Physician's attitudes towards diagnosing and treating glucocorticoid induced hyperglycaemia: Sliding scale regimen is still widely used despite guidelines

AbstractAimsTreatment with glucocorticoids for neoplasms and inflammatory disorders is frequently complicated by glucocorticoid induced hyperglycaemia (GCIH). GCIH is associated with adverse outcomes and its treatment has short term and long term benefits. Currently, treatment targets and modalities depend on local protocols and habits of individual clinicians. We explored current practice of screening and treatment of GCIH in patients receiving glucocorticoid pulse therapy.MethodsA factorial survey with written case vignettes. All vignette patients received glucocorticoid pulse therapy. Other characteristics (e.g., indication for glucocorticoid therapy, pre-existent diabetes) varied. The survey was held between November 2013 and May 2014 on 2 nationwide conferences and in hospitals across The Netherlands. Pulmonologists and internists expressed their level of agreement with statements on ordering capillary glucose testing and treatment initiation.ResultsRespondents ordered screening for GCIH in 85% of vignette patients and initiated treatment in 56%. When initiating treatment, respondents opt for sliding scale insulin in 62% of patients. Sliding scale insulin was more frequently prescribed in patients with pre-existent insulin dependent diabetes (OR 2.4, CI 1.3–4.2) and by residents (vs. specialists, OR 2.1, CI 1.2–3.5). Sixty-nine percent of clinicians experienced a lack of guidelines for GCIH.ConclusionsClinicians have a strong tendency to screen for GCIH but subsequent initiation of treatment was low. Sliding scale insulin is still widely used in episodic GCIH despite evidence against its effectiveness. This may be due to lacking evidence on feasible treatment options for GCIH

Nocturnal hypoglycaemia in type 1 diabetic patients, assessed with continuous glucose monitoring: frequency, duration and associations

WSTĘP. W niniejszej pracy określono ilościowo częstość występowania i czas trwania epizodów nocnej hipoglikemii u chorych na cukrzycę typu 1, leczonych ciągłym podskórnym wlewem insuliny (CSII) lub za pomocą wielokrotnych wstrzyknięć insuliny (MIT), wykorzystując ciągły podskórny pomiar glukozy z zastosowaniem czujnika. METODY. Czujnik mikrodializacyjny był noszony w warunkach domowych przez 24 pacjentów leczonych CSII (średnie stężenie HbA1c 7,8 ± 0,9%) oraz przez 33 pacjentów, u których stosowano MIT (średnie stężenie HbA1c 8,7 ± 1,3%) przez 48 godzin. Oceniano częstość występowania i czas trwania epizodów hipoglikemii oraz związek między stężeniem HbA1c, czasem trwania cukrzycy, sposobem jej leczenia (CSII vs. MIT), wartościami glikemii na czczo oraz przed spoczynkiem nocnym, całkowitą dobową dawką insuliny, a także średnimi wartościami glikemii w nocy a częstością występowania i czasem trwania epizodów hipoglikemii. WYNIKI. Epizody nocnej hipoglikemii z wartościami glikemii ≤ 3,9 mmol/l wystąpiły u 33,3% pacjentów w obu grupach - zarówno w grupie leczonej CSII (8/24), jak i stosującej MIT (11/33). średni czas trwania hipoglikemii (± SD; mediana, przedział międzykwartylowy) wynosił 78 min na noc (± 76; 57, 23-120) u chorych poddanych CSII oraz 98 min na noc (± 80; 81, 32-158) u pacjentów stosujących MIT. W analizie metodą regresji wieloczynnikowej wykazano, że glikemia przed spoczynkiem nocnym najsilniej wiąże się z częstoœcią (p = 0,026) oraz czasem trwania (p = 0,032) epizodów nocnej hipoglikemii. WNIOSKI. Ciągłe monitorowanie glikemii z wykorzystaniem metody mikrodializy umożliwiło bardziej precyzyjne określenie ilościowe częstoœci występowania i czasu trwania epizodów nocnej hipoglikemii u chorych na cukrzycę typu 1. Parametry te wiążą się głównie z wartościami glikemii przed spoczynkiem nocnym.AIMS. We quantified the occurrence and duration of nocturnal hypoglycaemia in individuals with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) or multiple-injection therapy (MIT) using a continuous subcutaneous glucose sensor. METHODS. A microdialysis sensor was worn at home by 24 patients on CSII (mean HbA1c 7.8 ± 0.9%) and 33 patients on MIT (HbA1c 8.7 ± 1.3%) for 48 h. Occurrence and duration of nocturnal hypoglycaemia were assessed and using multivariate regression analysis, the association between HbA1c, diabetes duration, treatment type (CSII vs. MIT), fasting and bedtime blood glucose values, total daily insulin dose and mean nocturnal glucose concentrations, and hypoglycaemia occurrence and duration was investigated. RESULTS. Nocturnal hypoglycaemia ≤ 3.9 mmol/l occurred in 33.3% of both the CSII- (8/24) and MITtreated patients (11/33). Mean (± SD; median, interquartile range) duration of hypoglycaemia ≤ 3.9 mmol/l was 78 (± 76; 57, 23-120) min per night for the CSII- and 98 (± 80; 81, 32-158) min per night for the MIT-treated group. Multivariate regression analysis showed that bedtime glucose value had the strongest association with the occurrence (p = 0.026) and duration (p = 0.032) of nocturnal hypoglycaemia. CONCLUSIONS. Microdialysis continuous glucose monitoring has enabled more precise quantification of nocturnal hypoglycaemia occurrence and duration in type 1 diabetic patients. Occurrence and duration of nocturnal hypoglycaemia were mainly associated with bedtime glucose value

Glucose counterregulation in Type 2 diabetes mellitus.

Glucose counterregulatory failure and hypoglycaemia unawareness frequently complicate treatment of Type 1 diabetes mellitus, especially when aiming for intensive metabolic control. Since tight metabolic control reduces microvascular long-term complications in Type 2 diabetes mellitus, the integrity of glucose counterregulation in Type 2 diabetic patients is important. Using a Medline search, we identified 12 studies in which counterregulatory responses to insulin-induced hypoglycaemia were compared between Type 2 diabetic patients and appropriate controls. A review of these studies showed that some patients with Type 2 diabetes mellitus develop mild counterregulatory dysfunction and reduced awareness of insulin-induced hypoglycaemia. Some studies suggested an association between counterregulatory impairment and intensity of metabolic control. We speculate that the relatively low frequency of (severe) hypoglycaemic events in Type 2 diabetes may explain why glucose counterregulation remains unaffected in most patients. We hypothesize that residual beta-cell reserve and insulin resistance provide protection against severe hypoglycaemia and limit impaired counterregulation. Diabet. Med. 18, 519-527 (2001

[Screening for diabetic retinopathy]

Concurrent with the increasing incidence of diabetes mellitus, the incidence of diabetic retinopathy is also rising. Timely recognition with the aid of screening, followed by laser therapy, can prevent the greater part of the resulting visual impairment and blindness. However, many patients with diabetes are not screened or not screened adequately. The necessary screening frequency is annually or biannually, depending on the degree of retinopathy and the presence of risk factors, of which glycaemic control, duration of diabetes, blood pressure, lipid profile, and race are the most important. Digital 2-field fundus photography, preferably in mydriasis, is of sufficient quality for routine screening. The impact of screening programmes can be further improved by applying the optimal method and by initiating an active implementation strategy