American Association of Clinical Endocrinology Consensus Statement: Comprehensive Type 2 Diabetes Management Algorithm - 2023 Update.

OBJECTIVE: This consensus statement provides (1) visual guidance in concise graphic algorithms to assist with clinical decision-making of health care professionals in the management of persons with type 2 diabetes mellitus to improve patient care and (2) a summary of details to support the visual guidance found in each algorithm. METHODS: The American Association of Clinical Endocrinology (AACE) selected a task force of medical experts who updated the 2020 AACE Comprehensive Type 2 Diabetes Management Algorithm based on the 2022 AACE Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan and consensus of task force authors. RESULTS: This algorithm for management of persons with type 2 diabetes includes 11 distinct sections: (1) Principles for the Management of Type 2 Diabetes; (2) Complications-Centric Model for the Care of Persons with Overweight/Obesity; (3) Prediabetes Algorithm; (4) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Dyslipidemia; (5) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Hypertension; (6) Complications-Centric Algorithm for Glycemic Control; (7) Glucose-Centric Algorithm for Glycemic Control; (8) Algorithm for Adding/Intensifying Insulin; (9) Profiles of Antihyperglycemic Medications; (10) Profiles of Weight-Loss Medications (new); and (11) Vaccine Recommendations for Persons with Diabetes Mellitus (new), which summarizes recommendations from the Advisory Committee on Immunization Practices of the U.S. Centers for Disease Control and Prevention. CONCLUSIONS: Aligning with the 2022 AACE diabetes guideline update, this 2023 diabetes algorithm update emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in the management of prediabetes and diabetes mellitus and highlights the importance of appropriate management of atherosclerotic risk factors of dyslipidemia and hypertension. One notable new theme is an emphasis on a complication-centric approach, beyond glucose levels, to frame decisions regarding first-line pharmacologic choices for the treatment of persons with diabetes. The algorithm also includes access/cost of medications as factors related to health equity to consider in clinical decision-making.

Changes in Inflammatory and Bone Turnover Markers After Periodontal Disease Treatment in Patients With Diabetes.

BACKGROUND: The underlying mechanisms for increased osteopenia and fracture rates in patients with diabetes are not well understood, but may relate to chronic systemic inflammation. We assessed the effect of treating periodontal disease (POD), a cause of chronic inflammation, on inflammatory and bone turnover markers in patients with diabetes. MATERIALS AND METHODS: Using an investigator-administered questionnaire, we screened a cross-section of patients presenting for routine outpatient diabetes care. We recruited 22 subjects with POD. Inflammatory and bone turnover markers were measured at baseline and 3 months following POD treatment (scaling, root planing and subantimicrobial dose doxycycline). RESULTS: There were nonsignificant reductions in high-sensitivity C-reactive protein (6.34-5.52mg/L, P = 0.626) and tumor necrosis factor-alpha (10.37-10.01pg/mL, P = 0.617). There were nonsignificant increases in urinary C-terminal telopeptide (85.50-90.23pg/mL, P = 0.684) and bone-specific alkaline phosphatase (7.45-8.79pg/mL, P = 0.074). Patients with >90% adherence with doxycycline were 6.4 times more likely to experience reduction in tumor necrosis factor-alpha (P = 0.021) and 2.8 times more likely to experience reductions in high-sensitivity C-reactive protein (P = 0.133). CONCLUSIONS: Treatment of POD in patients with diabetes resulted in nonsignificant lowering of inflammatory markers and nonsignificant increase in bone turnover markers. However, adherence to doxycycline therapy resulted in better treatment effects.

DENTAL LOSS AMONG AMBULATORY PATIENTS WITH DIABETES.

AIMS: There is a high prevalence of dental loss among patients with diabetes. Understanding the factors that impact dental loss in this population will aid with developing new strategies for its prevention. METHODS: Using a cross-sectional study design, diabetes patients presenting for routine clinic visit were evaluated with an investigator-administered questionnaire. Data was collected on demographics, dental history, duration, control and complications of diabetes. RESULTS: Among 202 subjects, 100 were female, mean age: 58.9 ± 13.2 years, duration of diabetes: 15.8 ± 11.0 years, and hemoglobin A1c: 7.7 ± 1.6%. Thirty-one patients (15.3%) had lost all their teeth and only 13 (6.4%) had all 32 of their natural teeth. Using multiple linear regression, older age (ß= - 0.146; 95% CI: - 0.062 to - 0.230), not flossing (ß= - 3.462; 95% CI: - 1.107 to - 5.817), and presence of diabetic retinopathy (ß= - 4.271; 95% CI: - 1.307 to - 7.236) were significant predictors of dental loss. CONCLUSIONS: Dental loss is common in patients with diabetes and is associated with older age, diabetic retinopathy and not flossing. In order to reduce dental loss among patients with diabetes, regular flossing should be emphasized as an important component of dental care.

Outcomes of Less Intensive Glycemic Target for a Subcutaneous Insulin Protocol in Hospitalized Patients.

BACKGROUND: This study looked at the effect of replacing an intensive subcutaneous insulin correction protocol (old subcutaneous insulin correction protocol [OP]) with a less intensive protocol (new subcutaneous insulin correction protocol [NP]) in a tertiary hospital with the hypothesis that using the NP will result in less hypoglycemia and improved hospital outcomes. METHODS: The charts for 200 hospitalized patients managed with the OP (glycemic target 90-116 mg/dL for intensive care and 90-130 mg/dL for nonintensive care patients) and 200 with the NP (glycemic target 150-200 mg/dL) were reviewed. Data were collected and analyzed using Fisher's exact test and Student's t test. The primary outcome was the difference in hypoglycemia rates between the 2 protocols. Hypothesis test P values of <0.05 were deemed significant. RESULTS: There was no statistically significant difference in age, sex, ethnicity, body mass index, level of hospital care or use of scheduled insulin for the 2 groups (P > 0.05 for all). Average blood glucose values were 160.45 and 169.98 mg/dL for the OP and NP, respectively (P = 0.063). There were 14 readings ≤ 40 mg/dL in the OP compared with 6 in the NP (P = 0.046). With the OP, 27 patients required dextrose treatment compared to 11 with the NP (P = 0.0097). The average length of hospitalization was longer for the NP compared with the OP (13.16 versus 6.56 days, P = 0.00085). CONCLUSIONS: A less intensive subcutaneous insulin correction protocol in hospitalized patients resulted in similar glucose values with less severe hypoglycemia. However, it was associated with longer length of hospitalization.

Frax prediction without BMD for assessment of osteoporotic fracture risk.

OBJECTIVE: To compare Fracture Risk Assessment Tool (FRAX) calculations with and without bone mineral density (BMD) in predicting the 10-year probability of hip and major osteoporotic fractures (MOF). METHODS: A cross-sectional review of patients requiring screening for osteoporosis as part of their routine medical care was conducted. Postmenopausal women and men over 50 years of age who were never diagnosed with osteoporosis or treated with U.S. Food and Drug Administration-approved agents for osteoporosis were included. Height, weight, FRAX questionnaire, femoral neck BMD, and T-score data were obtained. FRAX scores with BMD (FRAX/BMD) and without BMD (FRAX) were calculated. Subjects were separated on the basis of identical and different treatment recommendations. Fracture risk factors were compared between groups using simple Student's t test analysis of numerical variables and Fisher's exact test analysis of binary variables. RESULTS: Of 151 total subjects, 127 (84%) had identical fracture risk predictions with or without BMD included in the FRAX calculation. Thirty subjects met treatment criteria and 97 did not, but the FRAX prediction was the same with risk factors alone or with risk factors plus BMD. Age was the only risk factor that was significantly different between those with identical and different predictions (median age, 64.42 and 76.25 years, respectively; P<.001). CONCLUSION: In most cases, FRAX alone provides the same prediction as FRAX with BMD. Younger age is more indicative of an identical prediction.

Impact of a hyperglycemic crises protocol.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of an adult hyperglycemic crises protocol based upon the 2009 American Diabetes Association (ADA) consensus statement. METHODS: We performed a retrospective review of patients treated before and after protocol implementation at a university teaching hospital. A total of 256 adult patients met the criteria for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) and were treated with an insulin infusion between February 2011 and February 2012 (nonprotocol n = 143, protocol n = 113). Protocol efficacy was evaluated by assessing time to resolution of DKA or HHS, length of stay (LOS) in the intensive care unit (ICU), and LOS in the hospital. Protocol safety was evaluated by assessing the numbers of patients with hypoglycemic and hypokalemic events. RESULTS: Patients on the hyperglycemic crises protocol experienced a 9.2 hour (95% confidence interval (CI): 4.70-13.70; P<.001) decrease in time to resolution, with nonprotocol patients (n = 143) resolving in 22.78 hours and protocol patients (n = 113) resolving in 13.58 hours. There was no difference in safety outcomes, including the number of patients with moderate hypoglycemia (blood glucose <70 mg/dL), severe hypoglycemia (blood glucose <50 mg/dL), or hypokalemia (K+ <3.3 mmol/L). CONCLUSION: Implementation of a hyperglycemic crises protocol decreased times to resolution of DKA and HHS without increasing the rate of hypoglycemia or hypokalemia.

Fracture assessment tool risk scores in bone density reports do not change physician prescribing behavior for osteoporosis.

INTRODUCTION: Prevention of osteoporotic fractures is desirable to decrease morbidity, mortality and health care costs. The World Health Organization Fracture Assessment Tool (FRAX) enhances physician treatment decisions by combining epidemiologic fracture risk calculations with bone density. The authors sought to determine the effect of reporting FRAX results and treatment recommendations in bone density reports on clinician prescribing behavior. METHODS: Retrospective review of adherence to treatment recommendations for 368 osteopenic patients at a VA Medical Center 7 months before (pre-FRAX) and after (post-FRAX) inclusion of fracture risk assessment data into the dual energy X-ray absorptiometry. Only osteopenic patients were included (T score: -1.0

Improved glycemic control without an increase in severe hypoglycemic episodes in intensively treated patients with type 1 diabetes receiving morning, evening, or split dose insulin glargine.

OBJECTIVE: To see if insulin glargine improves glycemic control in a clinical setting. RESEARCH DESIGN AND METHODS: A questionnaire and electronic database were used to assess glycemic parameters for 292 type 1 diabetic subjects taking > or =4 injections per day and receiving glargine as their only long-acting basal insulin for at least 6 months. Sixty-three subjects were taking glargine in the morning, 125 were taking glargine in the evening, and 104 were splitting the glargine dose between the morning and evening. RESULTS: The mean (+/-S.D.) age and duration of diabetes were 32 +/- 10 years and 15.9 +/- 10.3 years, respectively. The mean (+/-S.E.M.) durations of treatment with glargine were 13.1 +/- 0.6 months, 12.2 +.- 0.4 months, and 14.3 +/- 0.5 months for the morning, evening, and split treatment groups, respectively (P < 0.01). The A1C values improved significantly from baseline for the evening and the split dosage groups or when all groups were combined. The mean basal insulin dose was significantly reduced at the end of the study in all the three groups from baseline with no change in the short-acting insulin dose. The number of severe hypoglycemic episodes decreased from 379 in the year prior to glargine treatment to 167 in the post-glargine year. The weight gain was significantly higher in the group that took the split glargine dose (P < 0.01). CONCLUSIONS: Similar or improved glycemic control was achieved by administering glargine in the morning, evening, or using a split dose without any further increase in severe hypoglycemic episodes. Splitting the glargine dose did not offer any advantages in glycemic control parameters.