A case of calciphylaxis in a patient with hypoparathyroidism and normal renal function

OBJECTIVE: To present the case of a patient with a history of thyroid cancer, postsurgical hypoparathyroidism, chronic calcitriol use, and normal renal function who presented with painful skin lesions secondary to calciphylaxis. METHODS: We describe the history, biochemistry, histopathology, evaluation, and management of this patient. RESULTS: A 47-year-old female with hypoparathyroidism, chronically treated with calcitriol and calcium, presented with exquisitely painful skin ulcerations. Four months prior to the onset of symptoms, she had initiated warfarin therapy for atrial fibrillation. Review of laboratory data from the past year revealed elevated calcium and phosphorus levels. A diagnosis of calciphylaxis was made based upon pathologic evaluation of a skin biopsy. Management included titration of calcitriol and calcium to maintain serum calcium and phosphate levels in the low-normal range. Sodium thiosulfate was administered at a dose of 25 mg intravenously 3 times a week with some resolution in the patient's pain. Unfortunately, the patient battled recurrent bacteremia and sepsis, presumably related to her calciphylaxis wounds, and ultimately succumbed to complications from sepsis. CONCLUSION: Although calciphylaxis is typically associated with renal insufficiency and secondary hyperparathyroidism, we highlight the case of a patient with normal renal function and hypoparathyroidism. Patients treated with chronic calcitriol should have serum calcium and phosphorus monitored closely and may benefit from non-calcium-based phosphate binders if hyperphosphatemia becomes unavoidable. This is especially important in the presence of other risk factors for calciphylaxis, including warfarin use

Use of a Subcutaneous Insulin Computerized GlucoStabilizer™ Program on Glycemic Control in the Intensive Care Setting: A Retrospective Data Analysis.

Background: Despite guidelines that recommend strongly against Sliding Scale Insulin (SSI) it continues to be the most commonly insulin regimen used in hospitals to treat hyperglycemia. In addition to being reactionary to a glucose that has already increased, SSI offers practical challenges in the randomness of the doses of insulin prescribed and often a disconnect with glucose testing that should be occurring in congruence to the insulin dosing. While many clinical trials have shown improved glycemic control in critical care patients receiving intravenous insulin; few studies have demonstrated the efficacy of subcutaneous (SQ) insulin in this setting. In this study, we have evaluated the safety and efficacy of SQ insulin administration utilizing a computerized program, the Clarian GlucoStabilizer™ Subcutaneous Program (CGS-SQ) in the intensive care unit (ICU). This program is designed to overcome some of the most common barriers of SQ insulin delivery, those of dose calculation and timing. Methods: A computerized SQ insulin delivery program -The Clarian GlucoStabilizer™ Subcutaneous Program (CGS-SQ)- was made available to ICU practitioners, facilitating standardized calculation of insulin doses and incorporating reminder alarms for blood glucose (BG) testing. This program used three defaults Insulin Sensitivity Factors (ISF) and Insulin to Carbohydrate Ratios (CR) to calculate insulin doses. Additionally, there is an option for practitioner determined ISF and ICR. Patients, aged ≥ 18 years, initiated on the CGS-SQ and admitted to the (ICU) were eligible for inclusion in this retrospective evaluation. Patients were divided into four groups based on initial insulin sensitivity factor (ISF) and carbohydrate ratio (CR). Three of the groups used a default ISF and CR; ISF 60, CR 15; ISF 30, CR 10 and ISF 15, CR 8. These groups were compared with those where the practitioner specified an individualized ISF and CR, referred to as PDS (practitioner defined setting). Primary endpoints included: mean glucose, time to target glucose, hyperglycemic and hypoglycemic events. Results: In the 1,384 patients identified, patients initiated with a predefined setting had lower mean glucose compared to patients with PDS (ISF 60, CR 15: 135 mg/dL vs. ISF 30, CR 10: 140 mg/dL vs. ISF 15, CR 8: 134 mg/dL vs. PDS: 143 mg/dL; p \u3c 0.0001). Patients in the default settings had shorter time to target glucose and decreased incidence of hyperglycemia and hypoglycemia. Conclusions: Using a system of computerized prompts with standardization of insulin dose calculation, SQ insulin can be effectively used in the treatment of ICU patients to target BG of 100-150 mg/dL with minimal risk of hypoglycemia

The S troke H yperglycemia I nsulin N etwork E ffort ( SHINE ) trial protocol: a randomized, blinded, efficacy trial of standard vs. intensive hyperglycemia management in acute stroke

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/102726/1/ijs12045.pd

The Basis for Weekly Insulin Therapy:Evolving Evidence With Insulin Icodec and Insulin Efsitora Alfa

Basal insulin continues to be a vital part of therapy for many people with diabetes. First attempts to prolong the duration of insulin formulations were through the development of suspensions that required homogenization prior to injection. These insulins, which required once- or twice-daily injections, introduced wide variations in insulin exposure contributing to unpredictable effects on glycemia. Advances over the last 2 decades have resulted in long-acting, soluble basal insulin analogues with prolonged and less variable pharmacokinetic exposure, improving their efficacy and safety, notably by reducing nocturnal hypoglycemia. However, adherence and persistence with once-daily basal insulin treatment remains low for many reasons including hypoglycemia concerns and treatment burden. A soluble basal insulin with a longer and flatter exposure profile could reduce pharmacodynamic variability, potentially reducing hypoglycemia, have similar efficacy to once-daily basal insulins, simplify dosing regimens, and improve treatment adherence. Insulin icodec (Novo Nordisk) and insulin efsitora alfa (basal insulin Fc [BIF], Eli Lilly and Company) are 2 such insulins designed for once-weekly administration, which have the potential to provide a further advance in basal insulin replacement. Icodec and efsitora phase 2 clinical trials, as well as data from the phase 3 icodec program indicate that once-weekly insulins provide comparable glycemic control to once-daily analogues, with a similar risk of hypoglycemia. This manuscript details the technology used in the development of once-weekly basal insulins. It highlights the clinical rationale and potential benefits of these weekly insulins while also discussing the limitations and challenges these molecules could pose in clinical practice.</p