Comments on the August 2020 issue of Diabetes
Care.
First, a brief description of how COVID-associated hyperglycemia in ICUs is managed in the
Joslin Clinic. They try to maintain a balance between 3 main aims: 1) reduce
the number of contacts with nursing staff; 2) avoid hypoglycemia; 3) keep blood
glucose in a narrow range. In order to that, each one of the 4 strategies they
propose has strengths and weaknesses: IV insulin infusion requires hourly contacts,
basal insulin + 4 corrective boluses are at risk of hypoglycemia if nutrition
is suspended, NPH minimizes contacts (3 daily), but it is worse in everything
else, and regular SC insulin is the worst in terms of glycemic control. Thus,
depending on the established priority , one or other regime is preferred.
They also comment on medications and other conditions that could interfere
on blood glucose measurement: high doses of vitamin C that are sometimes used
in this setting can give falsely high values of capillary blood glucose. On the other hand, hypoxemia, acetaminophen or beta
adrenergics could give unreliable results in CGM. They also had two cases of patients with hybrid closed-loop systems
that worked quite well in ICU.
Another section: results of the Novo-Nordisk-sponsored ONSET-9 trial on
faster-aspart (FA), comparing it to aspart in type 2 diabetes, both with
degludec, with or without metformin. They found similar glycemic control and fewer
"severe or confirmed" hypoglycemic episodes. It is very striking that
severe hypoglycemia was indeed more frequent with FasterAspart (2.9 vs. 1.8%),
but this is only seen in a table and is not mentioned in the text, much less in
the abstract, and it is not even analyzed for statistical significance. We find
this lack of mention very out of place in an influential journal like this, where
peer-review is supposed, and cannot
understand how both Diabetes Care and Novo-Nordisk could have written the
results in such a misleading way, because we believe that severe hypoglycemia
is one of the main aims when evaluating a new insulin.
Finally, a secondary analysis of the Carmelina study with linagliptin shows that in type 2 diabetes with kidney or cardiovascular disease, it has no positive or negative effect on CV or renal events.
This is all for today, thank you for reading and we greatly appreciate your comments,
