Discharge Planning for People with Inpatient Hyperglycaemia: A Review on Pharmacological Management.

Inadequate glycaemic control post-discharge is the root cause of readmission in people with diabetes mellitus (DM) and is often linked to improper discharge planning (DP). A structured DP plays a crucial role in ensuring continuing home care and avoiding readmissions. DP should help patients in self-care and provide appropriate guidance to maintain optimal glycaemic control. There is a scarcity of reports and recommendations on the proper DP for people with DM on insulin therapy. The present review provides important consideration based on experts' opinions from the National Insulin and Incretin summit (NIIS), focusing on the effective treatment strategies at the time of discharge, especially for insulin therapy. A review of literature from PubMed and Embase was conducted. The consensus was derived, and recommendations were made on effective DP for patients with DM. Recommendations arrived at the NIIS for post-discharge treatment for medical and surgical cases, stress-induced hyperglycaemia, elderly, pregnant women, and coronavirus disease 2019 (COVID-19) cases. The committee also recommended a comprehensive checklist to assist the physicians during discharge.

Antidiabetic Treatment before Hospitalization and Admission Parameters in Patients with Type 2 Diabetes, Obesity, and SARS-CoV-2 Viral Infection.

BACKGROUND: SARS-CoV-2 viral infection is a current and important topic for patients with comorbidities of type 2 diabetes and obesity, associated with increased risk of mortality and morbidity. This study aims to analyze, compare and describe admission parameters in patients with type 2 diabetes, obesity, and SARS-CoV-2 infection based on whether they received insulin therapy before hospital admission. METHODS: Our study enrolled patients diagnosed with type 2 diabetes, obesity, and SARS-CoV-2 viral infection, 81 patients without insulin treatment before hospital admission, and 81 patients with insulin at "Gavril Curteanu" Municipal Clinical Hospital of Oradea, Romania, between August 2020 and March 2022. RT-PCR/rapid antigen tests were used for detecting SARS-CoV-2 viral infection. RESULTS: The severe form of COVID-19 was found in 66% of all patients (65% in the group without insulin and 67% in the group with insulin). Oxygen saturation at the time of hospital admission was greater or equal to 90% in 62% of all patients. The most associated comorbidities we founded in this study were: hypertension in 75% of all patients (grade two hypertension 63% in the group without insulin and 64% in the group with insulin), ischemic heart disease in 35% of patients (25% in the group without insulin and 44% in the group with insulin, n = 0.008), heart failure in 9.3% of all patients (8.6% in the group without insulin and 10% in the group with insulin). CRP and procalcitonin are increased in both groups at hospital admission, with a slightly higher trend in the group with insulin therapy before hospital admission. We found that 56% of patients in the group with insulin treatment were with uncontrolled diabetes on admission. Only 10% of patients required a change in antidiabetic treatment with insulin therapy at discharge. In our study, 89% of all patients did not require short-term home oxygen therapy at discharge. CONCLUSIONS: Antidiabetic therapy taken before hospital admission did not protect patients against cytokine storm in COVID-19, but is very important in the pathophysiological stage of comorbidities. Paraclinical parameters at hospitalization showed differences in correlation with oral antidiabetic treatment like metformin or insulin therapy. Changing the antidiabetic treatment for a small percentage of patients in the group who had not been receiving insulin therapy before discharge was necessary. It is necessary for future studies to see all changes involved in antidiabetic treatment in patients with diabetes type 2 and obesity after SARS-CoV2 viral infection and its long-term evolution.

A UK nationwide study of adults admitted to hospital with diabetic ketoacidosis or hyperosmolar hyperglycaemic state and COVID-19.

AIMS: To investigate characteristics of people hospitalized with coronavirus-disease-2019 (COVID-19) and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycaemic state (HHS), and to identify risk factors for mortality and intensive care admission. MATERIALS AND METHODS: Retrospective cohort study with anonymized data from the Association of British Clinical Diabetologists nationwide audit of hospital admissions with COVID-19 and diabetes, from start of pandemic to November 2021. The primary outcome was inpatient mortality. DKA and HHS were adjudicated against national criteria. Age-adjusted odds ratios were calculated using logistic regression. RESULTS: In total, 85 confirmed DKA cases, and 20 HHS, occurred among 4073 people (211 type 1 diabetes, 3748 type 2 diabetes, 114 unknown type) hospitalized with COVID-19. Mean (SD) age was 60 (18.2) years in DKA and 74 (11.8) years in HHS (p < .001). A higher proportion of patients with HHS than with DKA were of non-White ethnicity (71.4% vs 39.0% p = .038). Mortality in DKA was 36.8% (n = 57) and 3.8% (n = 26) in type 2 and type 1 diabetes respectively. Among people with type 2 diabetes and DKA, mortality was lower in insulin users compared with non-users [21.4% vs. 52.2%; age-adjusted odds ratio 0.13 (95% CI 0.03-0.60)]. Crude mortality was lower in DKA than HHS (25.9% vs. 65.0%, p = .001) and in statin users versus non-users (36.4% vs. 100%; p = .035) but these were not statistically significant after age adjustment. CONCLUSIONS: Hospitalization with COVID-19 and adjudicated DKA is four times more common than HHS but both associate with substantial mortality. There is a strong association of previous insulin therapy with survival in type 2 diabetes-associated DKA.

Effect of Insulin Injection Techniques on Glycemic Control Among Patients with Diabetes.

Objective: Previous studies have shown that healthcare professionals rarely instruct patients about proper insulin injection techniques. This study aimed to assess the practices of insulin injection techniques among patients with diabetes treated and assess the effect of these practices on glycemic control. Patients and Methods: This cross-sectional study was conducted between November 2020 and February 2021. A random systematic sampling technique was used to recruit study subjects at specialist outpatient clinics. Subjects with type 1 or 2 diabetes mellitus who had been using insulin injections for at least a year were included in this study. Results: A total of 298 subjects with type 1 diabetes and 553 with type 2 diabetes participated in this study. The mean age of patients with type 1 diabetes was 20.1 ± 10.4 years. The mean age of patients with type 2 diabetes was 58.6 ± 9.5 years. The median type 1 diabetes duration was 6.0 years, and median type 2 diabetes duration was 15.0 years. About 66.8% of patients with type 1 diabetes and 69.4% of patients with type 2 diabetes were rotating insulin injection sites. Almost 36.6% of patients with type 1 diabetes and 50.5% of patients with type 2 diabetes reported using the same insulin needle more than three times. The prevalence of lipohypertrophy was 57.0% among patients with type 1 diabetes and 55.5% among patients with type 2 diabetes. The absence of lipohypertrophy, rotation of insulin injection site, and total daily insulin dose ≤50 units were all independently significantly associated with better glycemic control. Conclusion: Insulin injection techniques were suboptimal among significant proportion of patients with diabetes in Jordan. Improper insulin injection technique, especially the rotation of injection sites and lipohypertrophy formation, was associated with uncontrolled blood glucose levels. Educational interventions that focus on insulin injection techniques among Jordanian patients with diabetes are strongly recommended.

Type 1 diabetes incidence in children and adolescents during the COVID-19 pandemic in Germany.

AIMS/HYPOTHESIS: The aim of this study was to analyze the incidence of type 1 diabetes in children and adolescents (<20 years of age) during the COVID-19 pandemic (3/2020 to 12/2021) in Germany. METHODS: The present study was based on the IQVIA longitudinal prescription database (LRx), All persons (age ≤ 20 years) with new insulin prescriptions from 2016 to 2021 (index date) were selected and stratified by age group. Weekly (age-specific) data were used to forecast the prescription incidence for the pandemic period based on pre-pandemic data and to explore the relationship between weekly reported age-specific COVID-19 incidences and type 1 diabetes incidence and rate ratios of observed vs. predicted diabetes incidence respectively. RESULTS: During the pre-pandemic period, there was a stable higher insulin prescription incidence during the winter period and a lower insulin prescription incidence during summer. During the pandemic period, there was less seasonal variation in incidence related to the finding that the observed incidence during summer in 2002 and 2021 was 44 % and 65 %, higher, respectively, than the expected incidence based on pre-pandemic year. We did not find any cross-correlations between the COVID-19 incidence and the type 1 diabetes incidence for any age group. Likewise, there were no cross-correlations between the COVID-19 incidence and the incidence rate ratios of observed incidences to predicted incidences. CONCLUSIONS/INTERPRETATION: During the COVID-19 pandemic, there was less seasonal variation in the incidence of type 1 diabetes (defined by new insulin prescriptions), with higher observed than expected incidences during summer. We found no evidence that the increase in type 1 diabetes incidence during the COVID-19 pandemic relates to direct effects of COVID-19 pandemic.

Association between hyperglycemia treatment and mortality in patients with diabetes and COVID-19 in a Peruvian hospital: A retrospective cohort study.

OBJECTIVE: To evaluate the association between hyperglycemia treatment and mortality in patients with diabetes and COVID-19 in a Peruvian hospital. METHODS: A retrospective cohort study was conducted between March and July 2020. Individual-level data were extracted from an implemented virtual platform. We included patients with type 2 diabetes hospitalized with COVID-19. The assessed outcome was in-hospital mortality. The Independent variable of interest was hyperglycemic treatment. We used Poisson regressions with robust variance to obtain crude and adjusted relative risks (RR) and their 95% confidence intervals (95% CI). RESULTS: Out of 1635 patients hospitalized for COVID-19 during the study period, 248 patients with diabetes mellitus were included. The majority were men (66.9%), the median age was 62 years. Ninety-seven patients died in the hospital (39.1%). The median glycemia on admission was 222.5 mg/dL. At 48 h after hospital admission, 125 patients (50.4%) received sliding scale insulin alone (SSI), 46 (18.5%) received a fixed-dose insulin regimen. In the adjusted analysis, the group with SSI at 48 h of hospitalization had higher mortality than those with fixed-dose insulin (adjusted RR: 1.69; 95% CI: 1.01 - 2.83), and those and who continued with SSI in the following days had higher mortality compared to the group that switched to fixed-dose insulin (adjusted RR: 1.64; 95% CI: 1.17 - 2.32). CONCLUSION: Among assessed patients with diabetes and COVID-19, more than a third died during hospitalization. Early and continuous use of the sliding scale was associated with higher mortality compared to fixed-dose insulin regimens.

Insulin therapy for the non-specialist physician.

Insulin is required for all people living with type 1 diabetes, and may be required in nearly half of those with type 2 diabetes. It is a complex drug, manufactured in several forms and utilised in various regimens and devices. There is evidence that non-specialist professionals lack confidence in insulin therapy and, in addition, insulin-related prescribing errors are common in hospital care. In this article, I summarise commonly used insulin regimens, along with indications and safety considerations when prescribing insulin therapy.

Characteristics, Management, and Outcomes of Elderly Patients with Diabetes in a Covid-19 Unit: Lessons Learned from a Pilot Study.

Background and objectives: Diabetes may affect in-hospital mortality of patients with Coronavirus disease 2019 (COVID-19). We have retrospectively evaluated clinical characteristics, diabetes management, and outcomes in a sample of COVID-19 patients with diabetes admitted to our hospital. Materials and Methods: All patients admitted to the Infectious Diseases Unit from 28 March 2020, to 16 June 2020, were enrolled. Clinical information and biochemical parameters were collected at the time of admission. Patients were ranked according to diabetes and death. Results: Sixty-one patients with COVID-19 were analyzed. Most of them were from a long-term health care facility. Mean age was 77 ± 16 years, and 19 had type 2 diabetes (T2D). Eighteen patients died, including 8 with T2D and 10 without T2D (p = 0.15). Patients with diabetes were significantly older, had a higher prevalence of cardiovascular diseases, and a significantly lower lymphocyte count. No significant relationship was found between diabetes and in-hospital mortality (Odds Ratio OR 2.3; Confidence Interval CI 0.73-7.38, p = 0.15). Patients with diabetes were treated with insulin titration algorithm. Severe hypoglycemic events, ketoacidosis and hyperosmolar hyperglycemias did not occur during hospitalization. Mean pre-meal capillary blood glucose was 157 ± 45 mg/dL, and the coefficient of variation of glycaemia was 29%. Conclusions: Our study, albeit limited by the small number of subjects, did not describe any significant association between T2D diabetes and mortality. Clinical characteristics of patients, and acceptable glucose control prior and during hospitalization may have influenced the result. The use of an insulin titration algorithm should be pursued during hospitalization.

Impact of COVID-19 lockdown on glucose control of elderly people with type 2 diabetes in Italy.

AIMS: to evaluate the effect of home confinement related to COVID-19 lockdown on metabolic control in subjects with T2DM in Italy. METHODS: we evaluated the metabolic profile of 304 individuals with T2DM (65% males; age 69 ± 9 years; diabetes duration 16 ± 10 years) attending our Diabetes Unit early at the end of lockdown period (June 8 to July 7, 2020) and compared it with the latest one recorded before lockdown. RESULTS: There was no significant difference in fasting plasma glucose (8.6 ± 2.1 vs 8.8 ± 2.5 mmol/L; P = 0.353) and HbA1c (7.1 ± 0.9 vs 7.1 ± 0.9%; P = 0.600) before and after lockdown. Worsening of glycaemic control (i.e., ΔHbA1c ≥ 0.5%) occurred more frequently in older patients (32.2% in > 80 years vs 21.3% in 61-80 years vs 9.3% in < 60 years; P = 0.05) and in insulin users (28.8 vs 16.5%; P = 0.012). On multivariable analysis, age > 80 years (OR 4.62; 95%CI: 1.22-16.07) and insulin therapy (OR 1.96; 95%CI: 1.10-3.50) remained independently associated to worsening in glycaemic control. CONCLUSIONS: Home confinement related to COVID-19 lockdown did not exert a negative effect on glycaemic control in patients with T2DM. However, age and insulin therapy can identify patients at greatest risk of deterioration of glycaemic control.

Management of Diabetes During a Dual Pandemic.

The dual pandemics of coronavirus disease-19 (COVID-19) and diabetes among patients are associated with 2- to 3-times higher intensive care admissions and higher mortality rates. Whether sheltering at home, quarantined with a positive COVID-19 test, or hospitalized, the person living with diabetes needs special considerations for successful management. Having diabetes and being COVID-19-positive increases the risk of poor outcomes and death. Providers need to give anticipatory pharmacologic guidance to patients with diabetes during COVID-19 lockdown. Patients with diabetes need to be more observant than others and to use self-protective actions. This review (1) discusses the clinical observations of COVID-19, diabetes and underlying mechanisms, (2) describes special considerations in caring for patients with diabetes in a COVID-19 environment, and (3) reviews clinical implications for the health care provider. This review highlights current evidenced-based knowledge. Additional research regarding clinical management is warranted.

Blood glucose levels should be considered as a new vital sign indicative of prognosis during hospitalization.

BACKGROUND AND AIMS: The measurement of vital signs is an important part of clinical work up. Presently, measurement of blood glucose is a factor for concern mostly when treating individuals with diabetes. Significance of blood glucose measurement in prognosis of non-diabetic and hospitalized patients is not clear. METHODS: A systematic search of literature published in the Electronic databases, PubMed and Google Scholar was performed using following keywords; blood glucose, hospital admissions, critical illness, hospitalizations, cardiovascular disease (CVD), morbidity, and mortality. This literature search was largely restricted to non-diabetic individuals. RESULTS: Blood glucose level, even when in high normal range, or in slightly high range, is an important determinant of morbidity and mortality, especially in hospitalized patients. Further, even slight elevation of blood glucose may increase mortality in patients with COVID-19. Finally, blood glucose variability and hypoglycemia in critically ill individuals without diabetes causes excess in-hospital complications and mortality. CONCLUSION: In view of these data, we emphasize the significance of blood glucose measurement in all patients admitted to the hospital regardless of presence of diabetes. We propose that blood glucose be included as the "fifth vital sign" for any hospitalized patient.

Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: A systematic review of literature.

BACKGROUND AND AIM: To conduct a systematic literature review and analyze the demographic/biochemical parameters and clinical outcomes of COVID-19 patients with diabetic ketoacidosis (DKA) and combined DKA/HHS (hyperglycemic hyperosmolar syndrome). METHODS: PubMed, Scopus, Embase, and Google Scholar databases were systematically searched till August 3, 2020 to identify studies reporting COVID-19 patients with DKA and combined DKA/HHS. A total of 19 articles reporting 110 patients met the eligibility criteria. RESULTS: Of the 110 patients, 91 (83%) patients had isolated DKA while 19 (17%) had DKA/HHS. The majority of the patients were male (63%) and belonged to black ethnicity (36%). The median age at presentation ranged from 45.5 to 59.0 years. Most of the patients (77%) had pre-existing type 2 diabetes mellitus. Only 10% of the patients had newly diagnosed diabetes mellitus. The median blood glucose at presentation ranged from 486.0 to 568.5 mg/dl, being higher in patients with DKA/HHS compared to isolated DKA. The volume of fluid replaced in the first 24 h was higher in patients with DKA/HHS in contrast to patients with DKA alone. The in-hospital mortality rate was 45%, with higher mortality in the DKA/HHS group than in the isolated DKA group (67% vs. 29%). pH was lower in patients who had died compared to those who were discharged. CONCLUSION: DKA in COVID-19 patients portends a poor prognosis with a mortality rate approaching 50%. Differentiating isolated DKA from combined DKA/HHS is essential as the latter represents nearly one-fifth of the DKA cases and tends to have higher mortality than DKA alone.

Inpatient Hyperglycemia Management and COVID-19.

Diabetes is one of the most common comorbidities in hospitalized patients with coronavirus disease 2019 (COVID-19). Inpatient hyperglycemia during this pandemic has been associated with worse outcomes, so it is mandatory to implement effective glycemic control treatment approaches for inpatients with COVID-19. The shortage of personal protective equipment, the need to prevent staff exposure, or the fact that many of the healthcare professionals might be relatively unfamiliar with the management of hyperglycemia may lead to worse glycemic control and, consequently, a worse prognosis. In order to reduce these barriers, we intend to adapt established recommendations to manage hyperglycemia during this pandemic in critical and noncritical care settings.

Interactions between antihyperglycemic drugs and the renin-angiotensin system: Putative roles in COVID-19. A mini-review.

BACKGROUND: Diabetes mellitus is associated with a more severe course of coronavirus disease 2019 (COVID-19). The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) utilizes angiotensin-converting enzyme II (ACE2) receptor for host cell entry. We aimed to assess the interactions between antihyperglycemic drugs and the renin-angiotensin system (RAS) and their putative roles in COVID-19. METHODS: A literature search was performed using Pubmed to review the interrelationships between hyperglycemia, RAS and COVID-19, and the effects of antihyperglycemic medications. RESULTS: The RAS has an essential role in glucose homeostasis and may have a role in COVID-19-induced lung injury. Some antihyperglycemic medications modulate RAS and might hypothetically alleviate the deleterious effect of angiotensin II on lung injury. Furthermore, most antihyperglycemic medications showed anti-inflammatory effects in animal models of lung injury. CONCLUSIONS: Some antihyperglycemic medications might have protective effects against COVID-19-induced lung injury. Early insulin therapy seems very promising in alleviating lung injury.