Mary T. Korytkowski

Mary T Korytkowski, Ranganath Muniyappa, Amy C Donihi, Andjela T Drincic, Irl B Hirsch, Marie E McDonnell, M Hassan Murad, Craig Nielsen, Robert J Rushakoff; Re

In an effort to enhance the trustworthiness of its clinical practice guidelines, the Endocrine Society has recently adopted new policies and more rigorous methodologies for its guideline program. In this Clinical Practice Guideline Communication, we describe these recent enhancements—many of which reflect greater adherence to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to guideline development—in addition to the rationale for such changes. Improvements to the Society’s guideline development practices include, but are not limited to, enhanced inclusion of nonendocrinologist experts, including patient representatives, on guideline development panels; implementation of a more rigorous conflict/duality of interest policy; a requirement that all formal recommendations must be demonstrably underpinned by systematic evidence review; the explicit use of GRADE Evidence-to-Decision frameworks; greater use and explanation of standardized guideline language; and a more intentional approach to guideline updating. Lastly, we describe some of the experiential differences our guideline readers are most likely to notice.

Background: Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management.Objective: To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia.Methods: A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.Results: The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition–associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes.Conclusion: The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.

The use of SGLT2i and GLP-1RA in patients with T2D remains low despite their known CV benefits. This may be due in part to high drug costs. We sought to assess the association between out-of-pocket (OOP) costs and the likelihood of initiating these two classes in patients with T2D and established CVD. We conducted a cohort study using claims data (Optum) , which included commercial and Medicare Advantage beneficiaries. Adults with T2D on metformin monotherapy between 12/5/17 and 12/31/were eligible. We excluded those:1) not continuously enrolled for ≥1 yr prior to their first metformin dispensing,2) with no evidence of established CVD, or3) whose OOP costs (defined as the sum of copays and deductibles for a 30-day supply) for SGLT2i or GLP-1RA could not be determined. We used Cox proportional hazards models adjusting for demographics, clinical characteristics, insurance plan, provider and laboratory characteristics to estimate hazard ratios (HR) of initiation across quartiles (Q) of OOP costs, with Q1 representing the lowest and Q4 the highest OOP costs. The cohort included 72,743 patients (mean[SD] age 72[9.4], 56% male) followed for a median of 914 days. Most (88%) were covered by a Medicare Advantage plan. The unadjusted incidence of initiating a SGLT2i (or GLP-1RA) was 2.8% (2.1%) in Q4 vs. 3.8% (2.8%) in Q1 of OOP costs. The median time to initiation of a SGLT2i/GLP-1RA was longer in Q4 (418/325 days) vs. Q1 (395/3 days) of OOP costs. In fully adjusted models, the HR for Q4 vs. Q1 of OOP costs was 0.79 (95%CI 0.70 to 0.90) for initiating a SGLT2i and 0.88 (95%CI: 0.77 to 1.01) for a GLP-1RA. In this national cohort of patients w/ T2D and established CVD, beneficiaries enrolled in plans in the highest quartile of OOP costs were significantly less likely to initiate a SGLT2i or GLP-1RA compared to those enrolled in plans in the lower quartile. Disclosure: J.Luo: None. R.Feldman: None. S.D.Rothenberger: None. I.Hernandez: Consultant; Bristol-Myers Squibb Company, Pfizer Inc. M.T.Korytkowski: None. W.F.Gellad: None. Funding: NIDDK (K23DK120956) NCATS (KL2TR001856)

Background: Although DKA has been traditionally managed in intensive care units (ICU) , some studies suggest that DKA can be safely treated in non-critical care areas. Objective: To compare safety & efficacy of a DKA IV insulin protocol in ICU with stepdown unit (SDU) . Methods: A retrospective chart review of all DKA patients (Age >yrs) admitted to ICU (N=45) & SDU (N=23) from January 20to August 2020. The admission to SDU was based on our hospital protocol (pH>7.2 without organ failure) . We analyzed the compliance to the DKA protocol (Table) and adverse outcomes. Mann-Whitney U & Chi-square/Fishers exact tests were used to compare continuous & categorical variables respectively. Results: ICU & SDU groups were demographically similar: mean age (36.2 ± 15.2 vs. 37.6 ± 18.9 yrs) , sex (F 67% vs. 70%) & BMI (21.2 vs. 21.8 kg/m2) . As expected, ICU group had severe DKA as compared to SDU group with higher mean BG & lower mean serum Bicarb (p0.05) . Conclusions: Our study suggested that a DKA IV insulin can be safely managed in SDU in selected patients, which can help avoid ICU overcrowding. The observed trend toward less strict compliance with the DKA protocol can be overcome with nurse education and optimal nurse to patient ratio. Disclosure: T.Ahmad: None. N.Mehrotra: None. W.Ali: None. D.Ren: None. J.Arnold: None. M.T.Korytkowski: None. S.Mon: None.

Introduction The purpose of this prospective observational cohort study was to examine sex differences in glycemic measures, diabetes-related complications, and rates of postdischarge emergency room (ER) visits and hospital readmissions in non-critically ill, hospitalized patients with diabetes. Research design and methods Demographic data including age, body mass index, race, blood pressure, reason for admission, diabetes medications at admission and discharge, diabetes-related complications, laboratory data (hematocrit, creatinine, hemoglobin A1c, point-of-care blood glucose measures), length of stay (LOS), and discharge disposition were collected. Patients were followed for 90 days following hospital discharge to obtain information regarding ER visits and readmissions. Results 120 men and 100 women consented to participate in this study. There were no sex differences in patient demographics, diabetes duration or complications, or LOS. No differences were observed in the percentage of men and women with an ER visit or hospital readmission within 30 (39% vs 33%, p=0.40) or 90 (60% vs 49%, p=0.12) days of hospital discharge. More men than women experienced hypoglycemia prior to discharge (18% vs 8%, p=0.026). More women were discharged to skilled nursing facilities (p=0.007). Conclusions This study demonstrates that men and women hospitalized with an underlying diagnosis of diabetes have similar preadmission glycemic measures, diabetes duration, and prevalence of diabetes complications. More men experienced hypoglycemia prior to discharge. Women were less likely to be discharged to home. Approximately 50% of men and women had ER visits or readmissions within 90 days of hospital discharge. Trial registration number NCT03279627.

The majority of observed couple communication research has focused on physically healthy couples and those who are White, educated, and affluent. In the present study, we observed persons with Type 2 diabetes and their romantic partners discuss how to improve diabetes management; afterward, we measured positive affect, negative affect, and discussion evaluations. We also measured mood and self-care behavior over the next 2 weeks. Couples (n = 207) were recruited from the community and varied in education, income, and race. Half of patients were White (53%), and half were Black (47%). Results showed that observed patient warmth was related to a more positive evaluation of the discussion, more postdiscussion positive affect, less postdiscussion negative affect, and better 2-week daily happy mood; observed patient negativity was related to less postdiscussion progress, a more negative evaluation of the discussion, less postdiscussion positive affect, and poorer 2-week dietary adherence; and observed patient distress was related to a more negative discussion evaluation, more postdiscussion negative affect, and worse mood over the next 2 weeks. Two of the findings were moderated by race, in the direction of links being stronger for Black than White patients. Partner warmth was rarely related to outcomes, but partner negativity was related to patients' poorer discussion evaluation, patient's lower happy mood and higher angry mood over the next 2 weeks, and patient's poorer 2-week dietary adherence. Future research on couple interactions should attend to important contextual variables such as race, ethnicity, income, and social status. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Purpose Insomnia is frequently co-morbid with obstructive sleep apnea (OSA); the effect of insomnia or co-morbid insomnia and OSA (OSA + I) on associated metabolic outcomes in adults with type 2 diabetes (T2D) remains unclear. This study in adults with T2D compared metabolic outcomes among persons with OSA, insomnia, or OSA + I. Methods This study analyzed baseline data from the Diabetes Sleep Treatment Trial of persons recruited for symptoms of OSA or poor sleep quality. Home sleep studies determined OSA presence and severity. Insomnia was evaluated using the Insomnia Severity Index. Height and weight to calculate body mass index (BMI) and blood for laboratory values were obtained. Multivariate general linear models were used to examine the impact of the type of sleep disorder and sociodemographic, lifestyle, and sleep risk factors on metabolic outcomes. Results Participants (N = 253) were middle-aged (56.3 ± 10.5 years), white (60.5%), obese (mean BMI of 35.3 ± 7.1 kg/m²), and male (51.4%) with poor glucose control (mean HbA1c of 8.0 ± 1.8%). Most participants had OSA + I (42.7%) or insomnia only (41.0%). HbA1c and BMI differed among the sleep disorder groups. In addition, in the adjusted models, having insomnia only, compared to OSA only, was associated on average with higher HbA1c levels (b = 1.08 ± 0.40, p < 0.007) and lower BMI (b = − 7.03 ± 1.43, p < 0.001). Conclusions Findings suggest that insomnia frequently co-exists with OSA, is independently associated with metabolic outcomes in adults with T2D, and should be considered in investigations of the effects of OSA in persons with T2D. Trial registration Diabetes-Obstructive Sleep Apnea Treatment Trial (NCT01901055), https: Clinicaltrials.gov/ct2/show/NCT01901055; Registration date: July 17, 2013.