwestern University, 645 N Michigan Ave, Ste 530, Chicago, IL
60611, USA.
| | - Kimberly Webb
- Northwestern Medicine Diabetes Training
and Education Program, Division of Endocrinology, Metabolism and Molecular Medicine,
Northwestern Medical Group, Chicago, IL, USA
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Abstract
Improvements in glycemic control using continuous glucose monitoring (CGM) systems have been demonstrated in the outpatient setting. Among hospitalized patients the use of CGM is largely investigational, particularly in the non-ICU setting. Although there is no commercially available closed-loop system, it has recently been evaluated in the non-critical care setting. Both CGMs and closed-loop systems may lead to improved glycemic control, decreased length of stay, reduced risk of adverse events related to severe hypoglycemia or hyperglycemia. Limitations of inpatient use of CGM and closed-loop systems include lack of FDA approvals, inexperience with this technology, and costs related to supplies. Significant investment may be necessary for hospital staff training and for development of infrastructure to support inpatient use. Additional limitations for CGM systems includes potential inaccuracy of interstitial glucose measurements due to medication interferences, sensor lag, or sensor drift. Limitations for closed-loop systems also includes need for routine monitoring to detect infusion site issues as well as monitoring to ensure adequate insulin supply in reservoir to avoid abrupt cessation of insulin infusion leading to severe hyperglycemia. Hospital staff must be familiar with trouble-shooting and conversion to alternative mode of insulin delivery in the event of insulin pump malfunction. Given these complexities, implementation of closed-loop systems may require involvement of an endocrinology team, limiting widespread adoption. This article reviews current state of CGM and closed-loop system use in the non-ICU setting, available literature, advantages and limitations, as well as suggestions for future CGM design, specifically for the inpatient setting.
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Affiliation(s)
- Meng Wang
- Division of Hospital Medicine, Baltimore
Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Lakshmi G. Singh
- Division of Diabetes and Endocrinology,
Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Elias K. Spanakis
- Division of Diabetes and Endocrinology,
Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
- Division of Endocrinology, Diabetes and
Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
- Elias K. Spanakis, MD, Division of Diabetes
and Endocrinology, Baltimore Veterans Affairs Medical Center and Division of
Endocrinology, Diabetes and Nutrition, University of Maryland School of
Medicine, 10 N Greene St, 5D134, Baltimore, MD 21201, USA.
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Pu Z, Tu J, Han R, Zhang X, Wu J, Fang C, Wu H, Zhang X, Yu H, Li D. A flexible enzyme-electrode sensor with cylindrical working electrode modified with a 3D nanostructure for implantable continuous glucose monitoring. LAB ON A CHIP 2018; 18:3570-3577. [PMID: 30376024 DOI: 10.1039/c8lc00908b] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
A novel cylindrical flexible enzyme-electrode sensor was fabricated with a bigger working electrode (WE) surface than the traditional pin-like one for implantable continuous glucose monitoring. On the WE surface, a 3D nanostructure consisting of graphene and platinum nanoparticles was constructed to enhance the sensitivity; in conjunction with the bigger WE, this nanostructure enabled hypoglycemia detection, which is still a big challenge in clinics. The cylindrical sensor was fabricated by rotated inkjet printing which enabled direct patterning of microstructures on a curved surface, thus overcoming the restriction of the traditional planar micromachining by photolithography. Specifically, the cylindrical substrate (polyetheretherketone, PEEK) was modified by (3-aminopropyl) trimethoxysilane and (3-mercaptopropyl) trimethoxysilane to facilitate surface wettability, which discourages the coalescence of adjacent droplets, and to facilitate the adhesion of metals to PEEK in order to construct robust electrodes. A synchronous heating method was used to evaporate the solvent of the droplets quickly to prevent them from running along the cylindrical surface, which affects the formation of the printed electrode significantly. In vitro experimental results showed that the proposed sensor was able to detect the glucose concentration ranging from 0 to 570 mg dL-1 which demonstrated its capability for physiological glucose detection. In vivo experiments were conducted with rats, and the measurement results recorded using the implanted cylindrical sensor showed great compliance to those recorded using a commercial glucometer which exhibited the viability of the proposed sensor for implantable continuous glucose monitoring, even under the hypoglycemic conditions.
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Affiliation(s)
- Zhihua Pu
- State Key Laboratory of Precision Measuring Technology and Instruments, Tianjin University, Tianjin 300072, China.
| | - Jiaan Tu
- State Key Laboratory of Precision Measuring Technology and Instruments, Tianjin University, Tianjin 300072, China.
| | - Ruixue Han
- Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin 300072, China.
| | - Xingguo Zhang
- State Key Laboratory of Precision Measuring Technology and Instruments, Tianjin University, Tianjin 300072, China.
| | - Jianwei Wu
- State Key Laboratory of Precision Measuring Technology and Instruments, Tianjin University, Tianjin 300072, China.
| | - Chao Fang
- State Key Laboratory of Precision Measuring Technology and Instruments, Tianjin University, Tianjin 300072, China.
| | - Hao Wu
- State Key Laboratory of Precision Measuring Technology and Instruments, Tianjin University, Tianjin 300072, China.
| | - Xiaoli Zhang
- State Key Laboratory of Precision Measuring Technology and Instruments, Tianjin University, Tianjin 300072, China.
| | - Haixia Yu
- Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin 300072, China.
| | - Dachao Li
- State Key Laboratory of Precision Measuring Technology and Instruments, Tianjin University, Tianjin 300072, China.
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Satyarengga M, Siddiqui T, Spanakis EK. Designing the Glucose Telemetry for Hospital Management: From Bedside to the Nursing Station. Curr Diab Rep 2018; 18:87. [PMID: 30159754 DOI: 10.1007/s11892-018-1067-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF THE REVIEW Hospitalized patients with diabetes are monitored with point-of-care glucose testing. Continuous glucose monitoring (CGM) devices represent an alternative way to monitor glucose values; however, the in-hospital CGM use is still considered experimental. Most inpatient studies used "blinded" CGM properties and only few used the real-time/unblinded CGM features. One major limitation of the CGM devices is that they need to be placed at the patients' bedside, limiting any therapeutic interventions. In this article, we review the real-time/unblinded CGM use and share our thoughts about the development of future inpatient CGM systems. RECENT FINDINGS We recently reported that glucose values can be wirelessly transmitted to the nursing station, providing remote continuous glucose monitoring. Future inpatient CGM devices may be utilized for patients at risk for hypoglycemia similarly to the way that we use cardiac telemetry to monitor hospitalized patients who are at increased risk for cardiac arrhythmias.
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Affiliation(s)
- Medha Satyarengga
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, 827 Linden Avenue, Baltimore, MD, 21201, USA
| | - Tariq Siddiqui
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, 827 Linden Avenue, Baltimore, MD, 21201, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, 10 N. Greene Street, Baltimore, MD, 21201, USA
| | - Elias K Spanakis
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, 827 Linden Avenue, Baltimore, MD, 21201, USA.
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, 10 N. Greene Street, Baltimore, MD, 21201, USA.
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47
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Thompson B, Leighton M, Korytkowski M, Cook CB. An Overview of Safety Issues on Use of Insulin Pumps and Continuous Glucose Monitoring Systems in the Hospital. Curr Diab Rep 2018; 18:81. [PMID: 30120619 DOI: 10.1007/s11892-018-1056-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Summarize safety issues related to patients using insulin pump therapy and continuous glucose monitoring systems (CGMS) in the outpatient setting when they are hospitalized and to review steps that can be taken to mitigate risk associated with use or discontinuation of these devices. RECENT FINDINGS Two recent consensus conferences were held on the topics of inpatient use of insulin pumps and CGMS devices. In addition to commonly known safety issues (e.g., device malfunction, infection), cybersecurity and the vulnerability of contemporary technology to hacking have emerged. CGMS capabilities offer the promise of advancing the goal for development of glucometry (centralized monitoring of real-time glucose data). Strategies to assuring safe use of insulin pumps and CGMS in the hospital include collaboration between the patient and staff, proper patient selection, and clear policies and procedures outlining safe use. Available data indicates few adverse events associated with these devices in the hospital. Current data suggests, with proper patient selection and a clear process in place for glycemic management, that adverse events are rare, and consensus favors allowing use of the technology in the hospital. The topic of insulin pump and CGMS in the hospital would greatly benefit from more institutions reporting on their experiences and prospective clinical trials.
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Affiliation(s)
- Bithika Thompson
- Division of Endocrinology, Mayo Clinic Arizona, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA.
| | - Melinda Leighton
- Division of Endocrinology, Mayo Clinic Arizona, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA
| | - Mary Korytkowski
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Curtiss B Cook
- Division of Endocrinology, Mayo Clinic Arizona, 13400 E. Shea Blvd., Scottsdale, AZ, 85259, USA
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Umpierrez GE, Klonoff DC. Diabetes Technology Update: Use of Insulin Pumps and Continuous Glucose Monitoring in the Hospital. Diabetes Care 2018; 41:1579-1589. [PMID: 29936424 PMCID: PMC6054505 DOI: 10.2337/dci18-0002] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/20/2018] [Indexed: 02/03/2023]
Abstract
The use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems has gained wide acceptance in diabetes care. These devices have been demonstrated to be clinically valuable, improving glycemic control and reducing risks of hypoglycemia in ambulatory patients with type 1 diabetes and type 2 diabetes. Approximately 30-40% of patients with type 1 diabetes and an increasing number of insulin-requiring patients with type 2 diabetes are using pump and sensor technology. As the popularity of these devices increases, it becomes very likely that hospital health care providers will face the need to manage the inpatient care of patients under insulin pump therapy and CGM. The American Diabetes Association advocates allowing patients who are physically and mentally able to continue to use their pumps when hospitalized. Health care institutions must have clear policies and procedures to allow the patient to continue to receive CSII treatment to maximize safety and to comply with existing regulations related to self-management of medication. Randomized controlled trials are needed to determine whether CSII therapy and CGM systems in the hospital are associated with improved clinical outcomes compared with intermittent monitoring and conventional insulin treatment or with a favorable cost-benefit ratio.
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Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA
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Thabit H, Hovorka R. Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non-critical care settings. Diabet Med 2018; 35:460-471. [PMID: 29266376 DOI: 10.1111/dme.13563] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 12/17/2022]
Abstract
Emerging evidence shows that suboptimal glycaemic control is associated with increased morbidity and length of stay in hospital. Various guidelines for safe and effective inpatient glycaemic control in the non-critical care setting have been published. In spite of this, implementation in practice remains limited because of the increasing number of people with diabetes admitted to hospital and staff work burden. The use of technology in the outpatient setting has led to improved glycaemic outcomes and quality of life for people with diabetes. There remains an unmet need for technology utilisation in inpatient hyperglycaemia management in the non-critical care setting. Novel technologies have the potential to provide benefits in diabetes care in hospital by improving efficacy, safety and efficiency. Rapid analysis of glucose measurements by point-of-care devices help facilitate clinical decision-making and therapy adjustment in the hospital setting. Glucose treatment data integration with computerized glucose management systems underpins the effective use of decision support systems and may streamline clinical staff workflow. Continuous glucose monitoring and automation of insulin delivery through closed-loop systems may provide a safe and efficacious tool for hospital staff to manage inpatient hyperglycaemia whilst reducing staff workload. This review summarizes the evidence with regard to technological methods to manage inpatient glycaemic control, their limitations and the future outlook, as well as potential strategies by healthcare organizations such as the National Health Service to mediate the adoption, procurement and use of diabetes technologies in the hospital setting.
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Affiliation(s)
- H Thabit
- Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - R Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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Galindo RJ, Fayfman M, Umpierrez GE. Perioperative Management of Hyperglycemia and Diabetes in Cardiac Surgery Patients. Endocrinol Metab Clin North Am 2018; 47:203-222. [PMID: 29407052 PMCID: PMC5805476 DOI: 10.1016/j.ecl.2017.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Perioperative hyperglycemia is common after cardiac surgery, reported in 60% to 90% of patients with diabetes and in approximately 60% of patients without history of diabetes. Many observational and prospective randomized trials in critically-ill cardiac surgery patients support a strong association between hyperglycemia and poor clinical outcome. Despite ongoing debate about the optimal glucose target, there is strong agreement that improved glycemic control reduces perioperative complications.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA
| | - Maya Fayfman
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive, Glenn Building, Suite 202, Atlanta, GA 30303, USA.
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