A Wasteful and Harmful Practice: Sliding Scale Insulin Use Among Nursing Home Veterans

The American Medical Directors Association and the American Diabetes Association discourage the use of sliding scale insulin (SSI) in nursing home residents with diabetes due to its association with hypoglycemia, hyperglycemia, nursing burden, and patient discomfort. However, prevalence of SSI use is unclear. We used Veterans Affairs (VA) data from October 2013 to September 2016 to determine the weekly prevalence of SSI among 22,847 veterans with diabetes admitted to VA nursing homes (NHs). Average age was 75.3 (SD 8.3) years, mean A1c was 7.3% (SD 1.6%) and 57% were admitted from hospital. We first identified residents receiving any short-acting insulin. We then classified short-acting insulin use into three mutually exclusive regimens: (1) fixed scheduled doses, (2) SSI, defined as a variable dose of short-acting insulin without a concurrent fixed dose or (3) bolus with correction (BWC), defined as a variable dose given concurrently with a fixed dose that day. During the first week of NH admission, 64.7% of residents with diabetes received no short-acting insulin, 7.4% received fixed scheduled doses, 6.3% received BWC and 21.4% were on SSI. At week 12, the prevalence of fixed dose and BWC regimens was unchanged from baseline (fixed dose = 8.4%; BWC = 7.0%). In contrast, the prevalence of SSI decreased weekly to 15.8% (p for linear trend < 0.0001). Although SSI prevalence decreased from week 1 to week 12, 51% of residents on short-acting insulin were still using SSI in their 12th week of their NH stay.

Insulin glucose infusion versus nebulised salbutamol versus combination of salbutamol and insulin glucose in acute hyperkalaemia in the emergency room: protocol for a randomised, multicentre, controlled study (INSAKA)

IntroductionHyperkalaemia is a common electrolyte disorder and can be life-threatening. In the emergency room (ER), interventions aim to protect patients from the immediate dangers of elevated serum potassium by redistributing potassium ions from the bloodstream into the cells via intravenous insulin or nebulised beta2-agonists. However, to date, evidence for acute management of hyperkalaemia is limited. The aim of this randomised controlled trial is therefore to compare three strategies, namely insulin/glucose intravenous infusion, nebulised salbutamol or a combination of nebulised salbutamol and insulin/glucose intravenous infusion to reduce serum potassium concentration at 60 min as a first-line treatment in patients admitted to the ER with serum potassium concentrations superior or equal to 6 mmol/L.Methods and analysisINSAKA is a prospective, multicentre, controlled, open-label, parallel-group, randomised in a 1:1:1 ratio clinical trial. Patients will be eligible for randomisation if they have serum potassium concentrations superior or equal to 6 mmol/L measured in the ER. Patients will receive either: (1) 10 mg of nebulised salbutamol, (2) 10 units of short-acting insulin in an intravenous bolus with 500 mL of 10% glucose or (3) 10 units of short-acting insulin in an intravenous bolus with 500 mL of 10% glucose combined with 10 mg of nebulised salbutamol. The primary endpoint will be the mean change in the absolute serum potassium level from baseline to 60 min measured in mmol/L. We plan to include 525 patients.Ethics and disseminationThe INSAKA trial will be conducted in accordance with the International Council on Harmonization Good Clinical Practices. All trial documents and procedures have been reviewed and approved by the Ethics Committee Sud Méditerranée III (approval ID number: 19.07.16.36428). The results will be actively disseminated through peer-reviewed journals, conference presentations, social media, broadcast media, print media and the internet.Trial registrationEudraCT number: 2019-002710-39, Clinicaltrials.gov identifier: NCT04012138.

Effectiveness and safety of flexible therapeutic schemes including first- and secondgeneration basal insulins during a pediatric summer diabetes camp

Outcomes of insulin analogues in pediatric diabetes camps are poorly investigated; no data is available about insulin degludec (IDeg).Our aim was to assess impact of insulin therapy adopted by the participants to a 4-day diabetes camp held in 2017, hypothesizing a possible excess risk of hypoglycemia in patients treated with IDeg. Overall, 40 children with type 1 diabetes (mean age 13.4±3.0 years; 62.5% males) attended the camp (20.0% on continuous subcutaneous insulin infusion and 80.0% on multiple daily injections - MDI). Among children in MDI regimen, 71.9% were treated with IDeg as basal insulin and 28.1% with glargine U100 (IGlar). All patients used Lispro or Aspart as short-acting insulin. Daily plan of the camp included educational sessions, physical exercise, 3 main meals and 2 snacks. At the arrival, IGlar and short-acting insulin doses were revised according to existing guidelines, while IDeg dose was revised based on an empirical individualized approach. At the arrival, insulin doses were reduced in 22 participants (-19.4±10.5%), while doses were increased in 17 children (+17.8±12.7%), based on individual needs. No statistically significant between-group difference emerged in mean blood glucose and glucose variability. No excess risk of hypoglycemia was found in the IDeg group. The study suggests similar effectiveness and safety of different insulin schemes when associated with appropriate diabetes education and management, and flexible dose adjustments. Despite its longer halflife and the lack of a validated algorithm, IDeg was not associated with an excess risk of hypoglycemia.

SUN-697 Importance of Immunosuppressive Therapy for Managing Insulin Resistance Type B

Background: Autoimmune Antibodies against insulin receptors leading to refractory hyperglycemia is known as Type B insulin resistance. In addition to insulin management, immunosuppressive therapy appears to be an essential part for successful management. Clinical Case: A 20 year old African American woman with no significant past medical history presented to the Emergency Department with worsening nausea and vomiting for 5 days and shortness of breath. She admitted to polyuria, unintentional weight loss of 15 pounds in the last six months, decreased appetite, and hyper-pigmented rashes mostly on her back. The patient was not on any medications at home. No known drug allergies, no past surgical history. Family history was significant for Grandmother with Type 2 Diabetes Mellitus and Lupus on father’s side of family. The patient denied use of alcohol, tobacco, illicit and IV drug use. T: 37.2 °C, HR: 124, RR: 25, BP: 105/74, SpO2: 100%. Weight 45kg. Physical exam significant for Tachycardia but normal rhythm. Initial work up revealed new onset diabetes HbA1c 9.6% and massive pericardial effusion on echocardiogram s/p pericardiocentesis. Due to developing complaints of intermittent cyanosis of fingertips and intermittent joint pain of fingers, Rheumatology work up was ordered and positive for mixed connective tissue disease. Patient was treated with Cellcept 1500 mg BID, Plaquenil Sulfate 300 mg daily, and prednisone 12.5 mg BID. Hospital course was complicated due to hyperglycemia in 300s-400mg/dL requiring high amounts of insulin. Diabetes work up was negative for GAd-65 and islet cell antibodies. C-peptide was elevated at 16.1 ng/mL (0.8-3.1 ng/mL) and anti-Insulin an antibodies was 20uU/mL. Patient was euthyroid. Hyperglycemia persisted despite increasing doses of long and short acting insulin subcutaneously. The patient eventually required Insulin intravenously at 50 units/hour plus 50 units of short acting Insulin every 4 hours subcutaneously. The patient was transferred to a facility to begin Combined Immunosuppressive Therapy plus insulin to manage hyperglycemia due to insulin resistance. After six months of rituximab, high-dose pulsed steroids, cyclophosphamide, plus insulin therapy, glycemic index improved with HbA1c reduced to 5.6%. Conclusion: Combined Immunosuppressive Therapy in addition to insulin management of refractory hyperglycemia due to type B insulin resistance has been shown to not only be effective in controlling refractory hyperglycemia but preventing against recurrences as well. Reference: 1) Klubo-Gwiezdzinska J, Lange M, Cochran E, Semple RK, Gewert C, Brown RJ, Gorden P. Combined Immunosuppressive Therapy Induces Remission in Patients With Severe Type B Insulin Resistance: A Prospective Cohort Study. Diabetes Care. 2018 Nov;41(11):2353-2360.

MON-646 Novel Use of GLP-1 Receptor Agonist Therapy in MODY-1 (HNF4A Mutation)

Monogenic Diabetes (MODY) results from mutations or changes in a single gene, and currently account for about 1 to 4% of all cases of diabetes (1). Our group has previously published on the successful use of glucagon-like peptide-1 receptor agonist (GLP-1 RA) therapy in three consecutive generations of a family with an HNF1A mutation (MODY-3) (2). Although GLP-1 RA therapy has been studied in patients with HNF1A mutations (MODY-3) (3), it has not been studied in patients with HNF4A mutations (MODY-1). In this father-son cohort, we demonstrate successful use of GLP-1 RA therapy in two patients with c.790:1 bp deletion of G; codon:264 mutations of HNF4A. The son first presented with neonatal hypoglycemia, then later developed diabetes and presented to our clinic at age 20, when genetic testing was performed and confirmatory for an HNF4A mutation. He was prescribed glimepiride and titrated to 4 mg twice daily, and two years later, his hemoglobin A1c (HbA1c) rose to 8.7%. He was switched to semaglutide 0.25 mg once weekly and was titrated to a maximum dose of 1 mg weekly over 8 weeks. The patient reports improvement in his post-prandial blood glucose values at this time, but HbA1c has not yet been repeated. The father had been diagnosed with monogenic diabetes in his early 20s and had been on sulfonylurea therapy until age 40, at which time he was transitioned to a regimen of long- and short-acting insulin therapy. Thereafter, he presented to our clinic in July, 2018 with a HbA1c of 9.6% and was transitioned to long-acting insulin once daily and liraglutide 0.6 mg once daily which was subsequently titrated to 1.8 mg once daily over 3 weeks. The patient tolerated this well and has been off short acting insulin since December 2018, with notable improvement in his HbA1c to 5.9% and marked improvement in his post-prandial glycemic control. To our knowledge this is the first report demonstrating the benefits of GLP-1 RA therapy in patients with the HNF4A mutations (MODY-1). Based on this report, it appears that GLP-1 RA therapy could be an effective therapy in patients with MODY-1. 1). Pihoker C, Gilliam LK, Ellard S, et al. Prevalence, characteristics and clinical diagnosis of maturity onset diabetes of the young due to mutations in HNF1A, HNF4A, and glucokinase: results from the SEARCH for Diabetes in Youth. The Journal of Clinical Endocrinology and Metabolism. 2013;98(10):4055–4062. 2). Maricor Docena, Charles Faiman, Christine Stanley, and Kevin Pantalone (2014) Mody-3: Novel HNF1A Mutation and the Utility of Glucagon-Like Peptide (GLP)-1 Receptor Agonist Therapy. Endocrine Practice: February 2014, Vol. 20, No. 2, pp. 107–111. 3). Ostoft SH, Bagger JI, Hansen T, et al. Glucose-lowering effects and low risk of hypoglycemia in patients with maturity-onset diabetes of the young when treated with a GLP-1 receptor agonist: a double-blind, randomized, crossover trial. Diabetes Care. 2014;37(7):1797–17805.

MON-LB122 Psychiatric Medication Induced Diabetes Mellitus

Psychiatric medications are well established cause of diabetes. Our case had similar presentation. 67-year-old African-American male with history of hypertension and dementia was brought to the ER for auditory hallucination and bizarre behavior. His home medications were Hydrochlorothiazide, Nifedipine and Spironolactone. Psychiatry was consulted and he was admitted to psychiatric floor. He was diagnosed for first time with psychosis and depression. He was treated with citalopram 20 mg for depression; donepezil 10 mg for dementia and risperidone 0.5 mg twice a day for psychosis. 2 weeks later he developed difficulty swallowing and weakness, blood glucose level of 1263 mg/dl. All of his psychiatric medications were stopped except for citalopram 10 mg daily and patient was transferred to ICU. In the ICU, pH was 7.28 (normal 7.34-7.45), normal anion gap, bicarbonate 29mmol/L (normal 20-24), plasma osmolality 428 mOsm/kg (normal 280-320), HbA1c 10% (normal 4-5.6). He was intubated and managed as Hyperosmolar Hyperglycemic Non-Ketotic coma (HONK). He was started on insulin drip and later transitioned to Lantus and short-acting insulin. He improved and was then extubated. After 40 days, repeat A1C was 7.4%. The patient moved to another state and follow-up was lost. Discussion While the patient was on thiazide for a long time, he had a fairly good glucose control; his A1C ranged from normal to prediabetic (A1c 5.7%-6.4%). This makes thiazide unlikely cause of diabetes mellitus for him. The fact that right after 21 days of starting psych medications caused him to land in ICU for HONK, with A1c of 10% and glucose of 1273 mg/dl, strongly suggests that this is a case of psych medications induced T2DM. This is also supported by the fact that discontinuation of those medications lowered the A1c to 7.4% in 40 days. 3 weeks before the hospitalization his A1c was 5.1%. Metformin is demonstrated to be most promising long term medication in cases like this. Conclusion Psychiatric medications are important cause of drug induced diabetes and should always be thought as a cause of acute new onset diabetes. Stopping the offending drugs ensues good glycemic control.