Mary T. Korytkowski

Diabetes in Older Adults

More than 25% of the U.S. population aged ≥65 years has diabetes (1), and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization (2). Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets—for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged ≥65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions: 1. What is the epidemiology and pathogenesis of diabetes in older adults? 2. What is the evidence for preventing and treating diabetes and its common comorbidities in older adults? 3. What current guidelines exist for treating diabetes in older adults? 4. What issues need to be considered in individualizing treatment recommendations for older adults? 5. What are consensus recommendations for treating older adults with or at risk for diabetes? 6. How can gaps in the evidence best be filled? According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged ≥65 years varies from 22 to 33%, depending on the diagnostic criteria …

Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline

OBJECTIVE The aim was to formulate practice guidelines on the management of hyperglycemia in hospitalized patients in the non-critical care setting. PARTICIPANTS The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, six additional experts, and a methodologist. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society members, American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine reviewed and commented on preliminary drafts of this guideline. CONCLUSIONS Hyperglycemia is a common, serious, and costly health care problem in hospitalized patients. Observational and randomized controlled studies indicate that improvement in glycemic control results in lower rates of hospital complications in general medicine and surgery patients. Implementing a standardized sc insulin order set promoting the use of scheduled basal and nutritional insulin therapy is a key intervention in the inpatient management of diabetes. We provide recommendations for practical, achievable, and safe glycemic targets and describe protocols, procedures, and system improvements required to facilitate the achievement of glycemic goals in patients with hyperglycemia and diabetes admitted in non-critical care settings.

American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.

This report is being published concurrently in 2009 in Endocrine Practice and Diabetes Care by the American Association of Clinical Endocrinologists and the American Diabetes Association. From the 1Department of Medicine, University of California Los Angeles, Los Angeles, California, 2Department of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, 3Division of Endocrinology and Metabolism, Veterans Affairs Pittsburgh Health Center and University of Pittsburgh School of Nursing PhD Program, Pittsburgh, Pennsylvania, 4Scripps Whittier Diabetes Institute, La Jolla, California, University of California San Diego School of Medicine, San Diego, California, and Diabetes and Endocrine Associates, La Jolla, California, 5Department of Medicine, University of Missouri-Kansas City School of Medicine and Hellman and Rosen Endocrine Associates, North Kansas City, Missouri, 6Department of Medicine, University of Washington School of Medicine, Seattle, Washington, 7Department of Medicine, Section of Endocrinology, Yale University School of Medicine and the Yale Diabetes Center, Yale-New Haven Hospital, New Haven, Connecticut, 8Department of Medicine, Physiology and Biophysics, Division of Clinical and Molecular Endocrinology, Case Western Reserve University, Cleveland, Ohio, 9Clinical Affairs, American Diabetes Association, Alexandria, Virginia, and 10Department of Medicine/Endocrinology, Emory University, Atlanta, Georgia. Address correspondence and reprint requests to Dr. Etie S. Moghissi, 4644 Lincoln Boulevard, Suite 409, Marina del Rey, CA 90292.

Diabetes in Older Adults: A Consensus Report

More than 25% of the U.S. population aged 65 years has diabetes mellitus (hereafter referred to as diabetes), 1 and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization. 2 Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets— for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged 65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions:

A multicenter, randomized, open-label, comparative, two-period crossover trial of preference, efficacy, and safety profiles of a prefilled, disposable pen and conventional vial/syringe for insulin injection in patients with type 1 or 2 diabetes mellitus

BACKGROUND The accuracy and convenience of pen devices for insulin injection have improved quality of life for patients with insulin-treated diabetes mellitus (DM). Prefilled, disposable pens have the advantage of simplicity, with minimal training and attention required and no installation of new cartridges necessary. OBJECTIVE The aim of this study was to assess patient preference, efficacy, and safety profiles of a prefilled, disposable pen (FlexPen) and conventional vial/syringe injection method for insulin injection therapy among patients with DM. METHODS In a multicenter, randomized, open-label, crossover study, patients with type 1 or 2 DM were transferred from previous QD or BID conventional insulin therapy to a mixture of 70% insulin aspart protamine suspension and 30% insulin aspart injection (NovoLog Mix 7030) for 4 weeks of dose optimization using their usual type of syringe. Patients were then randomly assigned to use either vial/syringe or a prefilled, disposable pen to inject the biphasic insulin aspart 7030 mixture for the next 4 weeks, followed by 4 weeks of use of the other injection device. Efficacy, safety profiles, and patient preference for the delivery systems were compared. RESULTS A total of 121 patients (mean [SD] age, 57.0 [12.4] years; age range, 28-81 years; mean [SD] body mass index, 31 [5.5] kg/m(2)) were enrolled. One hundred three patients completed the study. Seventy-four percent of patients (78105) indicated a preference for the pen over the vial/syringe method (95% CI, 71%-87%), compared with 20% (21105) who preferred the vial/syringe. Eighty-five percent (88104) considered the pen more discreet for use in public (compared with 9% [9104] for the vial/syringe), 74% (77104) considered it easier to use overall (compared with 21% [22104] for the vial/syringe), and 85% (89105) found the insulin dose scale on the pen easier to read (compared with 10% [10105] for the vial/syringe). Patients had statistically significant improvement in glycosylated hemoglobin values during the study (P < 0.05). No statistically significant differences in fasting plasma glucose, mean 4-point blood glucose profiles, or serum fructosamine values were found between groups. Overall, the safety profiles during treatment periods with the pen were comparable to those with the vial/syringe. CONCLUSIONS In this trial, differences in efficacy and safety profiles between the vial/syringe and prefilled, disposable pen appeared negligible. However, more patients expressed a preference to continue use of the pen.

Prevalence and predictors of corticosteroid-related hyperglycemia in hospitalized patients.

OBJECTIVE To investigate the prevalence of and risk factors for hyperglycemia in hospitalized patients receiving corticosteroids, which have been identified as an independent predictor of hyperglycemia. METHODS We conducted a retrospective review of electronic medical records of patients admitted to the general medicine service at a university hospital during a 1-month period. Pharmacy charges were used to identify patients receiving high doses (> or = 40 mg/day of prednisone or the equivalent) of corticosteroids for at least 2 days. Occurrence of hyperglycemia and the presence of risk factors, including history of diabetes, duration of corticosteroid therapy, concurrent parenteral nutrition, antibiotic therapy, use of medications associated with hyperglycemia, severity of illness scores, and hospital length of stay, were determined. Patients experiencing multiple episodes of hyperglycemia (glucose levels > or = 200 mg/dL) were compared with those who had < or = 1 hyperglycemic episode. Patients without a history of diabetes were assessed separately. RESULTS During the 1-month study period, 66 of 617 patients received high doses of corticosteroids, but only 50 of the 66 had glucose measurements. Hyperglycemia was documented in 32 of these 50 patients (64%), and multiple hyperglycemic episodes occurred in 26 (52%). A history of diabetes was documented in 12 of 26 patients who experienced multiple episodes, in comparison with 4 of 24 patients with < or = 1 episode of hyperglycemia (P = 0.035). Among patients without a history of diabetes, 19 of 34 (56%) had hyperglycemia at least once. Patients with multiple episodes of hyperglycemia had more comorbid diseases, longer duration of corticosteroid therapy, and longer duration of hospital stay. CONCLUSION Hyperglycemia occurs in a majority of hospitalized patients receiving high doses of corticosteroids. In light of the poor outcomes associated with hyperglycemia, protocols targeting its detection and management should be available for patients who receive corticosteroid therapy.

Insulin Therapy and Glycemic Control in Hospitalized Patients With Diabetes During Enteral Nutrition Therapy A randomized controlled clinical trial

OBJECTIVE To compare two subcutaneous insulin strategies for glycemic management of hyperglycemia in non–critically ill hospitalized patients with diabetes during enteral nutrition therapy (ENT). RESEARCH DESIGN AND METHODS Fifty inpatients were prospectively randomized to receive sliding-scale regular insulin (SSRI) alone (n = 25) or in combination with insulin glargine (n = 25). NPH insulin was added for persistent hyperglycemia in the SSRI group (glucose >10 mmol/l). RESULTS Glycemic control was similar in the SSRI and glargine groups (mean ± SD study glucose 8.9 ± 1.6 vs. 9.2 ± 1.6 mmol/l, respectively; P = 0.71). NPH insulin was added in 48% of the SSRI group subjects. There were no group differences in frequency of hypoglycemia (1.3 ± 4.1 vs. 1.1 ± 1.8%; P = 0.35), total adverse events, or length of stay. CONCLUSIONS Both insulin strategies (SSRI with the addition of NPH for persistent hyperglycemia and glargine) demonstrated similar efficacy and safety in non–critically ill hospitalized patients with type 2 diabetes during ENT.

Carotid artery intima-media thickness in polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND Polycystic ovary syndrome (PCOS) is a common reproductive endocrine disorder associated with cardiovascular disease (CVD) risk factors and metabolic disturbances. This systematic review and meta-analysis was conducted to determine whether carotid intima-media thickness (CIMT), a marker of subclinical atherosclerosis, is higher in women with PCOS compared with women without PCOS. METHODS Primary articles reporting the mean CIMT in women with PCOS and controls were identified using Ovid MEDLINE, EMBASE and PUBMED. We performed a random-effects meta-analysis and created forest plots of the mean difference in CIMT and conducted tests for heterogeneity and publication bias. Studies were grouped by quality, defined by reporting reproducibility of CIMT and averaging both common carotid arteries versus one side for CIMT. RESULTS From the 36 eligible full-text studies, 8 studies were included in the systematic review and 19 studies were included in the meta-analysis (total n= 1123 women with PCOS, n= 923 controls). The summary mean difference in CIMT among women with PCOS compared with controls was 0.072 mm [95% confidence interval (CI) 0.040, 0.105, P < 0.0001] for highest quality studies, 0.084 mm (95% CI 0.042, 0.126, P = 0.0001) for good quality studies, 0.041 (95% CI -0.038, 0.120, P = 0.310) for fair-quality studies and 0.045 (95% CI -0.020, 0.111, P = 0.173) for lower quality studies. CONCLUSIONS Larger studies with a well-defined PCOS population using rigorous methodology may be required to draw a more robust conclusion. However, these results suggest women with PCOS are at a greater risk of premature atherosclerosis, which emphasizes the importance of screening and monitoring CVD risk factors in women with PCOS.

Improvement of Insulin Sensitivity by Short-term Exercise Training in Hypertensive African American Women

African American women have a high prevalence of insulin resistance, non-insulin-dependent diabetes mellitus, obesity, and hypertension that may be linked to low levels of physical activity. We sought to determine whether 7 days of aerobic exercise improved glucose and insulin metabolism in 12 obese (body fat >35%), hypertensive (systolic blood pressure > or =140 and/or diastolic blood pressure > or =90 mmHg) African American women (mean age 51+/-8 years). Insulin-assisted frequently-sampled intravenous glucose tolerance tests were performed at baseline and 14 to 18 hours after the 7th exercise session. There was no significant change in maximal oxygen consumption, body composition, or body weight after the 7 days of aerobic exercise. The insulin sensitivity index increased (2.68+/-0.45 x 10[-5] to 4.23+/-0.10 x 10[-5] [min(-1)/pmol/L], P=.02). Fasting (73+/-9 to 50+/-9 pmol/L, P=.02) and glucose-stimulated (332+/-58 to 261+/-45 pmol/L, P=.05) plasma insulin levels decreased. Additional measures related to the insulin resistance syndrome also changed with the 7 days of exercise: basal plasma norepinephrine concentrations were reduced (2.46+/-0.27 to 1.81+/-0.27 nmol/L, P=.02) and sodium excretion rate increased from 100+/-13 to 137+/-7 mmol/d (P=.03); however, there was no change in potassium excretion or 24-hour ambulatory blood pressure. We conclude that a short-term aerobic exercise program improves insulin sensitivity in African American hypertensive women independent of changes in fitness levels, body composition, or body weight. The present study indicates that short-term exercise can improve insulin resistance in hypertensive, obese, sedentary African American women and confirms previous reports that a portion of the exercise-induced improvements in glucose and insulin metabolism may be the result of recent exercise.

EVOLUTION OF A DIABETES INPATIENT SAFETY COMMITTEE

OBJECTIVE To develop a multidisciplinary team, the Diabetes Inpatient Safety Committee (DPSC), to effectively address the many barriers to achieving glycemic control in the inpatient setting. METHODS The development, implementation, and successes of the DPSC are described. RESULTS By focusing on prevention of severe hypoglycemia, the DPSC identified and addressed areas related to inpatient management that contributed to uncontrolled glucose levels. The introduction of a hypoglycemia treatment protocol was followed by the development of a standardized order set for use of sliding scale insulin, with the eventual introduction of an Insulin Order Set guiding the use of scheduled and correctional insulin. Protocols and guidelines addressing more specific areas of inpatient glycemic management (insulin pump therapy, perioperative management, diabetic ketoacidosis, intravenous insulin) also have been developed. CONCLUSION The successes of the DPSC to date have been directly related to strong institutional support, the dedication of a multidisciplinary team to address specific areas of glycemic management, the programmed introduction of order sets in conjunction with structured educational programs that accompany each protocol, and the use of quality improvement measures to evaluate the safety and efficacy of these protocols. Effective committees such as this will be instrumental in preventing errors and maximizing euglycemia.