RF16 | PSUN204 Improving Inpatient Insulin Management amongst Internal Medicine Residents with a Multi-Media Structured Educational Program

Introduction

Approximately 1 in 4 patients admitted to the hospital carry a diagnosis of diabetes mellitus¹ and 1 in 10 patients are admitted due to diabetes complications.² Although Internal Medicine residents comprise the primary care team for the vast majority of patients admitted to major academic hospitals, there is a paucity of resources and standardized training for inpatient diabetes management, specifically designed for residents.

Methods

We developed a structured resident education program consisting of a mobile/web application ("EndoApp") as an accessible resource combined with a series of short lectures. The EndoApp is comprised of checklists, guidelines, and calculators based on the most recent American Diabetes Association (ADA) and American Association of Family Physicians (AAFP) recommendations. The application addresses five major areas of inpatient insulin management—i) insulin pharmacokinetics, ii) admission dosage calculation, iii) inpatient insulin regimen adjustment, iv) management of diabetic emergencies, and v) equipment and prescription management at discharge. The confidence level of residents for each of the five areas were surveyed at months 0, 1, and 3, after the start of the program on a scale of 1-5.

Results

Our 3-month interim analysis showed that the confidence of residents in all five areas of inpatient insulin management improved over the study period. Increased confidence was seen in post-graduate year (PGY) 1, 2, and 3 residents. The Admission Insulin Dosing Calculator was the most frequently used function (45% of residents), followed by DKA/HHS helper (23% of residents), and Inpatient Dosage Adjustment Guidelines (21% of residents). Residents who used the Admission Insulin Dosing Calculator had greater increase in provider confidence compared to those who did not use the function. Subjective feedback from residents included expanding functions to include hypoglycemia and non-emergent hyperglycemia management, as well as having recordings of supplementary lectures available on the application.

Conclusion

Structured resident education in inpatient insulin management utilizing a mobile/web application and lectures as supplementary material is a promising approach to improve resident education and confidence in inpatient diabetes management.

References

1. Moghissi ES, Korytkowski MT, DiNardo M, et al. American association of clinical endocrinologists and american diabetes association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4): 353-369. doi: 10.4158/EP09102.RA

2. Russell LB, Valiyeva E, Roman SH, Pogach LM, Suh DC, Safford MM. Hospitalizations, nursing home admissions, and deaths attributable to diabetes. Diabetes Care. 2005;28(7): 1611-1617. doi: 10.2337/diacare.28.7.1611

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Sunday, June 12, 2022 12:30 p.m. - 12:35 p.m.

PSUN253 Cocaine Use Resulting in Inadvertent Sulfonylurea Overdose

Introduction

Most street cocaine is cut with other substances to increase drug volume. Often, cutting agents are used that change or intensify the effects of the drug. We present a case in which sulfonylurea-laced cocaine resulted in life-threatening hypoglycemia.

Clinical Case

A 61-year-old male with a history of heart failure with reduced ejection fraction, moderate aortic stenosis, and substance abuse was found unconscious with a fingerstick of 25 mg/dL. He had no personal history of diabetes. No one in his household had diabetes, and he denied any use of insulin or oral anti-diabetic medications. In the emergency department, he had recurrent hypoglycemia despite D10 boluses, glucagon, oral glucose tablets, and a full meal. He required initiation of a continuous intravenous D10 drip, which was titrated to 250 mL/hr to maintain normoglycemia. The endocrinology service was consulted for further evaluation and treatment. The patient recalled smoking a new supply of cocaine prior to his current admission. He had been admitted to two other hospitals within the month prior with similar episodes of severe hypoglycemia. Biochemical evaluation during a prior hospitalization suggested hyperinsulinemic hypoglycemia and a CT abdomen did not visualize an insulinoma. However, diagnostic evaluation was not completed at that time as the patient left against medical advice.Tests during this hospitalization included a low serum glucose 42 mg/dL, high insulin 107 uIU/mL (normal <3), high proinsulin 42.8 pmol/L (normal <5 pmol/L), high c peptide 13 ng/mL (normal <0.6) and low beta-hydroxybutyrate 1.2 mg/dL (normal >2.7mg/dL), consistent with hyperinsulinemic hypoglycemia. Other results included negative insulin antibody, normal TSH, and appropriately elevated cortisol levels. Given desire to rapidly wean D10 drip to avoid volume overload, octreotide therapy was initiated. He received octreotide 50mcg subcutaneously three times over a span of 24 hours, and the D10 drip was discontinued. His sulfonylurea screen subsequently resulted positive for glipizide. Considering the timing of cocaine use preceding the onset of hypoglycemia, it was postulated that the hyperinsulinemic hypoglycemic event was due to use of cocaine that was intermixed with sulfonylurea.

Conclusion

In cases of hypoglycemia with a known history of illicit substance abuse, clinicians should consider the presence of contributing cutting agents, such as sulfonylureas.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Continuous Glucose Monitoring-Guided Insulin Administration in Hospitalized Patients With Diabetes: A Randomized Clinical Trial

OBJECTIVE

The efficacy and safety of continuous glucose monitoring (CGM) in adjusting inpatient insulin therapy have not been evaluated.

RESEARCH DESIGN AND METHODS

This randomized trial included 185 general medicine and surgery patients with type 1 and type 2 diabetes treated with a basal-bolus insulin regimen. All subjects underwent point-of-care (POC) capillary glucose testing before meals and bedtime. Patients in the standard of care (POC group) wore a blinded Dexcom G6 CGM with insulin dose adjusted based on POC results, while in the CGM group, insulin adjustment was based on daily CGM profile. Primary end points were differences in time in range (TIR; 70-180 mg/dL) and hypoglycemia (<70 mg/dL and <54 mg/dL).

RESULTS

There were no significant differences in TIR (54.51% ± 27.72 vs. 48.64% ± 24.25; P = 0.14), mean daily glucose (183.2 ± 40 vs. 186.8 ± 39 mg/dL; P = 0.36), or percent of patients with CGM values <70 mg/dL (36% vs. 39%; P = 0.68) or <54 mg/dL (14 vs. 24%; P = 0.12) between the CGM-guided and POC groups. Among patients with one or more hypoglycemic events, compared with POC, the CGM group experienced a significant reduction in hypoglycemia reoccurrence (1.80 ± 1.54 vs. 2.94 ± 2.76 events/patient; P = 0.03), lower percentage of time below range <70 mg/dL (1.89% ± 3.27 vs. 5.47% ± 8.49; P = 0.02), and lower incidence rate ratio <70 mg/dL (0.53 [95% CI 0.31-0.92]) and <54 mg/dL (0.37 [95% CI 0.17-0.83]).

CONCLUSIONS

The inpatient use of real-time Dexcom G6 CGM is safe and effective in guiding insulin therapy, resulting in a similar improvement in glycemic control and a significant reduction of recurrent hypoglycemic events compared with POC-guided insulin adjustment.

Continuous glucose monitoring in the hospital: an update in the era of COVID-19

PURPOSE OF REVIEW

Continuous glucose monitoring (CGM) systems are Food and Drug Administration approved devices for the ambulatory setting; however, they remain investigational systems for inpatient use. This review summarizes the most recent and relevant literature on the use of continuous glucose monitoring in the hospital setting.

RECENT FINDINGS

CGM provides real-time glucose data that enable healthcare professionals to make proactive and timelier clinical decisions with regards to diabetes management. CGM devices appear to be safe and accurate systems for glucose monitoring in the hospital setting. Real-time CGM systems and glucose telemetry can decrease hypoglycemia and reduce hyperglycemia in hospitalized patients with diabetes. Remote glucose monitoring decreases the need of frequent Point-of-care checks and personal protective equipment use while also mitigating staff exposure risk which is timely in the advent of the COVID-19 pandemic. Although most nursing staff have limited exposure and training on CGM technology, early studies show that CGM use in the hospital is well received by nurses.

SUMMARY

Given the evidence in the current literature regarding CGM use in the hospital, CGM devices may be incorporated in the inpatient setting.