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1.
Closed-loop management of inpatient hyperglycaemia.
Boughton, CK, Hovorka, R
British journal of hospital medicine (London, England : 2005). 2019;(11):665-669
Abstract
The prevalence of diabetes in the inpatient setting is increasing, and suboptimal glucose control in hospital is associated with increased morbidity and mortality. Attaining the recommended glucose levels is challenging with standard insulin therapy. Hypoglycaemia and hyperglycaemia are common and diabetes management in hospital can be a considerable workload burden for health-care professionals. Fully automated insulin delivery (closed-loop) has been shown to be safe, and achieves superior glucose control than standard insulin therapy in the hospital, including in those patients receiving haemodialysis and enteral or parenteral nutrition where glucose control can be particularly challenging. Evidence that the improved glucose control achieved using closed-loop systems can translate into improved clinical outcomes for patients is key to support widespread adoption of this technology. The closed-loop approach has the potential to provide a paradigm shift in the management of inpatient diabetes, particularly in the most challenging inpatient populations, and may reduce staff work burden and the health-care costs associated with inpatient diabetes.
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Symptomatic Hyperglycemia in a Patient with Dialysis Ascites.
Vigil, D, Kien, C, Gibb, J, Glew, RH, Tzamaloukas, AH
The American journal of the medical sciences. 2019;(6):512-516
Abstract
An anuric woman with ascites rapidly developed extreme hyperglycemia and seizures after hemodialysis. During development of hyperglycemia, the decrease in serum sodium concentration (Δ[Na]) was nearly twice the value predicted by a formula accounting for the degree of hyperglycemia and the intracellular-to-extracellular volume ratio. The prediction assumed that ascitic fluid is part of the extracellular volume. Potential contributors to the development of seizures include the rapid development of severe hypertonicity, a remote history of seizure disorder and development of dialysis disequilibrium syndrome. Observations in peritoneal dialysis suggest that fluid with sodium concentration lower than in the ascitic fluid is transferred from the abdominal cavity into the blood during rapid development of hyperglycemia. In this case, Δ[Na], which determines the tonicity level expected after correction of hyperglycemia, resulted from exit of both intracellular and ascitic fluid into the extracellular compartment and, therefore, ascitic fluid functions as an extension of the intracellular fluid.
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Vitamin C for Type 2 Diabetes Mellitus and Hypertension.
Das, UN
Archives of medical research. 2019;(2):11-14
Abstract
It is suggested that supplementation of vitamin C reduces hyperglycemia and lowers blood pressure in hypertensives by enhacing the formation of prostaglandin E1 (PGE1), PGI2 (prostacyclin), endothelial nitric oxide (eNO), and restore essential fatty acid (EFA) metabolism to normal and enhance the formation of lipoxin A4 (LXA4), a potent anti-inflammatory, vasodilator and antioxidant. These actions are in addition to the ability of vitamin C to function as an antioxidant. In vitro and in vivo studies revealed that PGE1, PGI2 and NO have cytoprotective and genoprotective actions and thus, protect pancreatic β and vascular endotheilial cells from the cytotoxic actions of endogenous and exogenous toxins. AA, the precursor of LXA4 and LXA4 have potent anti-diabetic actions and their plasma tissue concentrations are decreased in those with diabetes mellitus and hypertension. Thus, vitamin C by augmenting the formation of PGE1, PGI2, eNO, LXA4 and restoring AA content to normal may function as a cytoprotective, anti-mutagenic, vasodilator and platelet anti-agregator actions that explains its benefical action in type 2 diabetes mellitus and hypertension.
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Nutritional strategies in managing postmeal glucose for type 2 diabetes: A narrative review.
Ch'ng, LZ, Barakatun-Nisak, MY, Wan Zukiman, WZH, Abas, F, Wahab, NA
Diabetes & metabolic syndrome. 2019;(4):2339-2345
Abstract
Medical Nutrition Therapy (MNT) plays an essential role in overall glycemic management. Less focus is given on managing postmeal hyperglycemia despite the facts that, it is a common feature of Type 2 Diabetes (T2D). The purpose of this narrative review is to provide a comprehensive understanding of the existing literature on the nutritional approaches to improve postmeal hyperglycemia in patients with T2D. We searched multiple databases for the studies examining the nutritional approaches to manage postmeal glucose in patients with T2D. We included studies that involve human trials that were published in English for the past 10 years. Our review of the current literature indicates that the postmeal hyperglycemia can be improved with four nutritional approaches. These approaches include (i) utilizing the appropriate amount and selecting the right type of carbohydrates, (ii) using specific types of dietary protein, (iii) manipulating the meal timing and orders and (iv) others (promoting postmeal physical activity, incorporating diabetes-specific formula and certain functional foods). The potential mechanisms underlying these approaches are discussed and the identified gaps warranted further research. This array of nutritional strategies provide a set of options for healthcare professionals to facilitate patients with T2D in achieving the optimal level of postmeal glucose.
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Efficacy and safety of sodium-glucose cotransporter-2 inhibitors versus dipeptidyl peptidase-4 inhibitors as monotherapy or add-on to metformin in patients with type 2 diabetes mellitus: A systematic review and meta-analysis.
Wang, Z, Sun, J, Han, R, Fan, D, Dong, X, Luan, Z, Xiang, R, Zhao, M, Yang, J
Diabetes, obesity & metabolism. 2018;(1):113-120
Abstract
AIMS: To compare the efficacy and safety of dipeptidyl peptidase-4 inhibitors (DPP-4is) and sodium-glucose cotransporter-2 inhibitors (SGLT-2is) as monotherapy or add-on to metformin (Met) in patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS PubMed, Embase and ClinicalTrials.gov sites were systematically searched for randomized controlled trials to assess the efficacy and safety of DPP-4is and SGLT-2is in patients with T2DM. Risk ratio (RR) and weighted mean difference (WMD) were used to evaluate outcomes. RESULTS In the analysis of 25 randomized trials, which involved 14 619 patients, SGLT-2is were associated with a significantly stronger reduction in haemoglobin A1c (HbA1c) (WMD 0.13%, 95% credible interval [CI], 0.04%-0.22%, P = .005) and fasting plasma glucose (FPG) (WMD 0.80 mmol/L, 95% CI, 0.58-1.01 mmol/L, P < .00001) than were DPP-4is. However, no significant difference between the 2 drug categories was found in the risk of hypoglycaemic events (RR, 0.99; 95% CI, 0.78-1.26, P = .92). SGLT-2is plus Met was associated with a more significant decrease in FPG (WMD 0.71 mmol/L, 95% CI, 0.43-1.00 mmol/L, P < .00001) than was DPP-4is plus Met. However, no differences were found in the reduction of HbA1c (WMD 0.11%, 95% CI, -0.03%-0.25%, P = .12) or the risk of hypoglycaemic events (RR, 1.02; 95% CI, 0.80-1.31, P = .86). CONCLUSIONS This review revealed that, compared to DPP-4is, SGLT-2is significantly reduced HbA1c, FPG and body weight without increasing the risk of hypoglycaemia in diabetes treatment.
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Critical Care Management of Stress-Induced Hyperglycemia.
Vanhorebeek, I, Gunst, J, Van den Berghe, G
Current diabetes reports. 2018;(4):17
Abstract
PURPOSE OF REVIEW We discuss key studies that have set the scene for the debate on the efficacy and safety of tight glycemic control in critically ill patients, highlighting important differences among them, and describe the ensuing search towards strategies for safer glucose control. RECENT FINDINGS Differences in level of glycemic control, glucose measurement and insulin administration, expertise, and nutritional management may explain the divergent outcomes of the landmark studies on tight glycemic control in critical illness. Regarding strategies towards safer glucose control, several computerized algorithms have shown promise, but lack validation in adequately powered outcome studies. Real-time continuous glucose monitoring and closed loop blood glucose control systems are not up to the task yet due to technical challenges, though recent advances are promising. Alternatives for insulin have only been investigated in small feasibility studies. Severe hyperglycemia in critically ill patients generally is not tolerated anymore, but the optimal blood glucose target may depend on the specific patient and logistic context.
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The challenges of achieving postprandial glucose control using closed-loop systems in patients with type 1 diabetes.
Gingras, V, Taleb, N, Roy-Fleming, A, Legault, L, Rabasa-Lhoret, R
Diabetes, obesity & metabolism. 2018;(2):245-256
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Abstract
For patients with type 1 diabetes, closed-loop delivery systems (CLS) combining an insulin pump, a glucose sensor and a dosing algorithm allowing a dynamic hormonal infusion have been shown to improve glucose control when compared with conventional therapy. Yet, reducing glucose excursion and simplification of prandial insulin doses remain a challenge. The objective of this literature review is to examine current meal-time strategies in the context of automated delivery systems in adults and children with type 1 diabetes. Current challenges and considerations for post-meal glucose control will also be discussed. Despite promising results with meal detection, the fully automated CLS has yet failed to provide comparable glucose control to CLS with carbohydrate-matched bolus in the post-meal period. The latter strategy has been efficient in controlling post-meal glucose using different algorithms and in various settings, but at the cost of a meal carbohydrate counting burden for patients. Further improvements in meal detection algorithms or simplified meal-priming boluses may represent interesting avenues. The greatest challenges remain in regards to the pharmacokinetic and dynamic profiles of available rapid insulins as well as sensor accuracy and lag-time. New and upcoming faster acting insulins could provide important benefits. Multi-hormone CLS (eg, dual-hormone combining insulin with glucagon or pramlintide) and adjunctive therapy (eg, GLP-1 and SGLT2 inhibitors) also represent promising options. Meal glucose control with the artificial pancreas remains an important challenge for which the optimal strategy is still to be determined.
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8.
Addressing Clinical Inertia in Type 2 Diabetes Mellitus: A Review.
Okemah, J, Peng, J, Quiñones, M
Advances in therapy. 2018;(11):1735-1745
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Abstract
The current epidemic of type 2 diabetes (T2D) represents a significant global and national health concern. Globally, the prevalence of diabetes has doubled between 1980 and 2014. In 2014 the World Health Organization estimated that there were 422 million adults living with diabetes worldwide. In the USA, the number of people diagnosed with T2D is estimated to increase to over 70 million by 2050, putting an immense strain on the US healthcare system. Achieving glycemic control is widely acknowledged as the key goal of treatment in T2D and is critical for reducing the onset and progression of diabetes-related complications such as cardiovascular diseases, neuropathies, retinopathies, and nephropathies. Despite the increase in the availability of antihyperglycemic medications and evidence-based treatment guidelines, the proportion of people with T2D who fail to achieve glycemic goals continues to rise. One major contributor is a delay in treatment intensification despite suboptimal glycemic control, referred to as clinical or therapeutic inertia. Clinical inertia prolongs the duration of patients' hyperglycemia which subsequently puts them at increased risk of diabetes-associated complications and reduced life expectancy. Clinical inertia results from a complex interaction between patient, healthcare providers, and healthcare system barriers that need to be addressed together, rather than as separate entities. In this article we provide an overview of clinical inertia in the clinical management of T2D and provide suggestions for overcoming aspects that may have a negative impact on patient care.Funding: Sanofi US, Inc.
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Hemichorea after hyperglycemia correction: A case report and a short review of hyperglycemia-related hemichorea at the euglycemic state.
Cho, HS, Hong, CT, Chan, L
Medicine. 2018;(10):e0076
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Abstract
RATIONALE Hyperglycemic hemichorea tends to affect elderly patients with type 2 diabetes, women, and the Asian population. The onset of involuntary movement typically occurs at the hyperglycemic state and subsides at the euglycemic state. In this report, we present an unusual case that developed delayed-onset hemichorea after hyperglycemia correction. PATIENT CONCERNS A 70-year-old man was admitted to neurology ward with symptoms of subacute dizziness. Hyperglycemia and high level ketone body was incidentally noted. Hemichorea occurred in his left limbs 2 days after hyperglycemia correction. DIAGNOSES Patient remained conscious, and no other focal neurological deficits were noted while hemichorea occurred. Blood test revealed no contributory cause. Brain magnetic resonance imaging revealed no lesions in the putamen or subthalamus. A diagnosis of probable hyperglycemia-related hemichorea was made. INTERVENTIONS Haloperidol (2 mg, 3 times per day) was prescribed. OUTCOMES Hemichorea improved gradually before discharge and resolved 4 months later. LESSONS Differential diagnosis of hemichorea should include delayed-onset hemichorea after hyperglycemia correction.
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Hyperglycemia in pregnancy among South Asian women: A single tertiary care center experience from Colombo, Sri Lanka.
Jayawardane, A, Patabendige, M, Samaranayake, D, Boteju, M, Dahanayake, S, Perera, R, Jayasinghe, S, Galappatti, D, Wijeyaratne, CN
Diabetes research and clinical practice. 2018;:138-145
Abstract
AIM: To study case mix, risk factors, adverse outcomes and associations of hyperglycemia in pregnancy in a cohort of Sri Lankans. METHODS Prospective observational study, from April 2011-October 2015 at a tertiary care referral center, Colombo, Sri Lanka. Data from first trimester to delivery of HIP was analyzed. Three subgroups were defined: Diabetes in pregnancy (DIP), Hyperglycemia in early Pregnancy (HIEP) [<24 weeks] and Gestational diabetes (GDM) [>24 weeks]. RESULTS Of 782 patients 572 (73.1%) had complete data. Case-mix: 137(24.0%) DIP, 331(57.9%) GDM and 104 (18.2%) HIEP. Primigravidae commoner in GDM (<0.05). DIP older - mean 33.3 ± 5.5 years (<0.01). Previous GDM commoner and pharmacological interventions needed in DIP and HIEP. Majority GDM (66.8%) required Medical Nutrition Therapy (MNT) alone. There was no difference in pregnancy outcomes between the 3 subgroups. Macrosomia significantly greater in HIEP (33.7%); neonatal cardiac defects more in DIP and HIEP. CONCLUSIONS Increasing maternal age is a significant risk for DIP, while previous GDM is a risk for DIP and HIEP and neonatal congenital cardiac defects in subsequent pregnancies of South Asian women. We recommend preconception screening for glucose intolerance and achieving normoglycaemia among South Asian women with advanced maternal age and previous GDM.