Glucose control after glucocorticoid administration in hospitalized patients – a retrospective analysis

Background Glucocorticoid (GC)-induced hyperglycemia is a frequent adverse effect in hospitalized patients. Guidelines recommend insulin treatment to a target range of 6–10 mmol/L (108–180 mg/dl), but efficacies of particular regimes have not been well-studied. Methods In this retrospective cohort study, hospitalized patients receiving GCs at the medical ward were analyzed by treatment (basal-bolus vs. bolus-only vs. pre-mixed insulin) and compared to a non-insulin-therapy reference group. Coefficients of glucose variation (CV), percentage of glucose readings in range (4–10 mmol/L (72–180 mg/dl)) and hypoglycemia (< 4 mmol/L (< 72 mg/dl)) were evaluated. Results Of 2424 hospitalized patients receiving systemic GCs, 875 (36%) developed GC-induced hyperglycemia. 427 patients (17%) had a previous diagnosis of diabetes. Adjusted relative risk ratios (RRR) for the top tertile of CV (> 29%) were 1.47 (95% Cl 1.01–2.15) for bolus-only insulin, 4.77 (95% CI 2.67–8.51) for basal-bolus insulin, and 4.98 (95% CI 2.02–12.31) for premixed insulin, respectively. Adjusted RRR for percentages of glucose readings in range were 0.98 (95% Cl 0.97–0.99) for basal-bolus insulin, 0.99 (95% Cl 0.98–1.00) for premixed insulin, and 1.01 (95% Cl 1.00–1.01) for bolus-only insulin, respectively. Adjusted RRR for hypoglycemia was 13.17 (95% Cl 4.35–39.90) for basal-bolus insulin, 8.92 (95% Cl 2.60–30.63) for premixed insulin, and 2.99 (95% Cl 1.01–8.87) for bolus-only insulin, respectively. Conclusions Current guidelines recommend a basal-bolus regimen for treatment of GC-induced hyperglycemia, but we found similar outcomes with pre-mixed and bolus-only insulin regimens. As GC-induced hyperglycemia is a frequent issue in hospitalized patients, it might be reasonable to prospectively study the ideal regimen.

Mauriac Syndrome in a Nigerian child with Type 1 Diabetes Mellitus: A Case Report

A 14-year-old boy with Type 1 Diabetes mellitus (diagnosed at eight years of age) presented with complaints of fever, weight loss, growth failure, pubertal delay, abdominal swelling and discomfort. He was on Premixed insulin (70/30) with inadequate follow-up and poor diabetic control. Examination revealed cachexia, generalised lymphadenopathy, a protuberant abdomen and hepatosplenomegaly. Anthropometry showed a bodyweight of 19.6kg, a height of 116cm and a BMI of 14.1kg/m2, all markedly below the 3rd centile. He had no secondary sexual characteristics: axillary hair stage 1, pubic hair stage 1, penile length of 4.9cm and prepubertal testicular volumes of 3mls bilaterally. At presentation, his random blood glucose was 400mg/dl, and glycosylated haemoglobin was 11.6%. Screening for tuberculosis, human immunodeficiency virus, hepatitis and lymphoproliferative disorders were negative. Other blood investigation findings included leucocytosis, erythrocyte sedimentation rate of 30mm/hr, normal liver function tests, normal serum electrolytes, urea and creatinine. His haemoglobin genotype was AS. Chest radiograph showed features of bronchopneumonia. A presumptive diagnosis of Mauriac Syndrome was made. With the optimisation of glycaemic control, he improved clinically with a weight gain of 5.7kg over four months and resolution of hepatosplenomegaly.

Efficacy and Safety of Insulin Degludec/Insulin Aspart Compared with a Conventional Premixed Insulin or Basal Insulin: A Meta-Analysis

Insulin degludec/insulin aspart (IDegAsp) is a novel co-formulation of 70% insulin degludec and 30% insulin aspart. The present meta-analysis was conducted to assess the efficacy and safety of IDegAsp compared with a conventional premixed insulin or basal insulin. We extracted data from citation databases, including PubMed, EMBASE, and the Cochrane Library, since inception to 2021. We calculated the mean differences for hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), self-measured mean glucose, and postprandial glucose (PPG) and odds ratios for confirmed hypoglycemia events. Compared with twice-daily conventional premixed insulin, twice-daily IDegAsp showed a similar effect on changes in HbA1c, but it significantly reduced FPG and self-measured mean glucose levels. Furthermore, compared to once-daily basal insulin, once-daily IDegAsp had a similar effect on changes in HbA1c, but it significantly reduced self-measured mean glucose and PPG levels. The risk of overall confirmed hypoglycemia was similar between treatments; however, the risk of nocturnal hypoglycemia events was significantly lower with IDegAsp than with conventional premixed insulin and basal insulin. Thus, IDegAsp was more effective than conventional premixed insulin and basal insulin at reducing blood glucose with fewer nocturnal hypoglycemia events.

Combination Therapy With Premixed & Basal Insulin Analogues in Asian Indians With Type 2 Diabetes

Many individuals with type 2 diabetes (T2DM) eventually need insulin for better glycaemic control. Different insulin regimens like basal, premixed, basal plus, split mixed and basal bolus are used in T2DM management. There is not much literature on a combination of premixed insulin in the morning along with basal insulin at night. Such a regimen is preferred by people with T2DM, who do not want to take an afternoon insulin dose due to inconvenience. To study the effect of a premixed insulin given in the morning and long acting basal insulin analogue given at night in T2DM subjects, we looked into this combination. We performed a retrospective study to look into the effects of premixed and basal insulin analogue combination in patients with T2DM (in addition to oral antidiabetic agents). From the diabetes electronic medical records of a tertiary care hospital for diabetes at Chennai in South India, 648 patients on premixed and basal insulin analogue combination, who came for a follow-up visit were included in the final analysis. Baseline characteristics included body weight, BMI, blood pressure, fasting lipid profile, fasting and post prandial plasma glucose and HbA1c were analysed at baseline, and a change in the parameters was studied at the first follow up visit between 5 to 7 months. Mean age of the study population was 60.7± 13.1 years with mean diabetes duration of 20.5 ± 8.0 years. Out of 648 patients included, three fifths were male. Statistically significant improvement was observed in body weight, BMI, HbA1c, systolic blood pressure, lipid profile, fasting blood sugars (P &lt; 0.001) and post prandial blood sugars (P= 0.005) in comparison to baseline values. Significant reduction in HbA1c (1.7 %, p &lt; 0.0001) was observed in those with in the highest tertile of HbA1c (11.3 ± 1.0 %) in comparison to the baseline values. At follow up, nearly a third of study subjects achieved a HbA1c target of &lt; 8% (30.1 % vs 18.4 0%, p =0.0005) in comparison to the baseline values. 28.7 % patients on combination therapy achieved a fasting blood sugar value of &lt; 130 mg/dl at follow up compared to 18.2 % patients at baseline (p &lt;.0001). Similarly, 22 % of the patients on combination therapy also achieved post prandial blood sugars of &lt;180 mg/dl at follow up, compared to 12.2 % (P&lt;.0001) at baseline. This study shows that in T2DM subjects, a simple regimen of premixed and basal insulin analogue combination helps in improving the glycaemic control.

HbA1c Is Not Potent Glucose Control Assessment Tool in Type 2 Diabetes Patients Treated With Insulin

Glycated haemoglobin (HbA1c) is used for defining of glucose control in diabetic patients nevertheless its insufficiency to present overall control in some specific cases. Continuous Glucose Monitoring (CGM) is usually used for adjustment of insulin doses but the derived data are helpful for exact glucose control. We assess the potency of HbAc for defining of real glucose control in subgroup of type 2 diabetes patients treated with different insulin regimens. We studied 54 diabetic patients (33 men, 21 women; age 60.23±5.99 years, disease duration 12.64±5.02 years) - 33 with type 2 diabetes on pre-mixed insulin, 21 with type 2 on multiple insulin injection (MII). Patients performed multiple daily blood glucose measurements of fasting and prandial blood glucose for three months period. HbA1c was measured and CGM by using iProTM for seven days was performed at the end of this period. In pre-mixed insulin treated group and in intensified regimen group, moderate positive correlation was found between HbA1c and mean blood glucose derived from CGM (7.64±1.40% and 7.69±1.23%, respectively 7.64±1.48mmol/l and 7.60±1.30mmol/l), with r1=0.642 (p&lt;0.01) and r2=0.570 (p&lt;0.05). Even lower was correlation between HbA1c and time-in-range (r1=0.431 and r2 =0.401). There were no correlations between HbA1c and percentage of time spent below the target and number of hypoglycemic episodes in each group. Same trend of correlations was found comparing HbA1c and mean BG level in eight-point profile. Based on HbA1c assessment 36.36% of patients on premixed insulin, 19.05% of type 2 patients on MII were with good control. After estimation of results from SMBG these percentage were respectively 28.14% and 12.11%. CGM defined 27.27% of patients on premixed insulin, 13.80% of type 2 patients on MII as well controlled. We conclude that in insulin treated type 2 patients HbA1c gives relative information about overall control with no precise presenting of glucose fluctuations and out-of-range values of blood glucose with no information about hypoglycemic episodes. Nevertheless, short observed period CGM data could give much information that is comparable to three months blood glucose measurement and could replace the use of HbA1c for assessment of overall control. Reference: (1) Chehregosha H, et al. Diabetes Ther. 2019; 10, 853–863 (2) Beyond A1c Writing Group. Diab Care. 2018; 41: e92-e94 (3) Hirsch I et al. Diabetes Tech Ther 2017, 19 (3): S38-S48

Pattern of anti-diabetic treatment and its relation with glycaemic control among diabetic patients in a tertiary care hospital of Bangladesh

Background: The main determinants of diabetes management, therapeutic habits and glycaemic control are likely to differ between populations. The pharmacological armamentarium to treat hyperglycaemia in type 2 diabetes mellitus (T2DM) has changed substantially over the past few years with the development of new therapeutic agents. This study evaluated relationships between pattern of pharmacological treatment and glycaemic control in patients with T2DM. Methods: This cross-sectional study was carried out among 486 T2DM patients attending the endocrinology outpatient clinic of MARKS Medical College & Hospital, Dhaka, Bangladesh during the period between July 2018 and June 2019. After obtaining written informed consent, both the treatment pattern and the degree of glycaemic control were estimated from T2DM patients. Glycosylated hemoglobin A1C (HbA1c) was determined by liquid chromatography. Glycaermic control categorized as fair control (HbA1c <7.0%), poor control (HbA1c ³7.0%- <9.0%) and very poor control (HbA1c ³9.0%). Results: Out of 486 participants, 65.8% were females. A total 68.1% of the patients were treated with oral antidiabetic drugs (OADs) and 31.9% were treated with both insulin and oral agents. Metformin (92.4%) was the most commonly used OAD; [p=0.01]. Over one fifth (22.1%) were taking combinations of sulfonylurea and metformin [p<0.05] and 19.5% were taking combination of sulfonylurea, metformin and dipeptidyl peptidase- IV inhibitors (DPP4i); [p=0.87]. More than one fourth (25.7%) were treated with two OADs along with insulin; [p=0.05]. In this context, familiar dual OADs combination (14.2%) was metformin and DPP4 inhibitors [p=0.86]. Premixed insulin (17.1%) was the frequently used regimen among different regimen of insulin used in both OADs and insulin group [p=0.22]. More than 50% of the subjects attained fair glycaemic target of HbA1c. But 46.3% accomplished poor and very poor glycaemic control [p=0.08]. Conclusion: The study shows that the proportion of patients treated with only oral diabetic agent was high. In most instances, they were treated with two or three drus combination therapies. The proportion of patients with fair glycaemic control was higher than reports from many countries. Birdem Med J 2021; 11(2): 90-96