Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 6

6 - SEVERE HYPOGLYCEMIA WITH USE OF INSULIN U-500

Saturday, Apr 27
10:00 AM – 10:30 AM

Objective : Patients with severe insulin resistance with total daily insulin dose (TDD) greater than 200 units (U) are ideal candidates for insulin U-500.  During hospitalization, the TDD of insulin in patients on U-500 is reported to be lower with return to ambulatory doses on discharge. Events of inpatient hypo and hyperglycemia are increased in these same studies. The aim of the current study was to characterize ambulatory patients on U-500 presenting with severe hypoglycemia.


Methods :

We reviewed the records of 22 veterans (Male-21, Female-1) in the VA Diabetes clinic who are or were treated with U-500 and followed for at least 6 months. We examined the prevalence of severe hypoglycemia, defined as hypoglycemia requiring hospitalization, and the characteristics of these patients.


Results :

Of the twenty-two patients in the Diabetes clinic receiving U-500, 5 developed severe hypoglycemia requiring a change to conventional basal-bolus after hospitalization. Average initial age, BMI and HbA1c was 62.4 ± 2.0 years, 42 ± 1.2 kg/m2 and 9.11 ± 0.43%, respectively. The TDD of insulin was initially 403 ± 54 U, with two individuals requiring >1000 U daily. The average follow-up duration was 17 ± 2.3 months with average current HbA1c of 8.64 ± 0.43% and current TDD of U-500 of 319 ± 53.3 U. In patients with severe hypoglycemia, average time to hypoglycemia from initiation of U-500 was 14.2 ± 2.1 months. The BMI of patients with hypoglycemia was lower than in non-hypoglycemic patients (32 ± 0.6 vs 42 ± 1.2kg/m2, p<0.005). The TDD of insulin following the episodes of hypoglycemia was markedly lower than those without hypoglycemia (p<0.05). The non-hypoglycemic group gained an average of 5.5 ± 2.3 lbs while the hypoglycemia group lost 23.8 ± 4.9 lbs (p<0.05). There was no difference in initial TDD of U-500, duration of diabetes, age, coronary artery disease, heart failure, or microvascular complications between groups<./p>


Discussion : Severe hypoglycemia is a serious complication with potential long-term consequences in patients on insulin. Although the numbers are small, lower BMI and weight loss were significant findings in patients on U-500 with hypoglycemia. Initial doses of insulin or prevalence of macro/microvascular complications did not seem to play a role in developing hypoglycemia.


Conclusion :

BMI and persistent weight loss may prove to be predictors of hypoglycemia in patients receiving U-500. Another consideration is that a marked improvement in glycemic control and subsequent reversal of glucotoxicity may lead to decreased TDD and predispose to severe hypoglycemia.

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Jonathan Trejo

Endocrine, Diabetes and Metabolism Fellow
UT Health San Antonio, Department of Medicine, Division of Endocrinology, Diabetes and Metabolism
San Antonio, Texas

Dr. Trejo received his Bachelor's of Science at Trinity University in San Antonio, and completed medical school and Internal Medicine Residency at UT Health San Antonio. He is currently an Endocrine, Diabetes and Metabolism Fellow at UT Health San Antonio. His research interests lie in diabetes, including the categorization of subtypes of diabetes. He also has an interest in health policy and community health.

Jan M. Bruder

Professor, Division Chief
UT Health San Antonio, Department of Medicine, Division of Endocrinology and Metabolism
San Antonio, Texas

Dr. Bruder received her undergraduate degree from Loyola University and medical degree from Louisiana State University in New Orleans. After internal medicine training at the Medical College of Virginia in Richmond, she completed her endocrine fellowship at the University of Colorado in Denver. Currently she is Professor of Medicine, Chief of the Division of Endocrinology and Metabolism, Director of the Osteoporosis and Metabolic Bone Disease Clinic and Program Director of the Endocrinology, Diabetes and Metabolism Fellowship Training Program. She is a member of the American Society for Bone and Mineral Research (ASBMR 1997), member of the Endocrine Society (TES 1990), American Association of Clinical Endocrinologist (AACE) and the International Society for Clinical Densitometry (ISCD 1997). She is a Certified Clinical Densitometrist (CCD 2000) and long time faculty for the Bone Densitometry Certification Course. Currently she serves as course faculty for the Osteoporosis Essentials Course. She cares for patients as part of the academic teaching mission of UTHealth at the Texas Diabetes Institute and at the Audie L Murphy Veteran’s Administration Hospital.

Maureen Koops

Associate Professor, Chief of Endocrine at ALMVAH
Audie L Murphy Veteran's Administration Hospital
San Antonio, Texas

Dr. Koops received her undergraduate degree from Colorado State University and medical degree from the University of Colorado Health Sciences Center in Denver. After internal medicine training at Tripler Army Medical Center in Hawaii, she completed her endocrine fellowship at the Walter Reed Army Medical Center in Washington DC. She served for more than 20 years on Active Duty. She is currently an Associate Professor of Medicine at the UT Health Science Center San Antonio and the Chief of Endocrinology and Metabolism for the South Texas Veteran Health Care System. She is a member of the Endocrine Society, American Association of Clinical Endocrinologist (AACE) and the American College of Physicians (ACP). She cares for patients as part of the academic teaching mission of UT Health at the Texas Diabetes Institute and at the Audie L Murphy Veteran’s Administration Hospital.

Devjit Tripathy

Professor
UT Health San Antonio, Department of Medicine, Division of Diabetes
San Antonio, Texas

Dr. Tripathy received his medical degree from SCB Medical College in Cuttack, India, and completed Internal Medicine residency and Endocrinology fellowship training in India prior to completing his PhD in Endocrinology in Lund University in Sweden. He then completed Internal Medicine residency and Endocrinology Fellowship in SUNY in Buffalo, NY. He is currently Professor of Medicine University of Texas Health San Antonio and Director of Diabetes Research in the Bartter Research Unit at Audie L south Texas Veterans Health Care Systems. His research interests include Diabetes and Metabolism with numerous publications in this area. He is a member of the Endocrine Society, American Association of Clinical Endocrinologists, and American Diabetes Association.

Jonathan Trejo

Endocrine, Diabetes and Metabolism Fellow
UT Health San Antonio, Department of Medicine, Division of Endocrinology, Diabetes and Metabolism
San Antonio, Texas

Dr. Trejo received his Bachelor's of Science at Trinity University in San Antonio, and completed medical school and Internal Medicine Residency at UT Health San Antonio. He is currently an Endocrine, Diabetes and Metabolism Fellow at UT Health San Antonio. His research interests lie in diabetes, including the categorization of subtypes of diabetes. He also has an interest in health policy and community health.