Continuous glucose monitoring in the hospital: an update in the era of COVID-19.

PURPOSE OF REVIEW: Continuous glucose monitoring (CGM) systems are Food and Drug Administration approved devices for the ambulatory setting; however, they remain investigational systems for inpatient use. This review summarizes the most recent and relevant literature on the use of continuous glucose monitoring in the hospital setting. RECENT FINDINGS: CGM provides real-time glucose data that enable healthcare professionals to make proactive and timelier clinical decisions with regards to diabetes management. CGM devices appear to be safe and accurate systems for glucose monitoring in the hospital setting. Real-time CGM systems and glucose telemetry can decrease hypoglycemia and reduce hyperglycemia in hospitalized patients with diabetes. Remote glucose monitoring decreases the need of frequent Point-of-care checks and personal protective equipment use while also mitigating staff exposure risk which is timely in the advent of the COVID-19 pandemic. Although most nursing staff have limited exposure and training on CGM technology, early studies show that CGM use in the hospital is well received by nurses. SUMMARY: Given the evidence in the current literature regarding CGM use in the hospital, CGM devices may be incorporated in the inpatient setting.

Accuracy of Dexcom G6 Continuous Glucose Monitoring in Non-Critically Ill Hospitalized Patients With Diabetes.

OBJECTIVE: Advances in continuous glucose monitoring (CGM) have transformed ambulatory diabetes management. Until recently, inpatient use of CGM has remained investigational, with limited data on its accuracy in the hospital setting. RESEARCH DESIGN AND METHODS: To analyze the accuracy of Dexcom G6, we compared retrospective matched-pair CGM and capillary point-of-care (POC) glucose data from three inpatient CGM studies (two interventional and one observational) in general medicine and surgery patients with diabetes treated with insulin. Analysis of accuracy metrics included mean absolute relative difference (MARD), median absolute relative difference (ARD), and proportion of CGM values within 15, 20, and 30% or 15, 20, and 30 mg/dL of POC reference values for blood glucose >100 mg/dL or ≤100 mg/dL, respectively (% 15/15, % 20/20, % 30/30). Clinical reliability was assessed with Clarke error grid (CEG) analyses. RESULTS: A total of 218 patients were included (96% with type 2 diabetes) with a mean age of 60.6 ± 12 years. The overall MARD (n = 4,067 matched glucose pairs) was 12.8%, and median ARD was 10.1% (interquartile range 4.6, 17.6]. The proportions of readings meeting % 15/15, % 20/20, and % 30/30 criteria were 68.7, 81.7, and 93.8%, respectively. CEG analysis showed 98.7% of all values in zones A and B. MARD and median ARD were higher in the case of hypoglycemia (<70 mg/dL) and severe anemia (hemoglobin <7 g/dL). CONCLUSIONS: Our results indicate that CGM technology is a reliable tool for hospital use and may help improve glucose monitoring in non-critically ill hospitalized patients with diabetes.

Reducing Inpatient Hypoglycemia in the General Wards Using Real-time Continuous Glucose Monitoring: The Glucose Telemetry System, a Randomized Clinical Trial.

OBJECTIVE: Use of real-time continuous glucose monitoring (RT-CGM) systems in the inpatient setting is considered investigational. The objective of this study was to evaluate whether RT-CGM, using the glucose telemetry system (GTS), can prevent hypoglycemia in the general wards. RESEARCH DESIGN AND METHODS: In a randomized clinical trial, insulin-treated patients with type 2 diabetes at high risk for hypoglycemia were recruited. Participants were randomized to RT-CGM/GTS or point-of-care (POC) blood glucose testing. The primary outcome was difference in inpatient hypoglycemia. RESULTS: Seventy-two participants were included in this interim analysis, 36 in the RT-CGM/GTS group and 36 in the POC group. The RT-CGM/GTS group experienced fewer hypoglycemic events (<70 mg/dL) per patient (0.67 [95% CI 0.34-1.30] vs. 1.69 [1.11-2.58], P = 0.024), fewer clinically significant hypoglycemic events (<54 mg/dL) per patient (0.08 [0.03-0.26] vs. 0.75 [0.51-1.09], P = 0.003), and a lower percentage of time spent below range <70 mg/dL (0.40% [0.18-0.92%] vs. 1.88% [1.26-2.81%], P = 0.002) and <54 mg/dL (0.05% [0.01-0.43%] vs. 0.82% [0.47-1.43%], P = 0.017) compared with the POC group. No differences in nocturnal hypoglycemia, time in range 70-180 mg/dL, and time above range >180-250 mg/dL and >250 mg/dL were found between the groups. The RT-CGM/GTS group had no prolonged hypoglycemia compared with 0.20 episodes <54 mg/dL and 0.40 episodes <70 mg/dL per patient in the POC group. CONCLUSIONS: RT-CGM/GTS can decrease hypoglycemia among hospitalized high-risk insulin-treated patients with type 2 diabetes.

The use of diazoxide in the management of spontaneous hypoglycemia in patients with ESRD.

Although diabetes remains the number one cause of renal failure nationwide, spontaneous hypoglycemia in patients with CKD has also been described in the absence of exogenous insulin or any other diabetes treatment. Decreased renal gluconeogenesis and impaired renal insulin clearance are underlying mechanisms of hypoglycemia in individuals with ESRD. Diazoxide was originally approved as an anti-hypertensive medication, but also is known to bind ATP-sensitive K channels in the beta cells of the pancreas, ultimately leading to inhibition of insulin release. We detail six cases of ESRD-associated hypoglycemia which responded to treatment with diazoxide therapy.

Severe hypercalcaemia due to household cleaner ingestion.

We report the case of a 59-year-old man with a history of type 2 diabetes, hypertension and chronic kidney disease who presented with symptomatic severe hypercalcaemia (calcium 15.8 mg/dL) and acute kidney injury. Evaluation revealed that the hypercalcaemia was not mediated by parathyroid hormone (PTH), PTH-related peptide or 1,25-hydroxyvitamin D. Adrenal insufficiency was subsequently diagnosed and was initially thought to be the aetiology of the hypercalcaemia. He was treated with intravenous fluid, pamidronate and started on hydrocortisone with resolution of his hypercalcaemia. Over the next several months, despite adherence to hydrocortisone therapy, the patient continued to have recurrent severe hypercalcaemia requiring hospitalisation. Additional laboratory evaluation showed similar results to the initial evaluation. On further questioning, the patient admitted to routinely ingesting the household cleaning product Comet, which contains a large amount of calcium. Psychiatric assessment confirmed the diagnosis of pica. The patient eventually discontinued ingestion of Comet with resolution of his hypercalcaemia.

Designing the Glucose Telemetry for Hospital Management: From Bedside to the Nursing Station.

PURPOSE OF THE REVIEW: Hospitalized patients with diabetes are monitored with point-of-care glucose testing. Continuous glucose monitoring (CGM) devices represent an alternative way to monitor glucose values; however, the in-hospital CGM use is still considered experimental. Most inpatient studies used "blinded" CGM properties and only few used the real-time/unblinded CGM features. One major limitation of the CGM devices is that they need to be placed at the patients' bedside, limiting any therapeutic interventions. In this article, we review the real-time/unblinded CGM use and share our thoughts about the development of future inpatient CGM systems. RECENT FINDINGS: We recently reported that glucose values can be wirelessly transmitted to the nursing station, providing remote continuous glucose monitoring. Future inpatient CGM devices may be utilized for patients at risk for hypoglycemia similarly to the way that we use cardiac telemetry to monitor hospitalized patients who are at increased risk for cardiac arrhythmias.

GLYCOGENIC HEPATOPATHY: A COMPLICATION OF UNCONTROLLED DIABETES.

OBJECTIVE: To describe a case of hepatomegaly and elevated transaminases in a patient with glycogenic hepatopathy (GH) as a complication of uncontrolled diabetes. METHODS: Clinical, laboratory, and pathological information are described. RESULTS: An 18-year-old male with uncontrolled type 1 diabetes and recurrent diabetic ketoacidosis (DKA) presented with abdominal distention and severe hyperglycemia. Physical examination revealed massive hepatomegaly. Laboratory evaluation showed anion-gap metabolic acidosis, ketonuria, and markedly elevated aspartate and alanine amino transaminases (AST = 1,162 IU/L and ALT = 598 IU/L, respectively). Despite resolution of DKA with insulin infusion, transaminases continued to increase (peak AST = 3,725 U/L, ALT = 1,049 U/L) with no signs of liver failure (normal coagulation profile and albumin level). Abdominal ultrasonography revealed an enlarged liver with moderate echogenicity, consistent with steatosis. Extensive evaluation for causes of hepatitis including toxic, autoimmune, genetic, and infectious diseases was unrevealing. Liver biopsy showed no signs of nonalcoholic fatty liver disease (NAFLD), such as fibrosis, steatosis, or portal inflammation. However, swollen hepatocytes with glycogen accumulation consistent with GH were seen. CONCLUSION: GH can present as hepatomegaly and elevated liver transaminases in patients with uncontrolled diabetes. Clinicians should consider GH in patients with uncontrolled diabetes after ruling out other common causes. Liver ultrasound cannot differentiate this condition from the more commonly seen NAFLD. Although liver biopsy remains a gold standard, evaluation with magnetic resonance imaging may be considered as a less invasive alternative in the appropriate clinical setting.