A conversation with Guillermo Umpierrez, MD, Professor of Medicine at Emory University, Director of the Grady Memorial Hospital Clinical Research Network, and past president of the American Diabetes Association.
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David Klonoff (00:15):
Hello, welcome to Diabetes Technology Report.
I'm Dr David Klonoff.
I'm an endocrinologist at MillsPeninsula Medical Center in San
Mateo.
Today we have a very specialguest and my co-moderator, Dr
David Kerr, will introduce him.
David Kerr (00:34):
Welcome everyone.
I'm David Kerr.
I'm speaking to you again fromSanta Barbara, california, and
our very special guest today isGuillermo Umpierrez, who
probably doesn't need anyintroduction to most people who
are involved in diabetes care.
Hello, guillermo, welcome.
We like to begin these podcastswith just finding a little bit
(00:55):
about how you ended up being asuperstar in diabetes technology
, and particularly in hospitaldiabetes care.
What kind of led you to thisplace?
Guillermo Umpierrez (01:07):
Well, david and David, I'm an
endocrinologist and donediabetes clinical care and
research for the past 40 years.
So my first job description atGrady Hospital at Emory
University was take care ofdiabetes at Grady and we have a
(01:28):
large number of admissions, manyof them with multiple
complications.
So I've always been in thehospital dealing with patient
care and of course it was verynatural that if I was going to
do research it was going to bein this area of inpatient
glycemic control.
So I started doing fullresearch.
(01:49):
Well, a significant percentageof my time doing research in the
late 1980s or no 1990s, sorry,and always been in diabetes care
.
So with severe hyperglycemiacomplications, amputations and,
of course, in the last few years, related to technology.
David Kerr (02:12):
And what are you working on at the moment?
What's the frontier oftechnology in diabetes research
that's keeping you awake atnight?
Guillermo Umpierrez (02:21):
awake at night.
Well, right now we arecompleting two studies with
technology.
One is can you improve glycemiccontrol with the use of
continuous glucose monitoring?
Can you target a glucosebetween 90 to 130 instead of 140
(02:43):
to 180?
That has been the traditionaltarget and using CGM?
So we did it with real-time CGMand patients were treated in
six different centers in theUnited States and with insulin
therapy.
Most of them received basalbolus and one had a real time.
(03:08):
The other has a blinded CGM.
And the answer is there was atrend to improve glycemic
control but we did not seesignificant difference.
And it's very, very hard in thehospital, especially for those
patients who have significanthyperglycemia with elevated
hemoglobin A1C, basicallygreater than 9%.
(03:29):
It's almost impossible to typecontrol them with so few insulin
.
So they are glucotoxic and thestandard here is to start
insulin in 0.5, 0.3, 0.5 unitsper kilo.
That's maybe not enough.
So what we learned in thatstudy it was just presented a
(03:50):
couple of months ago at the ADAis that if you have a patient
with a hemoglobin A1c less thaneight, it is much easier to have
good glucose control If thehemoglobin A1c is greater than 9
, we did not achieve goodglucose control with the average
pro glucose about 170, 175,even if you use or do not use a
(04:14):
continuous glucose monitoring.
So that was a big lesson for us.
We knew that those patients,especially those who come to
greater heart growth withhemoglobin 1C of 9, 10, 11,
those are very tough people tocontrol.
David Klonoff (04:30):
Guillermo, how do you balance the risks of
delivering insulin that can leadto hypoglycemia versus the
benefits of keeping people at atarget glucose level?
Guillermo Umpierrez (04:44):
Yeah, and that's the big challenge.
That's right, becausehypoglycemia less than seven has
been reported in differentstudies.
We're between 8% to 28%, andthere are a significant number
of retrospective data thathypoglycemia is associated with
poor outcome.
We also reported that about 45%of patients with glucose less
(05:09):
than 70 do not have symptoms.
So it's a challenge.
You're clinical how do youdiscover, how do you recognize
hypoglycemia and what is theimpact?
So the only way that you willbe able to recognize these
asymptomatic hypoglycemia iswith glucose monitoring or
continuous glucose monitoring.
And how do you do it?
(05:31):
Well, we, just in the last fewyears, we have relaxed our
target.
So you remember those papersfrom Belgium in the ICU, 80 to
110.
Now we know that's not the case.
They don't help at all.
In the non-ICU we used to say70 to 130 as the goal for
(05:51):
inpatients in the general world.
Now we say somewhere between100 to 180.
And then if you want to go inthe lower end, well, maybe use
agents not associated withhypoglycemia.
If not, just keep the bloodglucose between 100 to 180.
And that's the best way toprevent hypoglycemia.
If you talk at 100 to 180, thehypoglycemia rate is less than
(06:16):
10%.
David Klonoff (06:18):
Guillermo, I was at your presentation at the ADA
when you discussed this data,and I remember some of the
doctors were having trouble withpatients not getting fed either
the correct foods or gettingfed at the correct time.
That can be as big a problem as, let's say, not finding the
ideal dose of insulin.
What do you think?
Guillermo Umpierrez (06:37):
Yeah, and if you don't eat or the insulin
is given before meals and youdon't eat, there's a risk of
hypoglycemia.
But more importantly, it's thechallenge that we have with our
nursing staff and food delivery,the trade delivery.
Now we want the insulin to begiven before meals, but many
times it's during or after mealsand in many hospitals, at least
(07:01):
in Atlanta, we have short staffwith nursing and there is a lot
of nursing turnover that isvery hard to educate them in a
consistent basis.
So you are right, David, that'sthe main problem that we have in
the inpatient the timingbetween insulin and tray
delivery and food intake.
David Kerr (07:22):
Guillermo, I was going to ask you about something
you just said.
So the HbA1c when you get intohospital, say for an elective
procedure, seems to determinewhat's going to happen.
So is your advice for peoplewith diabetes who are maybe
going to have an orthopedicprocedure or whatever, that they
really should optimize theirglucose control before they even
(07:45):
get to hospital, because it'sso important?
Guillermo Umpierrez (07:49):
Yes, and the recent Endocrine Society
guidelines published about ayear, year and a half ago.
One of the big questions waswhat is the ideal?
Hemoglobin in one seed andideally it's less than 8%.
Those patients are going to beable to very well control in the
hospital less hyper andhypoglycemia, better glucose
(08:11):
control, less complications.
Now that's the ideal forelective procedures.
We don't want to hold surgeryor cancel surgery because you're
hemoglobin 1, ch9, knowing thatmaybe you need to be more
aggressive or use ways toimplement better glucose
monitoring to try to achievebetter glucose control.
David Kerr (08:33):
What about the other end of the hospital experience,
the discharge end?
Do you think we're doing a goodjob there at the moment?
People who say have diabeteswhen they come into hospital,
but there's also people wherediabetes is diagnosed when they
are admitted to hospital.
Are you happy with what we'redoing for the discharge back
(08:56):
into the community?
Guillermo Umpierrez (08:59):
Yeah, so you just highlighted extremely
important questions, right?
We know that poor glucosecontrol is associated with
increased rate of readmission tothe hospital and it has more
complications.
We know that if you use justpoint-of-care testing, finger
sticks, somewhere around 20% 25%of them within three months
(09:22):
have low blood glucose.
So David Klonoff he has a smileon his face because he's the
principal investigator of arandomized control study that we
just finished, investigator ofa randomized control study that
we just finished and that studyshows that the use of continuous
glucose monitoring recognizemuch more hyper and hypoglycemic
(09:45):
events compared topoint-of-care testing.
So you can ask the patient dofinger stick four times a day?
But unfortunately they don't doit.
So we send the patient home witha blind CGM and with a Libre
tool and those patients who workon the CGM have better.
(10:09):
There was a trend, there was apilot study just a hundred
patients that have a significanttrend on better glucose control
lower time above range greaterthan 180 and 180,.
Lower time below range lessthan 70, and much better what is
called timing range.
In that study we defined timingrange 70 to 180.
(10:33):
So I think that that studyreally opened up the field that
you should be monitoring thosepatients that are sent home with
insulin with a bettermonitoring tool, and that's the
current recommendation.
That's right.
So patients with type 1,patients with hyperglycemic,
even patients just on type 2 andinsulin should go home with a
(10:57):
continuous glucose monitoring.
David Klonoff (11:00):
Well, Guillermo, the study that you're talking
about, that we did together.
It showed improvement inoutcomes, but they were not
statistically significant andthe number of subjects we looked
at was probably not enoughwhere we could have proven it.
Do you think that there'll befuture studies with larger
numbers of patients to showstatistical significance?
Guillermo Umpierrez (11:22):
Yes, yes, absolutely.
And we in the large populationbase that we publish now in
Diabetes Technology andTherapeutics, a few months
earlier this year, a couplemonths ago, in the
implementation of CGM inAndalusia, the south of Spain,
in a couple hundred thousandpatients, you reduce the number
(11:45):
of hypoglycemia, hypoglycemiaadmissions and in patients with
type 1 diabetes, implementationin a population, large
population, will reduce the rateof diabetic ketoacidosis in
type 1 by half.
So I think that we have beendoing finger stick for the past
50 years.
I think that we have been doingfinger stick for the past 50
(12:07):
years.
I believe that we are now inthe time that we should consider
better glucose monitoring Inthe hospital.
We recognize hypoglycemia andhyperglycemia After discharge.
Now we know that you canimprove glycemic control In an
observational study.
You reduce the number ofreadmissions and you reduce the
(12:29):
number of diabetic ketoacidosis.
So a randomized control trialI'm waiting for you to get the
second paper, second study, runand we will recruit patients
with you, guillermo.
David Klonoff (12:40):
another condition that you've done more work on,
I think, than anybody else, isstress hyperglycemia.
Could you explain that and howit differs from diabetes, if
someone comes into the hospitalwith a high blood sugar?
Guillermo Umpierrez (12:54):
Yeah, our first study, I think it was 22
years ago.
We noticed that about 28% ofpatients in the hospital come
with high blood glucose and ofthem, somewhere around 10% to
15% have no previous history ofdiabetes.
And now we have looked intothis and we know that somewhere
(13:19):
around 20% of patients noprevious history of diabetes,
having even a glucose less than126 and hemoglobin 1C less than
6.5, develop hyperglycemia inthe hospital, defined as a
glucose greater than 140 andgreater than 180.
And both are associated withincreased rate of complications,
(13:40):
increased rate of surgicalinfections, admissions and even
a trend in mortality.
So stress hyperglycemia definedas newly diagnosed
hyperglycemia in those patients,even with hemoglobin O and C
less than 6.5, is common and isassociated with increased rate
(14:00):
of complication, maybe even thesame or worse than those
patients with prehistorydiabetes.
David Kerr (14:08):
Guillermo, I've got to take advantage of you being
on the podcast and ask you thered-hot, controversial question
about GLP-1 receptor agonistsand elective surgery.
Do you stop them?
If you do, when do you stopthem?
Should you stop them?
Where are you in this red hotstate?
Guillermo Umpierrez (14:29):
So you're following this recommendation of
the anesthesiology group and Ithink that's a little.
It's unfunded by goodscientific data.
Most of these were case reports, retrospective data.
We do know that GLP-1, one ofthe mechanisms that it works is
(14:49):
because it's delayed gastricemptying.
But there is a tachyphylaxis.
So we have symptoms that appearfor the first few weeks but
then patients do not havesymptoms.
So if somebody who do not haveany symptoms of gastrointestinal
nausea, vomiting, who have beenon stable doses of GLP-1, do
(15:09):
you really have to stop themedicine?
So by observation data doesn'treally help us much.
Dr Klanov Group published apaper in, I think, jama not too
long ago with a large number ofpatients and it shows that there
is no increased rate ofpulmonary complications.
We, on the other hand, havereviewed the literature and
(15:31):
published data suggesting thatyou have to individualize care.
So if you have a patient comingto me, let's say an orthopedic
surgeon says hemoglobin 1 CO9,tune him up.
Surgeon says hemoglobin 1-CO9,tune him up.
I'm not going to use GLP-1 ifthe patient is going to have
surgery within the next one ortwo weeks, because I know that
(15:52):
is when they have nausea,vomiting or they have gastric
emptying syndrome.
But if you have a patient thathas been on stable doses with
diabetes and without diabetes,maybe it's safe to continue to
use GLP-1, but alert theanesthesiologist that the
patient is in this medicine,they can follow the full stomach
protocol.
(16:12):
I mean, anesthesiologists havebeen doing anesthesia with
everybody for many years, sothey know how to deal with that.
Now if the patient has symptoms, then you have to say, well,
it's not urgent, maybe you stopthe medicine.
But if the patient has historyof diabetes, you have to be
concerned that the glucose isgoing to go out.
So I think that we need toindividualize, we need more data
(16:36):
, but I don't think that thisone way of doing things,
stopping this Yelp to one, makessense to me, for everybody, and
which is the data so far thatis coming out suggests that the
rate of pulmonary complicationsis not as common.
But of course all depends onwhen do you use it, how do you
(17:01):
use it.
The other thing, the finalthing about your question, david
, is if you have a group ofpeople who are using this
long-acting GLP-1,.
Where are those with diabetesand those?
The others are people who arejust doing for weight loss.
So in the people with diabetes,many of them already have
gastroparesis, so those patientsmay be at a higher risk.
(17:23):
But in patients who are obese,if they have been stable, I mean
, I don't see much of concernthat we have related to
pulmonary complications oraspiration.
But the real expert in thisfield is Dr Klanov.
So, david, any comments?
David Klonoff (17:44):
Yes, a group of us, including Dr Kerr, reviewed
a database of 130 million people.
We looked at nine commonsurgeries and six potential
complications of surgery thatcould be due to GLP-1, and we
(18:05):
found no increased risk for anyof these six complications.
Guillermo, I want to ask yousomething else now.
You recently led a veryimportant international project
to rewrite the treatment goalsfor hyperglycemic crises, and I
(18:26):
know that you and the teampresented this data at the ADA
meeting last month.
What does that project mean toyou and what effect do you think
it will have?
Guillermo Umpierrez (18:39):
So that was an update.
We were invited to write anupdate of the ADA guidelines for
the treatment of diabeticketoacidosis and I was honored
to serve as the chair.
So my first request to the ADAwas this has to be a global
consensus.
It just can't be ADA.
(19:00):
So we invited the DiabetesTechnology Society, we invited
AIDS, we invited the EuropeanAssociation of Studies of
Diabetes, uk Diabetes, and wehave an international group of
people working together toreview the literature, because
the last guidelines were writtenin 2009.
(19:21):
And there was over 7,000articles that have been
published in the area.
So we updated the consensus,providing new data on
epidemiology, highlighting theincreased number of patients
with hyperglycemic admissions.
We reviewed the diagnosticcriterias and ways to treat
(19:46):
people with hyperglycemicemergencies and, finally, we
updated on complications and howto go to prevent readmission
and how to go to preventcomplications of treatment.
But it was a global consensus,so with major organizations that
are involved in diabetes carein Europe and, of course, in the
(20:08):
United States.
David Klonoff (20:10):
Well, it had been 15 years and it was definitely
time.
Guillermo, I would like tothank you on behalf of both
Davids for speaking with ustoday.
You are definitely the expertin diabetes treatments and we're
very fortunate that you joinedus For the audience.
We look forward to you joiningus for future Diabetes
(20:33):
Technology Reports.
We're available on Spotify, theApple Store and the Diabetes
Technology Society website.
So, until our next DiabetesTechnology Report, we'll catch
each other later.
Bye-bye, thank you very much.
Guillermo Umpierrez (20:50):
Bye-bye, thank you.
Hello, welcome to Diabetes Technology Report.
I'm Dr David Klonoff.
I'm an endocrinologist at MillsPeninsula Medical Center in San
Mateo.
Today we have a very specialguest and my co-moderator, Dr
David Kerr, will introduce him.
David Kerr (00:34):
Welcome everyone.
I'm David Kerr.
I'm speaking to you again fromSanta Barbara, california, and
our very special guest today isGuillermo Umpierrez, who
probably doesn't need anyintroduction to most people who
are involved in diabetes care.
Hello, guillermo, welcome.
We like to begin these podcastswith just finding a little bit
(00:55):
about how you ended up being asuperstar in diabetes technology
, and particularly in hospitaldiabetes care.
What kind of led you to thisplace?
Guillermo Umpierrez (01:07):
Well, david and David, I'm an
endocrinologist and donediabetes clinical care and
research for the past 40 years.
So my first job description atGrady Hospital at Emory
University was take care ofdiabetes at Grady and we have a
(01:28):
large number of admissions, manyof them with multiple
complications.
So I've always been in thehospital dealing with patient
care and of course it was verynatural that if I was going to
do research it was going to bein this area of inpatient
glycemic control.
So I started doing fullresearch.
(01:49):
Well, a significant percentageof my time doing research in the
late 1980s or no 1990s, sorry,and always been in diabetes care
.
So with severe hyperglycemiacomplications, amputations and,
of course, in the last few years, related to technology.
David Kerr (02:12):
And what are you working on at the moment?
What's the frontier oftechnology in diabetes research
that's keeping you awake atnight?
Guillermo Umpierrez (02:21):
awake at night.
Well, right now we arecompleting two studies with
technology.
One is can you improve glycemiccontrol with the use of
continuous glucose monitoring?
Can you target a glucosebetween 90 to 130 instead of 140
(02:43):
to 180?
That has been the traditionaltarget and using CGM?
So we did it with real-time CGMand patients were treated in
six different centers in theUnited States and with insulin
therapy.
Most of them received basalbolus and one had a real time.
(03:08):
The other has a blinded CGM.
And the answer is there was atrend to improve glycemic
control but we did not seesignificant difference.
And it's very, very hard in thehospital, especially for those
patients who have significanthyperglycemia with elevated
hemoglobin A1C, basicallygreater than 9%.
(03:29):
It's almost impossible to typecontrol them with so few insulin
.
So they are glucotoxic and thestandard here is to start
insulin in 0.5, 0.3, 0.5 unitsper kilo.
That's maybe not enough.
So what we learned in thatstudy it was just presented a
(03:50):
couple of months ago at the ADAis that if you have a patient
with a hemoglobin A1c less thaneight, it is much easier to have
good glucose control If thehemoglobin A1c is greater than 9
, we did not achieve goodglucose control with the average
pro glucose about 170, 175,even if you use or do not use a
(04:14):
continuous glucose monitoring.
So that was a big lesson for us.
We knew that those patients,especially those who come to
greater heart growth withhemoglobin 1C of 9, 10, 11,
those are very tough people tocontrol.
David Klonoff (04:30):
Guillermo, how do you balance the risks of
delivering insulin that can leadto hypoglycemia versus the
benefits of keeping people at atarget glucose level?
Guillermo Umpierrez (04:44):
Yeah, and that's the big challenge.
That's right, becausehypoglycemia less than seven has
been reported in differentstudies.
We're between 8% to 28%, andthere are a significant number
of retrospective data thathypoglycemia is associated with
poor outcome.
We also reported that about 45%of patients with glucose less
(05:09):
than 70 do not have symptoms.
So it's a challenge.
You're clinical how do youdiscover, how do you recognize
hypoglycemia and what is theimpact?
So the only way that you willbe able to recognize these
asymptomatic hypoglycemia iswith glucose monitoring or
continuous glucose monitoring.
And how do you do it?
(05:31):
Well, we, just in the last fewyears, we have relaxed our
target.
So you remember those papersfrom Belgium in the ICU, 80 to
110.
Now we know that's not the case.
They don't help at all.
In the non-ICU we used to say70 to 130 as the goal for
(05:51):
inpatients in the general world.
Now we say somewhere between100 to 180.
And then if you want to go inthe lower end, well, maybe use
agents not associated withhypoglycemia.
If not, just keep the bloodglucose between 100 to 180.
And that's the best way toprevent hypoglycemia.
If you talk at 100 to 180, thehypoglycemia rate is less than
(06:16):
10%.
David Klonoff (06:18):
Guillermo, I was at your presentation at the ADA
when you discussed this data,and I remember some of the
doctors were having trouble withpatients not getting fed either
the correct foods or gettingfed at the correct time.
That can be as big a problem as, let's say, not finding the
ideal dose of insulin.
What do you think?
Guillermo Umpierrez (06:37):
Yeah, and if you don't eat or the insulin
is given before meals and youdon't eat, there's a risk of
hypoglycemia.
But more importantly, it's thechallenge that we have with our
nursing staff and food delivery,the trade delivery.
Now we want the insulin to begiven before meals, but many
times it's during or after mealsand in many hospitals, at least
(07:01):
in Atlanta, we have short staffwith nursing and there is a lot
of nursing turnover that isvery hard to educate them in a
consistent basis.
So you are right, David, that'sthe main problem that we have in
the inpatient the timingbetween insulin and tray
delivery and food intake.
David Kerr (07:22):
Guillermo, I was going to ask you about something
you just said.
So the HbA1c when you get intohospital, say for an elective
procedure, seems to determinewhat's going to happen.
So is your advice for peoplewith diabetes who are maybe
going to have an orthopedicprocedure or whatever, that they
really should optimize theirglucose control before they even
(07:45):
get to hospital, because it'sso important?
Guillermo Umpierrez (07:49):
Yes, and the recent Endocrine Society
guidelines published about ayear, year and a half ago.
One of the big questions waswhat is the ideal?
Hemoglobin in one seed andideally it's less than 8%.
Those patients are going to beable to very well control in the
hospital less hyper andhypoglycemia, better glucose
(08:11):
control, less complications.
Now that's the ideal forelective procedures.
We don't want to hold surgeryor cancel surgery because you're
hemoglobin 1, ch9, knowing thatmaybe you need to be more
aggressive or use ways toimplement better glucose
monitoring to try to achievebetter glucose control.
David Kerr (08:33):
What about the other end of the hospital experience,
the discharge end?
Do you think we're doing a goodjob there at the moment?
People who say have diabeteswhen they come into hospital,
but there's also people wherediabetes is diagnosed when they
are admitted to hospital.
Are you happy with what we'redoing for the discharge back
(08:56):
into the community?
Guillermo Umpierrez (08:59):
Yeah, so you just highlighted extremely
important questions, right?
We know that poor glucosecontrol is associated with
increased rate of readmission tothe hospital and it has more
complications.
We know that if you use justpoint-of-care testing, finger
sticks, somewhere around 20% 25%of them within three months
(09:22):
have low blood glucose.
So David Klonoff he has a smileon his face because he's the
principal investigator of arandomized control study that we
just finished, investigator ofa randomized control study that
we just finished and that studyshows that the use of continuous
glucose monitoring recognizemuch more hyper and hypoglycemic
(09:45):
events compared topoint-of-care testing.
So you can ask the patient dofinger stick four times a day?
But unfortunately they don't doit.
So we send the patient home witha blind CGM and with a Libre
tool and those patients who workon the CGM have better.
(10:09):
There was a trend, there was apilot study just a hundred
patients that have a significanttrend on better glucose control
lower time above range greaterthan 180 and 180,.
Lower time below range lessthan 70, and much better what is
called timing range.
In that study we defined timingrange 70 to 180.
(10:33):
So I think that that studyreally opened up the field that
you should be monitoring thosepatients that are sent home with
insulin with a bettermonitoring tool, and that's the
current recommendation.
That's right.
So patients with type 1,patients with hyperglycemic,
even patients just on type 2 andinsulin should go home with a
(10:57):
continuous glucose monitoring.
David Klonoff (11:00):
Well, Guillermo, the study that you're talking
about, that we did together.
It showed improvement inoutcomes, but they were not
statistically significant andthe number of subjects we looked
at was probably not enoughwhere we could have proven it.
Do you think that there'll befuture studies with larger
numbers of patients to showstatistical significance?
Guillermo Umpierrez (11:22):
Yes, yes, absolutely.
And we in the large populationbase that we publish now in
Diabetes Technology andTherapeutics, a few months
earlier this year, a couplemonths ago, in the
implementation of CGM inAndalusia, the south of Spain,
in a couple hundred thousandpatients, you reduce the number
(11:45):
of hypoglycemia, hypoglycemiaadmissions and in patients with
type 1 diabetes, implementationin a population, large
population, will reduce the rateof diabetic ketoacidosis in
type 1 by half.
So I think that we have beendoing finger stick for the past
50 years.
I think that we have been doingfinger stick for the past 50
(12:07):
years.
I believe that we are now inthe time that we should consider
better glucose monitoring Inthe hospital.
We recognize hypoglycemia andhyperglycemia After discharge.
Now we know that you canimprove glycemic control In an
observational study.
You reduce the number ofreadmissions and you reduce the
(12:29):
number of diabetic ketoacidosis.
So a randomized control trialI'm waiting for you to get the
second paper, second study, runand we will recruit patients
with you, guillermo.
David Klonoff (12:40):
another condition that you've done more work on,
I think, than anybody else, isstress hyperglycemia.
Could you explain that and howit differs from diabetes, if
someone comes into the hospitalwith a high blood sugar?
Guillermo Umpierrez (12:54):
Yeah, our first study, I think it was 22
years ago.
We noticed that about 28% ofpatients in the hospital come
with high blood glucose and ofthem, somewhere around 10% to
15% have no previous history ofdiabetes.
And now we have looked intothis and we know that somewhere
(13:19):
around 20% of patients noprevious history of diabetes,
having even a glucose less than126 and hemoglobin 1C less than
6.5, develop hyperglycemia inthe hospital, defined as a
glucose greater than 140 andgreater than 180.
And both are associated withincreased rate of complications,
(13:40):
increased rate of surgicalinfections, admissions and even
a trend in mortality.
So stress hyperglycemia definedas newly diagnosed
hyperglycemia in those patients,even with hemoglobin O and C
less than 6.5, is common and isassociated with increased rate
(14:00):
of complication, maybe even thesame or worse than those
patients with prehistorydiabetes.
David Kerr (14:08):
Guillermo, I've got to take advantage of you being
on the podcast and ask you thered-hot, controversial question
about GLP-1 receptor agonistsand elective surgery.
Do you stop them?
If you do, when do you stopthem?
Should you stop them?
Where are you in this red hotstate?
Guillermo Umpierrez (14:29):
So you're following this recommendation of
the anesthesiology group and Ithink that's a little.
It's unfunded by goodscientific data.
Most of these were case reports, retrospective data.
We do know that GLP-1, one ofthe mechanisms that it works is
(14:49):
because it's delayed gastricemptying.
But there is a tachyphylaxis.
So we have symptoms that appearfor the first few weeks but
then patients do not havesymptoms.
So if somebody who do not haveany symptoms of gastrointestinal
nausea, vomiting, who have beenon stable doses of GLP-1, do
(15:09):
you really have to stop themedicine?
So by observation data doesn'treally help us much.
Dr Klanov Group published apaper in, I think, jama not too
long ago with a large number ofpatients and it shows that there
is no increased rate ofpulmonary complications.
We, on the other hand, havereviewed the literature and
(15:31):
published data suggesting thatyou have to individualize care.
So if you have a patient comingto me, let's say an orthopedic
surgeon says hemoglobin 1 CO9,tune him up.
Surgeon says hemoglobin 1-CO9,tune him up.
I'm not going to use GLP-1 ifthe patient is going to have
surgery within the next one ortwo weeks, because I know that
(15:52):
is when they have nausea,vomiting or they have gastric
emptying syndrome.
But if you have a patient thathas been on stable doses with
diabetes and without diabetes,maybe it's safe to continue to
use GLP-1, but alert theanesthesiologist that the
patient is in this medicine,they can follow the full stomach
protocol.
(16:12):
I mean, anesthesiologists havebeen doing anesthesia with
everybody for many years, sothey know how to deal with that.
Now if the patient has symptoms, then you have to say, well,
it's not urgent, maybe you stopthe medicine.
But if the patient has historyof diabetes, you have to be
concerned that the glucose isgoing to go out.
So I think that we need toindividualize, we need more data
(16:36):
, but I don't think that thisone way of doing things,
stopping this Yelp to one, makessense to me, for everybody, and
which is the data so far thatis coming out suggests that the
rate of pulmonary complicationsis not as common.
But of course all depends onwhen do you use it, how do you
(17:01):
use it.
The other thing, the finalthing about your question, david
, is if you have a group ofpeople who are using this
long-acting GLP-1,.
Where are those with diabetesand those?
The others are people who arejust doing for weight loss.
So in the people with diabetes,many of them already have
gastroparesis, so those patientsmay be at a higher risk.
(17:23):
But in patients who are obese,if they have been stable, I mean
, I don't see much of concernthat we have related to
pulmonary complications oraspiration.
But the real expert in thisfield is Dr Klanov.
So, david, any comments?
David Klonoff (17:44):
Yes, a group of us, including Dr Kerr, reviewed
a database of 130 million people.
We looked at nine commonsurgeries and six potential
complications of surgery thatcould be due to GLP-1, and we
(18:05):
found no increased risk for anyof these six complications.
Guillermo, I want to ask yousomething else now.
You recently led a veryimportant international project
to rewrite the treatment goalsfor hyperglycemic crises, and I
(18:26):
know that you and the teampresented this data at the ADA
meeting last month.
What does that project mean toyou and what effect do you think
it will have?
Guillermo Umpierrez (18:39):
So that was an update.
We were invited to write anupdate of the ADA guidelines for
the treatment of diabeticketoacidosis and I was honored
to serve as the chair.
So my first request to the ADAwas this has to be a global
consensus.
It just can't be ADA.
(19:00):
So we invited the DiabetesTechnology Society, we invited
AIDS, we invited the EuropeanAssociation of Studies of
Diabetes, uk Diabetes, and wehave an international group of
people working together toreview the literature, because
the last guidelines were writtenin 2009.
(19:21):
And there was over 7,000articles that have been
published in the area.
So we updated the consensus,providing new data on
epidemiology, highlighting theincreased number of patients
with hyperglycemic admissions.
We reviewed the diagnosticcriterias and ways to treat
(19:46):
people with hyperglycemicemergencies and, finally, we
updated on complications and howto go to prevent readmission
and how to go to preventcomplications of treatment.
But it was a global consensus,so with major organizations that
are involved in diabetes carein Europe and, of course, in the
(20:08):
United States.
David Klonoff (20:10):
Well, it had been 15 years and it was definitely
time.
Guillermo, I would like tothank you on behalf of both
Davids for speaking with ustoday.
You are definitely the expertin diabetes treatments and we're
very fortunate that you joinedus For the audience.
We look forward to you joiningus for future Diabetes
(20:33):
Technology Reports.
We're available on Spotify, theApple Store and the Diabetes
Technology Society website.
So, until our next DiabetesTechnology Report, we'll catch
each other later.
Bye-bye, thank you very much.
Guillermo Umpierrez (20:50):
Bye-bye, thank you.
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