Abstract
Context
While individuals with diabetes appear to be at similar risk for SARS-CoV-2 infection to those without diabetes, they are more likely to suffer severe consequences, including death. ...Diabetic ketoacidosis (DKA) is a common and potentially lethal acute complication of diabetes arising from a relative insulin deficiency, which occurs more often in those with type 1 diabetes and in the setting of moderate to severe illness. Early reports indicate that among patients with pre-existing diabetes, DKA may be a common complication of severe COVID-19 and a poor prognostic sign.
Case Description
This clinical perspective explores the key elements of caring for individuals with DKA during the COVID-19 pandemic through 2 cases. Topics addressed include diagnosis, triage, and the fundamental principles of treatment with a focus on the importance of characterizing DKA severity and medical complexity to determine the best approach.
Conclusions
As discussed, some tenets of DKA management may require flexibility in the setting of COVID-19 due to important public health goals, such as preventing transmission to highest risk individuals, reducing healthcare worker exposure to infected patients, and preserving personal protective equipment. Evidence for alternative treatment strategies is explored, with special attention placed on treatment options that may be more relevant during the pandemic, including use of subcutaneous insulin therapy. Finally, DKA is often a preventable condition. We include evidence-based strategies and guidance designed to empower clinicians and patients to avoid this serious complication when possible.
The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, ...diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.
The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.
This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.
This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
To estimate the long-run mortality effects of Hurricanes Katrina and Rita on seniors with diabetes.
We performed a retrospective cohort analysis of Medicare enrollment and claims data covering four ...states and ∼10 years. Affected individuals were identified by whether they lived in a county that suffered a high impact and were stratified by whether they moved to a different county following the storms. Propensity scores matched affected and comparison subjects based on demographic and socioeconomic characteristics and the presence of chronic conditions. Our sample consisted of 170,328 matched affected subjects.
The affected subjects had a nearly 40% higher all-cause mortality risk in the 1st month after the storms, but the difference fell to <6% by the end of the full observation period. The mortality risks of heart disease and nephritis also exhibited the largest differences immediately following the storms. Among the affected subjects, the all-cause mortality risk was higher for those who moved to a different county, with an especially large difference among those who moved to an affected county.
The propensity matching procedure resulted in the comparison and affected groups having similar observable characteristics. However, we only examined the extreme outcome of mortality, our definition of affected was somewhat crude, and our sample did not include individuals enrolled in Medicare Advantage. Our findings highlight the importance of the immediate response to disasters, yet also demonstrate the long-lasting impact disasters can have.
Advances in diabetes technology, especially in the last few decades, have transformed our ability to deliver care to persons with diabetes (PWDs). Developments in glucose monitoring, especially ...continuous glucose monitoring (CGM) systems, have revolutionized diabetes care and empowered our patients to manage their disease. CGM has also played an integral role in advancing automated insulin delivery systems.
Currently available and upcoming advanced hybrid closed-loop systems aim to decrease patient involvement and are approaching the functionality of a fully automated artificial pancreas. Other advances, such as smart insulin pens and daily patch pumps, offer more options for patients and require less complicated and costly technology. Evidence to support the role of diabetes technology is growing, and PWD and clinicians must choose the right type of technology with a personalized strategy to manage diabetes effectively.
Here, we review currently available diabetes technologies, summarize their individual features, and highlight key patient factors to consider when creating a personalized treatment plan. We also address current challenges and barriers to the adoption of diabetes technologies.
Objective: Evaluate safety and efficacy of a novel, simultaneous 2-bag (2B) maintenance intravenous fluid (IVF) DKA protocol compared with a conventional, single 1-bag (1B) protocol in adults.
...Methods: Retrospective, observational review of patients treated with a DKA protocol from March-June 2017 (1B group) and March-June 2019 (2B group). One bag (1B) protocol: individual infusion of 1B IVF of ½ NS, ½ NS + KCL, D5W, OR D5W + KCL. Two bag (2B) protocol: simultaneous IVF infusion of 2B of D10W + KCL AND ½ NS + KCL. Safety endpoints of hypoglycemia, hyperkalemia, hypokalemia as well as efficacy endpoints of DKA resolution, incidence of rebound hyperglycemia, and hospital length of stay (LOS) were evaluated.
Results: A total of 605 patients were included (1B: n=204; 2B: n=401). Both groups had similar baseline characteristics except a higher baseline beta-hydroxybutyrate level in the 2B group than 1B (3.2 vs. 2.4; P=0.02) and differences in distribution of Body Mass Index (BMI) categories. Safety: Significantly fewer patients had hypoglycemia (BG <70 mg/dL) in the 2B group than 1B (15% vs. 22%, P=0.04), but severe hypoglycemia (BG < 40 mg/dL) was not different (0.5% vs. 1.5%, P=0.3). Incidence of hyperkalemia (K > 5.2 mEq/L) was significantly lower in the 2B group than 1B (10% vs. 21%, P<0.01), but hypokalemia (K < 3.3 mEq/L) was not different (21% vs. 24%, P=0.4). Efficacy: Median time to DKA resolution was similar between the 2B and 1B (15.0 vs. 15.6 hours, P=0.6). Rebound hyperglycemia (BG > 250 mg/dL) was less in 2B than 1B (29% vs. 44%, P<0.01). The 2B group had a trend of decreased LOS, but the difference was not statically significant (3.7 vs. 4.3 days, P=0.06).
Conclusion: In adult patients with DKA, a 2-bag protocol performed better in hypoglycemia, hyperkalemia, and rebound hyperglycemia without changing time to DKA resolution or LOS. In addition, the 2-bag protocol offered simplicity by decreasing the number of IVF bag options for the nurse.
Disclosure
R. Halfon: Stock/Shareholder; Spouse/Partner; Pfizer Inc. D. Dreucean: None. M. Sirimaturos: None. A. R. Sadhu: None.
Background:
Amidst the coronavirus disease 2019 (COVID-19) pandemic, continuous glucose monitoring (CGM) has emerged as an alternative for inpatient point-of-care blood glucose (POC-BG) monitoring. ...We performed a feasibility pilot study using CGM in critically ill patients with COVID-19 in the intensive care unit (ICU).
Methods:
Single-center, retrospective study of glucose monitoring in critically ill patients with COVID-19 on insulin therapy using Medtronic Guardian Connect and Dexcom G6 CGM systems. Primary outcomes were feasibility and accuracy for trending POC-BG. Secondary outcomes included reliability and nurse acceptance. Sensor glucose (SG) was used for trends between POC-BG with nursing guidance to reduce POC-BG frequency from one to two hours to four hours when the SG was in the target range. Mean absolute relative difference (MARD), Clarke error grids analysis (EGA), and Bland-Altman (B&A) plots were calculated for accuracy of paired SG and POC-BG measurements.
Results:
CGM devices were placed on 11 patients: Medtronic (n = 6) and Dexcom G6 (n = 5). Both systems were feasible and reliable with good nurse acceptance. To determine accuracy, 437 paired SG and POC-BG readings were analyzed. For Medtronic, the MARD was 13.1% with 100% of readings in zones A and B on Clarke EGA. For Dexcom, MARD was 11.1% with 98% of readings in zones A and B. B&A plots had a mean bias of −17.76 mg/dL (Medtronic) and −1.94 mg/dL (Dexcom), with wide 95% limits of agreement.
Conclusions:
During the COVID-19 pandemic, CGM is feasible in critically ill patients and has acceptable accuracy to identify trends and guide intermittent blood glucose monitoring with insulin therapy.
Per current guidelines, our institution advocates using basal-bolus insulin regimens for inpatient hyperglycemia. However, it is a challenging practice in the real-world setting. Hypoglycemia is an ...unwanted consequence and a national quality metric for hospitals. We sought to characterize the factors around use of basal insulin and hypoglycemic events (HE) in our hospital system for quality improvement and to develop preventative strategies.
Between April-June 2018, 4130 admissions receiving basal insulin (glargine, NPH, or Mixed 70/30, 75/25) were retrospectively reviewed for HE, defined as glucose <70 mg/dl. ICU and non-ICU patients were included. Insulin infusion or insulin pump therapy was excluded. Median age was 66 years, 48% were male and median A1C was 7.8%. In the entire cohort, 22% (923) had >/= 1 HE. Of those, 76% had 1-3 HE and 24% had >/= 4 HE per admission. The frequency of basal insulins were 75% glargine, 18% NPH, and 6% Mixed. Within 24 hours of the first HE, insulin dose was decreased in 42% receiving glargine, 66% NPH, and 59% mixed insulin by an average of 23%, 23% and 11%, respectively. Oral antidiabetic agents (OADs) were used concurrently in 16% of admissions with HE, of which sulfonylureas (SU) represented 43%, metformin 25%, and DPP-4i 26%. At the time of the HE, patients were on an oral diet in 73% of admissions, TPN or tube feeds in 6%, and NPO in 12%. In 75% of the HE, basal insulin was administered without the use of guideline-based hospital order sets and 83% of HE did not have an endocrinology consultation.
Our analysis demonstrates several key issues that need to be addressed around the recommended practice of basal insulin in the hospital setting. Among them, inadequate response in dose reduction after the first HE, underutilization of standardized order sets, concurrent use of OADs, particularly SU, add risk for HE. Endocrinology consultation is low, and the complicated nature of a basal-bolus insulin regimen as well as the many variables involved remain real world challenges.
Disclosure
A. Pandya: None. S. Nguyen: None. V. Saldivar: None. A.R. Sadhu: None.
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