Glycemic Control Metrics using Flash Glucose Monitoring in People with Type 2 Diabetes: Three Year Trends in Real Life Clinical Setting

Objective: Flash Continuous Glucose Monitoring (flash CGM) has been rapidly accepted in real life clinical setting. Methods: We conducted a cross sectional study across two centres, delivering the similar standard of care, over three years (n=362), in patients who utilised FreeStyle Libre Pro CGM to understand glycemic metrics and variability. The key glycemic metrics;TIR, Time Below Range (TBR), Time Above Range (TAR), estimated HbA1c, average glucose was analysed. Descriptive statistics, Pearson r and ANOVA were utilised for analysis. Results: Overall, in total 24.8% (90/362) were in TIR >70%, with 14.7% (18/122) patients in 2018, 17.6% (30/170) in 2019 and 60% (42/70) in 2020. In total 37% (134/362) were in TAR < 25%, 29.5% (36/122) in 2018, 28.2% (48/170) in 2019 and 71.4% (50/70) in 2020. In total 45.3% (164/362) were in TBR < 4%, 44.2% (54/122) in 2018, 46.4% (79/170) in 2019 and 44.2% (31/70) in 2020. Overall, 9.3% (34/362) achieved all three metrices (TIR >70%, TAR < 25%, TBR < 4%), with 4.9% (6/122) in 2018, 7.6% (13/170) in 2019, 24.2 (17/70) in 2020. There was a significant negative correlation between the eHbA1c and TIR (Pearson r – 0.74, 95% CI -0.79 to -0.69, p < 0.0001). There was significant improvement in TIR and TAR over three years. The eHbA1c (6.5%) and average glucose (139.7mg/dl) were lowest in the year 2020, which were comparable with values in previous years. Lesser hypoglycaemic events were noticed in CGM. (figure). [Formula presented] Discussion/Conclusion: There was a significant change in the glycemic metrics. We attribute the remarkable improvement, over three years, to the better awareness in the patients to manage diabetes, greater adoption of guideline directed, contemporary therapeutics including SGLT2 inhibitors, advanced insulins. This coincided with the COVID-19 induced fear of mortality and lockdown led better metabolic health, that resulted in better self-care of diabetes.

Relationship of the Continuity of Care and Glycemic Control in Outpatients with Type 2 Diabetes Mellitus- A Five Year Longitudinal Analysis

Objective: Continuity of care has demonstrated positive outcomes from the advanced countries with insurance care model. There is limited evidence for the benefits from developing countries, in limited resource setting where the patients directly pay from the pocket for the diabetes care. Methods: We retrospectively analysed the relationship between the continuity of care and the glycemic control in patients who atleast had a biannual visit to our comprehensive care centre from 2016 to 2020 (n=1160). Results: The mean number of visits in the year 2016, 2017, 2018, 2019 and 2020 were 3.6 (±1.6, max 11, 95% CI 3.38 to 3.98), 5 (±2.5, max 16, 95% CI 4.5 to 5.5), 4.8 (±2.1, max 12, 95% CI 4.4 to 5.2), 4.7 (±2.2, max 14, 95% CI 4.3 to 5.1), 3.4 (±1.6, max 12, 95% CI 3 to 3.7) (p< 0.0001), respectively. The mean number of visits cumulatively for the continuous five years for each patient was 22 (±7.9, min 11, max 56, 95% CI 20 to 23). The mean number of HbA1c readings done cumulatively for the continuous five years for each patient was 22 (±3.8, min 1, max 17, 95% CI 3.3 to 4.4). The mean interval (days) between the two consecutive visits was 85 (±26, min 33, max 155, 95% CI 81 to 90). The mean number of HbA1c tests were 3.8 (±2.8, min 1, max 17, 95% CI 3.3 to 4.4). The mean number of visits were 4.3 (±1.6, min 2.2, max 11, 95% CI 4 to 4.6). There was a non-significant positive correlation between the mean number of visits and the mean HbA1c readings (Pearson r 0.113, p= 0.22). The baseline value of HbA1c (%) was 8.0 (±1.5, min 5.3, max 13.3, 95% CI 7.7 to 8.3), which reduced by 0.7 when compared for the minimum value of HbA1c achieved at any point of time as mean 7.2 (±7.2, min 4.8, max 10.9, 95% CI 7 to 7.5), (p< 0.0001). There were 360 patients who had atleast one visit in 3 months and achieved HbA1c < 7, as compared to 250 patients with more than 3 months interval for consecutive visits and with HbA1c ≥ 7 (p=0.0404, OR 1.2 95% CI 1.01 to 1.62). COVID-19 induced lockdown led to the decrease in the patient visits in the year 2020. There were 55 all cause hospitalizations. Discussion/Conclusion: The results of our study demonstrate that comprehensive diabetes care have a potential positive implication, even in out-of-pocket ecosystem, which can drive the demand for a continuous follow up visits. We attribute long continuity of care for the smaller number of hospitalizations.

Premix Analog Insulin regimen is a Pragmatic approach in patients with T2DM with Mild to Moderate COVID-19 managed through Teleconsultations

Objective: Uncontrolled hyperglycaemia is associated with poor clinical outcomes in patients with COVID-19. Basal-bolus (BB) insulin regimen is recommended for intensification and is safe and effective. However, this is complex in COVID era, especially for initiation with challenges in deployment of healthcare personnel with gaps in required expertise. Hence, implementation of an effective insulin therapy is challenging. Methods: We evaluated the impact of initiating premix analog insulin regimen (PA) in T2D patients diagnosed with COVID-19 during the second wave of the pandemic (n=434), who consulted virtually. Insulin initiation was based on random blood sugar (RBS) as reported through SMBG by the patients who were already under regular care, across two dedicated diabetes management centres. Patients were advised to contact over Whatsapp in case self-reported RBS was above 300 mg/dL Results: The mean age of the patients was 59 years (SD±13, 95% CI 58 to 60). 256 were male. 48 patients (11%) were started with basal insulin (43 glargine, 5 degludec) and were optimally managed by dose uptitration. There were 92 patients (21.1%) who were initiated on PA twice daily to achieve glycemic control. Of these, 56 patients (12.9%) were diagnosed as moderate COVID-19 and required corticosteroids. Among these, 42 patients (75%), on PA regimen reported post lunch and dinner glycemic spikes which necessitated additional pre-lunch dose of premix analogue. 36 patients with mild COVID-19, were continued on PA twice daily and doses were uptitrated based on the SMBG reports. The rest 378 (87%) mild COVID-19 cases, were managed by standard care approach for diabetes care, including oral drugs. The mean RBS at the first consultation at insulin initiation was 211 mg/dL (SD±98, 95% CI 192 to 230). On first follow up teleconsultation;mean RBS in mild COVID-19 was 178 mg/dL (SD±50, 95% CI 138 to 195), while those who progressed to moderate COVID-19, RBS was 267 mg/dL (SD±101, 95% CI 210 to 298). On second follow up;mean RBS in mild COVID-19 was 168 mg/dL (SD±54, 95% CI 148 to 183) and in moderate COVID-19 was 203 mg/dL (SD±88, 95% CI 174 to 258). 138 patients (31.7%) needed uptitration of insulin regimen Discussion/Conclusion: Simplified insulin regimen based on premix analog insulin has the potential for timely initiation of insulin, titration and intensification to third dose of PA to optimise the management of T2D in COVID-19. Our study did not account for the compliance to beyond the second teleconsultation and the pandemic prevented the estimation of A1C and did not account for patients who transformed as severe COVID-19 patients who needed hospitalisation

Platypnea-orthodeoxia syndrome (POS) in moderate COVID-19: An uncommonly common bedside sign?

Platypnoea-Orthodeoxia syndrome (POS) is the presence of postural hypoxaemia along with breathlessness in recumbent position. It is an uncommon syndrome with elusive pathophysiologic mechanisms. We observed POS in patients of moderate COVID-19 who required hospital admission to our indoor facility and oxygen supplementation when saturation was documented in sitting and supine positions for evaluation of platypnea. Materials and methods: We conducted an observational, cross sectional, retrospective analysis of pulse oximetry readings of patients with stage 2 COVID-19 admitted in ward during the period from 15th May 2020 to 30th May 2020. The difference in the peripheral oxygen saturation in sitting and supine positions, documented as a routine standard of care, especially in patients with platypnea, was calculated and demographic details and co-morbidities were noted from indoor record forms. Results: Of the 53 patients of stage 2 COVID-19 who were included in the study, 15 (28%) had platypnoea-orthodeoxia syndrome at the time of presentation and 18(33.9%) patients with platypnoea had ≥ 3% desaturation in sitting position as compared to supine position. Rest of the 20 (37.7%) patients had neither platypnoea nor orthodeoxia. All the patients presenting with platypnoea-orthodeoxia required oxygen therapy during the course of treatment. Amongst the 33 patients who were hypoxic and required oxygen supplementation, 15 patients (45.4%) had oxygen saturation of ≥94% in the supine position at presentation. Conclusion: Platypnoea-orthodeoxia syndrome is common in patients with stage 2 COVID 19 infection who require oxygen therapy. POS can be easily documented by using pulse oximeter without the need of any specialised equipment. Hence, we propose that documentation of POS at the time of admission in primary health care or resource depleted settings would help in successful triage of the patients needing oxygen therapy. We also propose that oxygen saturation in sitting position be documented as far as possible. Further clinical studies are necessary to validate this observation. © 2021 Journal of Association of Physicians of India. All rights reserved.

COVID-19 reinfection: A case series

Coronovirus Disease 2019 (COVID-19) manifests with a varied spectrum of symptoms ranging from asymptomatic disease to Acute Respiratory Distress Syndrome (ARDS) and death. Contrary to the expectation of the herd immunity in controlling the pandemic, reinfection with COVID-19 poses a new threat in the control of the pandemic. Authors hereby have described three cases who developed COVID-19 infection for the second time after complete recovery from the first infection. All three patients were less than 50 years of age with no co-morbidities. First case developed the second infection three weeks after having recovered from the first infection whereas second and third case developed repeat infection after two and four months of recovery respectively. The severity of the repeat infection along with the duration between the two infections has been discussed in this article.