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At the beginning of April, I attended and spoke at one of the signature inpatient diabetes conferences, the Diabetes Technology Society’s (DTS) 2022 Virtual Hospital Diabetes Meeting. The two-day virtual conference covered a range of glycemic topics presented by leading national and international clinicians. Here’s my attempt to distill the 40+ talks into some key takeaways. Keep in mind, I may have a hospitalist insulin software bias, given my role as a hospitalist and CMO at Glytec, which offers eGMS® with its FDA-cleared insulin management software, Glucommander™.
Top 10 Takeaways from DTS Virtual Hospital Diabetes Meeting 2022
1. Tighter glycemic control in the ICU may be warranted for certain patient populations
The current inpatient guidelines generally support 140-180 mg/dL for critical care targets, based on the NICE SUGAR trial. Highlighting a study from 2022, with references to previous studies, Dr. James Krinsley reviewed the rationale for 140-180 mg/dL, and why this may need to be tighter for certain populations. For instance, he highlighted a study showing patients with a lower Hb A1c seem to have better outcomes with tighter targets, and those with a higher A1c do worse. Hence, for patients with a pre-admission hyperglycemia and elevated A1c, they benefit from 140-180 mg/dL, but patients with pre-admission normoglycemia with lower A1c, a target of 80-150 mg/dL may be preferred.
2. Maybe the ADA DKA guidelines should better match the UK guidelines. See this comparison article
Dr. Ketan Dhatariya, from Norfolk and Norwich University Hospitals, reviewed some key elements of DKA management that are missing from the 2009 ADA consensus statement on hyperglycemic crises. UK guidelines recognize the importance of euglycemic DKA, and use a BG of 200 mg/dL, while the ADA threshold remains at 250 mg/dL. Bedside ketone monitors are used regularly in the UK, and the opportunity for a quicker diagnosis should enable their use in the US. Finally, he discussed the use of basal insulin in select patients with DKA while on IV insulin, in the 12-24 hours before transition, with some evidence it may reduce rebound hyperglycemia.
3. Watch out for hyperglycemia from Immune Checkpoint Inhibitors
Immune checkpoint inhibitors are a newer class of medications used in malignancy. These medications can contribute to hyperglycemia in patients with diabetes who are on steroids, and trigger autoimmune responses that can elevate glucose. In particular, checkpoint inhibitors are associated with autoimmune diabetes (CIADM). In those patients, insulin would be required for management during the acute phase, and almost all of these patients will need to continue on insulin at discharge.
4. Predictive models can help triage inpatient glycemic management
There are numerous models to help predict patients who will have adverse glycemia in the hospital. One particular model, presented by Dr. Mervyn Kyi, used BG 72 and BG >270 mg/dL as a screening threshold, and then added the combination of glucose-lowering treatment prior to admission, steroid use, and A1c >8.1%. These factors helped predict who would have worse glycemic outcomes in the hospital. Given the large percentage of patients with dysglycemia in the hospital, tools to help triage which patients would need more attention, resources, and treatment can be invaluable.
5. Personalized care is the present and the future of inpatient glycemic management
Dr. Guillermo E. Umpierrez discussed the importance of individualized care of the patient with hyperglycemia in the hospital. As the author of the foundational work to guide basal-bolus management of hyperglycemia for patients with hyperglycemia and eating in the hospital, he recognized there are limitations of basal-bolus insulin, particularly the risk for hypoglycemia.
The use of correction insulin alone may be indicated for select patients with BGs <180 mg/dL, and the use of certain oral agents, such as DPP4i, may be reasonable for patients with BG <200 mg/dL. Therefore, he recommends reserving basal-bolus insulin therapy for patients with BG >200 mg/dL or otherwise not controlled in 24-48 hours. In addition, he discussed a study underway at Emory to help clarify when and if certain oral antidiabetic agents can be continued in the hospital.
6. CGM is also the future of glycemic management
Multiple organizations reviewed their work with continuous glucose monitors (CGM) during the pandemic, as the FDA has allowed their use, via an emergency discretion. Dr. Athena Philis-Tsimikas from Scripps Whittier Diabetes Institute highlighted the almost 1,000 patients they’ve now managed with CGM in the hospital, highlighting the successes and challenges. She reviewed ongoing research aimed at showing the benefit of this technology in the hospital, once it becomes FDA cleared.
Dr. Rodolfo J. Galindo highlighted an upcoming hospital glucose profile that will be published in ADA 2022, to help define the visualization needed for CGM analysis in the hospital.
Dr. Ilias K. Spanakis reviewed his research in the non-ICU setting, with glucose telemetry, to prevent hypoglycemia. He highlighted an upcoming study to evaluate the impact of tighter control using CGM to prevent hypoglycemia and reduce hyperglycemia rates.
7. There are many quality improvement strategies to drive change
Several speakers highlighted the importance of easy-to-use order sets, innovations to nudge behaviors, as well as strategies to deploy to better implement glycemic management solutions. In particular, Dr. Andjela T. Drincic, from the University of Nebraska, highlighted the steps they’ve taken over the years to improve diabetes management. They instituted a diabetes pharmacy stewardship pharmacist, a diabetes resource nurse, an endocrine hospitalist and many other innovative solutions. They’ve also worked closely with IT to develop better order sets, alerts, dashboards, and enhanced decision trees.
Dr. Andrew Demidowich discussed choice architecture within the EHR, the concept of utilizing behavioral nudges to drive change. For instance, key reminders, social influence, standardization, better use of defaults, and hiding orders when not needed all are ways to drive change.
8. Regulatory measures are here and will also drive change
Dr. Greg Maynard, the Chief Quality Officer at UC Davis, discussed the evolution and recent announcement of the new hyperglycemia and hypoglycemia CMS measures. These two new eCQMs will be collected in 2023 for sites that elect to report them. They will be helpful for gaining attention to the importance of glycemic management, though won’t tell you how to improve. Other measures may soon follow that can help with improvement strategies.
9. Glycemic management is difficult
One of the lessons from many of these speakers is the numerous projects and solutions implemented to drive improvement. This work is hard. The common themes reiterated were the importance of having a strong multidisciplinary team, with various champions, clear goals, and a deliberate approach to implement solutions.
10. Insulin management software, such as an eGMS or Glucommander, is the way to overcome some of the challenges of glycemic management
At Glytec, we know one of the ways to accelerate change is by implementing insulin management software. We also know that processes and people must work hand in hand with technology to drive change. I ended the conference with a talk highlighting the various ways teams come together, with technology to achieve their desired glycemic results. Our mission at Glytec is to improve the care of patients with the safe use of insulin.
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