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Hyperglycemia/Hypoglycemia and Glycemic Variability in the Hospital

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Hyperglycemia/Hypoglycemia and Glycemic Variability in the Hospital 8/4/2017 Hyperglycemia/Hypoglycemia and COI: F. Pasquel Glycemic Variability in the Hospital External Industry Company Name(s) Role Relationships * ___________________________ Equity, stock, or options BMJ Open Diabetes & Social Media Editor in biomedical industry Care companies or publishers Roma Gianchandani, MD Francisco J. Pasquel, MD, MPH Industry Merck Consultant activities Associate Professor of Medicine Assistant Professor of Medicine Advisory/Consultant Boehringer Ingelhein University of Michigan Emory University SOM activities AADE 2017 Hyperglycemia/Hypoglycemia Hyperglycemia and Glycemic Variability Hyperglycemia Hypoglycemia Hyperglycemia Hypoglycemia Outcomes Outcomes Glycemic Glycemic variability variability How does glycemic variability contribute to DCCT: Absolute Risk of Sustained complications? Retinopathy Progression by Mean A1c ___________________________ Peripheral & Autonomic ___________________________ Glucose Neuropathy 10 8 Rate of Hexosamine progression of AGE Formation Pathway retinopathy (per 6 Cellular 100 Oxidative Dysfunction ROS patient-years) 4 Stress ROS Vascular Nephropathy Damage 2 Cell Damage Retinopathy 0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 A1c (%) Different complications (eye, kidney, nerve, blood vessels) arise from limited Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993;329:977-986. number of triggers perturbing a limited number of metabolic pathways) Brownlee M Nature 2001;414:813-20) 1 8/4/2017 Inhospital Hyperglycemia Hospital Mortality by BG Levels during TPN ___________________________ ___________________________ Hyperglycemia is an independent risk factor for clinical outcomes Overall in-hospital mortality was 27.2% in critically-ill patients 50 Higher glucose values, in patients with and without diabetes, is 45 associated with greater risk for mortality and hospital 40 complications 35 30 Hyperglycemia and Mortality in the MICU rate (%) 25 45 40 20 35 Mortality 15 30 Mortality 25 10 Rate 20 (%) 15 5 10 0 5 0 <=120 121-150 151-180 >180 80-99 100-119 120-139120 -139 140 -159 160160-179 -179 180-199 200200-249 -249 250 -299 > 300 Max PreTPN BG N = 1826 ICU patients x 4 yrs Mean Glucose Value (mg/dL) Max BG within 24 hrs of TPN Max BG during Days2-10 of TPN 1. Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002; 2. Krinsley JS. Mayo Clin Proc. 2003;78:1471–1478; 3. van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367 Pasquel et al. Diabetes Care 2010 Hypoglycemia Hyperglycemia Hypoglycemia Outcomes Glycemic variability Hypoglycemia in T2DM Factors that may increase risk of hypoglycemia during therapy • The primary cause of hypoglycemia in T2DM is diabetes medication—sulfonylureas and insulin. • Behavioral factors • The risk of hypoglycemia is increased in older patients, • missed or irregular meals, exercise those with longer diabetes duration, lesser insulin reserve • Impaired drug clearance and with strict glycemic control. • renal impairment, hepatic failure, hypothyroidism • Hypoglycemia has substantial clinical impact, in terms of • Impaired counterregulatory capacity mortality, morbidity and quality of life. • Addison’s, growth hormone deficiency, hypopituitarism • The cost implications of severe episodes—high direct • Decreased endogenous glucose production hospital costs and indirect costs. • liver failure, alcohol • Hypoglycemia and fear of hypoglycemia limit the ability to • Concurrent medications achieve and maintain optimal glycemic control. • Decreased renal excretion of SUs - aspirin, allopurinol • Newer therapies, may carry a lower risk of hypoglycemia. • Displacement of SUs from albumin - aspirin, warfarin, trimethoprim Dixon et al. Diabetic Med 25:245-254, 2008 2 8/4/2017 Risk of Hypoglycemia Associated with Effect of intensive glucose lowering treatment Medications in T2DM on hypoglycemic events Medication Route Risk of Hypoglycemia % 0.3 (1) Metformin Oral Similar to placebo Sulfonylureas Oral 18% to 30% per year Glinides Oral < 5-10% < 3% TZDs Oral Similar to placebo < 3% -glucosidase inhibitors Oral Similar to placebo < 3 - 5% DPP-IV Inhibitors Oral Similar to placebo Compared with the standard treatment group, the risk of severe hypoglycemia was more than twice as high in the intensive treatment group (2.33, 1.62 to 3.36). Colesevelam Oral Similar to placebo Absolute five year risk increases in severe hypoglycemia ranged from 1.9% to 6.6%, Bromocriptine mesylate Oral 0.2-0.4 making the number of patients needed to harm between 52 and 15. Dixon et al. Diabetic Med 25:245-254, 2008 Boussageon et al. BMJ 343, 2011 Intensive Insulin Therapy and Hypoglycemic Events in Critically Ill Patients No. Events/Total No. Patients Hypoglycemic Events Study IIT Control Risk ratio (95% CI) Favors IIT Favors Control Van den Berghe et al 39/765 6/783 6.65 (2.83-15.62) Henderson et al 7/32 1/35 7.66 (1.00-58.86) Bland et al 1/5 1/5 1.00 (0.08-11.93) Van den Berghe et al 111/595 19/605 5.94 (3.70-9.54) Mitchell et al 5/35 0/35 11.00 (0.63-191.69) Azevedo et al 27/168 6/169 4.53 (1.92-10.68) De La Rosa et al 21/254 2/250 10.33 (2.45-43.61) Devos et al 54/550 15/551 3.61(2.06-6.31) Oksanen et al 7/39 1/51 9.15 (1.17-71.35) Brunkhorst et al 42/247 12/290 4.11(2.2-7.63) Iapichino et al 8/45 3/45 2.67 (0.76-9.41) Arabi et al 76/266 8/257 9.18 (4.52-18.63) Mackenzie et al 50/121 9/119 5.46 (2.82-10.60) NICE-SUGAR 206/3016 15/3014 13.72 (8.15-23.12) Overall 654/6138 98/6209 5.99 (4.47-8.03) 0.1 1 10 Reproduced with permission from Griesdale DE, et al. CMAJ. 2009;180(8):821-827. Risk Ratio (95% CI) Asymptomatic Hypoglycemia in Non-ICU Patients with Diabetes Neurological symptoms n (%) - Confusion /low concentration 70 (52) - Blurred vision 53 (40) Prevalence of Symptomatic Hypoglycemia - Slurred speech 39 (30) Adrenergic symptoms, - Sweating 79 (61) No - Anxiety 70 (52) Symptoms 45% - Trembling 72 (55) - Dry mouth 57 (44) 55% Symptoms Odds Confidence Ratio Interval (95%) A1C 0.93 (0.83, 1.03) Age* ≤50 yrs 1 (ref) 51-58 yrs 1.76 (0.77, 4.01) 59-65 yrs 2.45 (1.08, 5.55) N: 250 prospectively evaluated patients >65 yrs 4.26 (1.73, 10.51) BG at event 1.07 (1.04, 1.1) Male* 2.05 (1.15, 3.64) Gomez et al. ADA 2017 3 8/4/2017 Update on Definition of Hypoglycemia Glycemic Variability Before 2017 After 2017 • Hypoglycemia: • Hypoglycemia alert: < 70 mg/dl – < 70 mg/dl • Severe hypoglycemia: • Significant hypoglycemia: Hyperglycemia Hypoglycemia < 40 mg/dl: – < 54 mg/dl Outcomes • Severe hypoglycemia: – No level – severe cognitive Glycemic impairment requiring variability external assistance for recovery Diabetes Care 2017;40:155–157 Measures of glucose variability Questions How do we measure glucose variability (GV)? How does GV affect clinical outcomes like infection rates, mortality, length of hospital? Acute glycemic variations (GV) may be more ___________________________MAGE better measure of GV than SD deleterious than constant exposure to a high glucose concentration ___________________________ Differences in Glycemic Variability (GV) Meal * Med * ** Standard Deviation or MAGE Two patients with identical mean glucose and SD but 6 am 12 pm 6 pm 12am different patterns of variability expressed by MAGE Kilpatrick et al. Diabet. Med. 27, 868–871, 2010 4 8/4/2017 GV as a predictor of mortality within different ranges of mean glucose ___________________________ GLI: Squared difference between consecutive glucose Each of the increments of mean glucose level is subdivided into four measures per unit of actual time between samples quartiles of glycemic variability. Q1 represents the lowest quartile; Q4 represents the highest quartile Ali, et al. Crit Care Med 2008; 36:2316–2321 GV as a predictor of Hospital mortality GV Medical vs. Surgical (Mean in patient treated with TPN delta daily, SD and MAGE) Percentages of hospital mortality across different quartiles of GV of daily BG Medical Surgical 1A, GV calculated by SD. 1B, GV calculated by mean daily D change. P values denote differences in hospital mortality across GV categories. BG = blood glucose; GV = glycemic variability; Q = quartile. BB = Basal Bolus Farrokhi et al, ADA 2013 Farrokhi et al. Endocr Pract. 2014;20:41-45 BP = Basal Plus ___________________________Summary Improving outcomes • Hyperglycemia, hypoglycemia and GV are associated with poor outcomes in hospitalized patients Promote safe and effective glucose control • In non-diabetic subjects, hyperglycemia and greater • Reducing peak hyperglycemia rates glycemic variability are associated with higher hospital • Reducing hypoglycemia rates mortality and post-operative complications • Reducing glucose variability • In diabetic subjects, glycemic variability does not appear to be associated with increased risk of mortality • Increasing time in range or post-operative complications, hyperglycemia is. 5 8/4/2017 Case 1 54-year-old man with T2DM for exacerbation of congestive heart failure and cellulitis of left big toe. Home diabetes medications - metformin and glipizide, with good compliance. ED Labs- A1c 7.6%, BUN 40, creatinine 2.0, BG is 220 Strategies to manage mg/dl. hyperglycemia in the hospital In addition to ordering a carbohydrate consistent diet what should you order for his diabetic management? – A) Continue home metformin and glipizide doses – B) Continue home metformin but discontinue glipizide – C) Continue home glipizide but discontinue metformin – D) Discontinue both metformin and glipizide 2004 Recommendation “In summary, each of the major classes of oral agents has significant limitations for inpatient use. Additionally,
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