Rationale for a titratable fixed-ratio co-formulation of a basal insulin analog and a glucagon-like peptide 1 receptor agonist in patients with type 2 diabetes.

OBJECTIVE: Achieving and maintaining recommended glycemic targets, including those for glycated hemoglobin A1c (A1C), is key to improving outcomes in patients with type 2 diabetes (T2D). As fasting plasma glucose and postprandial glucose contribute to overall A1C, targeting both is essential for sustaining glycemic control. METHODS: This review examines the complementary mechanisms of action of glucagon-like peptide 1 (GLP-1) receptor agonists and basal insulin; they both enhance glucose-stimulated insulin release and suppress glucagon secretion. GLP-1 receptor agonists also slow gastric emptying and increase satiety. RESULTS: Adding a GLP-1 receptor agonist to therapy with a basal insulin analog has been associated with improved overall glycemic control, with comparable risk of hypoglycemia and no weight gain. Titratable fixed-ratio co-formulations of basal insulin and a GLP-1 receptor agonist have been shown to improve glycemic control, with less complex dosing schedules, possibly increasing treatment adherence. The slow titration of fixed-ratio co-formulations has been shown to reduce the occurrence and severity of gastrointestinal adverse events associated with the use of a separate GLP-1 receptor agonist. Titratable fixed-ratio co-formulations also mitigate insulin-associated weight gain, and show a comparable risk of hypoglycemia to basal insulin use alone. CONCLUSIONS: The efficacy and safety of titratable fixed-ratio co-formulations have been demonstrated for insulin degludec/liraglutide and insulin glargine/lixisenatide in the DUAL and LixiLan trials, respectively, in both insulin-naive and -experienced patients. Titratable fixed-ratio co-formulations represent an attractive treatment option for many patients with T2D.

Identifying risk factors for severe hypoglycemia in hospitalized patients with diabetes.

OBJECTIVE: Some of the deleterious effects of hypoglycemia in hospitalized patients include increased rates of mortality and longer length of stay. Our primary objective was to identify the risk factors associated with severe hypoglycemia to identify those patients at highest risk. METHODS: The medical records of 5,026 patients with diabetes mellitus (DM) admitted in 2010 were reviewed to identify those patients that developed severe hypoglycemia (blood glucose [BG] <40 mg/dL). We performed χ2 tests to assess statistical significance. Adjusted logical regression was used to determine the risk factors for hypoglycemia in the hospital. RESULTS: Out of 5,026 DM patients included in our review, 81 experienced severe hypoglycemia (1.6%). Statistically higher proportions of chronic kidney disease (CKD; 69.1% vs. 46.9%, P<.001), congestive heart failure (CHF; 48.1% vs. 28.5%, P<.001), sepsis (49.4% vs. 12.5%, P<.001), insulin use (45.7% vs. 26.04%, P = .000), type 1 DM (21% vs. 5.1%, P = .000), and cirrhosis (14.8% vs. 7.2%, P = .009) were seen in the severe hypoglycemic group compared to the nonsevere hypoglycemic group. Overall, 84% of patients who experienced an episode of severe hypoglycemia in the hospital (BG <40 mg/dL) had a previous episode of hypoglycemia (BG <70 mg/dL). The odds ratios (ORs) for type 1 DM, sepsis, previous hypoglycemia, and insulin use were 3.43 (95% confidence interval [CI] 1.81, 6.49), 2.64 (95% CI 1.6, 4.35), 46.1 (95% CI 24.76, 85.74), and 1.66 (95% CI 1.02, 2.69), respectively. CONCLUSION: Prior episodes of hypoglycemia in the hospital, the presence of type 1 DM, insulin use, and sepsis were identified as independent risk factors for the development of severe hypoglycemia in the hospital.

An inpatient hypoglycemia committee: development, successful implementation, and impact on patient safety.

BACKGROUND: Hypoglycemia is a major and preventable cause of morbidity and mortality in the hospital setting. Prevention of hypoglycemia in hospitalized patients relates to the practice climates and prescribing patterns of physicians, the development of safe and effective protocols, and the education of providers and nursing staff on hypoglycemia and its consequences. METHODS: Many hospitals use multidisciplinary committees to address issues of healthcare quality and patient safety. This article describes the creation of a subspecialty Hypoglycemia Committee, its design and function, and the steps taken to reduce hypoglycemia in a large, tertiary acute care hospital. RESULTS: The committee's initiatives included a systematic investigation of all severe hypoglycemic events, the development of a standalone hypoglycemia treatment protocol, reduction of sliding scale insulin therapy, revision of insulin order sets, and education of physicians and house staff. Hypoglycemic events have consequently decreased. CONCLUSION: The Hypoglycemia Committee is unique in that every case of severe hypoglycemia is reviewed by physicians, endocrinologists, and diabetes specialists. This multidisciplinary approach can effect measurable decreases in preventable hypoglycemic events.