In this keynote address, Guillermo Umpierrez, MD, CDCES, FACE, MACP walks viewers through all the latest research while commenting on how technology will play (and already is playing) an important role in the treatment of diabetes in the hospital.
Jordan Messler: Welcome and thank you everyone for joining us today. I'm Jordan Messler, the Chief Medical Officer here at Glytec. We are so glad that you are here for Time to Target, the glycemic management journey. You'll be hearing from some incredible speakers in these two days, and our next presenter is no exception.
I'm very pleased to introduce you to Dr. Guillermo Umpierrez. Dr. Umpierrez is a professor of medicine in the division of endocrinology and metabolism at Emory University School of Medicine. The Chief of Diabetes and Endocrinology at Grady Memorial Hospital in Atlanta. He is the author of more than 400 scientific manuscripts and book chapters, and has presented over 300 research abstracts at national and international scientific meetings.
I've been lucky to know Guillermo since my residency and was lucky enough to be down the hall from him when I was an academic hospitalist at Emory, based at Grady. He's a gifted teacher, has done more than almost anyone to raise attention and provide the evidence to improve the care of patients in the hospital with hyperglycemia and diabetes.
I speak on behalf of the entire Glytec team when I say how grateful we are to have him with us today. If you have any questions for Dr. Umpeirrez, please add them to the Q&A throughout the presentation. And if we're unable to get to your questions live, we'll make sure a member of our team follows up with you after the conference.
Now, without further delay, I'll hand the microphone over to you, Dr. Umpierrez.
Guillermo Umpierrez: Thank you, Jordan, for your nice introduction, and for the invitation to present to you an update on hospital management of diabetes. This slide presents potential conflict of interest. Emory University has received funding from these companies and I participated in some consultant activities.
And today I will present to you what is new in the management of hyperglycemia, both in the ICU and non ICU settings, and what are the insulin regimens and targets for glycemic control? And second, I will present some updates on where we are with technology and continuous glucose monitoring in the hospital setting.
So, when you talk about targets, the American Diabetes Association this year, and for sure it is going to be designed for next year, they're going to recommend to target a blood glucose between 100 to 180. And there is no need for tight control, as you will see in the next few minutes. So, you can target 100 to 140, 140 to 180, there's no difference in outcome for most people in the hospital.
Endocrine Society hasn't changed much, and they're still saying keep the target blood glucose less than 180 and pre meal less than 140. The UK diabetes 110 to 180. In reality, most of the organizations that are targeting a glucose between 100 to 180. And last month, there was the new publication from the group of Belgium, from the group of Vandenberg, that they published 9, 230 patients that were randomized to type control, 80 to 110 versus what they call liver glucose control.
We start insulin when the blood glucose was greater than 250. The 215 targeting 180 to 215, and they held and they didn't give parenteral insulin nutrition like they published before. And you may remember in 2001 when the group of Greek Vanderberg published these tremendous reduction in mortality targeting 80 to one 10.
In this group, they also achieved very good glucose control, and here you have high glucose control, about 110, and the liberal glucose control was about 150 to 160, because most of these people, 70 percent of them, have no previous history of diabetes. And to the right you have survival curve for mortality and there was absolutely no difference.
There was no difference in hospitalization, length of hospital stay, or complications. So I wrote an editorial and I put here in this table all of the most important trials during the past 20 years. And here you have Vandenberg, the previous one, who had this odds ratio, decreased odds ratio for mortality that was incredible, I mean significant, by 30, 40 percent.
And many other trials did not show the same, and you have here NICE-SUGARS that even show that as you try to achieve tight glucose control between 80 to 110, you increase mortality. We conducted a trial that is called GLUCO-CABG that we didn't see any difference. You go from 100 to 140, 140 to 180, and of course these new Gunst et al, that the new trial shows no difference in mortality.
So, in the previous trial that we did using the Glucommander, so we have very little hypoglycemia. Here you're seeing a composite of complications in 302 patients. They underwent CABG, or coronary artery bypass surgery. The composite included death, one infection, pneumonia, acute kidney injury, respiratory failure and major cardiovascular events, there was no difference between the intensive versus conservative treatment.
This suggests that 100 to 180 should be the way we should manage people in the ICU. And I believe this is going to be also the intensive, The Critical Care Society is coming with a new recommendation to be published next month that is also going to recommend 100 to 180 for most people in the ICU.
In the non ICU, we have the same target, and here is the way we have recommended in the past, treat everybody with insulin. However, new evidence suggests that perhaps some people can be managed with oral agents. Let me review the evidence for you. So the recommendation to use insulin, especially basal bolus insulin, comes from a couple of trials that we call Rabbit Medicine and Rabbit Surgery.
To the left is Rabbit Medicine, like a couple hundred people that we treated with basal bolus in yellow, versus sliding scales. And of course, basal bolus is superior. With better glucose control from day one or day two, you have this tremendous difference in glucose control. And to the right is a similar algorithm comparing basal bolus versus sliding scale.
And what you're looking at here is a composite of complications that include wound infection, pneumonia, respiratory failure, acute kidney injury, and bacteremia. And if you treat patients with sliding scale, you get a higher blood glucose concentration and higher rate of complications. 2 to 3 fold increase, especially increased rate of wound infections and acute kidney injury.
These were general surgery patients, and this led to the recommendation that basal bolus is better than sliding scale and should be the best way to manage people in the hospital. This was about... 10, 15 years ago. We also have done trials because many people still use MPH and regular. And the point to take home here is to the left is comparing Determir/Aspart versus NPH and regular, and to the right is Glargine NPH and regular.
You see that the glucose control is no different, because these are three to target, with the target less than 140 before meals, so at that time, that's what we use. There's no difference. You increase insulin, you're going to bring the blood glucose down. It doesn't matter which insulin you give, but there's a difference in hypoglycemia.
Of course, if you use NPH and regular, you get more hypoglycemia compared to basal insulin. No. No, no, no questions about. The other thing is that there are so many different basal insulin, and the question is, is Levemir, Glargine, U300, Degludec, how they compare to Glargine U100? So we have done several studies, and here today.
Left upper corner is Glargine versus Determir, and you see there is no difference in glucose control. There is a little more hypo with Determir, but not significant, clinically significant difference. To the right upper corner is comparing U100 versus U300 in a randomized control trial, and you see there is no difference in glucose control, and in the bottom is Degludec U100 versus Glargine U100, no difference in glucose control.
Again, the point is... If you treat with insulin, it doesn't matter which insulin you use, if you go for a target less than 140, less than 180, you see no difference in glucose control. What about hypoglycemia? If you look at, if you look at hypoglycemia, Levemir versus Glargine, there's no different, little more hypo, but not clinically significant difference in severe, even moderate hypoglycemia.
If you look here to the bottom, Degludec versus Glargine U100, no difference in glucose in hypoglycemia rate. A little less hypoglycemia, less than 54, with Glargine U300.
But, if you look at glucose less than 70, there's no difference. So, the bottom line is that, well, it looks like basal bolus is preferred over sliding scale, no question, in a surgical patient, especially if the blood glucose on admission is greater than 200. And there is no difference in... among different basal insulin analogs.
So, if your PMT committee suggests changing your basal insulin in your hospital, not much to be fighting about. But there are limitations on the basal bolus regime. First, I already presented to you hypoglycemia risk, and the fact that you require multiple injections. And for some people, maybe an overtreatment.
So the American Diabetes Association has recommended during the past 4 or 5 years that if the patient is admitted with a history of type 2 diabetes and the patient is going to be NPO or you are uncertain if the patient is going to eat or not, to give a single dose of Basal. And then you do corrections.
This is an approach that we call the Basal Plus. Basal, single dose, 0.2 to 0.25 units per kilo. Plus correction if needed, and you adjust the basal using the formula of 10, 20, 30% glucose in the high 100s you increased by 10%. Glucose in the 200s you increased by 20% glucose in the 300 you increased by 30% the basal dose of insulin.
And if the Basal plus is not enough, you move to basal bolus, or if you know the patient is going to eat, you can continue to use basal bolus. It is important that patients with type 1 diabetes should be treated with basal bolus. Those who were treated with basal bolus before admission, they should continue with basal bolus.
But in patients taking oral agents or a small amount of insulin, you can do the basal plus approach. This recommendation from the American Diabetes Association came from the study that we call the Basal Plus Study, and this is 370 patients, medicine patients to the left, surgical patients to the right, and you look in the top panel, the blood glucose concentration, the daily blood glucose concentration was no different, and here you have in the bottom is before meals and at bedtime, no significant difference between a single dose of basal versus.
So, the recommendations of the American Diabetes Association is that you use the Basal Plus as the primary way of treatment for most people who are admitted taking low dose insulin or more importantly, those treated with oral agents. And then you can use the Basal Plus for those selected patients that are not very well controlled.
During the last few years, there has been a tremendous amount of new evidence, or concern about should we use oral agents? So if you go to Israel, 70% of patients are treated with oral agents. In the uk, 40%. And if you fail, you add insulin. So at Emory University, we conducted this study several years ago, presented at the ADA, and with about 24, 28% are treated with oral agents.
And in this recent ADA meeting, just a few months ago, we presented data from Israel and two centers in the United States with about 80,000 patients that were treated with oral agents or insulin. And here you have, we call arbitrarily, good glycemic control. Those who had a blood glucose between 80 to 180 and no hypoglycemia, and you have the reference is basal insulin.
If you look here at oral agents, they have better glucose control, but they have better, lower blood glucose on admission. If you look at the hypoglycemia, oral agents, of course, have less hypoglycemia compared to basal insulin. If you look at mortality, well, they are less sick. These patients have lower mortality and there is no difference in lactic acidosis.
This paper is now under review. And when, what you have in here is that, well, maybe you can use in some people oral agents. There are previous studies, like this one, Retrospective Studies in General Surgery, in 7,000 patients, you get more infection if you use oral agents because they have higher blood glucose.
But if you look at mortality or complications of length of stay, well, they suggest that oral agents in some patients may do well, but we don't have good data. So there are publications like this, things that we do for no reason. One of them is routinely holding metformin in the hospital. But, of course, we are always concerned about lactic acidosis with the use of metformin.
That's right. Or hypoglycemia if you use sulfonylureas. But, I believe in a recent publication a couple of years ago, last year, in the New England, that you may continue metformin if the patient is stable, is tolerating meals, and there is no liver failure, no heart failure, no kidney failure. So, right now we have over 200 patients in the NIH study with Maya Fayman, an associate professor at Emory, the use of oral agents in the hospital.
And we're going to have, hopefully by next year, the results of these randomized control studies. Can you use oral agents in the hospital or not? So far, it looks like it's safe, but of course, we need to have more data. So, especially with the use of metformin. So, what we do have is several randomized control studies with the use of DPP-4.
And here to the upper left, you have 90 patients to the right. On the upper right is a hospital of 280 patients treated with sitagliptin versus basal bolus sitagliptin plus basal versus basal bolus. And to the bottom is lina surgery. 280 patients that will compare linagliptin one tablet day plus correction versus basal bolus.
And when you're looking its blood glucose concentration, then surprisingly you have no difference in glucose control. But it is important to, when can you use oral agents, it depends on the admission blood glucose. Here to the right is the Sita hospital and to the, to the left, Sita hospital. To the right is Lina surgery.
If the blood glucose is less than 180 or less than 200, there is no difference. You can use oral agents with corrections. But if the blood glucose is greater than 180 or 200, most people are immediately greater than 180 to 200, who don't use oralizations because they're going to fail. These patients should be treated with insulin therapy.
Their blood glucose is greater than 180, 200, or 240. I'm sure that you all are thinking, can I use SGLT2 in the hospital, and there are several trials. The ADA doesn't recommend yet the use of SGLT2 in the hospital, but there are studies like this by Cobo et al, and 1200 patients admitted with COVID, treated with Dapagliflozin or placebo.
The primary outcome was prevention of respiratory, cardiovascular, or renal oral dysfunction, or death. And what you have here to the left is the Dapa's a little better, but no significant difference in outcome. And to the right is the Kaplan-Meier estimate on outcome for death of any cause. A little better with Dapa, but of course no significant difference.
With this... What this study tells me is that, yeah, it doesn't do any harm, it may do a little better, but of course you can use it or not. For, this is a publication published in March last year in 400 patients with acute heart failure, and they were treated with impact Empagliflozin versus placebo. And what you're looking at here is that there was improvement in the impact of Empagliflozin in patients with heart failure.
And there are studies like this that at discharge in the hospital, this just was a pilot study with 80 patients with acute heart failure with diabetes treated with EMPA or placebo. And there was no difference in dyspnoea, but there was decreased length of stay, there was decreased readmission to the hospital, there was decreased improvement in worsening heart failure, or worsening heart failure and mortality.
Suggesting that you can use it carefully, but of course when the patient goes home, you should use it. This is the result of a study that is called DELIVER in 6,000 patients, where the primary outcome was worsening heart failure or cardiovascular death. Dapagliflozin was usually, was given shortly after discharge or at the time of discharge in patients admitted with heart failure.
And what you look at this is the significant reduction in cardiovascular death, significant reduction in hospitalization, or all cause of mortality. And there was no difference in diabetic ketoacidosis. So the current recommendation. is that you can use SGLT2, and this is common practice these days, at the time of discharge after the acute treatment or heart failure.
Of course, you have to be concerned that there is an inpatient with type 1 diabetes or insulin deficient patients, who can present with DKA. So, where we are with SGLT2s, that if you know that the patient is a type 2, there is no... No, for sure, no type 1, they're non insulin dependent, you can use it, but we still have to see what the next year standard of care will say.
So far, the standard of care of the American Diabetes Association do not recommend the use of SGLT2 in the hospital. They do recommend SGLT2 at the time of discharge. For patients with heart failure because they have been shown to reduce readmission rate, it has been shown to decrease mortality in those patients with low or reserve ejection fraction.
The other thing that the FDA calls the attention to is the risk of diabetic ketoacidosis and type 1 diabetes in those patients who are going to be NPO for several days. What do we know about GLP 1? So this is a pilot study that we reported a couple of years ago, that we treated with Exenatide, the short acting GLP 1, and yeah, it works, but of course there's a significant number of people who have nausea or vomiting in the hospital, and in the last few months there have been several publications calling the attention that GLP 1, because it's known to delay gastric emptying, may increase the rate of aspiration, pneumonitis during surgery. Most of these publications are retrospective studies or case reports.
For example, this one is a 31 year old female with type 2 diabetes who underwent an AGD and a surgical gastrointestinal fluid, or esophago…. Or whatever and and what you have is that there is a delayed gastro, and there is food content in the stomach and there are several publications like this and they have done ultrasound and they have shown the semaglutide and all of the GLP 1 has delayed gastric emptying.
This is one of the mechanisms where it works, and so there is a big now discussion of when do you have to stop GLP 1 before surgery? In our university, we have a meeting next week to discuss, and we are recommending that if this is an elective surgery, maybe you should stop the GLP 1 receptor analog for a week before surgery.
Now, if somebody has to go to surgery, you have to be aware of the risk of aspiration. So a big discussion. I don't think that we settled and most of these are retrospective studies. We need to do a prospective randomized studies to see the safety of this medication. So if I want to summarize so far, insulin should be the base treatment for most people, especially those admitted with significant hyperglycemia greater than 180, 200 or more than 200.
You have to be careful about hypoglycemia risk, especially those who have chronic kidney disease who are not eating well. Can you use metformin? Yes. If the patient is stable, it's an in and out mild hyperglycemia, but you have to be concerned. If the patient has type 1, of course, don't use it. They'll have renal, liver, heart failure, hypoxia, sepsis, because of the recent lactic acidosis.
And if you're going to continue metformin... You have to be very, very careful. TZDs don't usually, we don't use because it takes too long to work, and it's contraindicated in heart failure. There are several randomized control studies with DPP4 for patients with mild hyperglycemia less than 180, less than 200.
Then you can add rapid active insulin or basal insulin, but you have to be concerned, type 1 pancreatitis and it doesn't work if the glucose is greater than 200. SGLT2 heart failure is indicated. We don't know when to start but for sure before the patient goes home, and you have to be aware that there's the risk of DKA, ketonuria, especially those who are going to be NPO before major surgery.
And GLP 1, not routinely recommended because of gastroparesis, delayed gastric emptying and the risk of aspiration pneumonia. This is a story that has been developing as we speak today. So this Annals of Internal Medicine. If you have somebody admitted to the hospital with glucose greater than 2 or 300, the patient has been taking insulin, you should treat this patient with basal bolus.
If the patient, on the other hand, has mild hyperglycemia, just glucose 160, 180 with the hemoglobin A1C is less than 7.5, the patient has been on no therapy or just oral agents, you make continuous oral agents and you supplement or correct with slight scales of basal insulin. For most people, I believe that with type 2, basal plus is the way to go.
And if that's not okay, you do basal bolus insulin therapy. So it's quite important that you have to select the patient and target the blood glucose levels, and more importantly, target the treatment or select the treatment according to who is the patient that you are treating in the hospital setting.
In the next couple of minutes, let me show you where we are with technology. We have been working with continuous glucose monitoring, and we are developing now several protocols for closed loop, and the way that we have looked at blood glucose concentration in the last few years is to do finger sticks, and it works well, that's why for 50 years we have been pricking fingers.
And it gives you two or three blood glucose a day, but it doesn't tell you the whole story, the ups and downs of blood glucose during the day. So, in the last few years we have been working. Can you use CGM? Well, in the ICU in our university, we have implemented the use of CGM together, alone, or together with the Glucommander to infuse insulin.
And here you have the first publication was with a group of New York. We attached the CGM at the wall of the ICU. You can do it up to 20 feet away. And we reported good correlation between the finger sticks and the CGM value. This was during COVID. So that prevented the nurses to go have prick fingers.
We just look at the blood glucose concentration. We continue with this investigation and now what we have a standard of care at Emory, at Grady hospital, is to use the CGM, in this case we use the Dexcom, at that time we only have real-time was Dexcom. And you have the Glucommander together. And here you have the Glucommander with the insulin infusion, 20 feet away from the patient and there you have the blood glucose concentration, the meter.
So and you can give insulin in that way and we prevent it to do finger sticks every hour, every two hours. We just do and calibrate every four times a day. You have here at the nurse's station the same like cardiology have the whole thing, we have the blood glucose monitoring. So the nurses can know if the blood glucose is high or low and then you can adjust insulin therapy together with the CGM and in this case with Glytec or Glucommander and we manage the patients in this way.
In the non ICU, this is an abbreviated list of papers that have been published during the last few years with different CGMs. Well, how good is CGM in non ICU? Well, this is a publication by one of our people, Rodolfo Galindo, which shows that mean hospital daily blood glucose by point of care testing, capillary point of care testing, or CGM, and it correlates very well.
But the beauty of the CGM is that it recognizes hypoglycemia, and hyperglycemia. So in this study, we did blood glucose before meals and at bedtime. And, of course, between 10 p.m. and 6 a.m., there was significant hypoglycemia that would only be able to be recognized using the CGM. And now we have alarms so you can really know when the patient is low.
This was using the Libre. These studies, the 205 patients by Georgia Davis from our group, reported in the Dexcom G6 CGM. And here you have during the first 12 hours, in the middle first 24 hours, or to the right, the correlation between point of care testing and CGM during the hospital stay. And if you want, you want to be error grid between zones A and B, that's a good correlation, was 98.7%.
And it didn't matter if you are lean or obese, if you place the CGM in the arm or in the abdomen, or if you are white or Black. So, a good correlation has been demonstrated between the CGM and point of care testing. What it has been a problem so far is how do you transfer the information from the CGM, from the device to the nurses stations or the physician.
And here you have in the studies that using Dexcom with two Dexcoms, we have a cell phone to transmit to the cloud and it give you to the iPad here.
On this way of glucose profile, hospital glucose profile, here you have, you place the CGM the first day, the second day, the third day. So if you look at these individuals, low glucose is higher than 180 before and after meals, so I will increase the basal and the prandial dose. This one, the blood glucose is about 180, well, maybe I just give a little more basal insulin.
And using this telemetry system, we can look at the high in target blood glucose or the very high blood glucose or low blood glucose. You can also look at the glycemic variability and percent time. So is this going to be the future? We don't know. We are doing studies with the FDA to see if we can get CGM approved in the hospital setting.
We have reported in the past, in the couple of years ago, with a group of the University of Maryland, that using the continuous glucose, the real-time CGM, with the glucose telemetry system, so using the cell phone used to go into the cloud, you can decrease the number of hypoglycemia and the percent time below range.
In this case, in this study, we asked the nurses if the blood glucose was less than 85 to prick the finger, confirm hypoglycemia, and treat before the blood glucose got less than 80 or less than 50. So, what about, can you treat patients using CGM? So you can recognize hypo, recognize hyper, but can you adjust treatment, insulin treatment, just with CGM?
And in a recent paper we reported compared to the point of care testing, that's the standard of care so far, that you go to the hospital and you look at the blood glucose, three or four blood sugar the day before, and you adjust therapy. Or if I give you the glucose profile, looking at CGM, can you adjust insulin therapy?
And the answer is yes, you can, and this was just preliminary studies in 180 patients, and you can improve glucose control in the same way, but you reduce the rate of hypoglycemia. Especially recurrent hypoglycemia during the day and during the night was significantly lower because we used alarms. If the blood glucose is less than 80, or less than 85, it beeps, it got an alarm, so the nurses can treat the patient before the blood glucose is less than 60, less than 70 or less than 54.
And this was in the hospital, and it's under review, hopefully to be published in a couple of months. This is a paper that we did, a study that we did in the nursing home, in the long term care facilities. Again, you remember during the COVID, nobody wanted to, the higher mortality was in the older adults. So we implemented the use of point of care testing versus real time CGM.
And what we are reporting is that, yes, you can treat patients in the nursing home, but you don't need to do finger sticks three or four times a day. We just did it once a day in the morning for calibration. So, can you use CGM? Well, this is the new Endocrine Society guidelines published last year. The first question, the PICO question, was should CGM can be used versus bedside capillary blood glucose?
And the answer is yes. You can do it in non critical illness in the people at high risk for hypoglycemia. So the use of real time CGM with confirmatory point of care testing can be a good way to minimize the cost, finger sticks, and to have better glucose control, and hopefully it will be, it should be reviewed by the FDA in the next few months.
We will know more about that in the future. So if I have to summarize to you what I have learned during the past 20 years of conducting clinical studies and reviewing the literature. First, hyperglycemia in the hospital is very common. 20 to 30 percent of patients have high blood glucose and it's associated with increased rate of complication.
So if you, you should minimize the use of sliding scale alone in patients admitted with blood glucose greater than 180 to 200. You could do correction doses, but if you compare basal bolus versus sliding scale alone, you have an increased rate of complication. No question about it, because you have high blood glucose and high glycemic variability.
This peaks. And, for meals, it's very dramatic with the use of the sliding scale alone. For most people in the hospital, a single dose of basal insulin should be enough, especially for those patients treated with oral lesions prior to admission or with mild hyperglycemia or those treated with very low dose of insulin.
Just give 0.2, 0.25 units per kilo, so 20 units, 15, 20, 25 units of insulin should be enough to prevent significant hyperglycemia, and you do correction doses. And here you have the basal plus, basal plus correction versus basal bolus. There is no difference in medicine on surgical patients in these randomized controlled studies with 370 patients.
Can you use oral agents? Yes! If the patient has mild hyperglycemia, with blood glucose less than 180 200, you may continue the oral agent. This is a summary of 640 medicine and surgical patients. And you have the use of DPP4 plus correction. And so, DPP4 with lower dose collagen should be okay. We do not have randomized control studies for other agents, but SGLT2 may be appropriate for those patients with heart failure.
And finally, the use of technology. Here you have the use of hospital glucose profiles to use CGM to guide insulin therapy that have been shown to be effective in reducing hypoglycemia and improving glycemic control in the hospital setting with no increased rate of hypoglycemia. So, but it's not approved yet, CGM, in the hospital setting.
So, this is where we are right now. We are conducting closed loop studies, but this is kind of complicated for many people. I think that closed loop is going to be a research tool, except for those patients who are admitted with pumps. And you can continue pumps in the hospital setting, which I didn't cover today.
And so thank you so much, Jordan for the invitation to present what is going on with inpatient diabetes care. I think the last 20 years has been quite exciting to learn more about insulin therapy, when you use it, how to use it to reduce hypoglycemia, and now of course the use of technology. So I appreciate the invitation and I'm happy to answer any questions or comments that you may have.
Jordan Messler: Thanks so much, Guillermo. That really was a master class on what's happening in the inpatient diabetes space, so we appreciate you joining us today and all the work that you've done in this space over the years. So we do have a few questions. Maybe we can get one or two of them. We know you've been busy the last few weeks at a lot of conferences, at EASD recently.
Any pearls or takeaways from any of these conferences that really excite you about what's happening in the inpatient glycemic space?
Guillermo Umpierrez: Yeah, and we presented the new update on the management of hyperglycemic crisis. So the last publication from the American Diabetes Association was in 2009.
So with myself and a few others, we first published in 2001. We revised 2006 and 2009, so 13, 14 years ago. So this time the ADA asked me to revise the guidelines. So we invited the EASD, the European Association Study of Diabetes, UK Diabetes, Diabetes Technology Society and the American College of Endocrinology to join us and we put together the new guidelines for the treatment of DKA and HHS, the hyperglycemic hyperosmolar state.
And we've made some recommendations about how to prevent and how to diagnose DKA. So we are going to decrease the blood glucose from 250 to 200 because 10% of patients present with euglycemic DKA, especially those treated with SGLT2 or pregnancy. Second, we're going to try to increase the utilization of beta hydroxybutyrate measurement.
Unfortunately, in the United States, many hospitals still use acetoacetate, which is not the primary ketone in patients with DKA. So, we're going to recommend point of care testing or laboratory enzymatic measurement of Beta hydroxybutyrate as an important tool in diagnosing diabetic ketoacidosis and stay away from acetoacetate, who is not very good for diagnosis or to follow resolution of DKA.
And for HHS, We recommended effective serum osmolality, now we say it doesn't matter, you can do total or effective serum osmolality. And there is new recommendation for treatment. So, at this, we already submitted the papers to Diabetes Care and Diabetologist, should be published in the next few months.
The guidelines were presented at the EASD. Hopefully we get to present at the ADA to inform diabetologists. All news about how to manage, diagnose, and prevent complications with hyperglycemic crisis. One additional point that’s very important is that we present data on complications during treatment, especially hypoglycemia and hypokalemia who are both associated with increased morbidity and mortality.
So everything that we can do to prevent hypoglycemia is quite important because it's associated with two fold increase in mortality in those people who have diabetic ketoacidosis and HHS. Believe it or not, when you have a patient with DKA or HHS and you start insulin and fluid replacement, potassium drops about 1 to 2 ml more, 1 to 2 ml equivalent.
So it's quite important to prevent hypokalemia in these patients.
Jordan Messler: Yeah. Terrific. We know that the updated guidelines were definitely needed, they were timely. We appreciate all the work you've done in that space as well. Thanks again. Thank you so much, Guillermo.
You hit on so many pearls, topics that are really top of mind for anyone in the inpatient glycemic managed space. Thanks to everyone that joined this session. And again, Guillermo, thank you. We appreciate you sharing your expertise and insight with all of us today.
Guillermo Umpierrez: Thank you, Jordan.