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BACKGROUND: Few studies have reported the adherence to and efficacy of continuous glucose monitoring (CGM) for improving diabetes management in insulin-treated older adults with type 2 diabetes mellitus (T2DM). METHODS: Prospective observational cohort study using FreeStyle Libre Flash CGM in insulin-treated adults > 65 years with T2DM and HbA1c between 7% and 9%. The participants wore the CGM during the 6-weeks study period. The primary outcome was time in range (TIR) between 70 and 180 mg/dL. Secondary outcomes included time below range (TBR), glycemic variability (GV), adherence, and use of glucose data for self-insulin adjustment. Linear regressions with random effects verified the changes in TBR, TIR, time above range (TAR), GV, and GMI across the three visits using CGM (baseline, 4 weeks and 6 weeks), controlled for sex, age, educational level, and health system (private or public). RESULTS: A total of 66 participants completed the six weeks of CGM (age 72·8 ± 5·3 years; BMI 27·8 ± 3·6 kg/m2), HbA1c: 8·0 ± 0·6%, with an overall sensor utilization of 93·1 ± 6·0%. We observed a stability in TIR (baseline: 63.5 ± 18.9% vs. endpoint: 65.5 ± 18.8%; ß = 1,0, p = 0.190). Despite the low TBR at the baseline, we observed statistically significant reduction over the study period (baseline: 5.8 ± 7.0% vs. endpoint: 3.8 ± 4.7%; (ß=-1.00, p = 0.008). Glucose variability also reduced from the baseline (34.9 ± 7.2%) to the endpoint (33.0 ± 6.8%) (ß=-0.99, p = < 0.001). CONCLUSION: FreeStyle Libre Flash CGM is well accepted by older adults with T2DM and allows participants to make therapeutic decisions to reduce TBR and glycemic variability.
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OBJECTIVE: Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS: Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS: Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS: Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.
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Sistemas de Apoio a Decisões Clínicas , Diabetes Mellitus , Hiperglicemia , Hipoglicemia , Humanos , Adolescente , Adulto , Tempo de Internação , HospitaisRESUMO
ABSTRACT Objective: We assessed metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of our hospital. Subjects and methods: We performed a retrospective study of patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. InsulinAPP recommends NPH and regular insulins three times a day, in bolus-correction or basal-bolus schemes. Parameters that included BG within range of 70-180 mg/dL, insulin treatment regimen and frequency of hypoglycemia were evaluated. Results: A total of 147 T2D individuals (23% medicine and 77% surgery) were included (mean age 62.3 ± 12.7 years, HbA1c: 8.3 ± 3.0%). The initial insulin regimen was 50% bolus-correction, 47% basal-bolus and 3% with sliding scale insulin. During hospitalization, 71% patients required a bolus-basal regimen. In the first 10 days of the protocol, 71% BG measurements were between 70-180 mg/dL and 26% patients experienced one or more episodes of hypoglycemia < 70 mg/dL, and 5% with BG < 54 mg/dL. Conclusion: The results of this retrospective study indicate the InsulinAPP application using human insulin formulations was effective and safe for the management of hyperglycemia on a hospitalist-managed ward, with more than 70% BG measurements within the therapeutic range and a low rate of hypoglycemia.
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Introduction: We assessed metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of our hospital. Subjects and methods: We performed a retrospective study of patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. InsulinAPP recommends NPH and regular insulins three times a day, in bolus-correction or basal-bolus schemes. Parameters that included BG within range of 70-180 mg/dL, insulin treatment regimen and frequency of hypoglycemia were evaluated. Results: A total of 147 T2D individuals (23% medicine and 77% surgery) were included (mean age 62.3 ± 12.7 years, HbA1c: 8.3 ± 3.0%). The initial insulin regimen was 50% bolus-correction, 47% basal-bolus and 3% with sliding scale insulin. During hospitalization, 71% patients required a bolus-basal regimen. In the first 10 days of the protocol, 71% BG measurements were between 70-180 mg/dL and 26% patients experienced one or more episodes of hypoglycemia < 70 mg/dL, and 5% with BG < 54 mg/dL. Conclusion: The results of this retrospective study indicate the InsulinAPP application using human insulin formulations was effective and safe for the management of hyperglycemia on a hospitalist-managed ward, with more than 70% BG measurements within the therapeutic range and a low rate of hypoglycemia.
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Diabetes Mellitus Tipo 2 , Médicos Hospitalares , Hipoglicemia , Idoso , Glicemia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hospitais , Humanos , Hipoglicemia/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Pacientes Internados , Insulina/uso terapêutico , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Glycated hemoglobin is currently the gold standard for assessment of long-term glycemic control and response to medical treatment in patients with diabetes. Glycated hemoglobin, however, does not address fluctuations in blood glucose. Glycemic variability (GV) refers to fluctuations in blood glucose levels. Recent clinical data indicate that GV is associated with increased risk of hypoglycemia, microvascular and macrovascular complications, and mortality in patients with diabetes, independently of glycated hemoglobin level. The use of continuous glucose monitoring devices has markedly improved the assessment of GV in clinical practice and facilitated the assessment of GV as well as hypoglycemia and hyperglycemia events in patients with diabetes. We review current concepts on the definition and assessment of GV and its association with cardiovascular complications in patients with type 2 diabetes.
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Doenças Cardiovasculares , Diabetes Mellitus Tipo 2 , Glicemia , Automonitorização da Glicemia , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/epidemiologia , Hemoglobinas Glicadas/análise , HumanosRESUMO
BACKGROUND AND AIMS: Few studies have reported on the use of continuous glucose monitoring (CGM) during the Covid-19 pandemic. We aimed to examine glycemic control metrics using flash glucose monitoring during insulin treatment and the clinical outcome in hospitalized patients with COVID-19. METHODS: Prospective, single-center cohort of adult patients diagnosed with type 2 diabetes or hyperglycemia and COVID-19 infection treated with basal bolus insulin regimen. Glycemic control was assessed with the use of intermittent Freestyle Libre flash glucose monitoring during the hospital stay. Outcome of interest were time in range [TIR], time above [TAR] and below [TBR] range, glycemic variability [coefficient of variation [% CV]), and differences in a composite of complications including ICU admission, acute respiratory distress syndrome (ARDS) and acute kidney injury. RESULTS: A total of 60 patients were included (44 known diabetes and 16 new onset hyperglycemia). In total 190,080 data points of CGM were available, of which 72.5% of values were within the target area [TIR (70-180 mg/dL)], 22% TAR (>180 mg/dL), and 3% were TBR (<70 mg/dL). During treatment, the coefficient of variation (% CV) was 30%. There were no association with TIR, but patients with TAR >180 mg/dl had higher rates of a composite of complications (22.5% vs 16%, p = 0.04). CONCLUSIONS: Basal bolus insulin regimen was safe and effective in achieving inpatient glycemic control in most patients with COVID-19. The association between TAR and complications indicates the need for improved inpatient glycemic control in hospitalized patients with COVID-19.
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Injúria Renal Aguda/epidemiologia , Glicemia/metabolismo , COVID-19/metabolismo , Diabetes Mellitus Tipo 2/metabolismo , Hiperglicemia/metabolismo , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Síndrome do Desconforto Respiratório/epidemiologia , Idoso , COVID-19/complicações , Estudos de Coortes , Colômbia/epidemiologia , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Hemoglobinas Glicadas/metabolismo , Controle Glicêmico , Humanos , Hiperglicemia/tratamento farmacológico , Hiperglicemia/etiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Projetos Piloto , Testes Imediatos , Estudos Prospectivos , SARS-CoV-2RESUMO
Introducción: El artículo resume el proceso de elaboración de la Guía de Práctica Clínica (GPC) para el manejo de las crisis glucémicas en pacientes adultos con diabetes mellitus de la Red de Clínicas AUNA. Métodos: Las preguntas PICO fueron priorizadas por el Grupo Elaborador de la GPC (GEG) luego de lo cual se concluyó en trabajar 10 preguntas PICO. Para dar respuesta a las preguntas se realizó una búsqueda sistemática de GPC, revisiones sistemáticas y estudios primarios. Se utilizó la metodología "GRADE-Adolopment" y los lineamientos de la normativa nacional para la formulación de recomendaciones. Resultados: Se formularon 10 recomendaciones (nueve fuertes y una débil), 18 puntos de buena práctica clínica, dos flujogramas para el manejo (uno para el diagnóstico y el otro para el tratamiento de crisis glucémicas), 5 tablas resumen sobre el manejo y 1 tabla para la vigilancia y seguimiento. Los temas que abarcaron las recomendaciones para el manejo de las crisis glucémicas fueron: crisis hiperglucémicas (evaluación de hemoglobina glucosilada; evaluación de b-hidroxibutirato; tratamiento con insulina, potasio, cloruro de sodio 0.9%, fósforo y bicarbonato de sodio) y crisis hipoglucémicas (administración de carbohidratos, monitoreo y programa educativo para evitar el reingreso). Conclusión: El presente artículo resume la metodología y las recomendaciones basadas en evidencia de la GPC para el manejo de la crisis glucémica en pacientes con diabetes mellitus de la Red de Clínicas AUNA.
Introduction: The manuscript summarizes the process of elaboration of the Clinical Practice Guide (CPG) for the management of glycemic crises in adult patients with diabetes mellitus of the AUNA Clinic Network. A multidisciplinary team of medical assistants and methodologists carried out the development of the CPG and then there was an external review by a specialist in the field. Methods: The Elaboration Group of the CPG (GEG) concluded on 10 PICO questions. A systematic search for CPG, systematic reviews and primary studies was carried out to answer these PICO questions. To make recommendations we used the "GRADE-Adolopment" methodology and the guidelines of the national regulations. Results: Ten recommendations were made (nine strong and one weak), 18 points of good clinical practice and two flowcharts for management (one for diagnosis and the other for the treatment of glycemic crises), 04 consensus tables on management and 01 table for surveillance and monitoring. The topics covered by the recommendations for the management of glycemic crises were hyperglycemic crises (glycosylated hemoglobin evaluation; b-hydroxybutyrate evaluation; insulin, potassium, 0.9% sodium chloride, phosphorus, sodium bicarbonate treatments) and hypoglycemic crises (carbohydrate administration, monitoring, educational program to avoid reentry). Conclusion: This article summarizes the methodology and evidence-based recommendations of the CPG for the management of glycemic crisis in patients with diabetes mellitus in AUNA.
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The manuscript summarizes the process of elaboration of the Clinical Practice Guide (CPG) for the management of glycemic crises in adult patients with diabetes mellitus of the AUNA Clinic Network. A multidisciplinary team of medical assistants and methodologists carried out the development of the CPG and then there was an external review by a specialist in the field. The Elaboration Group of the CPG (GEG) concluded on 10 PICO questions. A systematic search for CPG, systematic reviews and primary studies was carried out to answer these PICO questions. To make recommendations we used the "GRADE-Adolopment" methodology and the guidelines of the national regulations. Ten recommendations were made (nine strong and one weak), 18 points of good clinical practice and two flowcharts for management (one for diagnosis and the other for the treatment of glycemic crises), 04 consensus tables on management and 01 table for surveillance and monitoring. The topics covered by the recommendations for the management of glycemic crises were hyperglycemic crises (glycosylated hemoglobin evaluation; b-hydroxybutyrate evaluation; insulin, potassium, 0.9% sodium chloride, phosphorus, sodium bicarbonate treatments) and hypoglycemic crises (carbohydrate administration, monitoring, educational program to avoid reentry)
El artículo resume el proceso de elaboración de la Guía de Práctica Clínica (GPC) para el manejo de las crisis glucémicas en pacientes adultos con diabetes mellitus de la Red de Clínicas AUNA. El proceso de elaboración se llevó a cabo con la participación de un equipo multidisciplinario de médicos asistenciales, metodólogos y un revisor externo (un especialista con dominio en la metodología y el tema). La priorización de preguntas PICO fue realizada por el Grupo Elaborador de la GPC (GEG) luego de lo cual se concluyó en trabajar 10 preguntas PICO. Para dar respuesta a las preguntas se realizó una búsqueda sistemática de GPC, revisiones sistemáticas y estudios primarios. Se utilizó la metodología "GRADE-Adolopment" y los lineamientos de la normativa nacional para la formulación de recomendaciones. Se formularon 10 recomendaciones (nueve fuertes y una débil), 18 puntos de buena práctica clínica, dos flujogramas para el manejo (uno para el diagnóstico y el otro para el tratamiento de crisis glucémicas), cinco (05) tablas resumen sobre el manejo y una (01) tabla para la vigilancia y seguimiento. Los temas que abarcaron las recomendaciones para el manejo de las crisis glucémicas fueron: crisis hiperglucémicas (evaluación de hemoglobina glucosilada; evaluación de b-hidroxibutirato; tratamiento con insulina, potasio, cloruro de sodio 0.9%, fósforo, bicarbonato de sodio) y crisis hipoglucémicas (administración de carbohidratos, monitoreo, programa educativo para evitar el reingreso).
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INTRODUCTION: Continuous glucose monitoring (CGM) is a better tool to detect hyper and hypoglycemia than capillary point of care in insulin-treated patients during hospitalization. We evaluated the incidence of hypoglycemia in patients with type 2 diabetes (T2D) treated with basal bolus insulin regimen using CGM and factors associated with hypoglycemia. METHODS: Post hoc analysis of a prospective cohort study. Hypoglycemia was documented in terms of incidence rate and percentage of time <54 mg/dL (3.0 mmol/L) and <70 mg/dL (3.9 mmol/L). Factors evaluated included glycemic variability analyzed during the first 6 days of basal bolus therapy. RESULTS: A total of 34 hospitalized patients with T2D in general ward were included, with admission A1c of 9.26 ± 2.62% (76.8 ± 13 mmol/mol) and mean blood glucose of 254 ± 153 mg/dL. There were two events of hypoglycemia below 54 mg/dL (3.0 mmol/L) and 11 events below 70 mg/dL (3.9 mmol/L) with an incidence of hypoglycemic events of 0.059 and 0.323 per patient, respectively. From second to fifth day of treatment the percentage of time in range (140-180 mg/dL, 7.8-10.0 mmol/L) increased from 72.1% to 89.4%. Factors related to hypoglycemic events <70 mg/dL (3.9 mmol/L) were admission mean glucose (IRR 0.86, 95% CI 0.79, 0.95, P < .01), glycemic variability measured as CV (IRR 3.12, 95% CI 1.33, 7.61, P < .01) and SD, and duration of stay. CONCLUSIONS: Basal bolus insulin regimen is effective and the overall incidence of hypoglycemia detected by CGM is low in hospitalized patients with T2D. Increased glycemic variability as well as the decrease in mean glucose were associated with events <70 mg/dL (3.9 mmol/L).