Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present — ‘D’, either elevated blood glucose levels or a family history of diabetes mellitus; ‘K’, the presence of high urinary or blood ketoacids; and ‘A’, a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children

Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

Acute hyperglycemic emergencies are a common cause of diabetes-related hospitalization. Diabetes ketoacidosis (DKA) is typically seen in patients with type 1 diabetes, and hyperosmolar hyperglycemic state (HHS) is typically seen in patients with type 2 diabetes. Presentation of DKA is acute with polyuria, polydipsia, and abdominal symptoms and characterized by hyperglycemia, ketonemia, and anion gap metabolic acidosis. Presentation of HHS is subacute with symptoms similar to DKA followed by altered mental status and extremely high blood glucose levels with high plasma osmolarity. The common precipitating causes of acute hyperglycemic emergencies include medication nonadherence, infections, and ischemic events. The key to treatment, for both DKA and HHS, is rehydration, insulin therapy, and electrolyte management. With proper treatment, mortality from acute hyperglycemic emergencies has been going down, but the morbidity is still very high

The relation of plasma homocysteine to radiographic knee osteoarthritis

SummaryObjectiveHomocysteine has been implicated in multiple diseases that involve changes in structural tissue. In vitro studies have found that it alters the structure of collagen cross-linking thus affecting stability and mineralization such as that occurring in bone tissue. In the present study we considered the possible relationship between plasma homocysteine levels and the development and progression of knee osteoarthritis (OA).MethodsThe study question was posed in 691 men and 966 women from the original and offspring cohorts of the Framingham Osteoarthritis Study. We divided individuals into three groups according to plasma homocysteine levels and compared their risk for the development of new and progression of existing OA. We adjusted for potential confounders including age, body mass index, weight change, and physical activity.ResultsIn the crude analysis, men in the middle homocysteine tertile were found to be at a greater risk than men in the lowest tertile for incident OA [odds ratios of 1.9 (1.1–3.5)]. This result persisted after adjusting for covariates [odds: 2.0, (1.1–3.8)]. No significant correlation was seen in women for the development of OA. In the evaluation of progression no significant trends were seen for both men and women.ConclusionsAlthough cellular and molecular studies of homocysteine-related pathophysiology suggest a possible correlation between plasma homocysteine levels and OA, the present clinical study did not conclusively demonstrate such an association. However, further research is needed to explore the role of homocysteine in specific aspects of OA etiopathogenesis

Comparison of Efficacy and Safety of Glargine and Detemir Insulin in the Management of Inpatient Hyperglycemia and Diabetes

OBJECTIVE: Glargine and detemir insulin are the two most commonly prescribed basal insulin analogues for the ambulatory and inpatient management of diabetes. The efficacy and safety of basal insulin analogues in the hospital setting has not been established. METHODS: This observational study compared differences in glycemic control and outcomes in non-intensive care unit patients with blood glucose (BG) >140 mg/dL who were treated with glargine or detemir, between January 1, 2012, and September 30, 2015, in two academic centers. RESULTS: Among 6,245 medical and surgical patients with hyperglycemia, 5,749 received one or more doses of glargine, and 496 patients received detemir during the hospital stay. There were no differences in the mean daily BG (glargine, 182 ± 46 mg/dL vs. detemir, 180 ± 44 mg/dL; P = .70). There were no differences in mortality, hospital complications, or re-admissions between groups (all, P>.05). After adjusting for potential confounders, there was no statistically significant difference in hypoglycemia rates between treatment groups. Patients treated with detemir required higher total daily basal insulin doses (0.27 ± 0.16 units/kg/day vs. 0.22 ± 0.15 units/kg/day; P<.001). Glargine-treated patients had statistically longer length of stay; however, this difference may not be clinically relevant (6.8 ± 7.4 days vs. 6.0 ± 6.3 days; P<.001). CONCLUSION: Our study indicates that treatment with glargine and detemir results in similar inpatient glycemic control in general medicine and surgery patients. Detemir treatment was associated with higher daily basal insulin dose and number of injections. A prospective randomized study is needed to confirm these findings. ABBREVIATIONS: BG = blood glucose BMI = body mass index CI = confidence interval eGFR = estimated glomerular filtration rate HbA1c = glycated hemoglobin ICD-9 = International Classification of Diseases, ninth revision ICU = intensive care unit IQR = interquartile range LOS = length-of-stay OR = odd ratio

Efficacy and Safety of Intensive vs Non-Intensive Supplemental Insulin with a Basal Bolus Insulin Regimen in Hospitalized Patients with Type 2 Diabetes: A Randomized Clinical Study

&lt;p&gt;  &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt; Administration of supplemental sliding scale insulin (SSI) for correction of hyperglycemia in non-ICU patients with type 2 diabetes is frequently used with basal-bolus insulin regimens. This non-inferiority randomized controlled trial tested whether glycemic control is similar with and without aggressive SSI before meals and bedtime in patients treated with basal-bolus insulin regimens. &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Research Design and Methods: &lt;/strong&gt;Patients with type 2 diabetes, with admission blood glucose (BG)140-400 mg/dl treated with basal-bolus insulin were randomized to Intensive (correction for BG&gt;140 mg/dl, n=108) or to Non-Intensive (correction for BG&gt;260 mg/dl, n=107) administration of rapid-acting SSI before meals and bedtime. Both groups received the same amount of SSI for BG&gt;260 mg/dl. Primary outcome was difference in mean daily BG levels between the groups during hospitalization. &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mean daily BG in the Non-Intensive group was non-inferior to BG in the Intensive group with equivalence margin of 18 mg/dl (Intensive: 172±38 mg/dl vs Non-Intensive: 173±43 mg/dl, p=0.001 for non-inferiority). There were no differences in the proportion of target BG readings of 70-180 mg/dl, hypoglycemia (&lt;70 or &lt;54 mg/dl), severe hyperglycemia (&gt;350 mg/dl), or total, basal or prandial insulin doses. Significantly fewer subjects received SSI in the Non-Intensive (n=36,34%) compared to the Intensive group (n=98,91% [p&lt;0.0001]) with no differences in SSI doses between the groups within those that received SSI (Intensive: 7±4 vs. Non-Intensive: 8±4 U/day, p=0.34). &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Among non-ICU patients with type 2 diabetes on optimal basal-bolus insulin regimen with moderate hyperglycemia (BG&lt;260 mg/dl), a less intensive SSI did not significantly affect glycemic control.&lt;/p&gt;</jats:p

Efficacy and Safety of Intensive vs Non-Intensive Supplemental Insulin with a Basal Bolus Insulin Regimen in Hospitalized Patients with Type 2 Diabetes: A Randomized Clinical Study

&lt;p&gt;  &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt; Administration of supplemental sliding scale insulin (SSI) for correction of hyperglycemia in non-ICU patients with type 2 diabetes is frequently used with basal-bolus insulin regimens. This non-inferiority randomized controlled trial tested whether glycemic control is similar with and without aggressive SSI before meals and bedtime in patients treated with basal-bolus insulin regimens. &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Research Design and Methods: &lt;/strong&gt;Patients with type 2 diabetes, with admission blood glucose (BG)140-400 mg/dl treated with basal-bolus insulin were randomized to Intensive (correction for BG&gt;140 mg/dl, n=108) or to Non-Intensive (correction for BG&gt;260 mg/dl, n=107) administration of rapid-acting SSI before meals and bedtime. Both groups received the same amount of SSI for BG&gt;260 mg/dl. Primary outcome was difference in mean daily BG levels between the groups during hospitalization. &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mean daily BG in the Non-Intensive group was non-inferior to BG in the Intensive group with equivalence margin of 18 mg/dl (Intensive: 172±38 mg/dl vs Non-Intensive: 173±43 mg/dl, p=0.001 for non-inferiority). There were no differences in the proportion of target BG readings of 70-180 mg/dl, hypoglycemia (&lt;70 or &lt;54 mg/dl), severe hyperglycemia (&gt;350 mg/dl), or total, basal or prandial insulin doses. Significantly fewer subjects received SSI in the Non-Intensive (n=36,34%) compared to the Intensive group (n=98,91% [p&lt;0.0001]) with no differences in SSI doses between the groups within those that received SSI (Intensive: 7±4 vs. Non-Intensive: 8±4 U/day, p=0.34). &lt;/p&gt; &lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Among non-ICU patients with type 2 diabetes on optimal basal-bolus insulin regimen with moderate hyperglycemia (BG&lt;260 mg/dl), a less intensive SSI did not significantly affect glycemic control.&lt;/p&gt;</jats:p

792-P: Understanding Barriers to Diabetic Foot Care in an Urban Low-Income Hospital: A Focus Group Qualitative Assessment

Diabetes is a leading cause of lower limb loss in the United States that disproportionately affects minority groups of lower socioeconomic status. The reasons for these disparities are poorly characterized. We employed qualitative (focus group discussions, FGD) and quantitative (survey) methods among persons with diabetic foot disease. Participants were stratified into two groups: a diabetic foot ulcer (DFU) group and minor amputation (ankle or below) group. The FGDs addressed patient experience with a goal of understanding: (1) foot care knowledge, (2) barriers to care, and (3) preferred foot-related educational methods. 5 sessions were conducted with 6-12 people each. Participants were recruited from clinics at a safety-net hospital in Atlanta that provides care to an inner-city population with a high burden diabetic foot related complications. Forty participants (90% Black) were enrolled. Surveys revealed an adequate knowledge of proper diabetic foot care, with ≥70% of participants correctly answering questions relating to proper self-care. Several dominant themes emerged from the FGDs. Personal barriers to self-care included lack of motivation, difficulty accessing supplies due to cost and/or lack of insurance, and being unable to limit activity for proper offloading. Participants frequently reported systematic barriers, citing difficulty making timely appointments and reaching a provider to arrange care. Participants reported that foot-related knowledge and access to care improved with greater disease severity but that knowledge and interventions seemed to come too late in their disease course. They expressed interest in peer support groups to facilitate learning and sharing information about diabetic foot care. These findings indicate patients with DFU or minor amputations in our institution have adequate footcare-related knowledge, but barriers to care and lack of motivation limit appropriate foot care. Disclosure M. Fayfman: None. M. Schechter: None. C.N. Amobi: None. R.N. Williams: None. J.L. Hillman: None. R. Rajani: None. D.C. Ziemer: None. M.M. Alam: None. R. Kempker: None. G.E. Umpierrez: None. </jats:sec

A Randomized Controlled Trial Comparing Glargine U300 and Glargine U100 for the Inpatient Management of Medicine and Surgery Patients With Type 2 Diabetes: Glargine U300 Hospital Trial

OBJECTIVE The role of U300 glargine insulin for the inpatient management of type 2 diabetes (T2D) has not been determined. We compared the safety and efficacy of glargine U300 versus glargine U100 in noncritically ill patients with T2D. RESEARCH DESIGN AND METHODS This prospective, open-label, randomized clinical trial included 176 patients with poorly controlled T2D (admission blood glucose [BG] 228 ± 82 mg/dL and HbA1c 9.5 ± 2.2%), treated with oral agents or insulin before admission. Patients were treated with a basal-bolus regimen with glargine U300 (n = 92) or glargine U100 (n = 84) and glulisine before meals. We adjusted insulin daily to a target BG of 70–180 mg/dL. The primary end point was noninferiority in the mean difference in daily BG between groups. The major safety outcome was the occurrence of hypoglycemia. RESULTS There were no differences between glargine U300 and U100 in mean daily BG (186 ± 40 vs. 184 ± 46 mg/dL, P = 0.62), percentage of readings within target BG of 70–180 mg/dL (50 ± 27% vs. 55 ± 29%, P = 0.3), length of stay (median [IQR] 6.0 [4.0, 8.0] vs. 4.0 [3.0, 7.0] days, P = 0.06), hospital complications (6.5% vs. 11%, P = 0.42), or insulin total daily dose (0.43 ± 0.21 vs. 0.42 ± 0.20 units/kg/day, P = 0.74). There were no differences in the proportion of patients with BG &amp;lt;70 mg/dL (8.7% vs. 9.5%, P &amp;gt; 0.99), but glargine U300 resulted in significantly lower rates of clinically significant hypoglycemia (&amp;lt;54 mg/dL) compared with glargine U100 (0% vs. 6.0%, P = 0.023). CONCLUSIONS Hospital treatment with glargine U300 resulted in similar glycemic control compared with glargine U100 and may be associated with a lower incidence of clinically significant hypoglycemia. </jats:sec