Guillermo E Umpierrez

Emory University | EU · Division of Endocrinology

Diabetes Technology Society organized an expert consensus panel to develop metrics for research in the use of continuous glucose monitors (CGMs) in a hospital setting. The experts met virtually in small groups both before and after an April 13, 2023 virtual meeting of the entire panel. The goal of the panel was to develop consensus definitions in a...

Background The relationship of sarcopenia with relevant features of T2DM and its treatment is inconsistent in the literature. Aims To evaluate the prevalence of sarcopenia in insulin treated elderly patients with T2DM. Methods A cross-sectional data from a prospective cohort study with T2DM patients aged ≥ 65 y/o on insulin treatment with or with...

Background Few studies have reported on the adherence and efficacy of continuous glucose monitoring (CGM) in improving diabetes management in insulin-treated older adults with type 2 diabetes mellitus (T2DM). Methods Prospective observational cohort study using FreeStyle Libre Flash CGM in insulin-treated adults > 65 years with T2DM and HbA1c betw...

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and pu...

The integration of technologies such as continuous glucose monitors, insulin pumps, and smart pens into diabetes management has the potential to support the transformation of health care services that provide a higher quality of diabetes care, lower costs and administrative burdens, and greater empowerment for people with diabetes and their caregiv...

Introduction The prevalence, severity, and quality of life (QoL) impact of diabetic retinopathy (DR) among African–Americans (AAs) with end-stage kidney disease (ESKD) undergoing dialysis are unknown. Research design and methods A cross-sectional study was conducted on 93 AA adults with diabetes and ESKD. The diagnosis of DR was based on a review...

Objective: SARS-CoV-2 infection increases the risk of diabetes and diabetic ketoacidosis (DKA) in both adults and children. We investigated the clinical course of new-onset type 2 diabetes in obese youth presenting with DKA during the SARS-CoV-2 pandemic. Methods: This single-center retrospective cohort study included 148 obese subjects, aged 10...

We compared the efficacy of continuous glucose monitoring (CGM) and point of care (POC) testing (standard of care) in assessing glycemic control in older adults with T2D treated with either basal insulin or insulin secretagogues plus sliding scale in long-term care facilities (LTCF). All 97 subjects underwent POC testing before meals and bedtime an...

The efficacy of real-time continuous glucose monitoring (rt-CGM) in adjusting insulin therapy in long-term care facilities (LTCF) has not been evaluated. Accordingly, we randomized 100 insulin-treated subjects with T2D in LTCF. All subjects underwent point-of-care (POC) capillary glucose testing before meals and bedtime. Patients in the standard of...

Available second-line glucose-lowering medications for type 2 diabetes (T2D) have variable efficacy and side effect profiles, administration requirements, and impacts on short-term and long-term health outcomes. Therefore, medication choice is informed by each patient's clinical needs and personal preferences. However, patient rationale for selecti...

Introduction Insulin resistance (IR) is associated with increased risk of T2D, CV disease and CKD. Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, has shown cardiorenal benefits in people with CKD and T2D. We investigated if IR is associated with risk of cardiorenal outcomes and if IR modifies finerenone efficacy in the pooled FID...

Differing blood glucose (BG) targets are recommended by professional organizations in noncritical care settings. Previous Endocrine Society and ADA guidelines recommended a target BG of 70-140 and 140-180 mg/dl; however, the 2023 ADA Standards of Care recommends a target of 100-180 mg/dl. The lack of consensus is due to the lack of randomized clini...

Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency in patients with type 1 and type 2 diabetes mellitus. DKA accounts for more than 185,000 hospital admissions per year in the United States and is reported in 4–9% of all hospital discharge summaries among patients discharged with a primary diagnosis of diabetes. The triad of unc...

Aim: To assess the relationship between HbA1c and body weight reductions with tirzepatide treatment (5, 10 or 15 mg). Materials and methods: HbA1c and body weight data at 40 weeks (SURPASS-1, -2 and -5) and 52 weeks (SURPASS-3 and -4) were analysed by trial. Results: Across the SURPASS clinical trials, HbA1c reductions from baseline were obser...

Background: Patients with heart failure (HF) have a high burden of symptoms and physical limitations, regardless of ejection fraction (EF). Whether the benefits of SGLT2 (sodium-glucose cotransporter-2) inhibitors on these outcomes vary across the full range of EF remains unclear. Methods: Patient-level data were pooled from the DEFINE-HF trial...

Introduction: Stress-induced hyperglycemia (SIH) is conventionally represented by Blood Glucose (BG) although recent evidence indicates the Glycemic Ratio (GR, quotient of mean BG and estimated preadmission BG) is a superior prognostic marker. We assessed the association between in-hospital mortality and SIH, using BG and GR in an adult medical-su...

Objective: This consensus statement provides (1) visual guidance in concise graphic algorithms to assist with clinical decision-making of health care professionals in the management of persons with type 2 diabetes mellitus to improve patient care and (2) a summary of details to support the visual guidance found in each algorithm. Methods: The Am...

Diabetes Technology Society assembled a panel of clinician experts in diabetes, biomarker screening, and heart failure to review the current evidence on biomarker screening of people with diabetes (PWD) for heart failure (HF), who are, by definition, at risk for HF (Stage A HF). This consensus report reviews features of HF in PWD from the perspecti...

Background: Older adults with diabetes in the hospital are generally managed similarly to younger adults, however, it is unknown if the degree of frailty can affect glucose control among hospitalized patients. Methods: We examined glycemic parameters derived from continuous glucose monitoring (CGM) in older adults with type 2 diabetes and frailt...

Ketone bodies are an energy substrate produced by the liver and used during states of low carbohydrate availability, such as fasting or prolonged exercise. High ketone concentrations can be present with insulin insufficiency and are a key finding in diabetic ketoacidosis (DKA). During states of insulin deficiency, lipolysis increases and a flood of...

Aims: To assess the efficacy and safety of sotagliflozin, a dual inhibitor of sodium-glucose cotransporters 1 and 2, in adults with type 2 diabetes (T2D) and stage 3 chronic kidney disease (CKD3). Materials and methods: This phase 3, randomized, placebo-controlled trial evaluated sotagliflozin 200 and 400 mg in 787 patients with T2D and estimate...

Estimated all-cause mortality within 30-days of hypoglycemic emergencies is 0.8% in adults with type 1 diabetes and 1.7% with type 2 diabetes; and within 30-days of hyperglycemic emergencies, it is 1.2% with type 1 diabetes and 2.8% with type 2 diabetes. These rates changed little between 2011 and 2020.

Objective: To characterize contemporary trends in glucagon fill rates and expenditures in a nationwide cohort of adults with diabetes overall and by key demographic and clinical characteristics. Research design and methods: In this retrospective cohort study, we examined 1) glucagon fill rates per 1,000 person-years and 2) patient out-of-pocket...

Numerous studies have demonstrated the clinical value of continuous glucose monitoring (CGM) in type 1 diabetes (T1D) and type 2 diabetes (T2D) populations. However, the eligibility criteria for CGM coverage required by the Centers for Medicare & Medicaid Services (CMS) ignore the conclusive evidence that supports CGM use in various diabetes popula...

Background Brown adipose tissue (BAT) plays a role in modulating energy expenditure. People with obesity have been shown to have reduced activation of BAT. Agents such as β-agonists, capsinoids, thyroid hormone, sildenafil, caffeine, or cold exposure may lead to activation of BAT in humans, potentially modulating metabolism to promote weight loss....

Randomised controlled trials and other prospective clinical studies for novel medical interventions in people with diabetes have traditionally reported HbA1c as the measure of average blood glucose levels for the 3 months preceding the HbA1c test date. The use of this measure highlights the long-established correlation between HbA1c and relative ri...

Context The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM). Objective – To define the clinical characteristics, glucose control metrics and outcomes of patients admitted to the ICU with undiagDM, and compare these to patients with known DM (DM). Methods This case:control...

Objective: To assess attitudes, behaviors and barriers with diabetes technology use in the general medicine hospital wards. Research design and methods: The authors developed a non-incentivized web-based anonymous survey which captured demographic and practice data regarding continuous subcutaneous insulin infusion (CSII) and continuous glucose...

Hypoglycemia and hyperglycemia are associated with poor outcomes among hospitalized patients with type 2 diabetes (T2D). Until 2012, the American Diabetes Association (ADA) and Endocrine Society hospital clinical guideline recommended a target blood glucose (BG) of 70-140 mg/dl; however, more recently a relaxed target of 140-180 mg/dl has been reco...

Recent observational and meta-analyses have reported a frailty prevalence between 10% and 25% in people with diabetes, in particular in those older than 60 years of age. The impact of frailty on hospital glycemic control and glycemic variability (GV) by continuous glucose monitoring (CGM) in insulin-treated older adults with type 2 diabetes (T2D) i...

Introduction Approximately 50% of obese Black patients presenting with diabetic ketoacidosis (DKA) at new-onset of diabetes have immunologic and metabolic features of type 2 diabetes, also called ketosis-prone diabetes (KPDM). With intensive insulin treatment, ∼70% have improvements in beta-cell function and insulin sensitivity and achieve diabetes...

Type 2 diabetes is characterized by progressive decline in pancreatic β-cell function. Studies in adult subjects with newly diagnosed type 2 diabetes have reported that intensive insulin therapy followed by various antihyperglycemic medications can delay β-cell decline. However, this improvement is lost after cessation of therapy. In contrast, yout...

Type 2 diabetes is characterized by progressive decline in pancreatic β-cell function. Newer agents, such as glucagon-like peptide-1 receptor agonist (GLP-1RA) and dual incretin agonists, can augment β-cell function and delay the need for additional antihyperglycemics. However, the effect on β-cell function ceases after stopping the medications. Wh...

Aims: To explore the modifying effect of glucagon-like peptide-1 receptor agonist (GLP-1RA) use on outcomes with finerenone across a wide spectrum of patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) in the pooled analysis of FIDELIO-DKD and FIGARO-DKD. Materials and methods: Patients with T2D and CKD treated with optimized re...

Background Individuals with posttraumatic stress disorder (PTSD) are more likely to present with metabolic diseases such as type-2 diabetes mellitus (T2DM), and cardiovascular dysfunction has been implicated in this link. These diseases disproportionately affect women and individuals exposed to chronic environmental stressors (e.g., community viole...

Background: Baseline risk variables and visit-to-visit variability (VV) of systolic blood pressure (SBP), HbA1c, serum creatinine, and uric acid (UA) are potential risk markers of kidney function decline in type 1 diabetes. Methods: Post-hoc analysis of a double-blind randomized placebo-controlled clinical trial investigating allopurinol's effec...

Background Interventional studies investigating blood glucose (BG) management in intensive care units (ICU) have been inconclusive. New insights are needed. We assessed the ability of a new metric, the Glycemic Ratio (GR), to determine the relationship of ICU glucose control relative to preadmission glycemia and mortality. Methods Retrospective co...

OBJECTIVE Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insul...

OBJECTIVE The efficacy and safety of continuous glucose monitoring (CGM) in adjusting inpatient insulin therapy have not been evaluated. RESEARCH DESIGN AND METHODS This randomized trial included 185 general medicine and surgery patients with type 1 and type 2 diabetes treated with a basal-bolus insulin regimen. All subjects underwent point-of-car...

Background There are limited data on post-hospital discharge clinic attendance rates and outcomes among patients with diabetic foot ulcers (DFUs). Methods Retrospective study of patients hospitalized with a DFU from 2016 to 2019 in a large public hospital. We measured rates and predictors of clinic attendance with providers involved with DFU care...

Objective The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. Methods The American Associat...

The annual Virtual Hospital Diabetes Meeting was hosted by Diabetes Technology Society on April 1 and April 2, 2022. This meeting brought together experts in diabetes technology to discuss various new developments in the field of managing diabetes in hospitalized patients. Meeting topics included (1) digital health and the hospital, (2) blood gluco...

The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Managemen...

Introduction: We assessed metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of our hospital. Subjects and methods: We performed a retrospective study of patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. InsulinAPP recommends...

Background: The Tandem Control-IQ (CIQ) system has demonstrated significant glycemic improvements in large randomized controlled and real-world trials. Use of this system is lower in people with type 1 diabetes (T1D) government-sponsored insurance and those with type 2 diabetes (T2D). This analysis aimed to evaluate the performance of CIQ in these...

Background Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management. Objective To review and update the 2012 Management of Hyperglycemia in Hospitalize...

Objective: Administration of supplemental sliding scale insulin for correction of hyperglycemia in non-intensive care unit (ICU) patients with type 2 diabetes is frequently used with basal-bolus insulin regimens. In this noninferiority randomized controlled trial we tested whether glycemic control is similar with and without aggressive sliding sca...

Introduction: Finerenone reduced risk of cardiorenal outcomes in patients with CKD and T2D in the FIDELIO-DKD and FIGARO-DKD studies. In FIDELIO-DKD the effects of finerenone on kidney and CV outcomes were consistent irrespective of glucagon-like peptide-1 receptor agonist (GLP-1RA) use, but analyses were better powered to evaluate change in urine...

In obese Blacks presenting with diabetic ketoacidosis (DKA) at new-onset of diabetes, intensive insulin treatment improves β-cell function so that ˜70% achieve near-normoglycemia remission (HbA1c < 7%, fasting blood glucose [BG]<130 mg/dl while off insulin for ≥1 week) and maintain glycemic control without medications. The 2021 American Diabetes As...

Tirzepatide (TZP) , a novel, once weekly, dual GIP/GLP-1 receptor agonist, is being developed as a glucose lowering agent in type 2 diabetes (T2D) . In the SURPASS clinical trial program, TZP demonstrated significant HbA1c and body weight reductions vs. placebo and active comparators. This post-hoc analysis assessed the relationship between HbA1c a...

Background: Higher HbA1c on admission is associated with increased amputation risk in patients with diabetic foot ulcers (DFUs) ; however, the impact of long-term glycemic control and glycemic variability after hospital discharge on amputation risk is unclear. Methods: We performed retrospective analyses of hospitalized patients with a DFU who were...

IDegLira-HIGH trial was a non-inferiority, prospective, randomized clinical trial, comparing the efficacy and safety of insulin degludec/liraglutide combination (IDegLira) and a regimen of multiple daily injections (MDI) with basal-bolus insulin (BB) in adults (>18-80 years of age) , with type 2 diabetes (T2D) , and very high HbA1c (>9%-15%) , prev...

Severe hypoglycemia and hyperglycemia (ketoacidosis, hyperglycemic hyperosmolar state) are common yet potentially preventable acute complications of diabetes. Our objectives were to use national data from OptumLabs® Data Warehouse, 2011-2020, to 1) characterize trends in all-cause mortality among adults with type 1 diabetes (T1D) and type 2 diabete...

Background and Methods: This cross-sectional study determined the prevalence of diabetic retinopathy (DR) in non-Hispanic African Americans (AA) with end-stage-kidney disease (ESKD) and their impact on quality of life. A total of 95 adults with type 1 (n= 10) and type 2 (n= 85) on dialysis diabetes were assessed for DR using portable hand-held (Opt...

Inpatient use of CGM results in higher detection of hypoglycemic and hyperglycemic events compared to point of care testing (POC) but its efficacy and safety in adjusting insulin therapy has not been evaluated. This randomized controlled trial included 181 general medicine and surgery patients with type 1 (n= 18) and type 2 (n= 155) diabetes treate...

Metformin is the broadly accepted the first-line medication for diabetes. Its use, however, is limited by gastrointestinal side effects, which occur in approximately 25% of patients. We performed a cross-sectional study assessing microbiota composition among African Americans (AA) with diabetes with or without metformin intolerance. Participants we...

The Emory Diabetes Management Program is a chronic care management model aimed to reduce the proportion (%) of adult patients with HbA1c >9% within the Emory Healthcare System. We report the proportion of patients with poor glycemic control (HbA1c >9% or missing values for 6 months) before and during the Covid-pandemic, from 02/01/18 to 10/30/2021....

Few studies have reported on differences in glycemic control and glucose variability by continuous glucose monitoring (CGM) in hospitalized insulin-treated older adults with type 2 diabetes (T2D) . Accordingly, we combined data from 3 inpatient randomized clinical trials using CGM in insulin-treated patients with T2D. Glycemic parameters were compa...

Background: Baseline risk variables and visit-to-visit variability (VV) of systolic blood pressure (SBP) , HbA1c, serum creatinine, and uric acid (UA) are potential risk markers of kidney function decline in type 1 diabetes. Methods: Post-hoc analysis of the PERL study (NCT02017171) - a double-blind randomized placebo-controlled clinical trial inve...

Objective Approximately 50% of obese Black patients with unprovoked diabetic ketoacidosis (DKA) or severe hyperglycemia (SH) at new-onset diabetes achieve near-normoglycemia remission with intensive insulin treatment. Despite the initial near-normoglycemia remission, most DKA/SH individuals develop hyperglycemia relapse after insulin discontinuatio...

Background: A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data. Methods: We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who...

Objectives: To determine the associations of relative hypoglycemia and hemoglobin A1c-adjusted time in blood glucose (BG) band (HA-TIB) with mortality in critically ill patients. Design: Retrospective cohort investigation. Setting: University-affiliated adult medical-surgical ICU. Patients: Three thousand six hundred fifty-five patients with...

The tools for monitoring and treating patients living with diabetes have expanded exponentially in the last decades, opening opportunities to identify targeted management approaches according to individualized needs and clinical characteristics. In addition, current advances in genetics and systems biology are further expanding our understanding of...

Objective The purpose of this study is to compare the prevalence of latent TB infection (LTBI) among patients with type-2 diabetes mellitus (T2DM) to healthy controls without T2DM. To achieve this objective, we conducted a case-control study in a large hospital in Atlanta from 2016 to 2019. Results We enrolled 98 cases; 119 potential controls were...

Background Type 2 diabetes mellitus (T2DM) is a major public health problem in the United States. Although cardiovascular autonomic functioning, blood glucose control, and inflammation are known to play a role in T2DM, the interaction between these variables remains largely unexplored, particularly in the context of stress. To address this gap, we...

Type 2 diabetes (T2D), chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD), and heart failure (HF)—along with their associated risk factors—have overlapping etiologies, and two or more of these conditions frequently occur in the same patient. Results from many recent cardiovascular outcome trials (CVOTs) have demonstrated t...

Purpose of review Outpatient and perioperative therapeutic decision making for patients with diabetes involves increasingly complex medical-decision making due to rapid advances in knowledge and treatment modalities. We sought to review mobile decision support tools available to clinicians for this essential and increasingly difficult task, and to...

Objective: We characterized annual trends of severe hypoglycemic and hyperglycemic crises (diabetic ketoacidosis/hyperglycemic hyperosmolar state) in patients with diabetes and end-stage kidney disease (ESKD). Research design and methods: This was a nationwide, retrospective study of adults (≥18 years old) with diabetes/ESKD, from the United Sta...

Aims Differences in risk profiles for individuals with early- (< 40 years old) vs. later-onset (≥ 40 years old) diabetes were examined. Methods A nested case-control study design using 30-year longitudinal data from the Coronary Artery Risk Development in Young Adults (CARDIA) study was used. Survey data (socio-demographics, family history, medica...

This article is the work product of the Continuous Ketone Monitoring Consensus Panel, which was organized by Diabetes Technology Society and met virtually on April 20, 2021. The panel consisted of 20 US-based experts in the use of diabetes technology, representing adult endocrinology, pediatric endocrinology, advanced practice nursing, diabetes car...

Objective: To explore the effect of discontinuing continuous glucose monitoring (CGM) after 8 months of CGM use in adults with type 2 diabetes treated with basal without bolus insulin. Research design and methods: This multicenter trial had an initial randomization to either real-time CGM or blood glucose monitoring (BGM) for 8 months followed b...

Aims: Limited data exists about the use of insulin degludec in the hospital. This multicentre, non-inferiority, open-label, prospective randomised trial compared the safety and efficacy of insulin degludec-U100 and glargine-U100 for the management of hospitalized patients with type 2 diabetes. Methods: A total of 180 general medicine and surgery...