Is incretin-based therapy ready for the care of hospitalized patients with type 2 diabetes?: Insulin therapy has proven itself and is considered the mainstay of treatment

Continuation of Oral Antidiabetic Medications Was Associated With Better Early Postoperative Blood Glucose Control Compared to Sliding Scale Insulin After Total Knee Arthroplasty

BACKGROUND

This study evaluated blood glucose (BG), creatinine levels, metabolic issues, length of stay (LOS), and early postoperative complications in diabetic primary total knee arthroplasty (TKA) patients. It examined those who continued home oral antidiabetic medications and those who switched to insulin postoperatively. The hypothesis was that continuing home medications would lead to lower BG levels without metabolic abnormalities.

METHODS

Patients who had diabetes who underwent primary TKA from 2013 to 2022 were evaluated retrospectively. Diabetic patients who were not on home oral antidiabetic medications or who were not managed as an inpatient postoperatively were excluded. Patient demographics and laboratory tests collected preoperatively and postoperatively as well as 90-day emergency department visits and 90-day readmissions, were pulled from electronic records. Patients were grouped based on inpatient diabetes management: continuation of home medications versus new insulin coverage. Acute postoperative BG control, creatinine levels, metabolic abnormalities, LOS, and early postoperative complications were compared between groups. Multivariable regression analyses were performed to measure associations.

RESULTS

A total of 867 primary TKAs were assessed; 703 (81.1%) patients continued their home oral antidiabetic medications. Continuing home antidiabetic medications demonstrated lower median maximum inpatient BG (180.0 mg/dL versus 250.0 mg/dL; P < .001) and median average inpatient BG (136.7 mg/dL versus 173.7 mg/dL; P < .001). Logistic regression analyses supported the presence of an association (odds ratio = 17.88 [8.66, 43.43]; P < .001). Proportions of acute kidney injury (13.5 versus 26.7%; P < .001) were also lower. There was no difference in relative proportions of metabolic acidosis (4.4 versus 3.7%; P = .831), LOS (2.0 versus 2.0 days; P = .259), or early postoperative complications.

CONCLUSIONS

Continuing home oral antidiabetic medications after primary TKA was associated with lower BG levels without an associated worsening creatinine or increase in metabolic acidosis.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Prescription appropriateness of anti-diabetes drugs in elderly patients hospitalized in a clinical setting: evidence from the REPOSI Register

Diabetes is an increasing global health burden with the highest prevalence (24.0%) observed in elderly people. Older diabetic adults have a greater risk of hospitalization and several geriatric syndromes than older nondiabetic adults. For these conditions, special care is required in prescribing therapies including anti- diabetes drugs. Aim of this study was to evaluate the appropriateness and the adherence to safety recommendations in the prescriptions of glucose-lowering drugs in hospitalized elderly patients with diabetes. Data for this cross-sectional study were obtained from the REgistro POliterapie-Società Italiana Medicina Interna (REPOSI) that collected clinical information on patients aged ≥ 65 years acutely admitted to Italian internal medicine and geriatric non-intensive care units (ICU) from 2010 up to 2019. Prescription appropriateness was assessed according to the 2019 AGS Beers Criteria and anti-diabetes drug data sheets.Among 5349 patients, 1624 (30.3%) had diagnosis of type 2 diabetes. At admission, 37.7% of diabetic patients received treatment with metformin, 37.3% insulin therapy, 16.4% sulfonylureas, and 11.4% glinides. Surprisingly, only 3.1% of diabetic patients were treated with new classes of anti- diabetes drugs. According to prescription criteria, at admission 15.4% of patients treated with metformin and 2.6% with sulfonylureas received inappropriately these treatments. At discharge, the inappropriateness of metformin therapy decreased (10.2%, P < 0.0001). According to Beers criteria, the inappropriate prescriptions of sulfonylureas raised to 29% both at admission and at discharge. This study shows a poor adherence to current guidelines on diabetes management in hospitalized elderly people with a high prevalence of inappropriate use of sulfonylureas according to the Beers criteria.

Management of diabetes and hyperglycaemia in the hospital

Hyperglycaemia in people with and without diabetes admitted to the hospital is associated with a substantial increase in morbidity, mortality, and health-care costs. Professional societies have recommended insulin therapy as the cornerstone of inpatient pharmacological management. Intravenous insulin therapy is the treatment of choice in the critical care setting. In non-intensive care settings, several insulin protocols have been proposed to manage patients with hyperglycaemia; however, meta-analyses comparing different treatment regimens have not clearly endorsed the benefits of any particular strategy. Clinical guidelines recommend stopping oral antidiabetes drugs during hospitalisation; however, in some countries continuation of oral antidiabetes drugs is commonplace in some patients with type 2 diabetes admitted to hospital, and findings from clinical trials have suggested that non-insulin drugs, alone or in combination with basal insulin, can be used to achieve appropriate glycaemic control in selected populations. Advances in diabetes technology are revolutionising day-to-day diabetes care and work is ongoing to implement these technologies (ie, continuous glucose monitoring, automated insulin delivery) for inpatient care. Additionally, transformations in care have occurred during the COVID-19 pandemic, including the use of remote inpatient diabetes management-research is needed to assess the effects of such adaptations.

A Pragmatic Approach to Inpatient Diabetes Management during the COVID-19 Pandemic

The pandemic of COVID-19 has presented new challenges to hospital personnel providing care for infected patients with diabetes who represent more than 20% of critically ill patients in intensive care units. Appropriate glycemic management contributes to a reduction in adverse clinical outcomes in acute illness but also requires intensive patient interactions for bedside glucose monitoring, intravenous and subcutaneous insulin administration, as well as rapid intervention for hypoglycemia events. These tasks are required at a time when minimizing patient interactions is recommended as a way of avoiding prolonged exposure to COVID-19 by health care personnel who often practice in settings with limited supplies of personal protective equipment. The purpose of this manuscript is to provide guidance for clinicians for reconciling recommended standards of care for infected hospitalized patients with diabetes while also addressing the daily realities of an overwhelmed health care system in many areas of the country. The use of modified protocols for insulin administration, bedside glucose monitoring, and medications such as glucocorticoids and hydroxychloroquine that may affect glycemic control are discussed. Continuous glucose monitoring systems have been proposed as an option for reducing time spent with patients, but there are important issues that need to be addressed if these are used in hospitalized patients. On-site and remote glucose management teams have potential to provide guidance in areas where there are shortages of personnel who have expertise in inpatient glycemic management.

Oral antidiabetes agents for the management of inpatient hyperglycaemia: so far, yet so close

BACKGROUND

Hyperglycaemia is an ongoing challenge in hospital settings and is associated with poor outcomes. Current recommendations for the management of inpatient hyperglycaemia suggest insulin as the main glucose-lowering treatment choice and limit the administration of oral antidiabetes agents to a small proportion of cases because of safety concerns.

AIM

To present and critically appraise the available evidence on the use of oral antidiabetes agents in the hospital setting and the risk-benefit balance of such an approach in the era of cardiovascular outcomes trials.

METHODS

PubMed, Embase and Google Scholar databases were searched to identify relevant published work. Available evidence on the efficacy and the safety profile of oral agents in the context of their use in hospitalized individuals are summarized and discussed in this narrative review.

RESULTS

There is no robust evidence to suggest the use of metformin, thiazolidinediones, sulfonylureas and sodium-glucose co-transporter-2 inhibitors in the hospital setting, although some of their effects on acute outcomes deserve further evaluation in future studies. However, the use of dipeptidyl peptidase-4 inhibitors in inpatients with type 2 diabetes is supported by a few, well-designed, randomized controlled trials. These trials have demonstrated good safety and tolerability profiles, comparable to insulin glucose-lowering efficacy, and a reduction in insulin dose when dipeptidyl peptidase-4 inhibitors are co-administered with insulin, in individuals with mild to moderate hyperglycaemia and a stable clinical condition.

CONCLUSION

The administration of dipeptidyl peptidase-4 inhibitors to specific groups of inpatients might be a safe and effective alternative to insulin.

DPP4 Inhibitors in the Management of Hospitalized Patients With Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

INTRODUCTION

We studied the effects of dipeptidyl peptidase 4 (DPP4) inhibitors on glycemic control in non-critically ill patients admitted to hospital.

METHODS

We searched MEDLINE and EMBASE for published studies in English up to July 2019. We included randomized clinical trials (RCTs) that compared DPP4 inhibitors plus insulin supplementation versus basal-bolus insulin regimen in the management of hyperglycemia non-critically ill patients with type 2 diabetes admitted to hospital. Mean difference (MD), relative risk (RR), and 95% confidence intervals (CI) were generated to interpret the data.

RESULTS

Of 401 papers, four RCTs including 648 participants met inclusion criteria. There was no significant difference in mean daily blood glucose level between the two groups (MD 4.63; 95% CI = - 1.57, 10.83; p = 0.14) (I² = 14%, p = 0.32). Total insulin dose per day was lower in patients receiving DPP4 inhibitors (MD - 14.27; CI = - 22.47, - 6.07; p = 0.001) (I² = 92%, p = 0.001). Also, the number of insulin injection was significantly lower in patients receiving DPP4 inhibitors (MD - 0.79; CI = - 1.01, - 0.57; p = 0.001) (I² = 0%, p = 0.68). The rate of hypoglycemia was not significantly different between the two groups (RR 0.60, CI = 0.34, 1.074; p = 0.08) (I² = 37.3%, p = 0.18). Treatment failure was not significantly different between the two groups (RR 0.87, CI = 0.64, 4.8; p = 0.38) (I² = 49%, p = 0.11).

CONCLUSION

The results indicate that using DPP4 inhibitors plus basal or supplemental insulin in hospitalized patients is non-inferior to a standard basal-bolus insulin regimen and leads to a lower amount of insulin use and a lower rate of insulin injection. Limitations of this study were heterogeneity of baseline characteristics of included patients, small sample size, short duration, and non-uniformly defined outcome assessment parameters in the included studies.

Management of Inpatient Hyperglycemia and Diabetes in Older Adults

Diabetes is one of the world's fastest growing health challenges. Insulin therapy remains a useful regimen for many elderly patients, such as those with moderate to severe hyperglycemia, type 1 diabetes, hyperglycemic emergencies, and those who fail to maintain glucose control on non-insulin agents alone. Recent clinical trials have shown that several non-insulin agents as monotherapy, or in combination with low doses of basal insulin, have comparable efficacy and potential safety advantages to complex insulin therapy regimens. Determining the most appropriate diabetes management plan for older hospitalized patients requires consideration of many factors to prevent poor outcomes related to dysglycemia.

Debate on Insulin vs Non-insulin Use in the Hospital Setting-Is It Time to Revise the Guidelines for the Management of Inpatient Diabetes?

PURPOSE OF REVIEW

Hyperglycemia contributes to a significant increase in morbidity, mortality, and healthcare costs in the hospital. Professional associations recommend insulin as the mainstay of diabetes therapy in the inpatient setting. The standard of care basal-bolus insulin regimen is a labor-intensive approach associated with a significant risk of iatrogenic hypoglycemia. This review summarizes recent evidence from observational studies and clinical trials suggesting that not all patients require treatment with complex insulin regimens.

RECENT FINDINGS

Evidence from clinical trials shows that incretin-based agents are effective in appropriately selected hospitalized patients and may be a safe alternative to complicated insulin regimens. Observational studies also show that older agents (i.e., metformin and sulfonylureas) are commonly used in the hospital, but there are few carefully designed studies addressing their efficacy. Therapy with dipeptidyl peptidase-4 (DPP-4) inhibitors, alone or in combination with basal insulin, may effectively control glucose levels in patients with mild to moderate hyperglycemia. Further studies with glucagon-like peptide-1 (GLP-1) receptor analogs and older oral agents are needed to confirm their safety in the hospital.

Use of Insulin in the Inpatient Setting: Need for Continued Use

PURPOSE OF REVIEW

Insulin has been the standard of care for the management of inpatient diabetes for achieving strict glycemic control. This review supports continuing insulin therapy for hyperglycemic management in the hospital compared with the use of non-insulin treatment regimens.

RECENT FINDINGS

Oral hypoglycemic agents and glucagon-like peptide 1 (GLP-1) receptor agonists have typically not been used in the inpatient setting. Recent studies regarding DPP-4 inhibitors have led to variable results with fairly high glycemic values during the hospitalization. Similarly, studies looking at GLP-1 receptor agonists are limited, but gastrointestinal side effects limit their inpatient use. Overall, there is a paucity of data to support the use of non-insulin-based therapy in the inpatient setting. Insulin has repeatedly demonstrated that its advantageous quality of being easily titratable leads to more consistently efficacious glycemic control that improves morbidity and mortality.

Noninsulin medication therapy for hospitalized patients with diabetes mellitus

PURPOSE

Published evidence regarding the role of noninsulin antidiabetic therapies in glycemic management of hospitalized patients with diabetes mellitus is reviewed.

SUMMARY

The American Diabetes Association recommends against the routine use of noninsulin antidiabetic therapies during hospitalization and supports insulin use instead. There are significant risks associated with insulin therapy, including hypoglycemia, and use of alternative therapies may be considered in hospitalized patients. A MEDLINE literature search was conducted to find articles on studies evaluating the use of noninsulin antidiabetic therapies in the inpatient setting; all full-text English-language publications presenting observational and randomized clinical trial data on the topic of interest were considered for inclusion in the review, with 9 publications selected for review. The majority of the reviewed research focused on incretin-based therapies, and favorable safety and efficacy outcomes were reported with the use of dipeptidyl peptidase-4 (DPP-4) inhibitors. The available evidence indicates that the use of other noninsulin medications, including glucagon-like peptide-1 receptor agonists and sulfonylureas, to achieve and maintain glycemic control in the inpatient setting may be limited by adverse effects.

CONCLUSION

Optimal glycemic control in hospitalized patients with diabetes is necessary to avoid adverse effects. Insulin therapy is currently the primary medication recommended for this patient population. DPP-4 inhibitors have been demonstrated to be safe and effective for use in the inpatient setting in patients with well-controlled diabetes. Further research is needed to help define the role of noninsulin medications in the inpatient setting.

Glycaemic efficacy and safety of linagliptin for the management of non-cardiac surgery patients with type 2 diabetes in a real-world setting: Lina-Surg study

Introduction: The use of dipeptidyl peptidase-4 inhibitors in hospitalized patients is an area of active research. We aimed to compare the efficacy and the safety of the basal-bolus insulin regimen versus linagliptin-basal insulin in non-critically ill non-cardiac surgery patients in a real-world setting. Methods: We enrolled patients with type 2 diabetes hospitalized in non-cardiac surgery departments with admission glycated haemoglobin level < 8%, admission blood glucose concentration < 240 mg/dL, and no at-home injectable treatments who were treated with basal-bolus (n = 347) or linagliptin-basal (n = 190) regimens between January 2016 and December 2017. To match patients on the two regimens, a propensity matching analysis was performed. Results: After matching, 120 patients were included in each group. No differences were noted in mean blood glucose concentration after admission (p = .162), number of patients with a mean blood glucose 100-140 mg/dL (p = .163) and > 200 mg/dL (p = .199), and treatment failures (p = .395). Total daily insulin and number of daily insulin injections were lower in the linagliptin-basal group (both p < .001). Patients on linagliptin-basal insulin had fewer hypoglycaemic events (blood glucose < 70 mg/dL) (p < .001). Conclusion: For type 2 diabetes surgery patients with mild to moderate hyperglycaemia without pre-hospitalization injectable therapies, linagliptin-basal insulin was an effective, safe alternative with fewer hypoglycaemic events in real-world practice. Key messages Treatment with basal-bolus insulin regimens is the standard of care for non-critically ill hospitalized patients with type 2 diabetes. A differentiated treatment protocol that takes into account glycaemic control and clinical factors should be implemented in the hospital setting. Linagliptin-basal insulin is an effective, safe alternative with fewer hypoglycaemic events during the hospitalization of non-critically ill non-cardiac surgery patients with T2D in real-world practice.

Use of incretin-based therapy in hospitalized patients with hyperglycemia

OBJECTIVE

Hyperglycemia is common in hospitalized patients with and without prior history of diabetes and is an independent marker of morbidity and mortality in critically and noncritically ill patients. Tight glycemic control using insulin has been shown to reduce cardiac morbidity and mortality in hospitalized patients, but it also results in hypoglycemic episodes, which have been linked to poor outcomes. Thus, alternative treatment options that can normalize blood glucose levels without undue hypoglycemia are being sought. Incretin-based therapies, such as glucagon-like peptide (GLP)-1 receptor agonists (RAs) and dipeptidyl peptidase (DPP)-4 inhibitors, may have this potential.

METHODS

A PubMed database was searched to find literature describing the use of incretins in hospital settings. Title searches included the terms "diabetes" (care, management, treatment), "hospital," "inpatient," "hypoglycemia," "hyperglycemia," "glycemic," "incretin," "dipeptidyl peptidase-4 inhibitor," "glucagon-like peptide-1," and "glucagon-like peptide-1 receptor agonist."

RESULTS

The preliminary research experience with native GLP-1 therapy has shown promise, achieving improved glycemic control with a low risk of hypoglycemia, counteracting the hyperglycemic effects of stress hormones, and improving cardiac function in patients with heart failure and acute ischemia. Large, randomized controlled clinical trials are necessary to determine whether these favorable results will extend to the use of GLP-1 RAs and DPP-4 inhibitors.

CONCLUSIONS

This review offers hospitalist physicians and healthcare providers involved in inpatient diabetes care a pathophysiologic-based approach for the use of incretin agents in patients with hyperglycemia and diabetes, as well as a summary of benefits and concerns of insulin and incretin-based therapy in the hospital setting.

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Use of Linagliptin for the Management of Medicine Department Inpatients with Type 2 Diabetes in Real-World Clinical Practice (Lina-Real-World Study)

The use of noninsulin antihyperglycaemic drugs in the hospital setting has not yet been fully described. This observational study compared the efficacy and safety of the standard basal-bolus insulin regimen versus a dipeptidyl peptidase-4 inhibitor (linagliptin) plus basal insulin in medicine department inpatients in real-world clinical practice. We retrospectively enrolled non-critically ill patients with type 2 diabetes with mild to moderate hyperglycaemia and no injectable treatments at home who were treated with a hospital antihyperglycaemic regimen (basal-bolus insulin, or linagliptin-basal insulin) between January 2016 and December 2017. Propensity score was used to match patients in both treatment groups and a comparative analysis was conducted to test the significance of differences between groups. After matched-pair analysis, 227 patients were included per group. No differences were shown between basal-bolus versus linagliptin-basal regimens for the mean daily blood glucose concentration after admission (standardized difference = 0.011), number of blood glucose readings between 100⁻140 mg/dL (standardized difference = 0.017) and >200 mg/dL (standardized difference = 0.021), or treatment failures (standardized difference = 0.011). Patients on basal-bolus insulin received higher total insulin doses and a higher daily number of injections (standardized differences = 0.298 and 0.301, respectively). Basal and supplemental rapid-acting insulin doses were similar (standardized differences = 0.003 and 0.012, respectively). There were no differences in hospital stay length (standardized difference = 0.003), hypoglycaemic events (standardized difference = 0.018), or hospital complications (standardized difference = 0.010) between groups. This study shows that in real-world clinical practice, the linagliptin-basal insulin regimen was as effective and safe as the standard basal-bolus regimen in non-critical patients with type 2 diabetes with mild to moderate hyperglycaemia treated at home without injectable therapies.

A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial

OBJECTIVES

Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities.

DESIGN

This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM.

SETTINGS

Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia.

PARTICIPANTS

A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%.

INTERVENTION

Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL.

MEASUREMENTS

Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers.

RESULTS

Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations.

CONCLUSION

Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.

Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non-critical care settings

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.

14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Management of Inpatient Hyperglycemia and Diabetes in Older Adults

Adults aged 65 years and older are the fastest growing segment of the U.S. population, and their number is expected to double to 89 million between 2010 and 2050. The prevalence of diabetes in hospitalized adults aged 65-75 years and over 80 years of age has been estimated to be 20% and 40%, respectively. Similar to general populations, the presence of hyperglycemia and diabetes in elderly patients is associated with increased risk of hospital complications, longer length of stay, and increased mortality compared with subjects with normoglycemia. Clinical guidelines recommend target blood glucose between 140 and 180 mg/dL (7.8 and 10 mmol/L) for most patients in the intensive care unit (ICU). A similar blood glucose target is recommended for patients in non-ICU settings; however, glycemic targets should be individualized in older adults on the basis of a patient's clinical status, risk of hypoglycemia, and presence of diabetes complications. Insulin is the preferred agent to manage hyperglycemia and diabetes in the hospital. Continuous insulin infusion in the ICU and rational use of basal-bolus or basal plus supplement regimens in non-ICU settings are effective in achieving glycemic goals. Noninsulin regimens with the use of dipeptidyl peptidase 4 inhibitors alone or in combination with basal insulin have been shown to be safe and effective and may represent an alternative to basal-bolus regimens in elderly patients. Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin as well as education in basic skills for home management.

Update on Glucose Management Among Noncritically Ill Patients Hospitalized on Medical and Surgical Wards

Hyperglycemia is a common issue affecting inpatient care. Although this is in part because of the higher rate of hospitalization among patients with preexisting diabetes, multiple factors complicate inpatient glucose management, including acute stress from illness or surgery, erratic dietary intake, and contribution of medications. It has been repeatedly demonstrated that poorly controlled blood glucose levels are associated with negative clinical outcomes, such as increased mortality, higher rate of surgical complications, and longer length of hospital stay. Given these concerns, there has been extensive study of the optimal strategy for management of glucose levels, with the bulk of existing literature focusing on insulin therapy in the intensive care unit setting. This review shifts the focus to the general adult medical and surgical wards, using clinical guidelines and sentinel studies to describe the scientific basis behind the current basal-bolus insulin-based approach to blood sugar management among noncritically ill inpatients. Patient-centered clinical trials looking at alternative dosing regimens and insulin analog and noninsulin agents, such as glucagon-like peptide-1 agonist therapies, introduce safe and effective options in the management of inpatient hyperglycemia. Data from these studies reveal that these approaches are of comparable safety and efficacy to the traditional basal-bolus insulin regimen, and may offer additional benefit in terms of less monitoring requirements and lower rates of hypoglycemia. Although existing data are encouraging, outcome studies will be needed to better establish the clinical impact of these more recently proposed approaches in an effort to broaden and improve current clinical practices in inpatient diabetes care.

Closed-loop insulin delivery in inpatients with type 2 diabetes: a randomised, parallel-group trial

BACKGROUND

We assessed whether fully closed-loop insulin delivery (the so-called artificial pancreas) is safe and effective compared with standard subcutaneous insulin therapy in patients with type 2 diabetes in the general ward.

METHODS

For this single-centre, open-label, parallel-group, randomised controlled trial, we enrolled patients aged 18 years or older with type 2 diabetes who were receiving insulin therapy. Patients were recruited from general wards at Addenbrooke's Hospital, Cambridge, UK. Participants were randomly assigned (1:1) by a computer-generated minimisation method to receive closed-loop insulin delivery (using a model-predictive control algorithm to direct subcutaneous delivery of rapid-acting insulin analogue without meal-time insulin boluses) or conventional subcutaneous insulin delivery according to local clinical guidelines. The primary outcome was time spent in the target glucose concentration range of 5·6-10·0 mmol/L during the 72 h study period. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01774565.

FINDINGS

Between Feb 20, 2015, and March 24, 2016, we enrolled 40 participants, of whom 20 were randomly assigned to the closed-loop intervention group and 20 to the control group. The proportion of time spent in the target glucose range was 59·8% (SD 18·7) in the closed-loop group and 38·1% (16·7) in the control group (difference 21·8% [95% CI 10·4-33·1]; p=0·0004). No episodes of severe hypoglycaemia or hyperglycaemia with ketonaemia occurred in either group. One adverse event unrelated to study devices occurred during the study (gastrointestinal bleed).

INTERPRETATION

Closed-loop insulin delivery without meal-time boluses is effective and safe in insulin-treated adults with type 2 diabetes in the general ward.

FUNDING

Diabetes UK; European Foundation for the Study of Diabetes; JDRF; National Institute for Health Research Cambridge Biomedical Research Centre; Wellcome Trust.

Inpatient Diabetes Management in the Twenty-First Century

In hospitalized patients, both hyperglycemia and hypoglycemia have been associated with poor outcomes. During the inpatient period, hyperglycemia has been associated with increased risk of infection, cardiovascular events, and mortality. It is also associated with longer length of hospital stay. Hypoglycemia has also been associated with an increased risk of mortality. Therefore, current evidence supports avoidance of both conditions among hospitalized patients whether they are admitted to critical care units or noncritical care units.

Management of hospitalized type 2 diabetes mellitus patients

Both hyperglycemia and hypoglycemia in hospitalized patients are associated with adverse outcomes including increased rates of infection, longer hospital length of stay, and even death. Clinical trials in patients with type 2 diabetes mellitus proved that by improving glycemic control, we can reduce all of them. Insulin is the preferred treatment for glycemic control in most cases, but alternative treatment options that can normalize blood glucose levels without hypoglycemia are being sought. Moreover, hospitalized patients are particularly vulnerable to severe, prolonged hypoglycemia since they may be unable to sense or respond to the early warning signs and symptoms of low blood glucose. Finally, nutritional support, corticosteroid therapy, and surgery increase the risk of hyperglycemia that leads to an increased risk of morbidity and mortality. We review the management of type 2 diabetes mellitus patients who are admitted to the general medical wards of the hospital for a procedure of intercurrent illness.

A practical and evidence-based approach to management of inpatient diabetes in non-critically ill patients and special clinical populations

Inpatient diabetes is a common medical problem encountered in up to 25-30% of hospitalized patients. Several prospective trials showed benefits of structured insulin therapy in managing inpatient hyperglycemia albeit in the expense of high hypoglycemia risk. These approaches, however, remain underutilized in hospital practice. In this review, we discuss clinical applications and limitations of current therapeutic strategies. Considerations for glycemic strategies in special clinical populations are also discussed. We suggest that given the complexity of inpatient glycemic control factors, the "one size fits all" approach should be modified to safe and less complex patient-centered evidence-based treatment strategies without compromising the treatment efficacy.

The potential role of incretin therapy in the hospital setting

Hyperglycemia has been associated with increased morbidity and mortality in hospitalized patients. Insulin has traditionally been the drug of choice for managing hyperglycemia in this setting, but carries a significant risk of hypoglycemia. Incretin-based therapies, including glucagon-like peptide-1, glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, have potential use in the hospital. These agents have a relatively low risk of hypoglycemia, favorable short-term side effect profile, and can be used alone or in combination with insulin. Several small studies have supported the safety and efficacy of incretin therapies in the inpatient setting with the majority of data coming from the intensive care setting. Large-scale clinical studies are needed to further evaluate the potential role of incretins in the management of inpatient hyperglycemia.

Practical implementation of incretin-based therapy in hospitalized patients with type 2 diabetes

Hyperglycemia in patients with and without a prior history of diabetes is an independent marker of morbidity and mortality in critically and noncritically ill patients. Improvement of glycemic control with insulin therapy has been shown to reduce hospital complications in patients with diabetes, but also results in increased rates of hypoglycemia, which have been linked to poor outcomes. Thus, alternative treatment options that can normalize blood glucose levels without undue hypoglycemia are being sought. Incretin-based therapies, such as glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors, stimulate insulin secretion in a glucose-dependent fashion, thus not causing hypoglycemia. Alternative points of view exist regarding insulin versus incretin therapy for the care of these patients. We have brought together the authors on the opposite sides of this discussion with the objective of providing a rational synthesis on how to achieve the best possible control of glycemia in the hospital, using both standard insulin approaches and incretin-based therapies to improve patient outcomes. This review examines the benefits of incretin-based therapy in improving glycemic control in hospitalized patients with stress-induced diabetes and in diabetic patients in critical care and non-critical care settings.

Pharmacotherapy for Hyperglycemia in Noncritically Ill Hospitalized Patients

In Brief Hyperglycemia in the hospital setting affects 38-46% of noncritically ill hospitalized patients. Evidence from observational studies indicates that inpatient hyperglycemia, in patients with and without diabetes, is associated with increased risks of complications and mortality. Substantial evidence indicates that correction of hyperglycemia through insulin administration reduces hospital complications and mortality in critically ill patients, as well as in general medicine and surgery patients. This article provides a review of the evidence on the different therapies available for hyperglycemia management in noncritically ill hospitalized patients.

Glucose control in non-critically ill inpatients with diabetes: towards closed-loop

Inpatient glycaemic control remains an important issue due to the increasing number of patients with diabetes admitted to hospital. Morbidity and mortality in hospital are associated with poor glucose control, and cost of hospitalization is higher compared to non-diabetes patients. Guidelines for inpatient glycaemic control in the non-critical care setting have been published. Current recommendations include basal-bolus insulin therapy, regular glucose monitoring, as well as enhancing healthcare provider's role and knowledge. In spite of growing focus, implementation in practice is limited, mainly due to increasing workload burden on staff and fear of hypoglycaemia. Advances in healthcare technology may contribute to an improvement of inpatient diabetes care. Integration of glucose measurements with healthcare records and computerized glycaemic control protocols are currently being used in some institutions. Recent interests in continuous glucose monitoring have led to studies assessing its utilization in inpatients. Automation of glucose monitoring and insulin delivery may provide a safe and efficacious tool for hospital staff to manage inpatient hyperglycaemia, whilst reducing staff workload. This review summarizes the evidence on current approaches to managing inpatient glycaemic control; its utility and limitations. We conclude by discussing the evidence from feasibility studies to date, on the potential use of closed loop in the non-critical care setting and its implication for future studies.

Understanding hypoglycemia in hospitalized patients

Controlling blood glucose in hospitalized patients is important as both hyperglycemia and hypoglycemia are associated with increased cost, length of stay, morbidity and mortality. A limiting factor in stringent control is the concern of iatrogenic hypoglycemia. The association of hypoglycemia with mortality has led to clinical guideline changes recommending more conservative glycemic control than had previously been suggested, with the use of patient specific approaches when appropriate. Healthier, stable patients may be managed with stricter control while the elderly and severely ill may be managed less aggressively. While the avoidance of hypoglycemia is essential in clinical practice, recent studies suggest that a higher mortality rate occurs in spontaneous rather than iatrogenic hypoglycemia. Therefore, inpatient hypoglycemia may be viewed more as a biomarker of disease rather than a true cause of fatality.

The use of non-insulin anti-diabetic agents to improve glycemia without hypoglycemia in the hospital setting: focus on incretins

Patients with hyperglycemia in hospital have increased adverse outcomes compared with patients with normoglycemia, and the pathophysiological causes seem relatively well understood. Thus, a rationale for excellent glycemic control exists. Benefits of control with intensive insulin regimes are highly likely based on multiple published studies. However, hypoglycemia frequency increases and adverse outcomes of hypoglycemia accrue. This has resulted in a 'push' for therapeutic nihilism, accepting higher glycemic levels to avoid hypoglycemia. One would ideally prefer to optimize glycemia, treating hyperglycemia while minimizing or avoiding hypoglycemia. Thus, one would welcome therapies and processes of care to optimize this benefit/ risk ratio. We review the logic and early studies that suggest that incretin therapy use in-hospital can achieve this ideal. We strongly urge randomized prospective controlled studies to test our proposal and we offer a process of care to facilitate this research and their use in our hospitalized patients.

(Poly)peptide-based therapy for diabetes mellitus: insulins versus incretins

Insulin therapy remains the standard of care for achieving and maintaining adequate glycemic control, especially in hospitalized patients with critical and noncritical illnesses. Insulin therapy is more effective against elevated fasting glycaemia but less in the reduction of postprandial hyperglycaemia. It is associated with a high incidence of hypoglycemia and weight gain. Contrary, GLP-1 mimetic therapy improves postprandial glycaemia without the hypoglycaemia and weight gain associated with aggressive insulin therapy. Moreover, it has the potential to reduce cardiovascular related morbidity. However, its increased immunogenicity and severe gastrointestinal adverse effects present a huge burden on patients. Thus, a right combination of basal insulin which has lowering effect on fasting plasma glucose and GLP-1 mimetic with its lowering effect on postprandial plasma glucose with minimal gastrointestinal adverse effects, seems the right therapy choice from a clinical point of view for some diabetic patients. In this article, we discuss the pros and cons of the use of insulin analogues and GLP-1 mimetics that are associated with the treatment of type 2 diabetes.

Hyperglycemia in the intensive care unit: is insulin the only option?

Current guidelines advocate the use of insulin for the management of hyperglycemia in the hospital setting. However, insulin is limited by a narrow therapeutic window, frequent errors, a need for expertise and systems-based monitoring, and lack of specificity for metabolic abnormalities that occur during critical illness. As a result, non-insulin alternatives have garnered increasing interest for managing hyperglycemia in the hospital. However, non-insulin therapies have had safety and tolerability concerns, patients may still need insulin for glycemic control, and there have been limited outcomes data supporting their use. In the study by Christiansen and colleagues in the previous issue of Critical Care, pre-admission metformin therapy was associated with reduced mortality in critically ill patients with type 2 diabetes. The mortality benefit persisted after controlling for other variables, and was particularly prominent when metformin was continued during admission. Furthermore, the reduction in mortality was observed despite a slightly increased prevalence of lactic acidosis in metformin users. The protective effects of metformin are purported to be related to pleiotropic, possibly anti-inflammatory mechanisms, raising the question of benefit in patients without diabetes. Thus, the findings warrant a re-appraisal of the risks and benefits of metformin use during critical illness. However, in order to justify the revision of multiple guidelines and changes in product labeling, clinical trials in carefully selected patient populations are indicated.