Background: Diabetic ketoacidosis (DKA) management by variable-rate insulin infusion is increasing with the widespread adoption of electronic glucose management systems (eGMS). Herein, we evaluate the implementation of an updated process for DKA management incorporating the eGMS algorithm. Methods: An eGMS was implemented within the Cedars-Sinai Health System at our tertiary academic center (AC) and community hospital (CH) in January 2024. We compared outcomes after eGMS implementation (post-GMS) to the previous standard of care (pre-GMS). Adult patients admitted to the intensive care unit with a primary diagnosis of DKA and treated with an insulin infusion between January 2023 and December 2024 were included. We separately evaluated outcomes of hypoglycemia (blood glucose, BG <70 mg/dL) and severe hypoglycemia (BG <40 mg/dL) and treatment efficacy. Results: In total, 324 patients were included in the pre-GMS and 211 patients in the post-GMS cohorts. There was a decrease in the prevalence of hypoglycemia (pre-GMS: 11.0%, post-GMS: 4.3%, P = .005) and severe hypoglycemia (pre-GMS: 1.90%, post-GMS: 0.00%, P = .047). At AC, the hospital length of stay (LOS) decreased from 8.6 to 6.0 days ( P = .012). At CH, insulin drip duration increased significantly (pre-GMS: 26.4 h, post-GMS: 36.7 h, P = .004), but there was no impact on LOS. Conclusion: Updating the DKA process and implementing an eGMS improved hypoglycemia rates throughout the institution. Hospital LOS was reduced at the AC, reflecting standardization and streamlining of the DKA processes.
Purpose: To evaluate longitudinal changes in continuous glucose monitoring (CGM)-derived glycemic metrics, glycemia risk indices (GRIs), triglyceride-glucose (TyG) index, and diabetes self-management before, during, and after Ramadan fasting in adults with type 2 diabetes (T2D) receiving non-intensive diabetes therapy and using real-time CGM (rtCGM). Methods: This ambispective longitudinal cohort study included 110 adults with T2D managed at a tertiary diabetes center in Riyadh, Saudi Arabia. The study combined retrospective ascertainment of pre-enrollment data with prospective follow-up from enrollment during Ramadan through the post-Ramadan period. Glycemic outcomes were assessed across pre-Ramadan, Ramadan, and post-Ramadan periods using CGM-derived metrics, including time in range (%TIR 70-180 ), time above range, glucose variability, GRI, and hypoglycemia indices. The TyG index and Perceived Diabetes Self-Management Scale (PDSMS) were also evaluated. Results: Compared with the pre-Ramadan period, median %TIR 70-180 increased significantly during Ramadan from 60.8% to 65.0% ( P < .001), while median sensor glucose decreased from 187 to 175 mg/dL ( P < .001). Glucose variability also improved during Ramadan (36.5% vs 32.0%, P < .001), accompanied by lower GRI values (38.0 vs 35.3, P < .001). Severe hypoglycemia exposure (time below range, %TBR <54 ) remained unchanged ( P = .358), although mild hypoglycemia exposure increased modestly. The TyG index decreased during Ramadan (9.65 vs 9.55, P = .003), whereas PDSMS scores increased from 27.0 to 29.0 ( P < .001). Several glycemic and metabolic parameters demonstrated post-Ramadan rebound toward pre-Ramadan levels. No hospitalizations or treatment-escalation events occurred during Ramadan. Conclusion: Improved glycemic control, reduced hyperglycemia exposure, and enhanced diabetes self-management were observed during Ramadan among selected adults with T2D receiving non-intensive diabetes therapy, rtCGM, and structured Ramadan-focused support, with stable severe hypoglycemia exposure despite a modest increase in mild hypoglycemia.
Background: Multisystem effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) beyond cardiometabolic outcomes are incompletely characterized against active comparators in type 2 diabetes (T2D). We compared GLP-1RA with sulfonylureas (SUs), sodium-glucose cotransporter-2 inhibitors (SGLT2is), and dipeptidyl peptidase-4 inhibitors (DPP4is) in adults with T2D. Method: In a multicenter target trial emulation across 5 University of California academic medical centers (2012-2025) using harmonized electronic health record data, adults with T2D newly initiating GLP-1RA, SU, SGLT2i, or DPP4i were propensity score-matched 1-to-1 within site via least absolute shrinkage and selection operator (>11 000 covariates), with up to 5-year follow-up. We screened 181 prespecified incident outcomes across 15 body systems, pooling hazard ratios by random-effects meta-analysis. Robustness required leave-one-medical-center-out stability, E -value ≥1.5, and false discovery rate–adjusted P < .10. Results: Among 70 982 matched adults, 118 robust associations were identified (65 for reduced risk and 53 for increased risk). Risk reductions were most consistent for cardiovascular outcomes, including myocarditis/cardiomyopathy (summary hazard ratio, 0.38 [95% CI, 0.32-0.44] vs SGLT2i), acute myocardial infarction (0.53 [0.42-0.66]), heart failure (0.71 [0.58-0.88] vs DPP4i), and thromboembolism (0.69-0.72), and for nephritis/nephrosis (0.73 [0.67-0.79]), nutritional anemia (0.70-0.81), coagulation disorders (0.73-0.81), and tobacco-related disorders (0.60 [0.49-0.74]). Risk increases were found for musculoskeletal conditions (22 associations); osteoarthritis 1.48 (1.29-1.68), stress fractures 1.68 (1.15-2.47), diverticular disease (1.18-1.33), sleep-wake disorders (1.27-1.54), and menopausal disorders (1.32-1.52). Conclusions: Glucagon-like peptide-1 receptor agonist initiation was associated with reduced cardiovascular, renal, hematologic, and tobacco-related risk, consistent with outcome trials. Increased risks for musculoskeletal, gastrointestinal, and sleep-wake disorders warrant monitoring as the clinical use of GLP-1RAs continues to expand.
