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OBJECTIVE The efficacy and safety of continuous glucose monitoring (CGM) in adjusting inpatient insulin therapy have not been evaluated. RESEARCH DESIGN AND METHODS This randomized trial included 185 general medicine and surgery patients with type 1 and type 2 diabetes treated with a basal-bolus insulin regimen. All subjects underwent point-of-care (POC) capillary glucose testing before meals and bedtime. Patients in the standard of care (POC group) wore a blinded Dexcom G6 CGM with insulin dose adjusted based on POC results, while in the CGM group, insulin adjustment was based on daily CGM profile. Primary end points were differences in time in range (TIR; 70–180 mg/dL) and hypoglycemia ( RESULTS There were no significant differences in TIR (54.51% ± 27.72 vs. 48.64% ± 24.25; P = 0.14), mean daily glucose (183.2 ± 40 vs. 186.8 ± 39 mg/dL; P = 0.36), or percent of patients with CGM values CONCLUSIONS The inpatient use of real-time Dexcom G6 CGM is safe and effective in guiding insulin therapy, resulting in a similar improvement in glycemic control and a significant reduction of recurrent hypoglycemic events compared with POC-guided insulin adjustment.

AIMS: Limited data exists about the use of insulin degludec in the hospital. This multicentre, non-inferiority, open-label, prospective randomised trial compared the safety and efficacy of insulin degludec-U100 and glargine-U100 for the management of hospitalized patients with type 2 diabetes. METHODS: A total of 180 general medicine and surgery patients with an admission blood glucose (BG) between 7·8 – 22·2 mmol/L, treated with oral agents or insulin prior to hospitalization were randomly allocated (1:1) to a basal bolus regimen using degludec (n=92) or glargine (n=88), as basal and aspart before meals. Insulin dose was adjusted daily to a target BG between 3·9 – 10·0 mmol/L. The primary end point was difference in the mean hospital daily BG between groups. RESULTS: Overall, the randomization BG was 12·2 ± 2·9 mmol/L and HbA1c 84 mmol/mol (9·8±2·0%). There were no differences in mean daily BG (10·0±2·1 vs. 10·0±2·5 mmol/L, p=0·9), proportion of BG in target range (54·5± 29% vs. 55·3 ± 28%, p=0·85), basal insulin (29·6 ± 13 vs 30·4 ± 18 units/day, p=0·85), length of stay (median (IQR): 6·7 (4·7–10·5) vs. 7·5 (4·7–11·6) days, p=0·61), hospital complications (23% vs. 23%, p=0·95) between treatment groups. There were no differences in the proportion of patients with BG

Objective: Administration of supplemental sliding scale insulin (SSI) for correction of hyperglycemia in non-ICU patients with type 2 diabetes is frequently used with basal-bolus insulin regimens. This non-inferiority randomized controlled trial tested whether glycemic control is similar with and without aggressive SSI before meals and bedtime in patients treated with basal-bolus insulin regimens. Research Design and Methods: Patients with type 2 diabetes, with admission blood glucose (BG)140-400 mg/dl treated with basal-bolus insulin were randomized to Intensive (correction for BG>140 mg/dl, n=108) or to Non-Intensive (correction for BG>260 mg/dl, n=107) administration of rapid-acting SSI before meals and bedtime. Both groups received the same amount of SSI for BG>260 mg/dl. Primary outcome was difference in mean daily BG levels between the groups during hospitalization. Results: Mean daily BG in the Non-Intensive group was non-inferior to BG in the Intensive group with equivalence margin of 18 mg/dl (Intensive: 172±38 mg/dl vs Non-Intensive: 173±43 mg/dl, p=0.001 for non-inferiority). There were no differences in the proportion of target BG readings of 70-180 mg/dl, hypoglycemia (350 mg/dl), or total, basal or prandial insulin doses. Significantly fewer subjects received SSI in the Non-Intensive (n=36,34%) compared to the Intensive group (n=98,91% [p Conclusions: Among non-ICU patients with type 2 diabetes on optimal basal-bolus insulin regimen with moderate hyperglycemia (BG

Metformin is the broadly accepted the first-line medication for diabetes. Its use, however, is limited by gastrointestinal side effects, which occur in approximately 25% of patients. We performed a cross-sectional study assessing microbiota composition among African Americans (AA) with diabetes with or without metformin intolerance. Participants were stratified into three groups: 1) Intolerant (I) : history of metformin intolerance, not currently on metformin) ; 2) Partially intolerant (PI) : reporting GI symptoms and currently on metformin 3) Tolerant (T) : current metformin use with no GI symptoms. Rectal swab was collected and microbiota analyzed by amplification and sequencing of the V4 region of the 16s rRNA gene.Among 29 participants, mean age 59 ± 11, 58 % female, group I had greatest alpha diversity, followed by T and PI, although differences were not significant (I: 4.9; T: 4.2; PI: 3.9) . Mean difference in alpha diversity for I versus PI were 1.0 (95% CI -0.1, 2.1) and I versus T were 0.7 (95% CI -0.4, 1.8) . Phyla enrichment shown in figure. Conclusion: This pilot study evaluated the role of microbiota in metformin intolerance among African Americans. We identify differences in alpha diversity and microbiota. Prospective studies are needed to assess the role of microbial diversity and dysbiosis in metformin-related gastrointestinal symptoms. Disclosure M.Fayfman: None. S.Srinivasan: None. G.E.Umpierrez: Research Support; AstraZeneca, Dexcom, Inc., Novo Nordisk. G.Blanco: None. A.Gewirtz: None. B.Chassaing: Advisory Panel; Nestlé Health Science, Consultant; Procter & Gamble, Qiagen. Funding P30-DK-111024

IDegLira-HIGH trial was a non-inferiority, prospective, randomized clinical trial, comparing the efficacy and safety of insulin degludec/liraglutide combination (IDegLira) and a regimen of multiple daily injections (MDI) with basal-bolus insulin (BB) in adults (>18-80 years of age) , with type 2 diabetes (T2D) , and very high HbA1c (>9%-15%) , previously treated with basal insulin or multiple oral agents. Primary endpoint was change in HbA1c from baseline to week 26. Secondary endpoints included incidence of hypoglycemia, changes on weight and glycemic variability (% coefficient of variation [%CV]) . Treatment with IDegLira and BB insulin resulted in similar improvement in glycemic control: 7.7±1.7% and 7.7±1.5%, (p=0.76) , with a reduction from baseline of -3.2±2.3% and -3.0±1.8%, (p=0.39) at 26-weeks. IDegLira resulted in lower rates of hypoglycemia Disclosure R.J.Galindo: Advisory Panel; Sanofi, WW International, Inc., Research Support; Dexcom, Inc., Eli Lilly and Company, Novo Nordisk. G.E.Umpierrez: Research Support; AstraZeneca, Dexcom, Inc., Novo Nordisk. B.Moazzami: None. M.F.Scioscia: None. P.Vellanki: n/a. G.M.Davis: Consultant; Medscape, Research Support; Insulet Corporation. F.J.Pasquel: Consultant; AI Health LLC, Boehringer Ingelheim International GmbH, Dexcom, Inc., Research Support; Dexcom, Inc., Insulet Corporation, Merck & Co., Inc. M.Fayfman: None. A.L.Migdal: None. J.Saling: None. Funding Investigator-initiated study to Emory University (PI. Dr. Rodolfo J. Galindo) from Novo Nordisk.

Few studies have reported on differences in glycemic control and glucose variability by continuous glucose monitoring (CGM) in hospitalized insulin-treated older adults with type 2 diabetes (T2D) . Accordingly, we combined data from 3 inpatient randomized clinical trials using CGM in insulin-treated patients with T2D. Glycemic parameters were compared in 103 older adults (≥60 years) and 160 younger adults ( Disclosure T.Idrees: None. F.J.Pasquel: Consultant; AI Health LLC, Boehringer Ingelheim International GmbH, Dexcom, Inc., Research Support; Dexcom, Inc., Insulet Corporation, Merck & Co., Inc. L.Peng: None. G.E.Umpierrez: Research Support; AstraZeneca, Dexcom, Inc., Novo Nordisk. R.J.Galindo: Advisory Panel; Sanofi, WW International, Inc., Research Support; Dexcom, Inc., Eli Lilly and Company, Novo Nordisk. M.A.Urrutia: None. I.A.Castro-revoredo: None. E.Moreno: None. A.L.Migdal: None. G.Davis: Consultant; Medscape, Research Support; Insulet Corporation. P.Vellanki: n/a. M.Fayfman: None.

Background: Metformin reduces intestinal absorption of Vitamin B12 in up to 30% of patients and lowers serum Vitamin B12 concentrations in 5-10%. In 2017, the American Diabetes Association (ADA) updated its guidelines to recommend patients taking metformin undergo regular monitoring of Vitamin B12 levels. To better understand acceptance and application of these guidelines, we undertook an assessment of such monitoring within a single hospital center serving the low-income population in Atlanta, GA to assist in guiding optimal monitoring and patient management. Methods: Data was collected from a single hospital center using electronic medical records (EMR) and the SlicerDicer tool to identify all outpatients for whom metformin was prescribed either as a single agent or in combination therapy during January 1 - December 31, 2021 and then measure Vitamin B12 prescribing among primary care patients and patients followed by endocrinology and further analyze which patients had neuropathy. Results: During the period studied, of the total 2,336,914 patients documented in the EMR, 30,803 (0.01%) were outpatients prescribed metformin either as a single agent or in combination therapy. Of these, 816 patients (2.6%) had Vitamin B12 levels ordered and measured. The prevalence of Vitamin B12 levels ordered and measured was 7.5% (674 of 8,975) among patients seen in primary care clinics and 2.3% among those followed in endocrinology (25 of 1,081) (chi-square p Conclusion: Among two outpatient cohorts who were prescribed metformin, there was suboptimal adherence to the ADA’s recommendation for regular monitoring of Vitamin B12 levels. Approaches for increasing and optimizing ordering and monitoring Vitamin B12 levels will be developed. Increased awareness of the relationship between metformin and Vitamin B12 deficiency and standardized approaches to monitoring are needed. Disclosure R. D. Ghiya: None. M. Fayfman: None.

Background: Higher HbA1c on admission is associated with increased amputation risk in patients with diabetic foot ulcers (DFUs) ; however, the impact of long-term glycemic control and glycemic variability after hospital discharge on amputation risk is unclear. Methods: We performed retrospective analyses of hospitalized patients with a DFU who were followed for >1 year after index admission with at least two HbA1c measurements and > 1-year follow-up (n=479) . Using multivariable logistic regression analysis, we examined the associations of HbA1c measures [HbA1c nadir change (difference between the baseline HbA1c and the single lowest prospective HbA1c level during the follow-up) , standard deviation (SD-HbA1c) , mean HbA1c change, and HbA1c variability score (HVS) ] with a composite outcome [minor and major lower extremity amputations (LEA) and mortality]. Results: The median age was 55.3 (IQR: 47.9, 62.8) years. During a mean follow-up of 2.4 years, 250 (52.2%) patients had a LEA or death [minor LEA: 116 (24.2%) ; major LEA: 113 (23.4%) ; death: 21 (4.4%) ]. In the fully adjusted model, HbA1c variability metrics were significantly associated with higher LEA and/or death rates, except HVS (Table) . Conclusion: Our findings indicate that visit-to-visit HbA1c variability, especially HbA1c nadir change, and SD-HbA1c are independent biomarkers of LEA risk in patients with DFU. Disclosure R.Jagannathan: None. M.Schechter: None. J.A.Alvarez: None. G.Blanco: None. R.Rajani: None. G.Santamarina: None. G.E.Umpierrez: Research Support; AstraZeneca, Dexcom, Inc., Novo Nordisk. M.Fayfman: None. Funding Emory Medical Care Foundation to MCS and MF

AIM: To compare a glucagon-like peptide-1 receptor agonist with basal insulin at hospital discharge in patients with uncontrolled type 2 diabetes in a randomized clinical trial. METHODS: A total of 273 patients with glycated haemoglobin (HbA1c) 7%–10% (53–86 mol/mol) were randomized to liraglutide (n = 136) or insulin glargine (n = 137) at hospital discharge. The primary endpoint was difference in HbA1c at 12 and 26 weeks. Secondary endpoints included hypoglycaemia, changes in body weight, and achievement of HbA1c

Background Hyperglycaemia is associated with increased incidence of perioperative complications. We assessed whether treatment with sitagliptin, starting before surgery and continued during the hospital stay, can prevent and reduce the severity of perioperative hyperglycaemia in patients with type 2 diabetes undergoing coronary artery bypass graft (CABG) surgery. Martials and methods We conducted a double-blinded, placebo-control trial in adults with type 2 diabetes randomly assigned to receive sitagliptin or matching placebo starting one day prior to surgery and continued during the hospital stay. The primary outcome was difference in the proportion of patients with postoperative hyperglycaemia (blood glucose [BG] >10mmol/L [>180mg/dL]) in the intensive care unit (ICU). Secondary endpoints included differences in mean daily BG in the ICU and after transition to regular wards, hypoglycaemia, hospital complications, length of stay, and need of insulin therapy. Results We included 182 participants randomised to receive sitagliptin or placebo (91 per group, age 64±9 years, HbA1C: 7∙6±1∙5%, and diabetes duration: 10±9 years). There were no differences in number of patients with postoperative BG >10 mmol/L, mean daily BG in the ICU or after transition to regular floors, hypoglycaemia, hospital complications or length of stay. There were no differences on insulin requirements in the ICU; however, sitagliptin therapy was associated with lower mean daily insulin requirements (21∙1±18∙4 vs 32∙5±26∙3 units, p=0∙007) after transition to regular floor compared to placebo. Conclusion The administration of sitagliptin prior to surgery and during the hospital stay, did not prevent perioperative hyperglycaemia or complications after CABG. Sitagliptin therapy was associated with lower mean daily insulin requirements after transition to regular floors. This article is protected by copyright. All rights reserved.

OBJECTIVE We compared the performance of the FreeStyle Libre Pro continuous glucose monitoring (CGM) and point-of-care capillary glucose testing (POC) among insulin-treated hospitalized patients with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS This was a prospective study in adult patients with T2D admitted to general medicine and surgery wards. Patients were monitored with POC before meals and bedtime and with CGM during the hospital stay. Study end points included differences between POC and CGM in mean daily blood glucose (BG), hypoglycemia RESULTS Mean daily glucose was significantly higher by POC (188.9 ± 37.3 vs. 176.1 ± 46.9 mg/dL) with an estimated mean difference of 12.8 mg/dL (95% CI 8.3–17.2 mg/dL), and proportions of patients with glucose readings CONCLUSIONS Compared with POC, FreeStyle Libre CGM showed lower mean daily glucose and higher detection of hypoglycemic events, particularly nocturnal and prolonged hypoglycemia in hospitalized patients with T2D. CGM’s accuracy was lower in the hypoglycemic range.

Background Metformin reduces intestinal absorption of Vitamin B12 in up to 30% of patients and lowers serum Vitamin B12 concentrations in 5-10%. The dose and duration of metformin use correlates with the risk of Vitamin B12 deficiency. Low serum levels may be detected as early as 3-4 months after starting metformin; however, symptomatic deficiency is more likely to present after 5-10 years of metformin therapy. In 2017, the American Diabetes Association (ADA) updated its treatment guidelines to recommend patients taking metformin undergo regular monitoring of Vitamin B12 levels. To better understand acceptance and application of these guidelines, we undertook an assessment of such monitoring within a single hospital center serving the low-income population in Atlanta, GA to assist in guiding optimal monitoring and patient management. Methods Data was collected from a single hospital center using electronic medical records (EMR) and the SlicerDicer tool to identify all outpatients for whom metformin was prescribed either as a single agent or in combination therapy during January 1 – December 31, 2021 and then measure Vitamin B12 prescribing among two cohorts during the same time period: primary care patients and patients followed by the diabetes center. Results During the period studied, of the total 2,336,914 patients documented in the EMR, 30,803 (0.01%) were outpatients whom metformin had been prescribed either as a single agent or in combination therapy. Of these, 816 patients (2.6%) had Vitamin B12 levels ordered and measured. The prevalence of Vitamin B12 levels ordered and measured was greater among primary care patients (673 of 8,971 [7.5%]) when compared with patients followed by the diabetes center (25 of 1,081 [2.3%]) (chi-square p Conclusion Our study determined that among two outpatient cohorts who were prescribed metformin there was suboptimal adherence to the ADA's recommendation for regular monitoring of Vitamin B12 levels. The findings of this study will be used to develop approaches for increasing and optimizing ordering and monitoring Vitamin B12 levels for patient care management. Increased awareness of the relationship between metformin and Vitamin B12 deficiency and standardized approaches to monitoring are needed. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

OBJECTIVE Administration of supplemental sliding scale insulin for correction of hyperglycemia in non–intensive care unit (ICU) patients with type 2 diabetes is frequently used with basal-bolus insulin regimens. In this noninferiority randomized controlled trial we tested whether glycemic control is similar with and without aggressive sliding scale insulin treatment before meals and bedtime in patients treated with basal-bolus insulin regimens. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes with admission blood glucose (BG) 140–400 mg/dL treated with basal-bolus insulin were randomized to intensive (correction for BG >140 mg/dL, n = 108) or to nonintensive (correction for BG >260 mg/dL, n = 107) administration of rapid-acting sliding scale insulin before meals and bedtime. The groups received the same amount of sliding scale insulin for BG >260 mg/dL. Primary outcome was difference in mean daily BG levels between the groups during hospitalization. RESULTS Mean daily BG in the nonintensive group was noninferior to BG in the intensive group with equivalence margin of 18 mg/dL (intensive 172 ± 38 mg/dL vs. nonintensive 173 ± 43 mg/dL, P = 0.001 for noninferiority). There were no differences in the proportion of target BG readings of 70–180 mg/dL, 350 mg/dL (severe hyperglycemia) or total, basal, or prandial insulin doses. Significantly fewer subjects received sliding scale insulin in the nonintensive (n = 36 [34%]) compared with the intensive (n = 98 [91%] [P < 0.0001]) group with no differences in sliding scale insulin doses between the groups among those who received sliding scale insulin (intensive 7 ± 4 units/day vs. nonintensive 8 ± 4 units/day, P = 0.34). CONCLUSIONS Among non-ICU patients with type 2 diabetes on optimal basal-bolus insulin regimen with moderate hyperglycemia (BG

There are limited data on post-hospital discharge clinic attendance rates and outcomes among patients with diabetic foot ulcers (DFUs).Retrospective study of patients hospitalized with a DFU from 2016 to 2019 in a large public hospital. We measured rates and predictors of clinic attendance with providers involved with DFU care within 30 days of hospital discharge ("30-day post-discharge clinic attendance"). Log-binomial regression was used to estimate risk ratios (RR) and 95 % confidence intervals (CI).Among 888 patients, 60.0 % were between 45 and 64 years old, 80.5 % were Black, and 24.1 % were uninsured. Overall, 478 (53.8 %) attended ≥1 30-day post-discharge clinic appointment. Initial hospital outcomes were associated with clinic attendance. For example, the RR of 30-day post-discharge clinic attendance was 1.39 (95%CI 1.19-1.61) among patients who underwent a major amputation compared to patients with DFUs without osteomyelitis and did not undergo an amputation during the initial hospitalization. Among 390 patients with known 12-month outcome, 71 (18.2 %) had a major amputation or died ≤12 months of hospital discharge.We found a low post-discharge clinic attendance and high post-discharge amputation and death rates among patients hospitalized with DFUs. Interventions to increase access to outpatient DFU care are needed and could prevent amputations.

The efficacy of continuous glucose monitoring (CGM) after hospital discharge in patients with diabetes (DM) has not been established. This prospective pilot study compared glycemic outcomes between capillary blood glucose (CBG) and CGM after hospital discharge. At discharge, a blinded Dexcom G6 CGM was inserted in 82 patients with DM. Patients were asked to perform CBG testing (3-4/d) and to return the CBG logs and CGM device after 10 days of discharge. Patients were treated with insulin ± oral antidiabetic agents and followed by their primary care team. A total of 65 patients (73.3%) returned their CGM and were included (age 58.3±11 years, 56% Males, HbA1c 8.7±2%, 98% DM2). Only 42 patients (51.2%) returned CBG logs (mean 3.01±0.9 CBG/d). CGM detection of hypoglycemia Disclosure R. J. Galindo: Consultant; Self; Abbott Diabetes, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk, Sanofi US, Valeritas, Inc., Research Support; Self; Dexcom, Inc., Novo Nordisk. M. C. Perez-guzman: None. S. Cardona: None. F. J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Research Support; Self; Dexcom, Inc., Merck & Co., Inc. L. Peng: None. G. E. Umpierrez: Research Support; Self; AstraZeneca, Dexcom, Inc., Novo Nordisk. G. Davis: None. T. Idrees: None. M. A. Urrutia: None. K. W. Zamudio: None. B. S. Albury: None. A. Migdal: None. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. M. Fayfman: None. Funding Dexcom, Inc.

Limited data exist about the use of insulin degludec in the hospital. This prospective, open-label, randomized clinical trial compared the efficacy and safety of a basal-bolus regimen using degludec U100 or glargine U100 for the management of patients with T2D. A total of 181 general medicine and surgery patients (age: 56±11, diabetes duration: 13.0±9.2 years) with an admission BG: 140-400 mg/dL and treated with oral agents or insulin prior to admission were randomized to degludec (n=93) or glargine (n=88). Total daily insulin dose started at 0.4 U/kg/d for BG: 140-200 mg/dL or 0.5 U/kg/d for BG: 201-400 mg/dL half dose given as basal (degludec or glargine) once daily and half as prandial (aspart) before meals. Insulin was adjusted daily to a target BG before meals between 70-180 mg/dL. The primary outcome was a difference in mean daily BG during the hospital stay. For the entire cohort, the BG at randomization was 218.6±52 mg/dL and HbA1c: 9.79±2.0% [mean±SD]. There were no differences in mean daily BG (180.1±38 vs. 180.0±45 mg/dL, p=0.9), proportion of BG in target range of 70-180 mg/dL (54.5±29% vs. 55.3±28%, p=0.85), total daily insulin dose (56±24 vs. 59±36 units/day, p=0.92), basal insulin (29.6±13 vs. 30.4±18 units/day, p=0.85), length of stay (median (IQR): 6.7 (4.7-10.5) vs. 7.5 (4.7,11.6) days, p=0.61), hospital complications (23% vs. 23%, p=0.95), or treatment failures ([mean daily BG>240 mg/dL or >2 consecutive BG>240 mg/dL] 9.8% vs. 13%, p=0.62) between degludec and glargine. There were no differences in the proportion of patients with BG In summary, our study indicates that hospital treatment with degludec U100 or glargine U100 is equally effective and safe in improving glycemic control in general medicine and surgery patients with T2D. Disclosure R. J. Galindo: Consultant; Self; Abbott Diabetes, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Novo Nordisk, Sanofi US, Valeritas, Inc., Research Support; Self; Dexcom, Inc., Novo Nordisk. S. Cardona: None. K. W. Zamudio: None. B. S. Albury: None. M. C. Perez-guzman: None. L. Peng: None. G. E. Umpierrez: Research Support; Self; AstraZeneca, Dexcom, Inc., Novo Nordisk. F. J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Research Support; Self; Dexcom, Inc., Merck & Co., Inc. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. R. Z. Alicic: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc. D. W. Lam: None. M. Fayfman: None. A. Migdal: None. M. A. Urrutia: None. G. Davis: None. Funding Novo Nordisk

Approximately 50% of obese Black individuals present with diabetic ketoacidosis (DKA) at new-onset of diabetes undergo remission from insulin (fasting blood glucose [FBG 1 week) with intensive insulin treatment due to improved pancreatic beta(β)-cell secretion. Controversy exists whether KPDM is type 1 or type 2 diabetes and whether β-cell death contributes to DKA and β-cell secretion. Circulating unmethylated to methylated insulin DNA ratio (unMeth/MethINS) levels were found to correlate with β-cell death and β-cell secretion in patients at high risk for type 1 diabetes. In this exploratory study, we hypothesized that increased circulating unMeth/MethINS ratio at presentation of DKA correlates with decreased β-cell secretion in KPDM. Obese Black individuals presenting with DKA without GAD-65 antibodies were recruited 3-4 days after discharge from the hospital (Visit 1, n=22) and at insulin remission (Visit 2, n=19). Serum circulating unMeth/MethINS levels were measured at Visit 1. β-cell secretion was measured with glucagon stimulation tests (GST) performed at Visit 1 and Visit 2 and calculated as 6-min (maximum[Max]) and Delta (Max-baseline) C-peptide levels. At Visit 1, mean age was 38 ± 12 years and 7 (32%) were female. Mean BMI was 39.4 ± 10.6 kg/m2 with mean baseline HbA1c of 12.4 ± 1.8%. C-peptide levels increased significantly from Visit 1 to Visit 2 and expressed as median with minimum and maximum: Max (Visit 1: 2.94 [0.65, 12.07] vs. Visit 2: 5.87 [1.83, 12.11] ng/ml, p=0.011) and Delta (Visit 1: 1.57 (0.24, 6.88) vs. Visit 2: 2.80 [0.46, 9.01], p=0.047). UnMeth/MethINS ratio at Visit 1 was not significantly correlated (Spearman) with C-peptide levels at Visit 1 (Max: r=0.02, p=0.93, Delta: r=0.04, p=0.84) or at Visit 2 (Max: r=-0.07, p=0.79, Delta: r=0.03, p=0.89). Our data shows that in patients with KPDM, markers of β-cell death are not correlated with insulin secretion indicating that KPDM is consistent with type 2 diabetes. Disclosure P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. O. Oladejo: None. M. Fayfman: None. G. Davis: None. A. Migdal: None. L. R. Staimez: None. A. K. Smith: None. G. E. Umpierrez: Research Support; Self; AstraZeneca, Dexcom, Inc., Novo Nordisk. Funding National Institute of Diabetes and Digestive and Kidney Diseases (P30DK111024, UL1TR002378, K23DK11324-01A1)

Background Diabetes is the leading cause of lower extremity nontraumatic amputation globally, and diabetic foot osteomyelitis (DFO) is usually the terminal event before limb loss. Although guidelines recommend percutaneous bone biopsy (PBB) for microbiological diagnosis of DFO in several common scenarios, it is unclear how frequently PBBs yield positive cultures and whether they cause harm or improve outcomes. Methods We searched the PubMed, EMBASE, and Cochrane Trials databases for articles in any language published up to December 31, 2019, reporting the frequency of culture-positive PBBs. We calculated the pooled proportion of culture-positive PBBs using a random-effects meta-analysis model and reported on PBB-related adverse events, DFO outcomes, and antibiotic adjustment based on PBB culture results where available. Results Among 861 articles, 11 studies met inclusion criteria and included 780 patients with 837 PBBs. Mean age ranged between 56.6 and 71.0 years old. The proportion of males ranged from 62% to 86%. All studies were longitudinal observational cohorts, and 10 were from Europe. The range of culture-positive PBBs was 56%–99%, and the pooled proportion of PBBs with a positive culture was 84% (95% confidence interval, 73%–91%). There was heterogeneity between studies and no consistency in definitions used to define adverse events. Impact of PBB on DFO outcomes or antibiotic management were seldom reported. Conclusions This meta-analysis suggests PBBs have a high yield of culture-positive results. However, this is an understudied topic, especially in low- and middle-income countries, and the current literature provides very limited data regarding procedure safety and impact on clinical outcomes or antibiotic management., The proportion of culture-positive percutaneous bone biopsies among patients with suspected diabetic foot osteomyelitis in this meta-analysis was high (84%) suggesting this could be a useful diagnostic tool. However, there are several limitations to the literature.

Background: We compared the performance of the FreeStyle Libre Pro continuous glucose monitoring (CGM) and point-of-care glucose testing among insulin-treated hospitalized patients with type 2 diabetes (T2D). Methods: Prospective study in general medicine and surgery adult patients with T2D. Patient were monitored with POC before meals and bedtime, and with CGM during the hospital stay. Major endpoints included differences between POC and CGM in mean daily blood glucose, hypoglycemia < 70 and < 54 mg/dl, and nocturnal hypoglycemia. We also calculated the mean absolute relative difference (MARD), and ±15%/15mg/dl, ±20%/20mg/dl, ± 30%/30mg/dl, and Error Grid analysis between matched glucose pairs. Results: Mean daily glucose was significantly higher by POC testing (188.9±37.3 vs. 176.1±46.9 mg/dl), and proportions of patients with glucoses < 70 mg/dl (14% vs 56%) and < 54 mg/dl (4.1% vs 36%) detected by POC BG were significantly lower compared to CGM, all p Conclusions: Compared to POC testing, FreeStyle Libre CGM showed lower mean daily glucose and higher detection of hypoglycemic events, particularly nocturnal and prolonged hypoglycemia in hospitalized patients with T2D. CGM’s accuracy was lower in hypoglycemic range.

The administration of rapid-acting insulin per sliding scale (SSI) for correction of hyperglycemia in non-ICU patients with type 2 diabetes (T2D) is used with most basal-bolus insulin (BBI) regimens; however, the safety and efficacy of using SSI has not been tested in RCTs. In this non-inferiority RCT, we tested whether correction of hyperglycemia before meals and bedtime improves glycemic control in patients treated with BBI regimens. Patients with T2D with a blood glucose (BG) > 140 mg/dl treated with BBI were randomized to SSI for BG >140 mg/dl (intensive supplement) or to SSI for BG >260 mg/dl (non-intensive supplement). Primary outcome was difference in mean BG levels between the groups during hospital stay. There were no differences in baseline characteristics between the intensive and non-intensive supplement groups. There were no differences between groups in mean daily BG, length of stay (LOS), hypoglycemia (BG < 70 or < 54 mg/dl), severe hyperglycemia (BG > 350 mg/dl), and total, basal, prandial or supplemental daily insulin doses (U/day). In patients with any BG 140-260 mg/dl and without BG > 260 mg/dl, mean BG did not differ but non-intensive group needed more prandial insulin. Conclusion: Adding correction/supplement SSI in non-ICU T2D patients with mild to moderate hyperglycemia ( Disclosure P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. S. Cardona: None. M.A. Urrutia: None. R.J. Galindo: Advisory Panel; Self; Lilly Diabetes. Consultant; Self; Valeritas, Inc. Research Support; Self; Novo Nordisk Inc. Other Relationship; Self; UpToDate. G. Davis: None. J. Haw: None. M. Fayfman: None. A. Migdal: None. Y. Guo: None. F.J. Pasquel: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp. Research Support; Self; Dexcom, Inc., Merck Sharp & Dohme Corp., National Institutes of Health. G.E. Umpierrez: None. Funding National Institutes of Health

Insulin pen devices have been reported to improve patient satisfaction and treatment adherence compared to the traditional vial/syringe. Insulclock® is a small electronic device plugged onto insulin pen to track information via Bluetooth to smart-phone technology on date, time and dosage of injections and with an alarm system to reduce insulin omissions. We performed a randomized, cross-over design study in patients with type 2 diabetes (T2D) on basal insulin to assess the efficacy and satisfaction of Insulclock device. Eighty T2D patients on basal insulin ± oral agents with HbA1c between 7.0% and 12.0% were randomized to a 12-week ’intervention’ phase receiving reminders or to a 12-week ’control’ phase with device without feedback. Basal insulin was titrated every 2 weeks to a target fasting and premeal glucose between 70-130 mg/dl. Study outcomes included differences between groups on glycemic control, treatment adherence and satisfaction (DTSQc survey). Baseline characteristics were similar between groups (56±11 years, HbA1c 9.2%±1.5). HbA1c improved significantly from baseline, with reduction of 0.9 % in the intervention and 0.7% in the control group. Insulclock improved glycemic control with an estimated reduction in average mean daily blood glucose (BG), fasting BG, and pre-meal BG of 6.03 (95% CI: [-3.21, 15.3]), 6.66 (95% CI: [-1.72, 15.04]), and 5.57 (95% CI: [-6.15, 17.31]) mg/dl, respectively. Repeated measures analyses based on linear mixed models suggest significant effects of insulclock on the trajectory of mean daily BG, fasting BG, pre-meal BG (p In conclusion, the use of Insulclock resulted in improved glycemic control and treatment satisfaction in insulin treated patients with T2D. Disclosure C. Ramos: None. R.J. Galindo: Advisory Panel; Self; Lilly Diabetes. Consultant; Self; Valeritas, Inc. Research Support; Self; Novo Nordisk Inc. Other Relationship; Self; UpToDate. M.M. Alam: None. S. Cardona: None. B.S. Albury: None. O. Oladejo: None. F.J. Pasquel: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp. Research Support; Self; Dexcom, Inc., Merck Sharp & Dohme Corp., National Institutes of Health. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. M. Fayfman: None. A. Migdal: None. G. Davis: None. J. Haw: None. G.E. Umpierrez: None.

Diabetes is a leading cause of lower limb loss in the United States that disproportionately affects minority groups of lower socioeconomic status. The reasons for these disparities are poorly characterized. We employed qualitative (focus group discussions, FGD) and quantitative (survey) methods among persons with diabetic foot disease. Participants were stratified into two groups: a diabetic foot ulcer (DFU) group and minor amputation (ankle or below) group. The FGDs addressed patient experience with a goal of understanding: (1) foot care knowledge, (2) barriers to care, and (3) preferred foot-related educational methods. 5 sessions were conducted with 6-12 people each. Participants were recruited from clinics at a safety-net hospital in Atlanta that provides care to an inner-city population with a high burden diabetic foot related complications. Forty participants (90% Black) were enrolled. Surveys revealed an adequate knowledge of proper diabetic foot care, with ≥70% of participants correctly answering questions relating to proper self-care. Several dominant themes emerged from the FGDs. Personal barriers to self-care included lack of motivation, difficulty accessing supplies due to cost and/or lack of insurance, and being unable to limit activity for proper offloading. Participants frequently reported systematic barriers, citing difficulty making timely appointments and reaching a provider to arrange care. Participants reported that foot-related knowledge and access to care improved with greater disease severity but that knowledge and interventions seemed to come too late in their disease course. They expressed interest in peer support groups to facilitate learning and sharing information about diabetic foot care. These findings indicate patients with DFU or minor amputations in our institution have adequate footcare-related knowledge, but barriers to care and lack of motivation limit appropriate foot care. Disclosure M. Fayfman: None. M. Schechter: None. C.N. Amobi: None. R.N. Williams: None. J.L. Hillman: None. R. Rajani: None. D.C. Ziemer: None. M.M. Alam: None. R. Kempker: None. G.E. Umpierrez: None.

Background: There is increasing interest in using CGM for the inpatient management of diabetes in non-ICU settings. Current industry guidelines recommend removing devices when undergoing certain radiology procedures due to concerns about potential interference with CGM system functioning. However, there is no published data on the impact of CGM precision and accuracy after radiation and contrast exposure to support this recommendation. Methods: We collected data on 49 adult medicine and surgery patients with type 1 and type 2 diabetes who were monitored with Dexcom CGM systems before and after radiology procedures (x-rays, CT scan, catheterization/angiography). The primary outcome was glycemic variability by percent coefficient of variation (%CV) as reported by CGM 2-hours pre and post imaging. Secondary outcome was the mean absolute relative difference (MARD) between matched glucose pairs from capillary point-of-care and CGM pre and post imaging procedure. Results: There were no significant differences in mean blood glucose (BG) or %CV seen on CGM readings for all imaging procedures combined (delta mean BG -7.7 ±26.0, p=0.051; %CV 18.0% pre vs. 19.1% post, p=0.65) or when stratified by x-ray (delta mean BG -8.8 ±29.9, p=0.15; %CV 20.1% pre vs. 21.5% post, p=0.60) vs. CT scan/catheterization/angiography (delta mean BG -6.3 ±20.6, p=0.19; %CV 15.2% pre vs. 15.9% post, p=0.97). The overall MARD was 13.3% pre-imaging and 12.7% post-imaging. The overall percentage of glucose values within ±15%/15mg/dl, ±20%/20mg/dl, and ±30%/30mg/dl of the POC reference value was 69%, 80%, and 94%, respectively pre-imaging, and 69%, 82% and 93% post-imaging (p=NS). Clarke Error Grid analysis showed 98.1% of glucoses falling into Zones A and B pre-imaging and 99.7% post-imaging. Conclusions: Preliminary data suggests that ongoing CGM usage during multiple radiology procedures is safe and reliable without interference or disruption in CGM data transmission. Disclosure A. Migdal: None. E. Spanakis: Research Support; Self; Dexcom, Inc. R.J. Galindo: Advisory Panel; Self; Lilly Diabetes. Consultant; Self; Valeritas, Inc. Research Support; Self; Novo Nordisk Inc. Other Relationship; Self; UpToDate. G. Davis: None. L.G. Singh: None. M. Satyarengga: None. M. Fayfman: None. F.J. Pasquel: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp. Research Support; Self; Dexcom, Inc., Merck Sharp & Dohme Corp., National Institutes of Health. B.S. Albury: None. M.A. Urrutia: None. K.W. Zamudio: None. S. Gibanica: None. S. Cardona: None. L. Peng: None. G.E. Umpierrez: None. Funding Dexcom, Inc.

Glycated hemoglobin (HbA1c) on admission has been suggested as a predictor of glycemic control in the hospital. However, no studies have examined the interaction of pre-admission patient characteristics (i.e., complexity of home regimen or diabetes duration) and HbA1c on inpatient glycemic control. We pooled data from eight randomized controlled trials of patients assigned to a standardized basal-bolus insulin regimen in the hospital. Patients were categorized according to: A) increasing home regimen complexity [group 1: diet alone or ≤1 oral antihyperglycemic drugs (OADs) (n=338, 39%); group 2: two or more OADs (n=177, 20%); and group 3: insulin based regimens (n=356, 41%) and B) admission HbA1c categories (9%). Logistic regression models adjusting for age, gender, BMI, admission BG, and hospital service (medicine vs. surgery) were constructed to determine associations between home regimen complexity, diabetes duration, HbA1c and inpatient glycemic control. Compared to patients treated at home with OADs, patients using insulin had a longer duration of diabetes and higher admission HbA1c (both p9% aOR 0.44 (0.24, 0.83), and had higher risk for hypoglycemia (all p10 years) were less likely to achieve good glycemic control compared to patients with shorter duration of diabetes irrespective of home regimen complexity. Though admission HbA1c has been proposed as a predictor of inpatient glycemic control, our data show patients requiring complex therapy with insulin at home are less likely to achieve inpatient glucose targets independent of admission HbA1c. Disclosure M.A. Urrutia: None. Y. Guo: None. M. Fayfman: None. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. R.J. Galindo: Advisory Panel; Self; Lilly Diabetes. Consultant; Self; Valeritas, Inc. Research Support; Self; Novo Nordisk Inc. Other Relationship; Self; UpToDate. A. Migdal: None. G. Davis: None. I. Anzola: None. B.S. Albury: None. M.F. Scioscia: None. K.W. Zamudio: None. G.E. Umpierrez: None. F.J. Pasquel: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp. Research Support; Self; Dexcom, Inc., Merck Sharp & Dohme Corp., National Institutes of Health.

Limited studies have compared diabetes treatment regimens during the transition from the inpatient to outpatient setting. This RCT compared the safety and efficacy of liraglutide with glargine U100 in general medicine and surgery patients with T2D at hospital discharge. A total of 227 patients with HbA1c 7-10%, treated at home with diet, oral agents, or insulin at a total daily dose ≤0.4 units/kg were randomized to liraglutide (1.8mg/day) or glargine. The primary efficacy endpoint was difference in HbA1c at 12 and 26 weeks. Secondary endpoints included changes in weight, postprandial glucose, hypoglycemia, achievement of HbA1c In summary, the use of liraglutide after hospital discharge is associated with similar change in HbA1c compared to glargine. Liraglutide treatment resulted in less hypoglycemia, greater weight reduction, with expected increased gastrointestinal adverse events. Disclosure F.J. Pasquel: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp. Research Support; Self; Dexcom, Inc., Merck Sharp & Dohme Corp., National Institutes of Health. M.A. Urrutia: None. S. Cardona: None. G. Iacobellis: None. J. Farias: None. A. Chaudhuri: Consultant; Self; Bayer U.S. Speaker’s Bureau; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Merck & Co., Inc., Novo Nordisk Inc., Sanofi US. I. Anzola: None. J.D. Palacios: None. B.S. Albury: None. P.C. Gomez: None. K.W. Zamudio: None. M.C. Perez-Guzman: None. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. M. Fayfman: None. J. Haw: None. R.J. Galindo: Advisory Panel; Self; Lilly Diabetes. Consultant; Self; Valeritas, Inc. Research Support; Self; Novo Nordisk Inc. Other Relationship; Self; UpToDate. G. Davis: None. A. Migdal: None. L. Peng: None. G.E. Umpierrez: None. Funding Novo Nordisk

Professional guidelines recommend insulin therapy for treatment of type 2 diabetes (T2D) in the hospital. However, oral antidiabetes drugs (OAD) are commonly used despite the lack of safety and efficacy data. We analyzed individual level data from non-critically ill patients with T2D admitted to three large healthcare systems between 2008-2018 (N=187,396). We conducted propensity score matching analyses to determine the relative efficacy and safety of OAD. Patients were treated with basal insulin (20%), sliding scale insulin alone (28%), basal insulin with OADs (23%), metformin (21%), sulfonylureas (11%), or DPP-4 inhibitors (4%). Less than 1% were treated with thiazolidinediones or SGLT2 inhibitors. Patients started on basal insulin had more comorbidities and had higher glucose levels on admission. After matching for age, BMI, Charlson Comorbidity Index, and admission blood glucose, exposure to OADs, with or without basal insulin, was associated with non-clinically meaningful differences in glycemic control compared to basal insulin use alone (183.1± 53.8 vs. 175.7± 53.9 vs. 180.3± 54.9, p In summary, the use of OADs with or without basal insulin is associated with acceptable glycemic control compared to insulin therapy. Basal insulin use and the use of sulfonylureas is associated with a high incidence of hypoglycemia. Disclosure F.J. Pasquel: Advisory Panel; Self; AstraZeneca, Eli Lilly and Company. Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp. Research Support; Self; Dexcom, Inc., Merck Sharp & Dohme Corp., National Institutes of Health. M.F. Magee: Consultant; Self; Mytonomy. Employee; Spouse/Partner; U.S. Food and Drug Administration. Research Support; Self; AstraZeneca, Eli Lilly and Company, National Institute of Diabetes and Digestive and Kidney Diseases. Speaker’s Bureau; Self; American Diabetes Association, Pri-Med LLC. Other Relationship; Self; Endocrine Society. I. Hochberg: None. C. Fortin: None. A. Migdal: None. S. Cardona: None. M. Fayfman: None. Y. Guo: None. L. Peng: None. G.E. Umpierrez: None. Funding Jacobs Family Funds

DPP-4 inhibitors (DPP-4i) have been shown to be effective for the management of inpatient diabetes. We report pooled data from 3 prospective studies using DPP-4i in general medicine and surgery patients with type 2 diabetes (T2D).We combined data from 3 randomized studies comparing DPP-4i alone or in combination with basal insulin or a basal-bolus insulin regimen. Medicine (n = 266) and surgery (n = 319) patients admitted with a blood glucose (BG) between 140 and 400 mg/dL, treated with diet, oral agents, or low-dose insulin therapy were included. Patients received DPP-4i alone (n = 144), DPP-4i plus basal insulin (n = 158) or basal-bolus regimen (n = 283). All groups received correctional doses with rapid-acting insulin for BG140 mg/dL. The primary endpoint was differences in mean daily BG between groups. Secondary endpoints included differences in hypoglycemia and hospital complications.There were no differences in mean hospital daily BG among patients treated with DPP-4i alone (170 ± 37 mg/dL), DPP-4i plus basal (172 ± 42 mg/dL), or basalbolus (172 ± 43 mg/dL), P = .94; or in the percentage of BG readings within target of 70 to 180 mg/dL (63 ± 32%, 60 ± 31%, and 64 ± 28%, respectively; P = .42). There were no differences in length of stay or complications, but hypoglycemia was less common with DPP-4i alone (2%) compared to DPP-4i plus basal (9%) and basal-bolus (10%); P = .004.Treatment with DPP-4i alone or in combination with basal insulin is effective and results in a lower incidence of hypoglycemia compared to a basal-bolus insulin regimen in general medicine and surgery patients with T2D.BG = blood glucose; BMI = body mass index; CI = confidence interval; DPP-4i = dipeptidyl peptidase-4 inhibitors; HbA1c = hemoglobin A1c; OR = odds ratio; T2D = type 2 diabetes.

OBJECTIVE The role of U300 glargine insulin for the inpatient management of type 2 diabetes (T2D) has not been determined. We compared the safety and efficacy of glargine U300 versus glargine U100 in noncritically ill patients with T2D. RESEARCH DESIGN AND METHODS This prospective, open-label, randomized clinical trial included 176 patients with poorly controlled T2D (admission blood glucose [BG] 228 ± 82 mg/dL and HbA1c 9.5 ± 2.2%), treated with oral agents or insulin before admission. Patients were treated with a basal-bolus regimen with glargine U300 (n = 92) or glargine U100 (n = 84) and glulisine before meals. We adjusted insulin daily to a target BG of 70–180 mg/dL. The primary end point was noninferiority in the mean difference in daily BG between groups. The major safety outcome was the occurrence of hypoglycemia. RESULTS There were no differences between glargine U300 and U100 in mean daily BG (186 ± 40 vs. 184 ± 46 mg/dL, P = 0.62), percentage of readings within target BG of 70–180 mg/dL (50 ± 27% vs. 55 ± 29%, P = 0.3), length of stay (median [IQR] 6.0 [4.0, 8.0] vs. 4.0 [3.0, 7.0] days, P = 0.06), hospital complications (6.5% vs. 11%, P = 0.42), or insulin total daily dose (0.43 ± 0.21 vs. 0.42 ± 0.20 units/kg/day, P = 0.74). There were no differences in the proportion of patients with BG 0.99), but glargine U300 resulted in significantly lower rates of clinically significant hypoglycemia ( CONCLUSIONS Hospital treatment with glargine U300 resulted in similar glycemic control compared with glargine U100 and may be associated with a lower incidence of clinically significant hypoglycemia.

OBJECTIVE Many patients with hyperglycemic crises present with combined features of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The implications of concomitant acidosis and hyperosmolality are not well known. We investigated hospital outcomes in patients with isolated or combined hyperglycemic crises. RESEARCH DESIGN AND METHODS We analyzed admissions data listing DKA or HHS at two academic hospitals. We determined 1) the frequency distributions of HHS, DKA, and combined DKA-HHS (DKA criteria plus elevated effective osmolality); 2) the relationship of markers of severity of illness and clinical comorbidities with 30-day all-cause mortality; and 3) the relationship of hospital complications associated with insulin therapy (hypoglycemia and hypokalemia) with mortality. RESULTS There were 1,211 patients who had a first admission with confirmed hyperglycemic crises criteria, 465 (38%) who had isolated DKA, 421 (35%) who had isolated HHS, and 325 (27%) who had combined features of DKA-HHS. After adjustment for age, sex, BMI, race, and Charlson Comorbidity Index score, subjects with combined DKA-HHS had higher in-hospital mortality compared with subjects with isolated hyperglycemic crises (adjusted odds ratio [aOR] 2.7; 95% CI 1.4, 4.9; P = 0.0019). In all groups, hypoglycemia ( CONCLUSIONS Combined DKA-HHS is associated with higher mortality compared with isolated DKA or HHS. Severe hypokalemia and severe hypoglycemia are associated with higher hospital mortality in patients with hyperglycemic crises.

Perioperative hyperglycemia is common after cardiac surgery, reported in 60% to 90% of patients with diabetes and in approximately 60% of patients without history of diabetes. Many observational and prospective randomized trials in critically-ill cardiac surgery patients support a strong association between hyperglycemia and poor clinical outcome. Despite ongoing debate about the optimal glucose target, there is strong agreement that improved glycemic control reduces perioperative complications.

Objective: To discuss a case of adrenal insufficiency (AI) caused by heparin-induced thrombocytopenia (HIT) and subsequent adrenal hemorrhage.Methods: We describe the case of a patient who developed postoperative HIT, which went undetected until the patient presented with fulminant adrenal crisis. We provide here an overview of the work-up, diagnosis, and treatment of HIT-associated AI.Results: HIT is a rare cause of bilateral adrenal hemorrhage, and subsequent AI secondary to HIT is often clinically unsuspected until overt hemodynamic collapse occurs.Conclusions: Lack of early detection and appropriate treatment of HIT-induced AI can lead to significant patient morbidity and mortality. Awareness of this clinical condition is key to early recognition and treatment.Abbreviations: AI adrenal insufficiency CABG coronary artery bypass grafting CT computed tomography HIT heparin-induced thrombocytopenia

Diabetes is a growing health epidemic in the United States. Racial and ethnic minorities are disproportionately affected by diabetes and associated comorbidities and complications. The present review article aims to characterize the various ways in which minority populations are affected by diabetes. We address differences in prevalence of diabetes and associated conditions that include cardiovascular disease, hypertension, microvascular complications, and mortality. Additionally, we discuss factors that contribute to disparate diabetes-related outcomes, including physiology, culture and healthsystems. Finally, we look at outcomes of various interventions taken to address health disparities in diabetes care, specifically in racial and ethnic minority populations.

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.

The financial impact of intensive (blood glucose [BG] 100-140mg/dl [5.5-7.8mM] vs. conservative (141-180mg/dl (7.9-10.0mM) glucose control in the ICU in patients, with and without diabetes, undergoing coronary artery bypass graft (CABG) surgery is not known.This post-hoc cost analysis determined differences in hospitalization costs, resource utilization and perioperative complications in 288 CABG patients with diabetes (n=143) and without diabetes (n=145), randomized to intensive (n=143) and conservative (n=145) glucose control.Intensive glucose control resulted in lower BG (131.4±14mg/dl-(7.2±0.8mM) vs. 151.6±17mg/dl (8.4±0.8mM, p0.001), a nonsignificant reduction in the median length of stay (LOS, 7.9 vs. 8.5days, p=0.17) and in a composite of perioperative complications including wound infection, bacteremia, acute renal and respiratory failure, major cardiovascular events (42% vs 52%, p=0.10) compared to conservative control. Median hospitalization costs were lower in the intensive group ($39,366 vs. $42,141, p=0.040), with a total cost savings of $3654 (95% CI: $1780-$3723), than conservative control. Resource utilization for radiology (p=0.008), laboratory (p=0.014), consultation service (p=0.013), and ICU utilization (p=0.007) were also lower in the intensive group. Compared to patients without perioperative complications, those with complications had longer hospital length of stay (10.7days vs. 6.7days, p0.001), higher total hospitalization cost ($48,299 vs. $32,675, p0.001), and higher resource utilization units (2745 vs. 1710, p0.001).Intensive glycemic control [BG 100-140mg/dl (5.5-7.8mM)] in patients undergoing CABG resulted in significant reductions in hospitalization costs and resource utilization compared to patients treated with conservative [BG 141-180mg/dl (7.9-10.0mM)] glucose control.

Hyperglycemia contributes to a significant increase in morbidity, mortality, and healthcare costs in the hospital. Professional associations recommend insulin as the mainstay of diabetes therapy in the inpatient setting. The standard of care basal–bolus insulin regimen is a labor-intensive approach associated with a significant risk of iatrogenic hypoglycemia. This review summarizes recent evidence from observational studies and clinical trials suggesting that not all patients require treatment with complex insulin regimens. Evidence from clinical trials shows that incretin-based agents are effective in appropriately selected hospitalized patients and may be a safe alternative to complicated insulin regimens. Observational studies also show that older agents (i.e., metformin and sulfonylureas) are commonly used in the hospital, but there are few carefully designed studies addressing their efficacy. Therapy with dipeptidyl peptidase-4 (DPP-4) inhibitors, alone or in combination with basal insulin, may effectively control glucose levels in patients with mild to moderate hyperglycemia. Further studies with glucagon-like peptide-1 (GLP-1) receptor analogs and older oral agents are needed to confirm their safety in the hospital.

This prospective, open-label, randomized clinical trial compared the safety and efficacy of a basal bolus regimen using glargine U300 or glargine U100 for the management of general medicine and surgery patients with T2D. A total of 171 patients (age: 57±12 years, admission BG: 229±82 mg/dl and HbA1c: 9.5±2.2% [mean±SD]), treated with oral agents or insulin prior to admission, were randomized to glargine U300 (n=90) or glargine U100 (n=81). Total daily dose (TDD) started at 0.4 U/kg/d for BG: 140-200 mg/dl or 0.5 U/kg/d for BG: 201-400 mg/dl. Half of TDD was given as glargine U300 or U100 once daily and half as glulisine before meals. We adjusted insulin daily to a target BG: 70-180 mg/dl. We measured BG by capillary point of care (POC) testing before meals and bedtime. To further examine glucose differences, we placed a professional Freestyle Libre CGM in a subgroup of patients (n=82). Major outcomes included differences in mean daily BG and frequency of hypoglycemia between groups. There were no differences between glargine U300 and U100 in mean daily BG (POC: 188 ±41vs. 184±45 mg/dl, p=0.47; CGM: 172±45 vs. 165±47 mg/dl, p=0.42), percentage (%) of glucose readings between 70-180 mg/dl (POC: 50±25% vs. 52±27%, p=0.74; CGM: 55±26% vs. 56±27%, p=0.80), length of stay (median (IQR): 6.0 (4.0-8.0) vs. 4.0 (3.0, 7.0) days, p=0.07), hospital complications (6.7% vs. 11%, p=0.42), or insulin TDD (0.44±0.21 vs. 0.43±0.20 U/kg/day, p=0.74). There were no differences % of BG 0.99; CGM: 5.88±14.49 vs. 5.74±8.15, p= 0.35), but U300 resulted in significant lower rates of BG In summary, our study indicates that hospital treatment with glargine U300 resulted in similar glycemic control and lower frequency of clinically significant hypoglycemia compared to glargine U100 in general medicine and surgery patients with T2D. Disclosure F.J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc. M. Lansang: None. A. Khowaja: None. R.J. Galindo: Advisory Panel; Self; Abbott, Novo Nordisk Inc., Sanofi US. Research Support; Self; Novo Nordisk Inc. M.A. Urrutia: None. S. Cardona: None. A. Shakally: None. R.C. Lyerla: None. I. Anzola: None. B.S. Albury: None. J. Haw: None. M. Fayfman: None. G. Davis: None. A. Migdal: None. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc. Research Support; Self; National Institutes of Health. L. Peng: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck & Co., Inc., Novo Nordisk Inc., Sanofi US. Funding Sanofi US

Changes in insulin requirements after hospital discharge in insulin-treated patients with type 2 diabetes (T2D) are not known. We conducted a pooled analysis of 4 randomized clinical trials with 3-month follow-up data to determine changes in insulin requirement after discharge. These studies followed a discharge algorithm based on admission HbA1c to guide outpatient insulin therapy. A total of 255 insulin-treated patients (age: 55.6 year, BMI 34.6 kg/m2, duration DM: 11.2±8 year) were discharged on glargine + oral antidiabetic (OAD) agents (75%), glargine + exenatide (4%), or basal bolus (21%). Patients with HbA1c 9% (51.4%) were discharged on glargine at 80% of hospital TDD in combination to OAD or with basal bolus regimen. Treatment was adjusted to achieve a target HbA1c level In summary, insulin TDD requirements vary greatly after hospital discharge in patients with T2D. Most patients required frequent insulin adjustments to maintain glycemic control and to avoid hypoglycemia after hospital discharge. Disclosure M. Fayfman: None. D. LeRoith: Advisory Panel; Self; AstraZeneca, MannKind Corporation. F.J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc. I. Anzola: None. M.A. Urrutia: None. H. Wang: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck 0026 Co., Inc., Novo Nordisk Inc., Sanofi US.

Despite recommendations of clinical guidelines, sliding scale insulin (SSI) is widely used for the inpatient management of patients with T2D. To understand if there is a population of patients for whom SSI may be an appropriate form of management, we utilized a large database from a single academic institution to define the frequency of SSI usage and determine factors that predict adequate glycemic control with SSI alone in the non-critical care setting. Among 15,348 patients with T2D (28% surgery, 72% medicine), 7,052 (45%) were managed with SSI and 8,296 (55%) with basal insulin. Average admission blood glucose (BG) and HbA1c were lower in patients treated with SSI (154.6±60.3 vs. 191.7±80.8 mg/dl, p280 mg/dl [OR 42.2 (29.5, 60.5)]. Similar results were seen when comparing patients with admission A1c 9% [OR 13.3 (8.8, 19.9)]. Conclusion: SSI is used in ~40% of non-critically ill patients, especially among those with mild/moderate hyperglycemia. Most patients with BG Disclosure A. Migdal: None. F.J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc. R.J. Galindo: Advisory Panel; Self; Abbott, Novo Nordisk Inc., Sanofi US. Research Support; Self; Novo Nordisk Inc. M. Fayfman: None. S. Cardona: None. G. Davis: None. H. Wang: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck & Co., Inc., Novo Nordisk Inc., Sanofi US.

Background: There are no published studies assessing the accuracy of the FreeStyle Libre CGM in the inpatient management of patients with type 2 diabetes (T2D). Methods: Adult patients (n: 81) on basal-bolus insulin therapy with a target BG between 70-180 mg/dl were monitored with POC before meals and bedtime and by CGM. The primary outcome was the mean amplitude relative difference (MARD) between matched glucose pairs obtained from POC and CGM. Results: Among 1453 pairs, the overall MARD was 14.4%. The overall percentage of glucose values within ±15% or 15mg/dl, ±20% or 20mg/dl, and ±30% or 30mg/dl of the POC reference value was 63%, 78%, and 92%, respectively. Clarke Error Grid analysis showed acceptable clinical accuracy with 98.0% of glucoses falling into Zones A (76.8%, n: 1,116) and B (22.0%, n: 320). Accuracy was lower for glucoses < 80 mg/dL (Table 1), however; there were limited matched glucose pairs in hypoglycemic range. Conclusions: FreeStyle Libre CGM showed an overall satisfactory performance in hospitalized patients, with lower accuracy observed for glucoses < 80 mg/dL. Larger inpatient studies are needed to confirm its accuracy in non-critically ill hospitalized patients. *Proportion of CGM values within ±15%/±15 mg/dL of POC glucose values, and the analogous %20/20, %30/30 Disclosure R.J. Galindo: Advisory Panel; Self; Abbott, Novo Nordisk Inc., Sanofi US. Research Support; Self; Novo Nordisk Inc. M.A. Urrutia: None. G. Davis: None. A. Khowaja: None. B.S. Albury: None. I. Anzola: None. A.A. Johnson: None. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc. Research Support; Self; National Institutes of Health. S. Cardona: None. M. Fayfman: None. A. Migdal: None. C. Zambrano: None. L. Peng: None. F.J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck & Co., Inc., Novo Nordisk Inc., Sanofi US. Funding Sanofi