Insulin therapy for inpatient diabetes management comes with a risk of hypoglycemia, leading to adverse outcomes. This increased risk combined with the injection burden to patients and staff has led to research into alternative glucose management options for patients with diabetes who are in the hospital.
“Most guidelines at this time have limited data on the use of non-insulin therapies inpatient,” said Smita Kumar, MD, Assistant Professor of Medicine, West Virginia University. “But there are several randomized trials that are focusing on the use of incretin-based therapy in patients hospitalized with diabetes.”
Dr. Kumar was among the speakers during the symposium, Updates on Inpatient Diabetes Management, on Monday, June 6. The session can be viewed on-demand by registered meeting participants at ADA2022.org. If you haven’t registered for the 82nd Scientific Sessions, register today to access the valuable meeting content through September 5.
Glucagon-like peptide-1 (GPL-1), an incretin hormone released from the intestinal cells in the gut mucosa, enhances insulin secretion, inhibits glucagon release, and delays gastric emptying. Dr. Kumar presented data from randomized controlled trials and observational studies on the use of the dipeptidyl peptidase-4 inhibitors, which block the breakdown of GLP-1, for inpatient hyperglycemia. One such study of Sitagliptin found that patients with blood glucose levels < 180 experienced lower mean daily glucose values and less treatment failures, independent of their treatment regimen.
“However, in patients who do have more severe hyperglycemia, we need to still consider the addition of basal insulin or basal bolus insulin,” Dr. Kumar said.
M. Citlalli Perez-Guzman, MD, Postdoctoral Fellow, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, discussed the use of continuous glucose monitoring (CGM) during hospitalization for non-critically ill patients.
Working with the University of Maryland, Dr. Perez-Guzman’s research team at Emory University developed a glucose telemetry system that allows wireless transmission of CGM data to a nurse’s station with alarms.
Several studies demonstrate the benefits of using the technology, including one that found CGM helped decrease mean glucose and increase time in range by 11%.
Another study comparing traditional point-of-care testing with CGM revealed several hypoglycemic events that went undetected by the former, often because staff were not testing at night.
CGM use for inpatient care also has limitations, said Dr. Perez-Guzman. It requires the education and involvement of a large number of stakeholders and can be impacted by other medications and health conditions, surgery, and certain radiology procedures.
Dr. Perez-Guzman also listed guidelines for confirming CGM readings with point-of-care testing. The guidelines include instances where there are hyperglycemic symptoms without a corresponding CGM reading, rapid glucose changes, a glucose value less than 85 or more than 300, and during the first 24 hours after surgery.
“Moving forward, we need the integration of real-time CGM into electronic medical records as well as summarizing metrics so patient glucose data is accessible to providers,” she said. “We need a pragmatic trial assessing the cost effectiveness in a real-world setting, development of hospital-specific systems, and standardization of treatment.”
Lia Bally, MD, PhD, Department of Diabetes, Endocrinology, Nutritional Medicine, and Metabolism, Inselspital, Bern University Hospital, and University of Bern, Switzerland, discussed the use of closed-loop insulin-delivery systems by complex patients with type 2 diabetes who require hemodialysis, nutrition support, or major surgeries while hospitalized.
Multiple studies have found that closed-loop insulin delivery in the hospital improves glucose control without increasing the risk of hypoglycemia, she said. It also seemed to substantially reduce the workload burden on hospital staff.
None of the studies looked at patient outcomes, so further research is needed to obtain a better understanding of the usability of the technology and how to personalize its use, Dr. Bally noted.
“To this end, we are currently performing implementation projects both in the U.K. and in Switzerland,” she said. “We are designing workflows to make sure that we can incorporate the technology into clinical workflows.”
Kristen Kulasa, MD, Associate Professor of Medicine, University of California, San Diego, discussed the rapidly changing face of hospital-based virtual glucose management and real-world implementation. She presented literature looking at the pros, cons, and inner workings of asynchronous and synchronous systems.
“Asynchronous lends itself well to inpatient insulin or medication management, particularly for those with type 1 diabetes and patients on a pump,” she said. “Synchronous is more ideal for patients who need that face-to-face, whether it be for education or to ask them questions about discharge planning.”