Endocrinology and Diabetes

Steroid-induced diabetes and hyperglycaemia. Part 1: mechanisms and risks (2018)

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Type of publication:
Journal article

Author(s):
*Morris, David

Citation:
Diabetes & Primary Care; Aug 2018; vol. 20 (no. 4); p. 151-153

Abstract:
Glucocorticoids are prescribed widely in primary care for the treatment of a range of conditions. Courses of treatment are usually short, but around 22% of use continues for over 6 months. As well as their therapeutic actions, glucocorticoids have a powerful impact on glucose metabolism, contributing to hyperglycaemia and a predisposition to diabetes. In the first of two articles on steroid-induced hyperglycaemia and diabetes, the author outlines the scale of the problem and explains the mechanisms by which glucocorticoids induce hyperglycaemia. High-risk situations are identified, and the short- and long-term dangers summarised. The second article will appear in the next issue of this journal.

How accurate is glycated haemoglobin in patients with liver cirrhosis? A case series (2018)

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Type of publication:
Conference abstract

Author(s):
*Basavaraju N.; *Rangan S.; *Singh P.; *Moulik P

Citation:
Diabetic Medicine; Mar 2018; vol. 35 ; S1

Abstract:
Introduction: Glycated haemoglobin (HbA1c) is the gold standard for monitoring glycaemic control in patients with diabetes. We present three cases of chronic liver disease where HbA1c may be misleading. Case 1: A 71-year-old Caucasian woman with liver cirrhosis due to hepatitis C, Type 2 diabetes, previous bladder tuberculosis and chronic kidney disease stage 3 was evaluated in clinic. Her capillary glucose (CG) was 6 to 9 mmol/l, no hypoglycaemia. She was anaemic; HbA1c was low at 34mmol/mol. Fructosamine was elevated at 296umol/l (205 to 285). Case 2: A 38-year-old Caucasian man with alcoholic liver cirrhosis, portal hypertension, and Type 2 diabetes was admitted with haematemesis. His CG was 10 to 14 mmol/l and HbA1c 26mmol/mol. He had iron deficiency anaemia, deranged liver enzymes and renal function. Fructosamine was normal at 246umol/l. Case 3: A 65-year-old Caucasian woman with non-alcoholic steatohepatosis/cirrhosis, portal hypertension, Type 2 diabetes, iron deficiency anaemia was admitted with melena. Her CG was 12 to 14mmol/l and HbA1c 44mmol/mol. Results showed acute kidney injury, deranged liver enzymes, normal albumin but low haemoglobin. Fructosamine is awaited. All patients required insulin for management of their diabetes. Discussion: The degree of glycation (glucose binding to N-terminal valine of HbA) is dependent on glycation rate, glucose availability and lifespan of red blood cells. Reference range of HbA1c is based on normal lifespan of RBC. There are very limited studies in evaluating the accuracy of HbA1c in chronic liver disease (CLD). Multiple factors can shorten RBC survival in CLD, including anaemia, portal hypertension, hypersplenism, variceal bleeding, resulting in falsely low HbA1c. Fructosamine, glycated albumin can also be inaccurate. Capillary glucose monitoring should guide glycaemic management.

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A prospective study of hospitalised patients with diabetes and hypoglycaemia following the National Inpatient Diabetes Audit (NaDIA) (2018)

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Type of publication:
Conference abstract

Author(s):
*Htun H.; *Richardson E.; *Barton D.

Citation:
Diabetic Medicine; Mar 2018; vol. 35 ; S1

Abstract:
Background: A growing concern regarding increasing incidence of hypoglycaemia in hospitalised patients with diabetes and its association to all-cause mortality is well recognised. There has been no further study regarding the implication of appropriate management of hypoglycaemia following the NaDIA data 2016. Aims: To determine the quality of care provided to patients with diabetes with hypoglycaemia and to minimise the risk of avoidable complications and prolonged hospital stay. Methods: We prospectively identified 50 patients with diabetes who experienced one or more episodes of hypoglycaemia during their hospital stay in 2017. We assessed their clinical information regarding specific risk factors, medication and insulin prescription errors. Results: The study population identified the evidence of mild hypoglycaemic and severe hypoglycaemic episodes as 68% and 20% respectively. Recurrent hypoglycaemic episodes were highlighted as nine cases, especially in older patients aged over 65 years, with HbA1c >70mmol/mol. Their morbidity status was captured with mean prolonged hospital stay of 18 days. Regarding risk stratification, 44 cases were largely contributed to by a variety of clinical risk factors, whereas six cases (half of NaDIA 2016 figures) of those resulted from medication management errors, especially insulin prescription and administration. More than 90% of patients were seen by a member of the diabetes team following hypoglycaemic episodes. Conclusion: Our data confirm strong morbidity risk with recurrent hypoglycaemia. The study suggests much closer attention to correctable risk factors, so as to minimise avoidable complications with structured diabetes team input to ensure good quality care is to be maintained.

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Clinical risk factors predicting genital fungal infections with sodium-glucose cotransporter 2 inhibitor treatment: The ABCD nationwide dapagliflozin audit (2018)

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Type of publication:
Journal article

Author(s):
Thong KY, Yadagiri M, Barnes DJ, *Morris DS, Chowdhury TA, Chuah LL, Robinson AM, Bain SC, Adamson KA, Ryder REJ; ABCD Nationwide Dapagliflozin Audit contributors.

Citation:
Primary Care Diabetes. 2018 Feb;12(1):45-50

Abstract:
INTRODUCTION: Treatment of type 2 diabetes with sodium-glucose cotransporter 2 (SGLT2) inhibitors may result in genital fungal infections. We investigated possible risk factors for developing such infections among patients treated with the SGLT2 inhibitor dapagliflozin. METHODS: The Association of British Clinical Diabetologists (ABCD) collected data on patients treated with dapagliflozin in routine clinical practice from 59 diabetes centres. We assessed possible associations of patient's age, diabetes duration, body mass index, glycated haemoglobin, renal function, patient sex, ethnicity and prior genital fungal infection, urinary tract infection, urinary incontinence or nocturia, with the occurrence of ≥1 genital fungal infection within 26 weeks of treatment. RESULTS:  1049 out of 1116 patients (476 women, 573 men) were analysed. Baseline characteristics were, mean±SD, age 56.7±10.2years, BMI 35.5±6.9kg/m2 and HbA1c 9.4±1.5%. Only patient sex (13.2% women vs 3.3% men) and prior history of genital fungal infection (21.6% vs 7.3%) were found to be associated with occurrence of genital fungal infections after dapagliflozin treatment, adjusted OR 4.22 [95%CI 2.48,7.19], P<0.001 and adjusted OR 2.41 [95% CI 1.04,5.57], P=0.039, respectively. CONCLUSION:  Women and patients with previous genital fungal infections had higher risks of developing genital fungal infections with dapagliflozin treatment.

Managing glycaemic trends in people with diabetes requiring enteral feeding support: The challenges in primary and secondary care (2017)

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Type of publication:
Journal article

Author(s):
*Richardson, Erica A.; Agbasi, Nneka

Citation:
Journal of Diabetes Nursing; Aug 2017; vol. 21 (no. 7); p. 241-246

Abstract:
Matching therapeutic treatments to manage glycaemic excursions in people with diabetes receiving enteral nutrition (e.g. nasogastric, gastrostomy or jejunostomy) can be difficult. There is evidence to suggest that there is an increased risk of complications and mortality, longer lengths of stay in hospital, higher risk of intensive care input and higher demands for transitional or nursing home care post discharge. Other intrinsic factors, such as illness, timing of medications, poly-pharmacy, types of feeding regimen chosen and history of diabetes, all need to be considered when choosing appropriate treatments. This article describes the challenges of supporting people with diabetes requiring enteral feeding and the implications for diabetes nurses.

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Clinical risk factors predicting genital fungal infections with sodium–glucose cotransporter 2 inhibitor treatment: The ABCD nationwide dapagliflozin audit (2017)

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Type of publication:
Journal article

Author(s):
Ken Yan Thong, Mahender Yadagiri, Dennis Joseph Barnes, *David Stuart Morris, Tahseen Ahmad Chowdhury, Ling Ling Chuah, Anthony Michael Robinson, Stephen Charles Bain, Karen Ann Adamson, Robert Elford John Ryder, ABCD Nationwide Dapagliflozin Audit contributors

Citation:
Primary Care Diabetes 2017 [published online 29th June 2017]

Abstract:
Introduction

Treatment of type 2 diabetes with sodium–glucose cotransporter 2 (SGLT2) inhibitors may result in genital fungal infections. We investigated possible risk factors for developing such infections among patients treated with the SGLT2 inhibitor dapagliflozin.

Methods

The Association of British Clinical Diabetologists (ABCD) collected data on patients treated with dapagliflozin in routine clinical practice from 59 diabetes centres. We assessed possible associations of patient’s age, diabetes duration, body mass index, glycated haemoglobin, renal function, patient sex, ethnicity and prior genital fungal infection, urinary tract infection, urinary incontinence or nocturia, with the occurrence of ≥1 genital fungal infection within 26 weeks of treatment.

Results

1049 out of 1116 patients (476 women, 573 men) were analysed. Baseline characteristics were, mean ± SD, age 56.7 ± 10.2 years, BMI 35.5 ± 6.9 kg/m2 and HbA1c 9.4 ± 1.5%. Only patient sex (13.2% women vs 3.3% men) and prior history of genital fungal infection (21.6% vs 7.3%) were found to be associated with occurrence of genital fungal infections after dapagliflozin treatment, adjusted OR 4.22 [95%CI 2.48,7.19], P < 0.001 and adjusted OR 2.41 [95% CI 1.04,5.57], P = 0.039, respectively.

Conclusion

Women and patients with previous genital fungal infections had higher risks of developing genital fungal infections with dapagliflozin treatment.