Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis

BACKGROUND

Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used.

METHODS

We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer's solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip.

RESULTS

Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001).

CONCLUSIONS

In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.

Diabetes Technology Meeting 2023

Diabetes Technology Society hosted its annual Diabetes Technology Meeting from November 1 to November 4, 2023. Meeting topics included digital health; metrics of glycemia; the integration of glucose and insulin data into the electronic health record; technologies for insulin pumps, blood glucose monitors, and continuous glucose monitors; diabetes drugs and analytes; skin physiology; regulation of diabetes devices and drugs; and data science, artificial intelligence, and machine learning. A live demonstration of a personalized carbohydrate dispenser for people with diabetes was presented.

Going into town or staying home: Rural patient experience and preference with home-based versus clinic-based telehealth

INTRODUCTION

Telehealth is a model of care with potential to improve access, and in turn outcomes, for people living in rural areas. Since 2013, our endocrine clinic-based telehealth program has provided care at rural community hospitals in Nebraska and Iowa. At the start of the COVID-19 pandemic, when regulations around telehealth were adjusted, patients previously seen via clinic-based telehealth had the option to continue clinic-based visits or have a home-based telehealth visit. There is no literature comparing patient experiences between home-based and clinic-based telehealth. The purpose of this study was to understand rural patient preferences regarding endocrinology home-based versus clinic-based telehealth visits.

METHODS

This was a survey study of adult, rural patients who experienced both a clinic-based and home-based telehealth visit with their established endocrinology provider. Respondents were asked about demographics, their reason for visit, preference for home versus clinic-based telehealth, and how they would have received care if telehealth were not an option.

RESULTS

Forty-two patients (40.8%) responded to the survey, with 27 patients (64.3%) preferring home-based telehealth. There were no significant differences between the groups. However, 47.5% of patients would not have sought specialty care if telehealth were not an option.

DISCUSSION

This survey of endocrine patients experienced in both clinic-based and home-based telehealth indicates that, while most respondents preferred home-based telehealth, there are distinct advantages to each model and patients appreciate having options. We believe it is important to maintain both lines of service to provide patient-centered care and improve access to specialty care.

Use of Continuous Glucose Monitors in the Hospital: The Diabetes Technology Society Hospital Meeting Report 2023

The annual Virtual Hospital Diabetes Meeting was hosted by the Diabetes Technology Society on April 14 and 15, 2023, with the goal of reviewing the progress made in the hospital use of continuous glucose monitors (CGMs). Meeting topics included (1) Nursing Issues, Protocols, Order Sets, and Staff Education for Using CGMs, (2) Implementing CGM Programs for Use in the Wards, (3) Quality Metrics and Financial Implications of CGMs in the Hospital, (4) CGMs in the Critical Care Setting, (5) Special Situations: Labor/Delivery and Hemodialysis, (6) Research Session on CGMs in the Hospital, (7) Starting a CGM on Hospitalized Patients, (8) Automated Insulin Delivery Systems in the Hospital, (9) CGMs in Children, (10) Data Integration of CGMs for Inpatient Use and Telemetry, (11) Accuracy of CGMs/Comparison with Point-of-care Blood Glucose Testing, and (12) Discharge Planning with CGMs. Outcome data as well as shared collective real-life experiences were reviewed, and expert recommendations for CGM implementation were formulated.

Diabetes Technology Meeting 2022

Diabetes Technology Society hosted its annual Diabetes Technology Meeting from November 3 to November 5, 2022. Meeting topics included (1) the measurement of glucose, insulin, and ketones; (2) virtual diabetes care; (3) metrics for managing diabetes and predicting outcomes; (4) integration of continuous glucose monitor data into the electronic health record; (5) regulation of diabetes technology; (6) digital health to nudge behavior; (7) estimating carbohydrates; (8) fully automated insulin delivery systems; (9) hypoglycemia; (10) novel insulins; (11) insulin delivery; (12) on-body sensors; (13) continuous glucose monitoring; (14) diabetic foot ulcers; (15) the environmental impact of diabetes technology; and (16) spinal cord stimulation for painful diabetic neuropathy. A live demonstration of a device that can allow for the recycling of used insulin pens was also presented.

Glycemic Management of Hospitalized Patients Receiving Nutrition Support

Enteral nutrition (EN) and parenteral nutrition (PN) increase the risk of hyperglycemia and adverse outcomes, including mortality, in patients with and without diabetes. A blood glucose target range of 140-180 mg/dL is recommended for hospitalized patients receiving artificial nutrition. Using a diabetes-specific EN formula, lowering the dextrose content, and using a hypocaloric PN formula have all been shown to prevent hyperglycemia and associated adverse outcomes. Insulin, given either subcutaneously or as a continuous infusion, is the mainstay of treatment for hyperglycemia. However, no subcutaneous insulin regimen has been shown to be superior to others. This review summarizes the evidence on and provides recommendations for the treatment of EN- and PN-associated hyperglycemia and offers strategies for hypoglycemia prevention. The authors also highlight their institution's protocol for the safe use of insulin in the PN bag. Randomized controlled trials evaluating safety and efficacy of targeted insulin therapy synchronized with different types of EN or PN delivery are needed.

Rural Telehealth Visits in the Management of Type 1 Diabetes

INTRODUCTION

Despite advances in and increased adoption of technology, glycemic outcomes for individuals with type 1 diabetes (T1D) have not improved. Access to care is limited for many, in part due to a shortage of endocrinologists and their concentration in urban areas. Managing T1D via telehealth has potential to improve glycemic outcomes, as the barriers of travel-related time and cost are mitigated.

METHODS

Our endocrine telehealth program started in 2013 and currently provides care to nine rural community hospitals in Nebraska and Iowa. A retrospective cohort study was performed to evaluate glycemic outcomes in people with T1D who received care at these telehealth clinics from 2013-2019. Data were collected on age, race, gender, prior diabetes provider, use of diabetes technology, and A1c values over time.

RESULTS

One hundred thirty-nine individuals were followed for an average duration of 32 months (range 4-69 months). Sixty-six percent of people were previously under the care of an endocrinologist. The most common therapeutic action, in addition to insulin adjustment, was addition of a CGM (52%). Each year in telemedicine care was associated with a decline of 0.13% in A1c (95% CI: -0.20, -0.06). There was no association between A1c and age or gender. When stratifying by previous diabetes provider, all groups had a statistically significant decline in A1c, even those with a previous endocrine provider. There was no statistically significant decline in A1c based on addition of technology.

CONCLUSION

We have shown that traditional telehealth visits are an effective way to provide care for people with T1D long-term and may provide distinct advantages to home telehealth visits.

Navigating Diabetes Online Communities in Clinical Practice

OBJECTIVE

This purpose of this study was to conduct a rapid review and environmental scan of diabetes online communities (DOCs) to highlight the clinical impact of DOC engagement and provide guidance to health care providers for navigating and prescribing DOCs.

METHODS

This two-phase review included a rapid review of clinical outcomes and an assessment of DOC content. We conducted a literature search for studies evaluating DOC use and glucometric (glycated hemoglobin [A1C], time-in-range, hypoglycemia), behavioral, and psychosocial outcomes. The environmental scan of current DOC sites established key features, including available platforms, target population, content areas, and reach.

RESULTS

Twelve papers were included-eight reported DOC use within a context of do-it-yourself (DIY) noncommercial, opensource hybrid closed loop systems community and four were non-DYI related. In latter, all studies were cross-sectional, describing patient-reported outcomes. Two studies reported A1C lowering with DOC use, two DOC use was associated with high self-efficacy, one showed association with higher self-care levels, and one showed higher quality of life scores when compared with population norms. All DIY studies showed improvement in glucometrics after initiation of sensor augmented pump technology with DOC support. Of 54 DOC sites reviewed in the environmental scan, 29 were included. Diabetes online community sites were heterogenous in social media platform and type of diabetes targeted.

CONCLUSION

Diabetes online communities have the potential to improve clinical, behavioral, and psychosocial outcomes. Randomized control trials and/or longitudinal prospective studies evaluating outcomes are needed to further examine the potential benefits of DOC use. Diabetes online communities are diverse and span a variety of social media platforms, providing clinicians opportunities to individualize recommendations for DOC use.

Extraocular Muscle Enlargement in Growth Hormone-Secreting Pituitary Adenomas

BACKGROUND AND PURPOSE

While Graves disease is the most common cause of extraocular muscle enlargement, case reports have also associated growth hormone-secretory pituitary adenomas with this same phenomenon. We investigated the prevalence and response to treatment of extraocular muscle enlargement in patients with growth hormone-secretory pituitary adenomas.

MATERIALS AND METHODS

We retrospectively reviewed extraocular muscle sizes using MR imaging in patients with growth hormone-secretory pituitary adenomas who underwent a transsphenoidal surgical resection compared with a matched control group with nonsecretory pituitary adenomas. Descriptive and comparative statistics were used to evaluate patient characteristics and extraocular muscle sizes between the 2 groups.

RESULTS

We identified 16 patients who presented with growth hormone-secreting pituitary adenomas and underwent transsphenoidal surgical resection from 2010 to 2019. The average diameter of the extraocular muscle at the time of diagnosis for the group with growth hormone-secretory pituitary adenomas was larger than that in the control group (4.7 versus 3.8 mm, P < .001). Nine patients achieved insulin-like growth factor 1 level normalization at a median of 11.5 months before their most recent MR imaging evaluation. The average size of the extraocular muscles of patients who achieved a normalized insulin-like growth factor 1 was smaller compared with those that did not (difference, 0.7 mm; 95% CI, 0.3-1.2 mm; P < .001), approaching the size of extraocular muscle in the control group.

CONCLUSIONS

We describe a high prevalence of extraocular muscle enlargement in patients with growth hormone-secreting pituitary adenomas. Additionally, we note that the size of extraocular muscles decreased with associated improvement in the biochemical control of acromegaly.

Patient-Centered Diabetes Care of Cancer Patients

PURPOSE OF REVIEW

There is a bidirectional relationship between cancer and diabetes, with one condition influencing the prognosis of the other. Multiple cancer therapies cause diabetes including well-established medications such as glucocorticoids and novel cancer therapies such as immune checkpoint inhibitors (CPIs) and phosphoinositide 3-kinase (PI3K) inhibitors.

RECENT FINDINGS

The nature and severity of diabetes caused by each therapy differ, with some predominantly mediated by insulin resistance, such as PI3K inhibitors and glucocorticoids, while others by insulin deficiency, such as CPIs. Studies have demonstrated diabetes from CPIs to be more rapidly progressing than conventional type 1 diabetes. There remains a scarcity of published guidance for the screening, diagnosis, and management of hyperglycemia and diabetes from these therapies. The need for such guidance is critical because diabetes management in the cancer patient is complex, individualized, and requires inter-disciplinary care. In the present narrative review, we synthesize and summarize the most relevant literature pertaining to diabetes and hyperglycemia in the setting of these cancer therapies and provide an updated patient-centered framework for their evaluation and management.

Effect of Behavioral Therapy With In-Clinic or Telephone Group Visits vs In-Clinic Individual Visits on Weight Loss Among Patients With Obesity in Rural Clinical Practice: A Randomized Clinical Trial

IMPORTANCE

Rural populations have a higher prevalence of obesity and poor access to weight loss programs. Effective models for treating obesity in rural clinical practice are needed.

OBJECTIVE

To compare the Medicare Intensive Behavioral Therapy for Obesity fee-for-service model with 2 alternatives: in-clinic group visits based on a patient-centered medical home model and telephone-based group visits based on a disease management model.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial conducted in 36 primary care practices in the rural Midwestern US. Inclusion criteria included age 20 to 75 years and body mass index of 30 to 45. Participants were enrolled from February 2016 to October 2017. Final follow-up occurred in December 2019.

INTERVENTIONS

All participants received a lifestyle intervention focused on diet, physical activity, and behavior change strategies. In the fee-for-service intervention (n = 473), practice-employed clinicians provided 15-minute in-clinic individual visits at a frequency similar to that reimbursed by Medicare (weekly for 1 month, biweekly for 5 months, and monthly thereafter). In the in-clinic group intervention (n = 468), practice-employed clinicians delivered group visits that were weekly for 3 months, biweekly for 3 months, and monthly thereafter. In the telephone group intervention (n = 466), patients received the same intervention as the in-clinic group intervention, but sessions were delivered remotely via conference calls by centralized staff.

MAIN OUTCOMES AND MEASURES

The primary outcome was weight change at 24 months. A minimum clinically important difference was defined as 2.75 kg.

RESULTS

Among 1407 participants (mean age, 54.7 [SD, 11.8] years; baseline body mass index, 36.7 [SD, 4.0]; 1081 [77%] women), 1220 (87%) completed the trial. Mean weight loss at 24 months was -4.4 kg (95% CI, -5.5 to -3.4 kg) in the in-clinic group intervention, -3.9 kg (95% CI, -5.0 to -2.9 kg) in the telephone group intervention, and -2.6 kg (95% CI, -3.6 to -1.5 kg) in the in-clinic individual intervention. Compared with the in-clinic individual intervention, the mean difference in weight change was -1.9 kg (97.5% CI, -3.5 to -0.2 kg; P = .01) for the in-clinic group intervention and -1.4 kg (97.5% CI, -3.0 to 0.3 kg; P = .06) for the telephone group intervention.

CONCLUSIONS AND RELEVANCE

Among patients with obesity in rural primary care clinics, in-clinic group visits but not telephone-based group visits, compared with in-clinic individual visits, resulted in statistically significantly greater weight loss at 24 months. However, the differences were small in magnitude and of uncertain clinical importance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02456636.

Hospital Diabetes Meeting 2020

Patients with diabetes may experience adverse outcomes related to their glycemic control when hospitalized. Continuous glucose monitoring systems, insulin-dosing software, enhancements to the electronic health record, and other medical technologies are now available to improve hospital care. Because of these developments, new approaches are needed to incorporate evolving treatments into routine care. With the goal of educating healthcare professionals on the most recent practices and research for managing diabetes in the hospital, Diabetes Technology Society hosted the Virtual Hospital Diabetes Meeting on April 24-25, 2020. Because of the coronavirus disease 2019 (COVID-19) pandemic, the meeting was restructured to be held virtually during the national lockdown to ensure the safety of the participants and allow them to remain at their posts treating COVID-19 patients. The meeting focused on (1) inpatient management and perioperative care, (2) diabetic ketoacidosis and hyperglycemic hyperosmolar state, (3) computer-guided insulin dosing, (4) Coronavirus Disease 2019 and diabetes, (5) technology, (6) hypoglycemia, (7) data and cybersecurity, (8) special situations, (9) glucometrics and insulinometrics, and (10) quality and safety. This meeting report contains summaries of each of the ten sessions. A virtual poster session will be presented within two months of the meeting.

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.

Has Technology Improved Diabetes Management in Relation to Age, Gender, and Ethnicity?

PURPOSE OF REVIEW

To review the current state of diabetes technology adoption and describe impact on outcomes in the context of age, gender, and ethnicity. We will discuss barriers and propose solutions that may help facilitate the adoption.

RECENT FINDINGS

We are witnessing rapid evolution and increase in adoption of diabetes technology in all its forms, including insulin delivery and glucose monitoring devices, mobile medical applications, and telemedicine. This technology has a great potential to improve diabetes-related outcomes, including acute and chronic complications as well as quality of life for people living with diabetes. However, currently available outcome data are showing modest efficacy and evidence for disparities when it comes to age, gender, and ethnicity. Despite multiple barriers, the adoption of technology is steadily increasing. It is clear that disparities exist in terms of access to and use of technology, but they may be at least in part driven by unmet needs of end users and as such are not unsurmountable. While more research is needed to identify the specific causes for the disparities, future development of diabetes technology that is based on adaptation of behavioral theories has a potential to address the gaps. The disparities can be lessened by understanding the needs of end users and with improvement in personalization of technology, allowing the right device to be used by the right patient. Targeted interventions to increase awareness and education and help navigate the processes involved in currently available technology may help diminish the gaps in health equity.

Quantifying vehicle control from physiology in type 1 diabetes

Objective: Our goal is to measure real-world effects of at-risk driver physiology on safety-critical tasks like driving by monitoring driver behavior and physiology in real-time. Drivers with type 1 diabetes (T1D) have an elevated crash risk that is linked to abnormal blood glucose, particularly hypoglycemia. We tested the hypotheses that (1) T1D drivers would have overall impaired vehicle control behavior relative to control drivers without diabetes, (2) At-risk patterns of vehicle control in T1D drivers would be linked to at-risk, in-vehicle physiology, and (3) T1D drivers would show impaired vehicle control with more recent hypoglycemia prior to driving.Methods: Drivers (18 T1D, 14 control) were monitored continuously (4 weeks) using in-vehicle sensors (e.g., video, accelerometer, speed) and wearable continuous glucose monitors (CGMs) that measured each T1D driver's real-time blood glucose. Driver vehicle control was measured by vehicle acceleration variability (AV) across lateral (AV_Y, steering) and longitudinal (AV_X, braking/accelerating) axes in 45-second segments (N = 61,635). Average vehicle speed for each segment was modeled as a covariate of AV and mixed-effects linear regression models were used.Results: We analyzed 3,687 drives (21,231 miles). T1D drivers had significantly higher overall AV_{X, Y} compared to control drivers (B_X = 2.5 × 10^-2B_Y = 1.6 × 10^-2, p < 0.01)-which is linked to erratic steering or swerving and harsh braking/accelerating. At-risk vehicle control patterns were particularly associated with at-risk physiology, namely hypo- and hyperglycemia (higher overall AV_X,Y). Impairments from hypoglycemia persisted for hours after hypoglycemia resolved, with drivers who had hypoglycemia within 2-3 h of driving showing higher AV_X and AV_Y. State Department of Motor Vehicle records for the 3 years preceding the study showed that at-risk T1D drivers accounted for all crashes (N = 3) and 85% of citations (N = 13) observed.Conclusions: Our results show that T1D driver risk can be linked to real-time patterns of at-risk driver physiology, particularly hypoglycemia, and driver risk can be detected during and prior to driving. Such naturalistic studies monitoring driver vehicle controls can inform methods for early detection of hypoglycemia-related driving risks, fitness to drive assessments, thereby helping to preserve safety in at-risk drivers with diabetes.

Digital Diabetes Congress 2019

New applications of digital health software and sensors for diabetes are rapidly becoming available. The link between healthcare, wearable or carryable devices, and the use of smartphones is increasingly being used by patients for timely information and by healthcare professionals to deliver information and personalized advice and to encourage healthy behavior. To assemble stakeholders from academia, industry, and government, Diabetes Technology Society and Sansum Diabetes Research Institute hosted the 3rd Annual Digital Diabetes Congress on May 14-15, 2019 in San Francisco. Physicians, entrepreneurs, attorneys, psychologists, and other leaders in the diabetes technology field came together to discuss current and future trends and applications of digital tools in diabetes. The meeting focused on eight topics: 1) User Interface/User Experience (UI/UX) for Digital Health, 2) clinical aspects, 3) marketing, 4) investment, 5) regulation, 6) who owns the data, 7) engagement, and 8) the future of digital health. This meeting report contains summaries of the meeting's eight plenary sessions and eight panel discussions, which were all focused on an important aspect of the development, use, and regulation of diabetes digital tools.

SAT-474 Giant Prolactinoma Case Series Assessing Response on Initial Dose of Cabergoline

Background: Giant prolactinomas (GPs) are rare representing 2-3% of prolactinomas and only ~ 0.5% of all pituitary tumors. Various definitions have been proposed for GP but commonly accepted criteria is tumor dimension of ≥4 cm. GP is often associated with very high prolactin (PRL) ranging 1,000 -100,000 ng/ml, significant extrasellar extension and no concomitant growth hormone or ACTH secretion. Patients predominantly present with neurological symptoms rather than endocrine dysfunction, and so the primary goal of treatment is amelioration of neurological symptoms. The literature search reveals approximately 190 papers on this topic and most are single case reports or series describing only unusual clinical manifestations. Hence, evidence based recommendations for treatment are lacking. Dopamine agonist (DA) is considered first line of therapy, as these tumors are highly sensitive to medical therapy. Surgery and radiation may be warranted in special situations. Low starting doses of cabergoline (CAB) are generally recommended due to concern for complications of apoplexy and cerebrospinal fluid (CSF) leak from rapid tumor shrinkage. However, no recommendations for a specific starting dose exist. Objective: Individual tumor and hormonal response were assessed on 15 patients (pts) with GP on low dose CAB; 0.25-0.5 mg weekly to determine the effectiveness of DA therapy. Methods: 15 GP pts from two tertiary care centers, meeting the diagnostic criteria mentioned above, were reviewed. Reduction in tumor volume and maximal tumor diameter along with PRL, after initiation of CAB, at or before 6 months and 1 year post diagnosis, was calculated. Results: Presenting symptom: visual disturbance (56%), headache (20%), apoplexy (13%) and incidental finding (6%). Mean age at diagnosis: 61 years. Male to Female: 4: 1. Basal prolactin concentration: >2000 ng/dl (12/15pts), and > 900 ng/ml (2/15). Initial total CAB dose/week: 0.25-0.5 mg (13/15) and 1-2 mg (2/15). Cranial surgery: 4/15. Complications: CSF leak (1/15). Tumor volume assessed at 6 months (11/15) and 1 year (4/15) along with decrease in maximum tumor diameter in the same period of time. PRL assessed at or before 6 months (13/15) and at 1 year (2/15). Improvement in tumor size occurred promptly even with low dose CAB (0.25-0.5mg/week). 100% of patients initiated on low dose CAB responded to therapy. Mean reduction in tumor volume at or before 6 months was 47% in 11/15, and 52% at 1 year (10/15). Mean decrease in maximal tumor dimension was calculated as 0.95 cm at 6 months (12/15) and 1.4 cm at 1 year (9/15). The overall prolactin response rate at or before 6 months was > 90% in 7/15 patients (53%) and >50% in 11/15 patients (73%). Conclusion: Our data confirms excellent tumor response to low dose cabergoline therapy. Dose as low at 0.25 mg twice weekly is proven to be effective, leading to decrease in both tumor volume and PRL levels.

SUN-406 Complete Recovery of Central Diabetes Insipidus Associated with Isolated Stalk Thickening in a Neurosarcoidosis Patient

Background: Neurosarcoidosis (NS) affects ~15% of patients with sarcoidosis. Hypothalamic-pituitary (HP) involvement is even rare and occurs in <1% of sarcoidosis. Clinically, NS presents as neuroendocrine dysfunction in 2.5% and radiologically, it typically manifests as HP lesion with parenchymal disease. The literature review demonstrates increased pituitary volume as the most frequent MRI abnormality observed in more than a half patients with HP involvement. Pituitary stalk thickening (PST) has been reported in combination with parenchymal abnormality but not in isolation. Central diabetes insipidus (CDI) is a known manifestation of stalk involvement. The exact mechanism of anti-diuretic hormone (ADH) dysfunction is not well understood, however CDI is mostly attributed to defective ADH release with direct infiltration of the stalk. Hormonal deficiencies are considered to be irreversible even in the setting of normalization of MRI findings after treatment. We herein report a case of NS associated with isolated PST presenting as CDI, where complete recovery was observed. Case: A 54-year-old male with pulmonary and gastrointestional (GI) sarcoidosis confirmed by gastric biopsy, developed abrupt onset of polyuria-polydipsia [Intake: 11-12 L/d, Output: 8-10 L/d] while treated with prednisone 5 mg/d. Urine osmolality (osm) was 64 mosm/kg, urine sodium (Na) 10 meq/l, serum osm 292 mosm/kg and serum Na 143 mmol/l. MRI of the Sella revealed 3.5 mm PST, absent posterior pituitary bright spot and partial empty sella. Anterior pituitary evaluation showed: Testosterone 122ng/dl, FSH 9.8mIU/ml, LH 3.3mIU/ml, Prolactin 17.8ng/ml, TSH 1.07 mcIU/ml, FT4; 0.7ng/dl, Cortisol 11.3mcg/dl, ACTH 12pg/ml and IGF-1; 129ng/ml. DDAVP 0.2mg bid controlled DI well. GI symptoms were treated with increased prednisone 40 mg/d and hydroxychloroquine. MRI showed decreased PST at 2.6 mm in 1 year and normal stalk thickness 1.8 mm in 2 years. He was successfully weaned off DDAVP, along with a slow taper of steroid. Four years since presentation, symptoms are well controlled on prednisone 3mg/d. Testosterone improved (213 ng/dl) and other anterior pituitary hormones remained in normal range. He has no polyuria, stalk measures 1.9 mm and posterior pituitary bright spot is absent. Conclusion: This case demonstrates a rare manifestation of NS presenting with isolated PST associated with CDI, without parenchymal disease. Furthermore, this is the first case report of complete resolution of CDI that correlated with normalization of MRI finding. In general hormonal deficits with HP sarcoidosis is considered irreversible and no correlation has been reported between the hormonal dysfunction and radiologic outcomes. Hence, in similar patients with isolated PST as the only manifestation of NS a trial off DDAVP may be offered, if improvement in MRI finding is noted over the course of the treatment.

Highly Aggressive and Radiation-Resistant, "Atypical" and Silent Pituitary Corticotrophic Carcinoma: A Case Report and Review of the Literature

Background

Pituitary tumors typically remain silent unless interaction with nearby structures occurs. Rare subsets of pituitary tumors display aggressive phenotypes: highly mitotic, locally invasive, metastatic, chemotherapy and radiation resistant, etc. Disease progression and response to therapy is ill-defined in these subtypes, and their true prognostic potential is debated. Thus, identifying tumor characteristics with prognostic value and efficacious treatment options remains a challenge in aggressive pituitary tumors.

Case Presentation

A 45-year-old female presented with a nonfunctioning corticotropic pituitary macroadenoma with biomarkers suggestive of an “atypical” subtype: Ki-67 of 8–12%, increased mitosis, and locally invasive. Despite resections and radiation, growth continued, eventually affecting her vision. Although histologically ACTH positive, the patient remained clinically asymptomatic. Twelve months later, an episode of Cushing's disease-induced psychosis prompted a PET-CT scan, identifying sites of metastasis. Temozolomide was added to her medical regimen, and her metastatic liver lesions and boney metastases were treated with radiofrequency ablation and stereotactic body radiation therapy, respectively. Systemic treatment resulted in a drop in her ACTH levels, with her most recent scans/labs at 12 months following RFA suggesting remission.

Conclusions

This is a unique presentation of a pituitary tumor, displaying characteristics of both clinically silent corticotropic and “atypical” macroadenoma subtypes. Although initially ACTH positive while clinically silent, the patient's disease ultimately recurred metastatically with manifestations of Cushing's disease and psychosis. With the addition of temozolomide to her treatment plan, her primary and metastatic sites have responded favorably to radiation therapy. Thus, the addition of temozolomide may be beneficial in the treatment of aggressive pituitary tumors.

Driving Safety and Real-Time Glucose Monitoring in Insulin-Dependent Diabetes

Our goal is to address the need for driver-state detection using wearable and in-vehicle sensor measurements of driver physiology and health. To address this goal, we deployed in-vehicle systems, wearable sensors, and procedures capable of quantifying real-world driving behavior and performance in at-risk drivers with insulin-dependent type 1 diabetes mellitus (DM). We applied these methodologies over 4 weeks of continuous observation to quantify differences in real-world driver behavior profiles associated with physiologic changes in drivers with DM (N=19) and without DM (N=14). Results showed that DM driver behavior changed as a function of glycemic state, particularly hypoglycemia. DM drivers often drive during at-risk physiologic states, possibly due to unawareness of impairment, which in turn may relate to blunted physiologic responses (measurable heart rate) to hypoglycemia after repeated episodes of hypoglycemia. We found that this DM driver cohort has an elevated risk of crashes and citations, which our results suggest is linked to the DM driver's own momentary physiology. Overall, our findings demonstrate a clear link between at-risk driver physiology and real-world driving. By discovering key relationships between naturalistic driving and parameters of contemporaneous physiologic changes, like glucose control, this study directly advances the goal of driver-state detection through wearable physiologic sensors as well as efforts to develop "gold standard" metrics of driver safety and an individualized approach to driver health and wellness.

Diabetes Technology Society Report on the FDA Digital Health Software Precertification Program Meeting

Diabetes Technology Society (DTS) convened a meeting about the US Food and Drug Administration (FDA) Digital Health Software Precertification Program on August 28, 2018. Forty-eight attendees participated from clinical and academic endocrinology (both adult and pediatric), nursing, behavioral health, engineering, and law, as well as representatives of FDA, National Institutes of Health (NIH), National Telecommunications and Information Administration (NTIA), and industry. The meeting was intended to provide ideas to FDA about their plan to launch a Digital Health Software Precertification Program. Attendees discussed the four components of the plan: (1) excellence appraisal and certification, (2) review pathway determination, (3) streamlined premarket review process, and (4) real-world performance. The format included (1) introductory remarks, (2) a program overview presentation from FDA, (3) roundtable working sessions focused on each of the Software Precertification Program's four components, (4) presentations reflecting the discussions, (5) questions to and answers from FDA, and (6) concluding remarks. The meeting provided useful information to the diabetes technology community and thoughtful feedback to FDA.

PITUITARY EVALUATION IN PATIENTS WITH LOW PROSTATE-SPECIFIC ANTIGEN

OBJECTIVE

To evaluate pituitary function in men with a low screening prostate-specific antigen (PSA) of ≤0.1 ng/mL and test the hypothesis that low PSA is associated with hypogonadism alone or other hormone deficiency.

METHODS

This was a case-control study evaluating the rates of hypogonadism and low insulin-like growth factor (IGF)-1 in a cohort of men with low or normal screening PSA level. Sixty-four men >40 years old without known prostate disease were divided into a low-PSA group (PSA ≤0.1 ng/mL) and normal-PSA group (PSA 1 to 4 ng/mL). Hormonal evaluation included total testosterone, prolactin, luteinizing hormone, follicle-stimulating hormone, IGF-1, growth hormone, thyroid-stimulating hormone, free thyroxine, morning cortisol, and adrenocorticotropic hormone. The difference between each patient's observed IGF-1 and the IGF-1 age-specific lower limit was calculated. The odds ratios (ORs) for having hypogonadism and associated 95% confidence intervals (CIs) were calculated using the Cochran-Mantel-Haenszel test.

RESULTS

The rate of hypogonadism was significantly higher in the low-PSA group (n = 44) compared with the normal-PSA control group (n = 20) (45.5% vs. 15.0%; OR, 4.7; 95% CI, 1.2 to 18.4; P = .027). The total testosterone in the low-PSA group was significantly lower compared with the control group (181.7 ng/dL vs. 263.7 ng/dL; P = .008). IGF-1 values were below their lower bound in 18.6% of subjects in the low-PSA group, compared with 0% in the control group.

CONCLUSION

Men with low PSA have significantly higher rates of hypogonadism and low IGF-1 compared with those with normal PSA. In such men, we recommend hormonal evaluation to exclude associated pituitary dysfunction.

ABBREVIATIONS

BMI = body mass index; GH = growth hormone; IGF-1 = insulin-like growth factor 1; MRI = magnetic resonance imaging; PSA = prostate-specific antigen; T2DM = type 2 diabetes mellitus; VA-NWIHCS = VA-Nebraska Western Iowa Health Care System.

App-Based Insulin Calculators: Current and Future State

PURPOSE OF REVIEW

To perform a comprehensive literature review and critical assessment of peer-reviewed manuscripts addressing the efficacy, safety, or usability of insulin calculator apps.

RECENT FINDINGS

Managing diabetes with insulin can be complex, and literacy and numeracy skills pose barriers to manual insulin dose calculations. App-based insulin calculators are promising tools to help people with diabetes administer insulin safely and have potential to improve glycemic control. While a large number of apps which assist with insulin dosing are available, there is limited data evaluating their efficacy, safety, and usability. Recently, a need for regulatory oversight has been recognized, but few apps meet federal standards. Thus, choosing an appropriate app is challenging for both patients and providers. An electronic literature review was performed to identify insulin calculator apps with either evidence for efficacy, safety or usability published in peer-reviewed literature or with FDA/CE approval. Twenty apps were identified intended for use by patients with diabetes on insulin. Of these, nine included insulin calculators. Summaries of each app, including pros and cons, are provided. Insulin-calculator apps have the potential to improve self-management of diabetes. While current literature demonstrates improvements in quality of life and glycemic control after use of these programs, larger trials are needed to collect outcome and safety data. Also, further human factor analysis is needed to assure these apps will be adopted appropriately by people with diabetes. App features including efficacy and safety data need to be easily available for consumer review and decision making. Higher standards need to be set for app developers to ensure safety and efficacy.

Continuous glucose monitoring: A review of the technology and clinical use

Continuous glucose monitoring (CGM) is an increasingly adopted technology for insulin-requiring patients that provides insights into glycemic fluctuations. CGM can assist patients in managing their diabetes with lifestyle and medication adjustments. This article provides an overview of the technical and clinical features of CGM based on a review of articles in PubMed on CGM from 1999 through January 31, 2017. A detailed description is presented of three professional (retrospective), three personal (real-time) continuous glucose monitors, and three sensor integrated pumps (consisting of a sensor and pump that communicate with each other to determine an optimal insulin dose and adjust the delivery of insulin) that are currently available in United States. We have reviewed outpatient CGM outcomes, focusing on hemoglobin A1c (A1C), hypoglycemia, and quality of life. Issues affecting accuracy, detection of glycemic variability, strategies for optimal use, as well as cybersecurity and future directions for sensor design and use are discussed. In conclusion, CGM is an important tool for monitoring diabetes that has been shown to improve outcomes in patients with type 1 diabetes mellitus. Given currently available data and technological developments, we believe that with appropriate patient education, CGM can also be considered for other patient populations.

The effect of diabetes case management and Diabetes Resource Nurse program on readmissions of patients with diabetes mellitus

AIMS

Patients with diabetes have higher readmission rates than those without diabetes, yet limited data on efforts to reduce their readmissions are available. We describe a novel model of inpatient diabetes care, expanding the role of diabetes educators to include case management, and establishment of a Diabetes Resource Nurse program, aimed at increasing the knowledge of staff nurses, and evaluate the impact of this program on readmission rates.

METHODS

We performed retrospective analysis of 30-day readmission rates of patients with diabetes before (July 2010-December 2011), and after (January 2012-June 2013) starting the implementation of this tiered inpatient diabetes care delivery model.

RESULTS

We analyzed 34,472 discharged patient records from the 18-month pre-intervention period, and 32,046 records from the 18-month post-intervention period. The overall 30-day readmission rate for patients with diabetes decreased significantly from 20.1% (pre) to 17.6% (post) intervention (p < 0.0001). Patients seen by diabetes educators had the lowest 30-day readmission rates (∼15% during the whole study), a rate approaching the overall hospital readmission rates in those without diabetes in our institution.

CONCLUSION

The Diabetes Resource Nurse program is effective in decreasing readmission rates. Patients seen by the diabetes educators have the lowest rates of readmission.

Evidence-based Mobile Medical Applications in Diabetes

This article reviews mobile medical applications that are commercially available in the United States or European Union (EU) and are (1) associated with published data of clinical outcomes in the peer-reviewed literature during the past 5 years, (2) cleared by the US Food and Drug Administration (FDA) in the United States, or (3) a recipient of a CE (Conformité Européenne) mark by the EU. Many of these applications have been shown to positively affect outcomes in the short term, but long-term studies are needed. Until more data are available, consumers and professionals can consider guidance based on FDA/CE status.

Massive adrenal vein aneurysm mimicking an adrenal tumor in a patient with hemophilia A: a case report and review of the literature

Background

Visceral venous aneurysms are exceedingly rare, and until now, there have been no reports of this phenomenon in the adrenal vasculature. This report details the first adrenal venous aneurysm reported in the literature. The aneurysm presented as an 18-cm mass that was initially suspected to be a hematoma or tumor on the basis of the complex medical history of the patient, which included hemophilia A and testicular cancer. After surgical excision, pathologic examination confirmed this mass to be a 15.9-cm adrenal vein aneurysm, the largest aneurysm of any type or location recorded in the medical literature.

Case presentation

A 58-year-old caucasian male with hemophilia A presented to the emergency room of another institution with abdominal pain, blood in the stool, and a history of diverticulosis and symptomatic hemorrhoids. A large, left-sided adrenal mass was detected by computed tomography, and because of the patient’s hemophilia A and imaging consistent with a hemorrhagic mass, a hematoma was initially suspected. The patient was transferred to our institution, monitored for further bleeding with a stable hospital course, and discharged from the hospital under close monitoring. After 7–8 weeks with no change in the size of the mass, concerns grew regarding increasing symptoms of both satiety and mass effects from the large anomaly, as well as about the patient’s complicated medical history, which also included cancer. Surgical excision was recommended because of the concerns about increasing symptoms and the possibility of a malignancy. Correction and maintenance of factor VIII levels were incorporated pre-, intra-, and postoperatively, and en bloc surgical resection was performed to minimize bleeding and provide oncologic extirpation of the mass. A bowling ball-sized mass was removed, and careful pathologic examination revealed the mass to be a venous adrenal aneurysm. After a brief hospital stay, the patient made a full recovery. Extensive review of the literature revealed 11 reports of adrenal artery aneurysms but no reported case of an adrenal aneurysm arising from the venous system.

Conclusions

Several case reports suggest a correlation between hemophilia and aneurysms. In patients with inherited clotting disorders such as hemophilia A, aneurysms may present in atypical fashions and should be carefully ruled out.

PRIDE Statement on the Need for a Moratorium on the CMS Plan to Cite Hospitals for Performing Point-of-Care Capillary Blood Glucose Monitoring on Critically Ill Patients

OBJECTIVE

A writing committee of the Planning Research in Inpatient Diabetes (PRIDE) group has written this consensus article on behalf of the group in response to a specific request for input from the Centers for Medicare and Medicaid Services (CMS). The purpose of this article is to respond to the March 13, 2015 statement from that agency regarding plans to enforce prohibition of the off-label use of point of care (POC) capillary blood glucose monitor (BGM) testing in most critically ill patients. The article discusses: 1) how POC BGM testing is currently regulated; 2) how POC BGM testing is currently used in the United States; and 3) how POC BGM testing can be safely and effectively regulated in the future through cooperation between the clinician, laboratory, regulatory, industry, and patient communities.

PARTICIPANTS

Nine members of PRIDE volunteered to write the statement on behalf of the entire group.

EVIDENCE

Descriptions of current medical practice for critically ill patients were derived from the experience of the authors. Descriptions of the performance of various methods for measuring glucose levels for intensive insulin therapy came from a literature review.

CONSENSUS PROCESS

Eleven questions were developed by the PRIDE writing group. After extensive electronic and telephone discussion, the article was written and reviewed by all nine authors and then reviewed by two outside experts in the care of critically ill patients. All suggestions by the authors and the outside experts were incorporated.

CONCLUSIONS

Although the CMS is attempting to protect patients with abnormal glycemic control from harm due to inaccurate POC fingerstick capillary BGM testing, their plan will result in more harm than good. A moratorium on enforcement of the prohibition of off-label use of POC capillary BGM testing is needed.

Inpatient hypoglycemia: a challenge that must be addressed

Hypoglycemia in the inpatient setting is a common occurrence with potentially harmful outcomes. Large trials in both the inpatient and outpatient settings have found a correlation between hypoglycemia and morbidity and mortality. The incidence of hypoglycemia is difficult to assess, due to a lack of standardized definitions and different methods of data collection between hospital systems. Risk factors that predispose to hypoglycemia involve the changing clinical statuses of patients, nutrition issues, and hospital processes. Mechanisms contributing to morbidity due to hypoglycemia may include an increase in sympathoadrenal responses, as well as indirect changes affecting cytokine production, coagulation, fibrinolysis, and endothelial function. Prevention of hypoglycemia requires implementation of several strategies that include patient safety, quality control, multidisciplinary communication, and transitions of care. In this article, we discuss all of these issues and provide suggestions to help predict and prevent hypoglycemic episodes during an inpatient stay. We address the issues that occur upon admission, during the hospital stay, and around the time of discharge. We believe that decreasing the incidence of inpatient hypoglycemia will both decrease costs and improve patient outcomes.

25-Hydroxyvitamin D response to graded vitamin D₃ supplementation among obese adults

CONTEXT

Guidelines have suggested that obese adults need 2 to 3 times more vitamin D than lean adults to treat vitamin D deficiency, but few studies have evaluated the vitamin D dose response in obese subjects.

OBJECTIVE

The purpose of this study was to characterize the pharmacokinetics of 25-hydroxyvitamin D [25(OH)D] response to 3 different doses of vitamin D₃ (cholecalciferol) in a group of obese subjects and to quantify the 25(OH)D dose-response relationship. DESIGN, SETTING, INTERVENTION, PATIENTS: This was a randomized, single-blind study of 3 doses of oral vitamin D₃ (1000, 5000, or 10,000 IU) given daily to 67 obese subjects for 21 weeks during the winter months.

MAIN OUTCOME MEASURES

Serum 25(OH)D levels were measured at baseline and after vitamin D replacement, and 25(OH)D pharmacokinetic parameters were determined, fitting the 25(OH)D concentrations to an exponential model.

RESULTS

Mean measured increments in 25(OH)D at week 21 were 12.4 ± 9.7 ng/mL in the 1000 IU/d group, 27.8 ± 10.2 ng/mL in the 5000 IU/d group, and 48.1 ± 19.6 ng/mL in the 10,000 IU/d group. Steady-state increments computed from the model were 20.6 ± 17.1, 35.2 ± 14.6, and 51.3 ± 22.0 ng/mL, respectively. There were no hypercalcuria or hypercalcemia events during the study.

CONCLUSION

Our data show that in obese people, the 25(OH)D response to vitamin D₃ is directly related to dose and body size with ∼2.5 IU/kg required for every unit increment in 25(OH)D (nanograms per milliliter).

The future of inpatient diabetes management: glucose as the sixth vital sign

Diabetes is an ever increasing health problem in our society. Due to associated small and large vessel conditions, patients with diabetes are two- to four-fold more likely to require hospitalization than nondiabetic individuals. Furthermore, hyperglycemia in hospitalized patients results in increased susceptibility to wound infections, worse outcomes postcardiac and cerebrovascular events, longer hospital length of stay and increased inpatient mortality. Several studies suggest that tight control of glucose levels yields improvement in these factors. Conversely, other studies have suggested increased mortality after tight glucose management, perhaps as a result of an increased incidence of hypoglycemic events. The most reasonable approach to control of hyperglycemia is to normalize glucose levels as much as possible without triggering hypoglycemia. In the hospital, insulin therapy of hyperglycemia is preferred due to the ability to flexibly manage glucose levels without side effects associated with many alternative antidiabetic agents. Due to the increasing burden of inpatient diabetes, and the detrimental effects of both hyper and hypoglycemia, the authors predict that blood-glucose levels will become the sixth vital sign to be frequently monitored in hospitalized patients and controlled in a narrow range. The future is in the use of insulin pumps controlled by continuous glucose monitors. This technology is complex and has not yet become standard. The development of future inpatient diabetes care will depend on adaptation of hospital systems to advance the new technology.

Liraglutide-associated acute pancreatitis

PURPOSE

A case of acute pancreatitis associated with liraglutide is reported.

SUMMARY

A 53-year-old African-American man (height, 185.4 cm; weight, 108.6 kg) with type 2 diabetes mellitus arrived at the emergency department (ED) with new-onset intolerable abdominal pain in the right upper quadrant and left upper quadrant that had appeared suddenly and lasted two to three hours. He had nausea but no vomiting, with tenderness in the epigastric region. In the ED, his serum amylase concentration was found to be extremely elevated (3,963 units/L), as was his serum lipase concentration (>15,000 units/L). In addition to type 2 diabetes, his medical history included hyperlipidemia, hypertension, peripheral neuropathy, erectile dysfunction, and obesity. His home medications included aspirin 81 mg orally daily, metformin 1000 mg orally every morning and 1500 mg every evening, simvastatin 80 mg orally daily at bedtime, tadalafil 20 mg orally as needed, glimepiride 4 mg orally twice daily, and liraglutide 1.2 mg subcutaneously daily. Two months before his arrival to the ED, the patient's dosage of liraglutide was increased from 0.6 to 1.2 mg subcutaneously daily. Radiographic data were obtained, and acute pancreatitis was diagnosed. Liraglutide was discontinued indefinitely after ruling out elevated triglycerides as the cause of pancreatitis. The patient was initiated on standard therapy for acute pancreatitis and discharged eight days later with complete resolution of symptoms and normal laboratory test values.

CONCLUSION

A 53-year-old man with type 2 diabetes mellitus developed a probable case of liraglutide-induced acute pancreatitis after receiving the drug for approximately two months.

Evaluation of an adult insulin infusion protocol at an academic medical center

OBJECTIVE

Acknowledging evidence of possible detrimental effects of tightly controlled blood glucose levels, the American Association of Clinical Endocrinologists and the American Diabetes Association published a consensus statement recommending less strict control for most diabetic patients. As a result of these recommendations, our academic center at Creighton University Medical Center revised its adult insulin infusion protocol to target blood glucose levels ranging from 120 to 180 mg/dL for regular (standard) glycemic control and 80 to 120 mg/dL for tight control; previous targets had ranged from 80 to 180 mg/dL and 70 to 110 mg/dL, respectively. The primary objective was to evaluate the time that blood glucose values were within the target range for patients receiving the new protocol, compared with patients receiving the previous protocol.

METHODS

Our study was designed to evaluate the effectiveness and safety of the revised protocol. Using a retrospective chart review, we collected data for 4 months from patients on the old insulin protocol (May to August 2009) and for 4 months from patients on the new protocol (September to December 2009). Secondary endpoints included the number of hypoglycemic episodes (blood glucose below 70 mg/dL) and severe hypoglycemic episodes (blood glucose 40 mg/dL or lower) experienced by patients receiving the new insulin protocol compared with those receiving the former protocol.

RESULTS

Patient characteristics were similar at baseline. Blood glucose values stayed within the target range for a significantly shorter time with the new protocol than with the former protocol (44.6% vs. 56.8%, respectively; P < 0.001), probably because of the narrower target range in the revised protocol. No statistically significant differences in hypoglycemia were observed after the protocol was changed. Hypoglycemia occurred in 31% of the former-protocol patients compared with 18% of the revised-protocol patients. Severe hypoglycemia was experienced by 2.1% of patients on the old protocol and by 3.1% of patients on the new protocol. Rates of severe hypoglycemia were low (2.6%) with the original protocol.

CONCLUSION

Patients' blood glucose levels were within the target range for a shorter time with the new protocol. Fewer episodes of hypoglycemia were recorded with the new protocol, but rates of severe hypoglycemia were similar with both protocols.

Alogliptin benzoate for the treatment of type 2 diabetes

INTRODUCTION

Alogliptin is a highly selective inhibitor of the enzyme dipeptidyl peptidase-4 (DPP-4). It is one of several agents of this class now available for treatment of type 2 diabetes.

AREAS COVERED

This review is based upon a PubMed search and personal experience with alogliptin. The pharmacokinetics and pharmacodynamics of alogliptin are reviewed. The glucose-lowering effect of this agent is discussed as monotherapy and in combination with metformin, sulfonylurea, piogilitazone and insulin. The potential adverse effects of alogliptin are summarized. Alogliptin is compared with the other available DPP-4 inhibitors.

EXPERT OPINION

Alogliptin is an additional choice in the group of DPP-4 inhibitors. As a group, these agents have a relatively modest glucose-lowering effect, inferior to that of metformin, sulfonylureas, and insulin. They do not have the benefit of weight loss offered by the glucagon-like polypeptide (GLP)-1 agonists. The primary use of DPP-4 inhibitors is in combination with other hypoglycemic agents, mainly metformin. Their principal advantage is a low incidence of hypoglycemia, making these agents desirable in patients such as the elderly and those with cardiac disease. A greater use of alogliptin and other DPP-4 inhibitors will occur if long-term studies show reduced cardiac events or long-term retention of insulin secretory capacity. The Examine Trial, a large study of alogliptin in coronary disease patients, is now underway and could provide important supportive data.

Trabecular bone histomorphometry in humans with Type 1 Diabetes Mellitus

Patients with Type 1 Diabetes Mellitus (DM) have markedly increased risk of fracture, but little is known about abnormalities in bone microarchitecture or remodeling properties that might give insight into the pathogenesis of skeletal fragility in these patients. We report here a case-control study comparing bone histomorphometric and micro-CT results from iliac biopsies in 18 otherwise healthy subjects with Type 1 Diabetes Mellitus with those from healthy age- and sex-matched non-diabetic control subjects. Five of the diabetics had histories of low-trauma fracture. Transilial bone biopsies were obtained after tetracycline labeling. The biopsy specimens were fixed, embedded, and scanned using a desktop μCT at 16 μm resolution. They were then sectioned and quantitative histomorphometry was performed as previously described by Recker et al. [1]. Two sections, >250 μm apart, were read from the central part of each biopsy. Overall there were no significant differences between diabetics and controls in histomorphometric or micro-CT measurements. However, fracturing diabetics had structural and dynamic trends different from nonfracturing diabetics by both methods of analysis. In conclusion, Type 1 Diabetes Mellitus does not result in abnormalities in bone histomorphometric or micro-CT variables in the absence of manifest complications from the diabetes. However, diabetics suffering fractures may have defects in their skeletal microarchitecture that may underlie the presence of excess skeletal fragility.

Alogliptin: a new addition to the class of DPP-4 inhibitors

BACKGROUND

Alogliptin is an oral antihyperglycemic agent that is a selective inhibitor of the enzyme dipeptidyl peptidase-4 (DPP-4). Inhibition of DPP-4 elevates levels of the incretin hormones glucagon-like peptide (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) by preventing their degradation.

OBJECTIVE

To review the evolution of alogliptin and its pharmacokinetics, pharmacodynamics, clinical efficacy and adverse effects. In addition, we compared alogliptin to other DPP-4 inhibitors.

METHODS

A comprehensive literature search was performed using the term 'alogliptin'. Original research articles and review articles as well as scientific abstracts were included.

RESULTS

Alogliptin raises postprandial levels of GLP-1. It has excellent bioavailability exhibiting a median T(max) ranging from 1 to 2 hours and a mean half-life of 12.4 to 21.4 hours across all doses. When given as monotherapy, mean hemoglobin A(1c) (HbA(1c)) reductions achieved were 0.5% to 0.6%. Combination therapy yielded similar reductions (-0.5% with metformin, -0.6% with glyburide, -0.8% with pioglitazone and -0.6% with insulin). Administration of alogliptin does not promote weight loss but has not resulted in weight gain. The agent is relatively well tolerated with few adverse effects, the major finding being a marginally higher rate of skin events, primarily pruritus.

CONCLUSIONS

Alogliptin causes significant reductions in HbA(1c) when used alone or in combination with other oral agents in patients with type 2 diabetes similar to other DPP-4 inhibitors in current clinical use. The side effect profile also does not differ from that of other DPP-4 inhibitors. However, long-term studies are necessary before the place of alogliptin in the management of type 2 diabetes can be established.

Insulin Glargine: a review 8 years after its introduction

Insulin Glargine was the first long-acting insulin analog produced by recombinant DNA technology, approved for use by the US FDA in April 2000 and by the European Agency for the Evaluation of Medicinal Products in June, 2000. It has become the most widely used insulin in the USA owing to its long duration of action without a pronounced peak. The principal advantage of insulin Glargine over neutral protamine Hagedorn (NPH) insulin is in a lower frequency of hypoglycemic reactions, thus affording improved safety. It is used in both type 1 and type 2 diabetes, usually as a single daily dose. In type 2 patients, it is often the first insulin introduced as a single daily dose. Although insulin Glargine is typically administered as a single nighttime dose, it can be given in the morning or at any other time convenient for the patient. In labile type 1 diabetes, it is often most effective given as two daily injections. In obese, insulin-resistant patients, it may be best to administer insulin Glargine in two separate doses, owing to the high volumes of injected insulin required. Insulin Glargine does not treat postprandial hyperglycemia. It is necessary to supplement with short-acting insulin at mealtimes to control glucose surges after meals. Insulin Glargine is effective in hospitalized and postsurgical patients on account of its lack of pronounced insulin peaks and long duration of action. Although there is considerable use of Glargine in pregnant diabetic women, there is no definitive study to confirm its benefits. Insulin Glargine is thought to coprecipitate supplementary short-acting insulins when co-administered in the same syringe. Therefore, more injections are typically needed in the usual treatment regimen for insulin requiring diabetes. In many cases, constant basal insulin levels may be achieved with multiple overlapping doses of NPH insulin given together with short-acting insulin at mealtimes. Such a therapy may be less costly, but the major advantage of insulin Glargine remains the greater safety of a lower frequency of hypoglycemic reactions.

New technology, new errors: how to prime an upgrade of an insulin infusion pump

BACKGROUND

A series of use errors occurred when switching an ambulatory care clinic patient from an older model to a newer model of an ambulatory continuous subcutaneous insulin infusion pump.

CASE REPORT

The nurse practitioner (N.P.) reviewed the new pump's mechanics with the patient, who had a 26-year history of Type 1 diabetes mellitus, and supervised the patient's programming of the pump. At bedtime, a blood sugar of > 250 mg/dL prompted the patient to give herself insulin via the pump. The next morning, she was treated at the emergency department for diabetic ketoacidosis.

CASE ANALYSIS

The pump had been improperly primed, resulting in no insulin delivery. The incident also reflected the absence of a fail-safe mechanism(s) on the pump to alert the user to the improper priming and inappropriate handoff of the patient's care. Unlike the old pump, the new pump did not require manual priming. The lack of delivery of insulin resulted in DKA, a potentially life-threatening complication of diabetes. A root cause analysis suggested several important safety issues, including skipping of steps on the patient training checklist and other shortcuts in patient training.

DISCUSSION

The clinic developed policies and procedures, including mandatory formal training for each pump model by the certified pump trainer and for initiation of insulin pump therapy. This case illustrates the importance of a structured device selection process, provider education, patient education, and monitoring for safety and effectiveness of technological devices in care.

Men with acquired hypogonadotropic hypogonadism treated with testosterone may be fertile

Men with acquired hypogonadotropic hypogonadism treated with testosterone are generally assumed to be infertile. The finding of two such patients with unexpected fertility and normal sperm counts prompted an evaluation of spermatogenesis in additional men with this condition. Case records were initially searched and one similar case with fertility was found. Subsequently, 12 consecutive men with acquired hypogonadotropic hypogonadism were evaluated for gonadal function and sperm production while receiving testosterone. In five of the cases with proven spermatogenesis, exon 10 of the FSH receptor was sequenced to look for activating mutations. The original three cases and four of the subsequent 12 men had sperm concentrations > or = 15 million/ml. Two additional men had concentrations of 1 million/ml and six were azoospermic. Residual LH and FSH levels were slightly higher in those with maintained spermatogenesis prior to testosterone replacement. No activating mutations were found in exon 10 of the FSH receptor in the five cases studied. We conclude that men with acquired hypogonadotropic hypogonadism being treated with testosterone should not be assumed to be sterile, as we have found that more than half have been shown to have persistent spermatogenesis with more than one-third having sperm concentrations > or = 15 million/ml. This may be related to fact that gonadotropin levels in such patients are present, albeit low. Semen analyses in such men should be routinely carried out so that they can be appropriately counseled regarding potential fertility.

The mitochondrial apoptotic pathway is activated by serum and glucose deprivation in cardiac myocytes

Many cell types undergo apoptosis under conditions of ischemia. Little is known, however, about the molecular pathways that mediate this response. A cellular and biochemical approach to elucidate such signaling pathways was undertaken in primary cultures of cardiac myocytes, a cell type that is especially sensitive to ischemia-induced apoptosis. Deprivation of serum and glucose, components of ischemia in vivo, resulted in myocyte apoptosis, as determined by nuclear fragmentation, internucleosomal cleavage of DNA, and processing of caspase substrates. These manifestations of apoptosis were blocked by zVAD-fmk, a peptide caspase inhibitor, indicating that caspase activity is necessary for the progression of apoptosis in this model. In contrast to control cells, apoptotic myocytes exhibited cytoplasmic accumulation of cytochrome c, indicating release from the mitochondria. Furthermore, both caspase-9 and caspase-3 were processed to their active forms in serum-/glucose-deprived myocytes. Caspase processing, but not cytochrome c release, was inhibited by zVAD-fmk, placing the latter event upstream of caspase activation. This evidence demonstrates that components of ischemia activate the mitochondrial death pathway in cardiac myocytes.

Caspase inhibition reduces myocyte cell death induced by myocardial ischemia and reperfusion in vivo

Myocardial ischemia and reperfusion lead to myocyte cell death, at least in part, by an apoptotic mechanism. Caspases are a conserved family of proteases that play an essential role in the execution of apoptosis; however, their potential contribution to ischemic myocardial cell death is largely unknown. To examine their role in this process, we subjected rabbits to 30 min of coronary artery occlusion followed by 3 h of reperfusion. Immunoblot analyses revealed that caspases-2, -3 and -7 were proteolytically activated during myocardial ischemia and reperfusion in vivo. In addition, the well-characterized caspase substrate poly(ADP-ribose) polymerase (PARP) was selectively cleaved into its signature apoptotic fragment in ischemic/reperfused myocardium. Systemic administration of the broad-spectrum caspase inhibitor acetyl-Tyr-Val-Ala-Asp chloromethylketone (YVAD-cmk, 4.8 mg/kg) partially blocked caspase activation and dramatically reduced the percentage of terminal dUTP deoyxynucleotidyl-transferase nick end-labeling (TUNEL)-positive myocyte nuclei in the infarct region (3.9+/-0.8%v 13.0+/-2.2% in control animals, P=0.012). Moreover, YVAD-cmk reduced myocardial infarct size by approximately 31% (31.1+/-3.3%v 45.3+/-4.9% in control animals, P=0.032). These results indicate that caspases are critical mediators of myocardial injury induced by ischemia and reperfusion in vivo, and they suggest that caspase inhibition may be therapeutically beneficial in myocardial infarction.