16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2024

Old and new anti-obesity drugs

Obesity is a pandemic problem that correlates with a cluster of metabolic factors leading to poor cardiovascular outcomes, morbidity, and an increased risk of overall mortality. It is necessary to approach obesity with a comprehensive treatment plan, which may involve lifestyle modifications (diet, exercise, and behavioral therapy) and pharmacological interventions. This article provides an overview of the mechanisms of action, efficacy, and safety of available long-term anti-obesity drugs and introduces other potential agents under investigation.

Artificial pancreas: the past and the future

In glucose management using continuous insulin infusion, artificial pancreas systems prevent blood glucose fluctuations and severe hypoglycemia using insulin pumps and continuous glucose monitoring. Advances in both insulin pumps and continuous glucose monitoring have enabled the transition from sensor augmented pump therapy, where insulin delivery is manually adjusted, to hybrid closed-loop insulin pump therapy, which automatically adjusts basal insulin infusion. Furthermore, fully automated insulin delivery systems that adjust insulin based on variations due to meals and exercise are now possible. These systems have been primarily applied to patients with type 1 diabetes but are now expanding to all insulin-dependent patients. Wearable artificial pancreas systems measure glucose levels in subcutaneous tissue fluid, while bedside artificial pancreas systems measure glucose levels in venous blood, making them suitable for managing the highly variable blood glucose levels of perioperative and critically ill patients. Future developments are anticipated to integrate the benefits of both wearable and bedside systems.

Continuous Intravenous Insulin Infusion in Patients with Diabetes Mellitus After Coronary Artery Bypass Grafting: Impact on Glycemic Control Parameters and Postoperative Complications

Objectives: This study compared the efficacy of continuous insulin infusion therapy (CIT) versus standard bolus insulin therapy in maintaining optimal perioperative glycemic control in patients with type 2 diabetes mellitus (T2DM) undergoing coronary artery bypass grafting (CABG), focusing on postoperative outcomes. Methods: In this single-center, open comparative study, 214 T2DM patients were selected from 1372 CABG cases (2016-2018) and divided into CIT (n = 28) and bolus therapy (n = 186) groups. Both groups were matched for sex, age, smoking status, body mass index, functional class of angina or heart failure, surgical characteristics and preoperative HbA1c. The target glucose range was 7.8-10 mmol/L (140-180 mg/dL), consistent with current guidelines. Glycemic control was assessed through frequent postoperative measurements, with particular attention to glucose variability and hypoglycemic events. Results: The CIT group demonstrated superior glycemic control, with significantly lower median glucose levels at 7, 8, 10, 12, and 13 h post-CABG (p < 0.05). Glycemic variability was reduced by 32% in the CIT group (p = 0.012), and the incidence of hypoglycemia (<3.9 mmol/L) was 3.6% versus 8.1% in the bolus group. While overall complication rates were similar, the CIT group had 0 cases of stroke, myocardial infarction, or wound infections versus 2.7%, 3.2%, and 5.9%, respectively, in the bolus group. Logistic regression confirmed that each 1 mmol/L increase in first-day glucose levels independently predicted both significant (OR 1.20, 95% CI 1.06-1.36) and serious complications (OR 1.16, 95% CI 1.03-1.30). Conclusions: CIT provided more stable postoperative glycemic control with reduced variability and hypoglycemia risk in T2DM patients after CABG. Although underpowered to detect differences in rare complications, our findings suggest CIT may improve outcomes. These results warrant validation in larger randomized trials.

Accuracy of Continuous Glucose Monitoring in Adults with Type 1 Diabetes Admitted to Hospital: A Real-World Multicenter Observational Study

Introduction: Continuous glucose monitoring (CGM) use in people with type 1 diabetes (T1D) is revolutionizing management. Use of CGM in hospital is poised to transform care, however routine use is not currently recommended due to lack of accuracy validation in acute care, including in people with T1D. We aimed to determine real-world CGM accuracy in hospitalized adults with T1D. Materials and Methods: In this multicenter retrospective observational study, we compared CGM interstitial fluid glucose with reference blood glucose (capillary/whole-blood point-of-care [POC], blood gas [GAS]) in adults with T1D requiring multiday admissions during 2020-2023 across three health services in Australia. Patients requiring dialysis or admitted under pediatric/obstetric/palliative care/psychiatry units were excluded. CGM accuracy was assessed by comparison with time-matched (±5 min) reference glucose measures, utilizing median absolute relative difference (ARD), mean ARD (MARD), and consensus error grid (CEG) analysis. Results: In total, 2,199 CGM-reference glucose pairs from 214 admissions (146 patients) were assessed. Overall, mean (SD) ARD was 12.8% (13.1) and median (IQR) ARD was 9.4% (3.7-17.7). MARD for CGM-POC pairs was 12.3%; MARD for CGM-GAS pairs was 14.3%. In CEG analysis, 99.3% of glucose pairs were within zones A/B. Accuracy was lower in critical care compared with noncritical care wards (MARD 16.1% vs. 12.0%, P < 0.001). Conclusions: In this real-world multicenter study, CGM glucose agreed well with reference blood glucose, suggesting modern CGM devices could be safely and effectively used in hospitalized adults with T1D. Further prospective studies of CGM accuracy with newer generation devices across different scenarios will further elucidate inpatient CGM accuracy and safety.

Association Between Daily Insulin Dose Adjustments and Glycemic Control in Noncritically Ill Hospitalized Hyperglycemic Patients: A Retrospective Cohort Study

OBJECTIVE

To evaluate the efficacy of daily insulin dose increases in managing inpatient hyperglycemia.

METHODS

Retrospective study of patients discharged from 2 urban academic medical centers and 3 large suburban community hospitals between 2015 and 2019 who received ≥10 units of basal insulin on any day. On hyperglycemic days (mean glucose ≥180 mg/dL), we categorized the relative insulin dose increases into 4 categories based on percentage changes from the previous day. We further subclassified these categories according to the average blood glucose (BG), total daily dose (TDD), and weight-based dosing quartiles. The primary goal was achieving an average BG of ≤160 mg/dL without subsequent hypoglycemia (≤70 mg/dL) on the following day.

RESULTS

From 25 186 hospital admissions, we collected data on 240 556 hospital days and 63 033 hyperglycemic index days. The median age was 64, with 53.4% being male and 52.1% White. The median BG level was 222.7 mg/dL. Type 2 diabetes was coded in 54.7%, while 36.3% lacked a diabetes code but received basal insulin. Insulin dose adjustments showed a strong correlation with glycemic control; specifically, a 44% to 100% increase in TDD was significantly more likely to achieve the primary outcome, compared to a TDD increase of 10% to 22%. This trend remained consistent across varied BG ranges and dosing categories.

CONCLUSION

More intensive insulin adjustments may be required for inpatient hyperglycemia compared to the typical 10% to 20% recommendation. Prospective studies are needed to validate and build upon these retrospective findings.

Screening fasting glucose before the OGTT: near-patient glucometer- or laboratory-based measurement?

OBJECTIVES

The measurement of fasting glucose is a common practice for lowering the risk of hyperglycemia before an oral glucose tolerance test (OGTT). In this study we analyze advantages and limitations of near-patient measurement of capillary fasting glucose with a portable glucometer or blood sampling and measurement of plasma glucose with laboratory instrumentation.

METHODS

The final study population consisted of 241 subjects (mean age: 36 ± 8 years; 97.9 % pregnant women) referred to our local phlebotomy center for an OGTT. Fasting glucose was measured in capillary blood using a near-patient glucometer (glucometer-based strategy) and in plasma with laboratory instrumentation using the hexokinase reference assay (laboratory-based strategy).

RESULTS

The mean turnaround time from sample collection to obtaining the glucose value was longer with the laboratory-based strategy (32 min 8 vs. 8 s). The imprecision of the glucometer was higher than that of the laboratory assay (3.4 vs. 0.8 %). A negative bias of -3.3 % in fasting glucose was found with the glucometer compared to the laboratory measurement. The diagnostic accuracy, sensitivity and specificity of the glucometer for detecting fasting glucose values ≥7.0 mmol/L were 99.2 , 50.0 and 100.0 % compared to the laboratory assay. The glucometer-based strategy had an incremental cost of 0.17€ per patient compared to the laboratory-based strategy.

CONCLUSIONS

Screening fasting glucose in capillary blood with a near-patient glucometer instead of measuring fasting plasma glucose with laboratory instrumentation allows faster patient management in the phlebotomy center but is associated with higher imprecision, inaccuracy, costs and avoidable finger pricks.

Use of the Model for Improvement to Reduce Hyperglycemia in Adult Patients Admitted to a Public Tertiary Care Hospital

BACKGROUND

The objective of this study was to reduce by 50% the occurrence of average daily blood glucose (ADBG) > 180 mg/dL among noncritical patients admitted to a surgical ward at a public tertiary care hospital.

METHODS

This project ran from April 2022 to June 2023 and used the Model for Improvement (MFI) method. Health care Failure Modes and Effects Analysis was used to identify and analyze failure modes in hyperglycemia management, and a driver diagram (DD) was used to prioritize and structure changes. The Plan-Do-Study-Act (PDSA) tool facilitated the change process. Data were collected using standardized forms and monitored with run charts, considering process, outcome, and balance indicators. The DD included 12 changes focusing on protocol implementation, adequate medical prescription, correct insulin administration, proper blood glucose monitoring, appropriate diet prescription, safe care transitions between units, routine of publication and discussion of indicators, leadership engagement with frontline workers on hyperglycemia management, educational actions, and defining roles and responsibilities.

RESULTS

A 69.0% reduction in ADBG > 180 mg/dL and a 100% reduction in ADBG > 300 mg/dL were achieved, though hypoglycemic events increased from 8 to 11 per 100 patient-days using insulin or oral antidiabetic medications. Reductions in nonconformities in medical prescription and insulin administration (50.0% and 71.4%, respectively) were also achieved.

CONCLUSION

In this pilot project, use of the MFI led to improved prescription practices, insulin administration, and blood glucose control, reducing the rate of hyperglycemia in hospitalized patients.

Heterogeneity in the management of diabetic ketoacidosis in Australia: a national survey

BACKGROUND

Diabetic ketoacidosis (DKA) is a hyperglycaemic emergency, and insulin administration is highly protocolised with either variable- or fixed-rate intravenous infusions. There are limited data supporting superiority of one regimen over another; however, international guidelines recommend fixed-rate infusions.

AIM

To characterise DKA management protocols used in Australian hospitals.

METHODS

An online survey of Australian endocrinologists and intensive care physicians between May and July 2024. The main outcome measure was the proportion of respondents using a fixed or variable rate, or combination, for the management of DKA. Secondary outcomes were the location of management, definition of resolution and intravenous fluid specification.

RESULTS

There were 31 respondents from individual hospitals around Australia, with 84% of endocrinologists and 84% from metropolitan hospitals. There was wide variation in insulin regimens including fixed (n = 12), variable (n = 14) and combination (n = 5) infusion protocols. Most (23/30, 77%) respondents had worked at another hospital that had a different DKA management protocol. There was a 50% split (n = 14 each) in personal preference for fixed- or variable-rate infusion, with three respondents having no preference. Most (21/31, 68%) protocols defined resolution of DKA. Blood pH (15/21, 71%) and/or ketone level (18/21, 86%) were the most frequently used end points to define resolution.

CONCLUSIONS

There are substantial variations in insulin regimens and resolution criteria in DKA management protocols across Australian hospitals. Clinician preference was diverse. This likely reflects the lack of high-quality evidence to guide practice.

Continuous Glucose Monitoring in Hospitalized Patients With Type 2 Diabetes: A Step Forward in Inpatient Glycemic Control

OBJECTIVE

To determine the effect and safety of continuous glucose monitoring (CGM) use in glycemic control compared to standard approach in hospitalized patients with type 2 diabetes.

METHODS

This was a pilot randomized controlled clinical trial that enrolled 37 hospitalized patients with type 2 diabetes admitted in medical and surgical wards. All patients used CGM (Abbott FreeStyle2 or FreeStyle3) and concomitantly 6-point point of care glucose. In group A (n = 19), daily CGM profiles, alarms, and trend arrows were considered for glycemic therapeutic decisions and in group B (n = 18) were based on point of care glucose. Primary outcomes included the difference in time in range 70-180 mg/dL, hospital glycemia risk index, time below range measured as the percentage below 70 mg/dL and below 54 mg/dL, and time above range measured as the percentage above 180 mg/dL and above 250 mg/dL.

RESULTS

Time in range was higher in group A: 78.26 ± 10.83% vs 67.39 ± 19.13% P = .04. Time above range level 1 in group A: 14.37 ± 8.33% vs group B: 23.28 ± 16.62% P = .04. Asymptomatic hypoglycemic events were more detected by CGM-group (1.65 ± 2.03 vs 0.31 ± 0.60 P = .01). Overall mean absolute relative difference: 14.7%. Diabetes technology society error grid: 69.5% zone A and 29.3% zone B.

CONCLUSIONS

The implementation of CGM in hospitals could represent a significant advancement in diabetes management, offering a more comprehensive and dynamic approach to monitoring glucose levels. Further research is needed to explore the long-term impacts of CGM on clinical outcomes and to optimize its integration into hospital protocols.

Accuracy and Reliability of Intermittent Scanning and Real-Time Continuous Glucose Monitoring Systems in Diabetes Emergencies

BACKGROUND

Diabetes care is a major challenge of patients treated in hospitals. A continuous glucose monitoring system (CGM) provides a more comprehensive assessment of glucose control than capillary blood glucose measurements. Especially in emergencies, data on CGM use in inpatients are limited. To evaluate real-world usability, accuracy of an intermittent scanning and a real-time CGM in patients admitted due to diabetes emergencies was assessed.

METHODS

In 151 patients admitted due to diabetes emergencies, this single-center prospective study investigated the mean absolute relative difference (MARD) in broad glycemic ranges. The CGM accuracy was evaluated by applying a modified version of the Food and Drug Administration (FDA) criteria for CGM use, Clark Error Grid (CEG), and Bland Altman analysis (BAA).

RESULTS

Analysis of 1,498 CGM-/POC-glucose (CGM-/POC-G) pairs revealed a MARD of 10.8% with stepwise improvement from the hypoglycemic to the hyperglycemic range. The CEG analysis showed that 99.1% of all glucose values fell within the optimal or acceptable zones. BAA indicated that 96.0% of CGM-G values fell within the limits of the POC-G values. Day-by-day analysis of overall MARD revealed the highest MARD on the first day of CGM use, followed by consistent and stable MARD levels from day 2 onward until the end of wear time. Applying a modified version of the %20/20 agreement rate of the FDA criteria, 90.7% of CGM-G laid within ±20 mg/dl/±20% agreement rule.

CONCLUSION

This study indicates the usability of CGM for inpatient diabetes care by demonstrating a high accuracy and reliability of CGM measurement.

In-hospital linagliptin for management simplification and hypoglycemia reduction in very old patients with type 2 diabetes

INTRODUCTION AND OBJECTIVES

The role of in-hospital dipeptidyl peptidase-4 inhibitors in very old patients has not been widely described. This work analyzes the simplification of in-hospital antihyperglycemic management (less insulin use) and reductions in hypoglycemia events using linagliptin in patients aged≥80 years with type 2 diabetes.

PATIENTS AND METHODS

This real-world observational study included hospitalized patients≥80 years with type 2 diabetes treated with an antihyperglycemic protocol of either basal-bolus insulin or linagliptin between January 2016 and December 2023. A 1:1 propensity score matching analysis was performed.

RESULTS

Post-matching, 944 patients were included in each group. The total and basal insulin doses and number of daily injections were significantly lower in the linagliptin group than the basal-bolus insulin group with no differences in glycemic efficacy. Regarding safety, patients on the basal-bolus insulin regimen had more hypoglycemic events. The use of basal-bolus insulin regimen (odds ratio: 4.22; 95% confidence interval: 2.14-6.28; p<0.001), a higher total insulin dose (odds ratio: 3.55; 95% confidence interval: 2.02-5.36; p<0.001) and the number of insulin injections (odds ratio: 2.86; 95% confidence interval: 1.50-4.12; p=0.002) were associated with a greater risk of hypoglycemia. Other hypoglycemia risk factors were older age, moderate-severe functional dependence, moderate-severe dementia, polypharmacy, and complex health status.

CONCLUSIONS

The linagliptin regimen simplified in-hospital antihyperglycemic management and reduced hypoglycemia events compared to basal-bolus insulin regimen in patients with type 2 diabetes aged≥80 years. Basal-bolus insulin use and clinical factors were associated with hypoglycemia. The linagliptin regimen could be considered as standard of care for older adult type 2 diabetes patients in the hospital setting.

Blood glucose management in hospitalized patients: a review of current literature

Diabetes mellitus is a chronic medical condition which affects millions of adults worldwide. It can result in various complications and is associated with a higher rate of hospitalizations. Blood glucose management in hospitalized patients is a critical aspect of care, which is important for preventing complications, improving patient outcomes, and reducing the length of hospital stay. Blood glucose control is difficult to achieve secondary to multiple factors involved in its regulation (e.g. type of medical illness, corticosteroid use, and enteral feeding) as well as varying evidence to determine different aspects of it. Our goal is to summarize the existing evidence from observational studies, clinical trials, and various society guidelines on blood glucose management in the hospitalized setting.

Insulin Degludec in Critically Ill Patients With Type 2 Diabetes Mellitus: A Prospective Interventional Study

OBJECTIVE

Dysglycemia has deleterious outcomes on critically ill patients with diabetes mellitus (DM). Insulin degludec, an ultralong-acting insulin, is associated with lower rates of hypoglycemia and blood glucose (BG) variability in non-critically ill patients. The experience with insulin degludec in the intensive care units is lacking. This study aimed to assess the effect of insulin degludec on glycemic control in critically ill patients with type 2 DM.

METHODS

A prospective, interventional study enrolled critically ill patients with type 2 DM. Subjects were started on insulin degludec plus insulin regular correctional doses. BG levels were assessed every 6 hours. The primary outcome was the percentage of BG levels within a target of 140 to 180 mg/dL. The secondary outcomes included the median BG levels, severe hypoglycemia rate, and BG variability.

RESULTS

In total, 155 patients were enrolled. The percentage of BG levels within the target was 28.5%. The first day that the median of BG levels within target was on day 2 of insulin degludec therapy, which continued to be within the target for 1 week. Severe hypoglycemia developed in 5 patients (3.2%). The BG variability in the study was 26% using the coefficient of variation.

CONCLUSION

In critically ill patients with type 2 DM, one-fourth of BG levels were within the glycemic target (140-180 mg/dL) with insulin degludec plus insulin regular correctional doses. The median BG levels were in target starting the second day of insulin degludec therapy. The favorable BG variability using insulin degludec merits further investigation for effect on clinical outcomes.

The Effects of Different Probiotic Administration on Dexamethasone-Associated Metabolic Effects

Glucocorticoids are steroid hormones used in clinical practice as an effective therapeutic option for their effects regarding the dysregulated immune reactions and hyperactive immune system. Their administration in the short- and long-term exposure has been associated with numerous metabolic side effects. Probiotics have been shown to modulate basal metabolism, inflammation, and oxidative stress through the regulation of composition and function of the gut microbial environment. The aim of this study was to assess the effects of Saccharomyces boulardii and Lactobacillus paracasei probiotics in dexamethasone-treated rats. The study comprised four groups, with 6 Charles River Wistar albino male rats/group; group 1 represented the negative control, rats from group 2 were administered dexamethasone, rats from group 3 were administered dexamethasone and probiotics containing the strain Saccharomyces boulardii, and rats from group 4 were administered dexamethasone and probiotics containing the strain Lactobacillus paracasei. We have assessed the plasmatic levels of glucose, total cholesterol, triglycerides, tumor necrosis factor-alpha, interleukin-10, catalase activity, and total antioxidant capacity. The administration of dexamethasone led to elevated serum concentrations of glycolipid metabolism parameters and cytokines and resulted in hepatic steatosis at the morphological level. Administration of probiotics containing Saccharomyces boulardii or Lactobacillus paracasei reduced glucose and tumor necrosis factor-alpha serum concentration in dexamethasone-treated rats. Moreover, the administration of Lactobacillus paracasei probiotics in rats that received dexamethasone increased interleukin-10 and reduced catalase activity. Regarding the liver tissue morphology, the rats that received probiotics showed improved liver histological aspects compared to the dexamethasone-treated group, suggesting that probiotics could provide positive effects regarding the metabolic and histological disturbances induced by glucocorticoids.

Preoperative Glycemic Control and Acute Endophthalmitis after Cataract Surgery in United States Veterans with Diabetes Mellitus

PURPOSE

To evaluate whether preoperative glycemic control is predictive of acute endophthalmitis after cataract surgery.

DESIGN

Retrospective case-control study.

PARTICIPANTS

Patients with diabetes mellitus (DM) who underwent cataract surgery from 2010 through 2022 in the United States Veterans Affairs (VA) Health Care System.

METHODS

Data extracted from the VA Corporate Data Warehouse included patient demographics, clinical features, timing of DM diagnosis, and preoperative hemoglobin A1c (HbA1c) levels drawn 0 to 6 months before surgery. Patients with acute postoperative endophthalmitis were identified using Current Procedural Terminology and International Classification of Diseases codes, then confirmed by chart review. Univariable and multivariable analyses were used to test for an association between preoperative HbA1c and the development of postoperative endophthalmitis.

MAIN OUTCOME MEASURES

Development of postoperative endophthalmitis within 42 days after cataract surgery.

RESULTS

Of 190 393 patients with a diagnosis of DM at the time of cataract surgery and HbA1c recorded 0 to 6 months before surgery, 157 patients (0.08%) demonstrated acute postoperative endophthalmitis. Mean ± standard deviation preoperative HbA1c was lower in patients with acute postoperative endophthalmitis (7.1 ± 1.4%) than in control participants without endophthalmitis (7.3 ± 1.5%), but this difference was not significant (P = 0.14). Similarly, subanalysis of the cohort with HbA1c levels drawn 0 to 2 months before surgery showed no association between preoperative HbA1c and endophthalmitis (P = 0.31). Multiple logistic regression analysis also showed no association between preoperative glycemic control as measured by HbA1c and postoperative endophthalmitis (adjusted odds ratio, 0.89; 95% confidence interval, 0.79-1.01; P = 0.08).

CONCLUSIONS

Preoperative HbA1c level was not associated with the development of acute postoperative endophthalmitis in patients with DM undergoing cataract surgery. These findings suggest that preoperative HbA1c guidelines based on infection rates after nonophthalmic surgery may not apply to cataract surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Targeting insulin stacking to address overnight hypoglycaemia in hospitalised patients with diabetes

Inpatient hypoglycaemia is a significant concern in patients with diabetes due to its association with increased mortality. At the Veterans Affairs Greater Los Angeles Healthcare System, we developed a project to reduce overnight hypoglycaemia in hospitalised patients with diabetes by addressing insulin stacking, defined as insulin dosed within 4 hours of each other. By delaying the timing of bedtime correctional insulin administration in the electronic health record, we achieved a 28% reduction in the proportion of patients experiencing insulin stacking after one year. This led to significant decreases in overnight hypoglycaemia.

Flash Glucose Monitoring for Predicting Cardiogenic Shock Occurrence in Critically Ill Patients: A Retrospective Pilot Study

Background/Objectives: Continuous and flash glucose monitoring (CGM and FGM) may enhance glucose management by providing real-time glucose data. Furthermore, growing evidence is linking altered blood glucose concentrations and worse short-term outcomes in critically ill patients. While hyperglycemia is more common in these patients and is associated with an increased risk of adverse events, hypoglycemia is particularly concerning and significantly raises the risk of fatal outcomes. This exploratory study investigated the link between FGM variables and cardiogenic shock in critically ill Coronary Care Unit (CCU) patients. Methods: Twenty-eight CCU patients (1 May 2021-31 January 2022) were monitored using a Libre FreeStyle system. Analyzed data included patient demographic and laboratory data, left ventricular ejection fraction, standard glucose monitoring, APACHE IV scores, and cardiogenic shock occurrence. Analysis was performed using the χ2 test, Mann-Whitney U test, and logistic regression. Results: Among the patients, 13 (46.43%) developed cardiogenic shock. FGM detected hypoglycemia in 18 (64.29%) patients, while standard methods in 6 (21.43%) patients. FGM-detected hypoglycemia was more frequent in patients who developed cardiogenic shock (p = 0.0129, χ2 test) with a significantly higher time below range reading (p = 0.0093, Mann Withney U test), despite no differences in mean glucose values. In addition, hypoglycemia detected by FGM was an independent predictor of shock (p = 0.0390, logistic regression). Conclusions: FGM identified more hypoglycemic events compared to standard glucose monitoring in the CCU. Frequent FGM-detected hypoglycemic events were associated with cardiogenic shock, regardless of a history of diabetes. Due to a limited sample size, these results should be interpreted cautiously and further research in this area is justified.

Construction and assessment of the quality of a care protocol for insulin use in hospitalized children and adolescents

OBJECTIVES

to develop and assess the quality of a care protocol for safe insulin use in hospitalized children and adolescents.

METHODS

a methodological study developed in three stages: scoping review, protocol development, and quality assessment. The scoping review followed the JBI recommendations, using the PRISMA-ScR checklist. The protocol was constructed according to the Guide for the Construction of Healthcare Protocols, and quality assessment was carried out byjudges using AGREE II.

RESULTS

the protocol achieved a quality rating of 94.4% in the scope and purpose domain; 90.4% in stakeholder involvement; 96.1% in rigor of development; 95.2% in clarity of presentation; 92.8% in applicability; 97.6% in editorial independence; and 92.8% for overall guideline assessment. Judges made suggestions, most of which were accepted.

FINAL CONSIDERATIONS

the protocol was constructed and assessed as a quality instrument recommended for use by healthcare professionals in the context of insulin therapy in pediatrics.

Anaesthesia in chronic dialysis patients: A narrative review

The provision of anaesthesia for individuals receiving chronic dialysis can be challenging. Sedation and anaesthesia are frequently managed by critical care clinicians in the intensive care unit or operating room. This narrative review summarizes the important principles of sedation and anaesthesia for individuals on long-term dialysis, with reference to the best available evidence. Topics covered include the pharmacology of anaesthetic agents, the impacts of patient characteristics upon the pre-anaesthetic assessment and critical illness, and the fundamentals of dialysis access procedures.

Management of the Hospitalized Patient with Hyperglycemia

Hyperglycemia and diabetes place hospitalized patients at a greater risk for serious complications such as infections, diabetic ketoacidosis, hyperosmolar hyperglycemic state, dehydration, electrolyte imbalances, polypharmacy, and lengthened hospitalization. Identification and proper treatment of hyperglycemia and diabetes are essential to reduce morbidity and mortality, as well as to conserve limited health care resources. This article will summarize the current American Diabetes Association and Endocrine Society recommendations for the management of hospitalized patients with hyperglycemia and diabetes. It will discuss the diagnostic criteria for the identification of diabetes and hyperglycemia, glycemic targets, pharmacologic management of hyperglycemia, and the transition to outpatient care.

Using Diabetes Technology in Hospitalized Patients

There is an estimated 350,000 persons wearing an insulin pump and 2.4 million wearing a continuous glucose monitor (CGM) sensor in the United States. The last few decades have ushered in advancements with the integration of insulin delivery and continuous glucose evaluations which offer a more precise tight insulin delivery and glycemic control. However, when hospital admissions are necessary, most desire to continue to wear their devices. The last several decades and during the pandemic, many agencies such as the Joint Commission, FDA, and diabetes organizations have generated position statements and guidelines to allow the most optimal diabetes treatment, even when hospitalized.

Educational Needs and Priorities of People with Diabetes and Healthcare Providers in South Korea: A Mixed-Methods Study

Introduction: Effective self-care for managing diabetes requires culturally sensitive and patient-centered education. This study explored the educational needs and priorities of people with diabetes (PWD) and healthcare providers (HCPs). Method: A mixed-methods approach was employed with participants from a university-affiliated hospital in South Korea. Descriptive and content analyses were used for the questionnaire and interview data. Results: Both PWD (n=33) and HCPs (n=42) ranked diabetes-related side-effect management and medication purpose as the most important aspects of diabetes education. PWD had higher educational needs regarding diagnosed diseases and lifestyle modifications than HCPs. Three themes were revealed: incorporating lifestyle changes and medication taking, collaborating with HCPs and caregivers and providing care to meet person-centered mental health needs, and enhancing education on disease and complications. Discussion: Culturally sensitive and patient-centered education programs that recognize communal values, reflect individual preferences and needs, and promote lifestyle changes by leveraging technologies for Korean PWD are crucial.

Current Recommendations for Insulin Therapy in the Hospitalized Patient

Dysglycemia increases morbidity and mortality in hospitalized patients. Insulin is recommended to manage blood glucose levels greater than or equal to 180 mg/dL. Establishing comprehensive protocols for dysglycemia management in all departments ensures consistent, evidence-based patient care. Basal, prandial, and correction dosing are the best methods for insulin administration. For patients on total parenteral nutrition (TPN) with hyperglycemia, add regular human insulin to the TPN. Corticosteroids can cause hyperglycemia and can be managed with neutral protamine hagedorn insulin. Pay special attention to the resumption of the patient's diet and oral medications during transitions of care and before discharge.

Toward Automation: The Road Traveled and Road Ahead for Integrating Automated Insulin Delivery into Inpatient Care

The introduction of automated insulin delivery (AID) systems represents a significant advancement in diabetes care, offering substantial benefits in outpatient settings. Although clinical studies suggest that these systems can also help improve glycemic control in acutely ill patients, several barriers remain for the actual implementation and use of these technologies in clinical practice. Three main contexts for inpatient use are addressed, including: (a) continuation of personal AID systems, (b) initiation of AID during hospitalization, and (c) initiation of AID systems at discharge. A research road map with immediate to long-term actions is presented. Initially, it calls for clinical studies assessing in-hospital efficacy, safety, and utility, addressing specific patient needs and health care operational impacts. Midterm, it focuses on practical integration, simplifying AID use, ensuring electronic health record compatibility, clarifying regulatory uncertainties, and supporting health care professionals and patients. Long-term goals include system optimizations and policy advocacy for in-hospital AID use.

Noninsulin Diabetes Medications in Hospitalized Children and Adolescents

The prevalence of pediatric diabetes continues to rise in the United States and worldwide. There are various forms of pediatric diabetes including type 1, type 2, and maturity onset diabetes of youth. The treatment depends on each unique type of diabetes and must be taken into consideration for patients based on presentation and clinical setting. There is limited literature supporting the use of noninsulin medications to manage pediatric diabetes in an inpatient setting. This article focuses on noninsulin medication management of children and adolescents presenting with hyperglycemia in acute care settings, both critically and noncritically ill.

Perioperative and periprocedural management of GLP-1 receptor-based agonists and SGLT2 inhibitors: narrative review and the STOP-GAP and STOP DKA-2 algorithms

The GLP-1 receptor-based agonists (GLP-1RAs) and SGLT2 inhibitors (SGLT2i) are major twenty first century breakthroughs in diabetes and obesity medicine but there are important safety considerations regarding the perioperative and periprocedural management of individuals who are treated with these agents. GLP-1RAs have been linked to an increased risk of retained gastric contents and pulmonary aspiration while SGLT2i can be associated with diabetic ketoacidosis. This manuscript provides a narrative review of the available evidence for perioperative and periprocedural risks in people prescribed GLP-1RAs and SGLT2i. The authors provide expert opinion-driven recommendations and algorithms on how to safely manage GLP-1RAs and SGLT2i under perioperative/periprocedural settings.

Review of Subcutaneous Insulin Regimens in the Management of Diabetic Ketoacidosis in Adults and Pediatrics

OBJECTIVE

Summarize the studies evaluating the use of subcutaneous (SQ) insulin in the management of diabetic ketoacidosis (DKA) in adults and pediatrics.

DATA SOURCES

A PubMed literature search was conducted for articles published between 2000 and the end of May 2024 which contained the following terms in their title: (1) subcutaneous, glargine, or basal and (2) ketoa*.

STUDY SELECTION AND DATA EXTRACTION

Review articles, guidelines, meta-analysis, commentaries, studies not related to the acute management of DKA, studies evaluating continuous SQ insulin, animal studies, if the time to DKA resolution was not clearly defined, and studies where basal insulin was administered greater than 6 hours after the insulin infusion was started were excluded.

DATA SYNTHESIS

The electronic search identified 58 articles. Following the initial screening 38 articles were excluded and 3 were added after bibliography review. Of the 23 articles assessed for eligibility, 7 were excluded. Sixteen articles were included. Five studies compared SQ rapid/short-acting insulin and intravenous (IV) insulin infusions in adults, 4 compared SQ rapid/short-acting insulin and IV insulin infusions in pediatrics, 4 evaluated IV insulin infusions with or without SQ basal insulin in adults, and 3 evaluated IV insulin infusions with or without SQ basal insulin in pediatrics.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

In comparison with IV insulin infusions, rapid/short-acting SQ insulin regimens were associated with reduced ICU admission rates, hospital length of stay, and hospitalization costs. IV insulin infusion regimens that included a single SQ basal insulin dose upon therapy initiation were associated with reduced concurrent IV insulin infusion durations.

CONCLUSION

Studies reviewed suggest that SQ insulin regimens may be as effective and safe as IV insulin infusions in the management of DKA and are associated with the conservation of resources. Providers may refer to this review when establishing or modifying their DKA management protocols.

Effects of Perioperative Glycemic Management Protocol on Glycemic Outcomes of Type 2 Diabetic Patients Undergoing Major Abdominal Surgery: A Prospective Cohort Study

PURPOSE

This study aimed to reveal the effects of a glycemic control protocol directed by nurses during the perioperative period on glycemic outcomes in diabetic patients undergoing major abdominal surgery.

DESIGN

This was a prospective cohort study METHODS: The study was conducted at the Department of General Surgery of a research and training hospital in Turkey. The study included 47 patients with type 2 diabetes mellitus who underwent elective major abdominal surgery between September 2017 and December 2018. The number of patients in the intervention and the control groups was 22 and 25, respectively. Routine clinical glycemic control was implemented in the control group, whereas a glycemic management protocol developed by a multidisciplinary team was implemented in the intervention group. We collected data on the control group first, followed by the introduction of the glycemic management protocol to clinical staff and glycemia data collection using the new protocol. Blood glucose (BG) levels in patients and the factors that may affect BG were measured in the preoperative, intraoperative, and postoperative periods. Data on glycemic control was also collected. Furthermore, we measured the satisfaction of the nurses implementing the glycemic management protocol.

FINDINGS

The rate of hyperglycemia in intensive care unit was 21% in the intervention group and 59% in the control group (P < .05). Time spent in the target BG range during insulin infusion was 76% in the intervention group and 35% in the control group (P < .05). The time required to achieve target BG range during insulin infusion was 6 hours for the intervention group and 15 hours for the control group, indicating that less time was required to achieve the target BG range in the intervention group (P < .05). Moreover, the insulin consumption rate in the intensive care unit was lower in the intervention group (P < .05). The satisfaction levels of the nurses that used the glycemic management protocol was 92.61 ± 7.93%.

CONCLUSIONS

Results of this study showed that the implementation of a glycemic management protocol by nurses for patients undergoing major abdominal surgery decreases the rate of hyperglycemia, insulin consumption rate, and the time required to achieve the targeted BG range during the perioperative period. Therefore, it is recommended to use a glycemia management protocol to control glycemia in patients during the surgical process.

The effect of percentage of time spent above different glucose levels on 90 days mortality of critically ill patients - A retrospective cohort study

INTRODUCTION

Glycemic control is a major concern during critical illness. Several prospective studies have yielded conflicting results regarding its mortality effect. Current recommendations are to initiate insulin therapy for all patients when glucose levels are higher than 180 mg/dL. Some suggest decreasing this threshold for non-diabetic patients to 140 mg/dL. These thresholds haven't been compared to each other or to other glucose thresholds. This study aimed to find out whether different glucose levels are associated with 90-d mortality.

METHODS

A retrospective cohort study. Critically ill patients who were admitted from 2019 to 2022 to a mixed medical-surgical intensive care unit for more than 48 h were included. Collected data included baseline characteristics, and all glucose levels recorded (time-indexed to the admission time). Glucose levels were considered constant until the following glucose level. The percentage of time above several chosen glucose cutoff levels was calculated and analyzed for mortality adjusted to other baseline covariates.

RESULTS

45,512 glucose measurements of 1429 patients were included in the study; 21.76 % of the patients had diabetes. Mean glucose level and glucose variability were higher in diabetic patients (165.86 mg/dL vs 135.47 mg/dL, p < 0.0001, and 30.81 % vs 20.86 %, p < 0.0001, respectively), along with a higher incidence of hypoglycemia (40.84 % vs 24.89 %, p < 0.001). 90-d mortality was higher in diabetic patietns (42.12 % vs 32.41 %, p = 0.0014) and was found associated with age, acute physiology and chronic health evaluation 2 score, medical or surgical admission reasons. Percentage of time above cutoffs ≥150 mg/dL was associated with 90-d mortality only in non-diabetic patients.

CONCLUSIONS

In non-diabetic patients, hyperglycemia greater than 150 mg/dL, was associated with increased 90-day mortality.

Retrospective observational study of the association of peak blood glucose during the second 24 hours of admission with hospital-acquired complications in non-critical care admissions to a tertiary referral teaching hospital

INTRODUCTION

Stress hyperglycaemia at hospital presentation is associated with poorer outcomes. Less is known about the risk of poorer outcomes according to achieved glycaemia early in the admission.

RESEARCH DESIGN/METHODS

This was a retrospective observational study of patients admitted to non-critical care wards. The aim was to determine the relationship between the day 2 peak blood glucose and the occurrence of hospital-acquired complications (HACs) or in-hospital mortality. A Cox proportional hazards model, adjusted for relevant covariates, was used to evaluate the impact of day 2 peak glucose on HACs and in-hospital mortality, and we identified peak glucose thresholds correlating with an increase in risk.

RESULTS

For the whole cohort, day 2 peak glucose was associated with an increased risk of any HAC, aHR=1.06, 95% CI: 1.04, 1.07; but not in-hospital mortality, aHR=0.98, 95% CI: 0.94, 1.01. The risk of HAC infection increased by 4.6% for every mmol/L rise in day 2 peak glucose (aHR=1.05, 95% CI: 1.02, 1.08) in the diabetes cohort compared with 5.5% (aHR=1.06, 95% CI: 1.00, 1.11) in the non-diabetes cohort. The risk of HAC cardiac in the diabetes cohort increased by 5.3% (aHR=1.05, CI: 1.01, 1.10) per mmol/L increase in day 2 peak glucose; no association was found in the non-diabetes cohort (aHR=1.03, 95% CI: 0.94, 1.13). The risk for in-hospital mortality was associated with day 2 peak glucose, aHR=1.11, 95% CI: 1.03, 1.20, in patients without diabetes, but not in patients with diabetes, aHR=1.00, 95% CI: 0.95, 1.06. There was an increase in the risk of HAC once day 2 peak blood glucose exceeded 19.0 mmol/L (whole cohort), with thresholds of 13.6 mmol/L in the non-diabetes group and 19.5 mmol/L in the diabetes group.

CONCLUSION

The peak glucose on day 2 was a predictor of HAC in the entire cohort and in-hospital mortality in patients without diabetes.

Impact of Hospitalization on Continuation of SGLT2 Inhibitors and GLP-1 Receptor Agonists for Comorbidities in Patients with Type 2 Diabetes

Purpose: In the treatment of type 2 diabetes mellitus (T2DM), select sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists are recommended based on comorbidities such as chronic kidney disease (CKD), heart failure (HF), and atherosclerotic cardiovascular disease (ASCVD). Because guidelines typically recommend insulin for inpatient treatment of T2DM, there is potential that these therapies may be negatively impacted by hospitalization. This study aimed to assess the effect of hospitalization on outpatient T2DM therapy. Methods: In this retrospective study, patients were included if they had a diagnosis of T2DM plus a comorbidity (CKD, HF, ASCVD) for which they were prescribed an SGLT2 inhibitor or GLP-1 receptor agonist and had a recent hospitalization and follow-up appointment at an outpatient clinic. Electronic medical records were reviewed to determine if these therapies were continued during transitions of care. Data was analyzed with basic descriptive statistics. Results: Thirty-six patients on SGLT2 inhibitor therapy met inclusion criteria. Four (11%) patients were never restarted on therapy outpatient following hospitalization, three of which did not have an appropriate reason for discontinuation. Twenty-two patients on GLP-1 receptor agonist therapy met inclusion criteria. Four (18%) were never restarted on therapy outpatient following hospitalization, two of which did not have an appropriate reason for discontinuation. Conclusion: Five out of 58 patients (8.6%) included in the study experienced an inappropriate discontinuation of therapy throughout the transitions of care process. While most patients had their T2DM medication restarted, this study shows hospitalization can impact guideline-directed outpatient therapy.

Pros and Cons of Inpatient SGLT2i Use for Hyperglycemia and Heart Failure

Sodium-glucose cotransporter 2 inhibitors (SGLT2is), originally approved by the US Food and Drug Administration for glycemic control in type 2 diabetes mellitus (DM2), have shown substantial cardiovascular and renal benefits, leading to their expanded use in managing heart failure (HF) and chronic kidney disease in the outpatient setting. Despite these benefits, their use for inpatient hyperglycemia management is not universally endorsed due to safety concerns and inadequate data. However, emerging evidence suggests potential advantages of initiating SGLT2i treatment for patients during hospitalization in the setting of HF. While SGLT2is are not recommended for managing inpatient hyperglycemia, initiation during hospitalization for HF provides significant benefits. We review the current literature on the pros and cons of using SGLT2is in hospitalized DM2 and HF patients and provide guidance on careful patient selection and risk mitigation for inpatient use.

Antidiabetic agent use and clinical outcomes in patients with diabetes hospitalized for COVID-19: a systematic review and meta-analysis

Background

The effect of antidiabetic agents on mortality outcomes is unclear for individuals with diabetes mellitus (DM) who are hospitalized for COVID-19.

Purpose

To examine the relationship between antidiabetic agent use and clinical outcomes in individuals with DM hospitalized for COVID-19.

Methods

A systematic review of the literature (2020-2024) was performed across five databases. Included articles reported primary research (English) reporting clinical outcomes of adult patients (≥18 yrs.) with DM receiving antidiabetic agents who were hospitalized for COVID-19. Following PRISMA guidelines articles underwent independent dual review. Quality appraisal was completed for included studies. Independent reviewers used a structured data extraction form to retrieve relevant data. Aggregated data were synthesized by treatment regimen and reported descriptively. Random effects meta-analyses were performed to assess relative risk and prevalence of mortality.

Results

After removing duplicates, title and abstract screening of 4,898 articles identified 118 articles for full-text review and 35 articles were retained for analysis. Included articles were primarily from China (15/35, 43%) and retrospective in nature (31/35, 89%). Fourteen studies (40%) assessed multiple antidiabetic agents, fifteen studies (42%) focused on metformin, three studies (9%) assessed the use of DPP-4 inhibitors, and three single studies (9%) investigated the use of insulin, TZD, and SGLT2 inhibitors. Despite differences among studies, the overall relative risk of mortality among metformin and DPP-4 inhibitor users was 0.432 (95% CI = 0.268-0.695, z = 3.45, p < 0.001) and the overall prevalence of mortality among all antidiabetic users was 16% (95% CI = 13%-19%, z = 10.70, p < 0.001).

Conclusions and implications

Synthesis of findings suggest that patients who remained on oral agents (with/without supplemental insulin therapy) exhibited decreased mortality and lower inflammatory markers. Results indicate that individuals with DM should continue oral antidiabetic agents with additional basal insulin as needed to improve glycemic control and reduce mortality. Further work is needed to uncover mechanism(s) and clarify medical management approaches.

Biological variation of capillary blood glucose: A systematic review

Biological variation (BV) refers to changes in biochemical constituents in the blood or other biological fluids, indicative of body regulation via homeostatic processes. Intra- and interindividual BV data are essential for establishing analytical performance specifications and evaluating the significance between consecutive measurements of an analyte. Given this context, the present study conducted a systematic review of the intra- and interindividual BV of capillary blood glucose. Out of 461 initial studies identified, only 4 met the inclusion criteria for detailed analysis after excluding 419 for title irrelevance, 10 for duplication, 21 based on abstract content and 7 based on article content. Notably, none of the studies primarily focused on the intra- and interindividual BV of capillary blood glucose; rather, they reported it as a secondary outcome. Regarding fasting, data analyses revealed intra-individual BVs of 4.5 and 31.1% for healthy and diabetic individuals, respectively, and interindividual coefficient of variations of 4.7-5.8 and 12.9-16.3% for healthy and diabetic individuals, respectively. Only one study provided the analytical coefficient of variation, corroborating the recommended practices. Additionally, the fasting duration, meal standardization before sampling, and number and interval between collections varied among the studies. Hence, the results suggest that there are no reliable data on intra- and interindividual BVs for capillary blood glucose in the literature.

Increased Prevalence of Psychiatric Conditions in Panniculectomy Patients With Prior Bariatric Surgery: A Nationwide Epic Cosmos Study

Introduction Patients with established body dysmorphic disorder (BDD) diagnoses are highly likely to be dissatisfied with plastic surgery and may have increased complication rates. Identifying at-risk patients prior to surgery is crucial to achieving patient satisfaction and minimizing adverse effects. This study seeks to assess the prevalence of BDD and associated psychiatric disorders in patients who have undergone panniculectomy and to evaluate potential associations between psychiatric comorbidity and prior bariatric surgery. Materials and methods Data used in this study came from Epic Cosmos (Epic Systems Corporation, Verona, WI, USA), a community collaboration of health systems representing over 233,000,000 patient records from over 1,325 hospitals and 28,900 clinics. All patients at least 18 years of age with an encounter between January 11, 2014, and January 10, 2024 (n=232,933,561) were included, and records were grouped based on procedural history using documented current procedural terminology codes. Prevalence of psychiatric diagnoses was measured using documented International Classification of Diseases (ICD) 10 codes, and 99% confidence intervals were recorded. Odds ratios (OR) were calculated for group comparison, and p<0.01 was used to determine significance. Results Patients who have undergone panniculectomy (n=62,671) demonstrated significantly increased prevalence of BDD (0.182% vs. 0.011%; OR=16.3, p<0.001), anxiety (43.2% vs. 13.5%; OR=4.9 p<0.001), and depression (35% vs. 9.7%; OR=5.0, p<0.001) compared to those who have not undergone the procedure (n=232,870,890). Of the 62,671 patients with a recorded panniculectomy, those who had also undergone bariatric surgery (n=7,313) showed a significantly increased prevalence of BDD (0.397% vs. 0.154%; OR=2.6, p<0.001), anxiety (64.1% vs. 40.5%; OR=2.6, p<0.001), and depression (57% vs. 32.1%; OR=2.8, p<0.001) than those without prior bariatric surgery (n=55,358). Conclusion Patients undergoing panniculectomy are at high risk for BDD and other psychiatric comorbidities that justify formal screening prior to scheduling surgery. Surgeons should maintain a low threshold in seeking psychiatric evaluation for any concerning patients presenting for panniculectomy evaluation, especially in those with a bariatric surgery history, to ensure holistic benefit for their patients. Additionally, psychiatric professionals who understand the stress of elective plastic surgery should be utilized when available.

Results From a Randomized Trial of Intensive Glucose Management Using CGM Versus Usual Care in Hospitalized Adults With Type 2 Diabetes: The TIGHT Study

OBJECTIVE

To evaluate whether continuous glucose monitoring (CGM) could assist providers in intensifying glycemic management in hospitalized patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

At six academic hospitals, adults with type 2 diabetes hospitalized in a non-intensive care setting were randomly assigned to either standard therapy with glucose target 140-180 mg/dL (standard group) or intensive therapy with glucose target 90-130 mg/dL guided by CGM (intensive group). The primary outcome was mean glucose measured with CGM (blinded in standard group), and the key secondary outcome was CGM glucose <54 mg/dL.

RESULTS

For the 110 participants included in the primary analysis, mean ± SD age was 61 ± 12 years and mean HbA1c was 8.9 ± 2.3% (73.8 ± 1.6 mmol/mol). During the study, CGM-measured mean glucose was 170 mg/dL for the intensive group (n = 60) vs. 175 mg/dL for the standard group (n = 50; risk-adjusted difference -7 mg/dL, 95% CI -19 to 5; P = 0.25). Only 7% of the intensive group achieved the mean glucose target range of 90-130 mg/dL. CGM readings <54 mg/dL were infrequent (0.2% for intensive and 0.4% for standard; adjusted treatment group difference -0.1%, 95% CI -0.6 to 0.3). One severe hypoglycemia event occurred in the standard group.

CONCLUSIONS

The study's glucose management approach using CGM did not improve glucose levels compared with standard glucose management in the non-intensive care unit hospital setting. A glucose target of 90-130 mg/dL may not be realistic in the current environment of insulin management in the hospital.

Diabetes Technology Use in Special Populations: A Narrative Review of Psychosocial Factors

As diabetes technologies continue to advance, their use is expanding beyond type 1 diabetes to include populations with type 2 diabetes, older adults, pregnant individuals, those with psychiatric conditions, and hospitalized patients. This review examines the psychosocial outcomes of these technologies across these diverse groups, with a focus on treatment satisfaction, quality of life, and self-management behaviors. Despite demonstrated benefits in glycemic outcomes, the adoption and sustained use of these technologies face unique challenges in each population. By highlighting existing research and identifying gaps, this review seeks to emphasize the need for targeted studies and tailored support strategies to understand and optimize psychosocial outcomes and well-being.

Glucose-Lowering Agents Developed in the Last Two Decades and Their Perioperative Implications

The last two decades have provided far more options f both patients and their physicians in the treatment of diabetes mellitus. While dipeptidyl peptidase-4 inhibitors (DPP-4is) and glucagon-like peptide 1 receptor agonists (GLP-1RAs) have been approved for nearly two decades, sodium-glucose cotransporter 2 inhibitors (SGLT-2is) are relatively new. Of interest to perioperative physicians, these drugs present specific perioperative concerns, prompting many societies to issue guidelines. Retained gastric contents due to slow gastric emptying is a significant drawback of GLP-1RAs, increasing the risk of aspiration. Recommendations include withholding GLP-1RAs for a predefined period of time, performing gastric ultrasound to evaluate gastric contents, modifying anesthesia management, particularly with regard to the airway, or canceling the scheduled (elective) surgery or procedure. SGLT-2is are known to increase the risk of euglycemic ketoacidosis. The benefits of both GLP-1RAs and SGLT-2is extend beyond the treatment of diabetes. As a result, perioperative physicians may encounter their use outside of their traditional indications. SGLT-2is are being used extensively to treat heart failure and obesity, for example. There have been other developments as well. For instance, Imeglimin, a variant of metformin available in Japan and India, Icodec, a once-weekly basal insulin formulation, and IcoSema, a once-weekly combination of Icodec plus semaglutide, are all being explored, although in their early stages or facing approval challenges.

Retrospective Comparison of Early Versus Late Initiation of Long-Acting Insulin in Critically Ill Pediatric Patients in Diabetic Ketoacidosis

OBJECTIVE

Determine whether early administration (EA) of long-acting insulin in pediatric diabetic -ketoacidosis (DKA) reduces time to acidosis resolution while maintaining safety when compared with late administration (LA).

METHODS

This retrospective review compared EA (within 4 hours) to LA (4 to 24 hours) of long-acting insulin in DKA management in the pediatric intensive care unit between 2015 and 2022. Admissions were excluded for patients ≥18 years of age, without type 1 diabetes, with insufficient laboratory data, or who did not receive insulin glargine within 24 hours of starting treatment. Primary outcome was resolution of acidosis, measured as time to normalization of serum sodium bicarbonate concentration (>15 mEq/L). Secondary outcomes included hospital and intensive care lengths of stay, and insulin infusion duration. Safety outcomes were hypokalemia, hypoglycemia, and cerebral edema.

RESULTS

Of the 233 admissions evaluated, 51 met inclusion for each group. The median patient age was 11 years, 42% female, and 59% had new-onset diabetes. No difference was found in the median time to acidosis resolution (8.13 hours [EA] and 8.02 hours [LA]; p = 0.4161). Median insulin infusion durations were 16.2 and 17.6 hours for EA and LA, respectively (p = 0.8750). Median hospital stay was 2 days for both groups (p = 0.9068). Hypoglycemia and hypokalemia rates were not significantly different but occurred more often than previously reported.

CONCLUSIONS

Early administration of long-acting insulin in pediatric DKA did not affect acidosis duration or treatment length when compared with late administration. Incidence of hypoglycemia and hypokalemia were similar between groups.

Management of Hyperglycemia in Hospitalized Patients

People with diabetes account for 25% of hospitalizations, or 8 million admissions annually. Poor glycemic control in the hospital is associated with increased morbidity, mortality, length of stay, and readmissions. Key considerations of inpatient diabetes management include initiation of appropriate insulin or medication regimens and frequent dose adjustments based on patient-specific factors. Inpatient diabetes management teams and new technologies are increasingly prevalent and can assist in achieving glycemic targets in the hospital. At discharge, standardized checklists should be used to ensure successful transitions of care.

A Systematic Review and Meta-analysis on the Safety and Efficacy of Sodium-Glucose Cotransporter 2 Inhibitor Use in Hospitalized Patients

BACKGROUND

The safety and efficacy of sodium-glucose cotransporter 2 (SGLT2) inhibitors in hospitalized patients are unclear.

PURPOSE

To evaluate outcomes of inpatient SGLT2 inhibitor use.

DATA SOURCES

MEDLINE, Embase, Emcare, and Cochrane databases were searched through 29 May 2024.

STUDY SELECTION

Randomized controlled trials (RCTs) and observational cohort studies with assessment of SGLT2 inhibitor use in patients hospitalized for any reason were included.

DATA EXTRACTION

Study characteristics and clinical outcomes were extracted.

DATA SYNTHESIS

We performed a random-effects meta-analysis analyzing RCTs and cohort studies separately. Heterogeneity was quantified with the I2 statistic. Twenty-three RCTs comprising 19,846 participants (29.5% with type 2 diabetes) with comparison of SGLT2 inhibitors with placebo or active comparator were included. Ketoacidosis rates were 0.210 per 100 person-years (95% CI 0.119, 0.370) for SGLT2 inhibitors and 0.140 per 100 person-years (95% CI 0.070, 0.280) for control (rate ratio 1.50 [95 CI 0.56, 4.23], P = 0.38). SGLT2 inhibitor use was associated with fewer readmissions and urgent visits (odds ratio [OR] 0.64 [95 CI 0.47, 0.86], P < 0.01) and lower mortality rates (OR 0.74 [95% CI 0.56, 0.98], P = 0.03) in heart failure trials and lower incidence of acute kidney injury (OR 0.76 [95% CI 0.60, 0.97], P = 0.03) among all RCTs. Twenty observational studies were included and did not show increased adverse events.

LIMITATIONS

Ketoacidosis rates were low, likely leading to lack of power to detect significant differences.

CONCLUSIONS

SGLT2 inhibitor use among hospitalized patients was associated with numerically higher rates of ketoacidosis, although further studies are required.

Accuracy of continuous glucose monitoring in the hospital setting: an observational study

AIMS/HYPOTHESIS

Continuous glucose monitoring (CGM) improves glycaemic outcomes in the outpatient setting; however, there are limited data regarding CGM accuracy in hospital.

METHODS

We conducted a prospective, observational study comparing CGM data from blinded Dexcom G6 Pro sensors with reference point of care and laboratory glucose measurements during participants' hospitalisations. Key accuracy metrics included the proportion of CGM values within ±20% of reference glucose values >5.6 mmol/l or within ±1.1 mmol/l of reference glucose values ≤5.6 mmol/l (%20/20), the mean and median absolute relative difference between CGM and reference value (MARD and median ARD, respectively) and Clarke error grid analysis (CEGA). A retrospective calibration scheme was used to determine whether calibration improved sensor accuracy. Multivariable regression models and subgroup analyses were used to determine the impact of clinical characteristics on accuracy assessments.

RESULTS

A total of 326 adults hospitalised on 19 medical or surgical non-intensive care hospital floors were enrolled, providing 6648 matched glucose pairs. The %20/20 was 59.5%, the MARD was 19.2% and the median ARD was 16.8%. CEGA showed that 98.2% of values were in zone A (clinically accurate) and zone B (benign). Subgroups with lower accuracy metrics included those with severe anaemia, renal dysfunction and oedema. Application of a once-daily morning calibration schedule improved accuracy (MARD 11.4%).

CONCLUSIONS/INTERPRETATION

The CGM accuracy when used in hospital may be lower than that reported in the outpatient setting, but this may be improved with appropriate patient selection and daily calibration. Further research is needed to understand the role of CGM in inpatient settings.

Perioperative Management of Adult Patients with Diabetes Wearing Devices: A Society for Perioperative Assessment and Quality Improvement (SPAQI) Expert Consensus Statement

In recent years, the integration of advanced diabetes technology into the care of individuals with diabetes has grown exponentially. Given their increasing prevalence, insulin-requiring people with diabetes may present to preoperative clinics or the operating rooms wearing such devices. While advantageous from a diabetes management perspective, for those unfamiliar with devices this can add another layer of complexity to diabetes management in both the outpatient and inpatient settings, particularly because of the rapidly evolving technology. Therefore, perioperative clinicians need to become familiar with diabetes technological advances, and device features and have an understanding of how they can be used in the perioperative period. This consensus statement aims to serve as an educational material as well as to serve as a guide to perioperative clinicians caring for patients wearing diabetes devices (insulin pumps and continuous glucose monitors).

Starting Insulin Algorithms for Noncritical Illness: A Survey of 32 Academic Hospitals in the United States

Glycemic control immediately upon hospitalization is difficult. Endocrine Society guidelines suggest starting scheduled insulin therapy at 0.2-0.5 units/kg/day, but there has been no rigorous study to support this recommendation. To understand the variability of current practice, we surveyed starting insulin algorithms for noncritically ill patients among the top-ranking academic hospitals in the United States. Among the 20 hospitals with reported algorithms, 12 specified which patients should start with basal/nutritional insulin, whereas 5 specified who should start with only correction insulin. Weight-based and/or home-dose-based calculations were used to estimate the initial insulin requirements with various modifiers. In addition, various factors were considered when choosing among the correction dose algorithms. In summary, among the U.S. academic hospitals, there is variability in methods for determining insulin dosing on admission for noncritically ill patients. This inconsistency suggests that future studies to estimate initial insulin requirements are required.

Are we Ready for Real-Time Continuous Glucose Monitoring in the Hospital Setting? Benefits, Challenges, and Practical Approaches for Implementation : Case Vignette: Remote Real-Time Continuous Glucose Monitoring for Hospitalized Care in Quincy Koala

PURPOSE OF REVIEW

While preliminary evidence for use of real-time continuous glucose monitoring (rtCGM) in the hospital setting is encouraging, challenges with currently available devices and technology will need to be overcome as part of real-world integration. This paper reviews the current evidence and guidelines regarding use of rtCGM in the hospital and suggests a practical approach to implementation.

RECENT FINDINGS

There is now a considerable body of real-world evidence on the benefits of reducing dysglycemia in the hospital using both traditional point-of-care (POC) glucose testing and rtCGM. Benefits of rtCGM include decreased frequency of hypo- and hyperglycemia with reduced need of frequent POC checks and it is both feasible and well-accepted by nursing staff and providers. If expansion to additional sites is to be considered, practical solutions will need to be offered. Recommendations for an operational workflow and tools are described to guide implementation in the non-ICU setting. Further testing in randomized controlled trials and real-world dissemination and implementation designs is needed, together with industry and technology collaborations, to further streamline the integration into health systems.

Technology in the management of diabetes in hospitalised adults

Suboptimal glycaemic management in hospitals has been associated with adverse clinical outcomes and increased financial costs to healthcare systems. Despite the availability of guidelines for inpatient glycaemic management, implementation remains challenging because of the increasing workload of clinical staff and rising prevalence of diabetes. The development of novel and innovative technologies that support the clinical workflow and address the unmet need for effective and safe inpatient diabetes care delivery is still needed. There is robust evidence that the use of diabetes technology such as continuous glucose monitoring and closed-loop insulin delivery can improve glycaemic management in outpatient settings; however, relatively little is known of its potential benefits and application in inpatient diabetes management. Emerging data from clinical studies show that diabetes technologies such as integrated clinical decision support systems can potentially mediate safer and more efficient inpatient diabetes care, while continuous glucose sensors and closed-loop systems show early promise in improving inpatient glycaemic management. This review aims to provide an overview of current evidence related to diabetes technology use in non-critical care adult inpatient settings. We highlight existing barriers that may hinder or delay implementation, as well as strategies and opportunities to facilitate the clinical readiness of inpatient diabetes technology in the future.