Guillermo E Umpierrez

• Emory University

New methods of CGM data analysis are emerging that are valuable for interpreting CGM patterns and underlying metabolic physiology. These new methods use functional data analysis and artificial intelligence (AI), including machine learning (ML). Compared to traditional metrics for evaluating CGM tracing results (CGM Data Analysis 1.0), these new met...

OBJECTIVE Despite the use of multiple glucose-lowering medications, glycemic targets are not met in a significant fraction of people with type 2 diabetes. In this prospective, observational study we assessed the prevalence of hypercortisolism, a potential contributing factor to inadequate glucose control. RESEARCH DESIGN AND METHODS Individuals wi...

The use of continuous glucose monitoring (CGM) and automated insulin delivery (AID) technologies can improve patient outcomes and overall quality of life while helping to reduce the long-term costs. However, current eligibility criteria imposed by many major commercial insurers limit access to these technologies among a large portion of the diabete...

Purpose of Review This narrative review aims to explore the literature on advancements in diabetes management within long-term care facilities (LTCFs). Managing chronic diseases like diabetes in LTCFs is particularly challenging due to the dynamic nature of these environments and the significant changes they have undergone over the past decade. Var...

Background Optimal glucose management in individuals with type 2 diabetes (T2D) and end-stage kidney disease (ESKD) on hemodialysis is challenging. We compared the detection of glycemic excursions with continuous glucose monitoring (CGM) and capillary glucose testing (CBG) in this population. Methods In this prospective observational study, insuli...

Background Continuous glucose monitoring (CGM) devices are increasingly used in critical and non-critical care hospital units. The efficacy of CGM in assessing glucose control in adults with diabetic ketoacidosis (DKA) is unknown. Methods This single-center pilot study compared glycemic control by real-time CGM (Dexcom G6), capillary point-of-care...

Importance The increasing use of glucagon-like peptide-1 receptor agonists (GLP-1RA) demands a better understanding of their association with thyroid cancer. Objective To estimate the risk of incident thyroid cancer among adults with type 2 diabetes being treated with GLP-1RA vs other common glucose-lowering medications. Design, Setting, and Part...

Aims Sodium–glucose co‐transporter‐2 (SGLT2) inhibitors improve health status and outcomes in the setting of heart failure (HF) across the range of ejection fraction (EF). Baseline kidney disease is common in HF, complicates HF management and is strongly linked to worse health status. This study aimed to assess whether the treatment effects of dapa...

With increasing prevalence of obesity and cardiovascular diseases, there is a growing interest in the use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) as an adjunct therapy in type 1 diabetes (T1D). The GLP-1RAs are currently not approved by the US Food and Drug Administration for the treatment of T1D in the absence of randomized control...

OBJECTIVE To evaluate whether continuous glucose monitoring (CGM) could assist providers in intensifying glycemic management in hospitalized patients with type 2 diabetes. RESEARCH DESIGN AND METHODS At six academic hospitals, adults with type 2 diabetes hospitalized in a non–intensive care setting were randomly assigned to either standard therapy...

Introduction: Preload insufficiency can mimic HFpEF or complicate its treatment, and SGLT2 inhibitors may worsen preload insufficiency by reducing stressed blood volume. A drop in pulse pressure (PP) when going from supine to standing (i.e., orthostatic PP) may indicate an inability to vasoconstrict the splanchnic circulation, leading to preload in...

With increasing prevalence of obesity and cardiovascular diseases, there is a growing interest in the use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) as an adjunct therapy in type 1 diabetes (T1D). The GLP-1RAs are currently not approved by the US Food and Drug Administration for the treatment of T1D in the absence of randomized control...

This review discusses recent evidence addressing risks in patients taking glucagon-like peptide-1 receptor agonist medications and proposes a framework for perioperative management.

This pooled cross-sectional study explores prescribing rates for glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors among US patients with type 1 diabetes.

BACKGROUND Mechanisms of benefit with SGLT2is (sodium-glucose cotransporter-2 inhibitors) in heart failure (HF) remain incompletely characterized. Dapagliflozin alters ketone and fatty acid metabolism in HF with reduced ejection fraction though similar effects have not been observed in HF with preserved ejection fraction. We explore whether metabol...

Background Chronic kidney disease (CKD) is a serious diabetes-related complication. While guidelines recommend use of sodium-glucose co-transporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists to mitigate cardiorenal risk in high-risk patients, the benefit of early initiation of these agents relative to other commonly...

Introduction An error grid compares measured versus reference glucose concentrations to assign clinical risk values to observed errors. Widely used error grids for blood glucose monitors (BGMs) have limited value because they do not also reflect clinical accuracy of continuous glucose monitors (CGMs). Methods Diabetes Technology Society (DTS) conv...

Continuous glucose monitoring (CGM) has been increasingly used in US hospitals for the care of patients with diabetes. Time in range (TIR), which measures the percent of time over a specified time window with glucose values within a target range, has served as a pivotal CGM-metric for assessing glycemic control. However, inpatient CGM is prone to a...

Purpose of review Perioperative outpatient (ambulatory) care of the adult patient with diabetes requires unique considerations that vary from the inpatient setting. This review highlights specific pre, intra, and postoperative care steps for patients with diabetes undergoing ambulatory surgery, summarizing recent clinical trials, expert reviews, an...

Aim Dysglycaemia accelerates cognitive decline. Intensive glucose control may help delay or prevent cognitive function decline (CFD). We aimed to determine how patient characteristics influence the effect of intensive glucose control [glycated haemoglobin (HbA1c) <6.0%] on delaying CFD in people with type 2 diabetes. Research design and methods In...

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglyce...

Aim To examine the associations between low cognitive performance (LCP) and diabetes‐related health indicators (including body mass index [BMI], HbA1c, systolic blood pressure [SBP], low‐density lipoprotein [LDL] and self‐reported poor physical health) and whether these associations vary across racial/ethnic subgroups. Methods We identified adults...

Introduction: People with obesity experience stigma and discrimination for their physical appearance and weight. Data is limited among stigmatization and prejudices among Hispanics (HISP) and non-Hispanic Whites (NHW) and Blacks (NHB) with obesity and diabetes in the U.S. We compare prejudices, stigma and internal negative bias in these groups. Met...

Introduction: Hypoglycemia is a potential side effect of Intensive Glycemic Control (IGC) in diabetes management. We aimed to investigate whether individuals with certain GLP1R gene variations were at greater hypoglycemia risk with IGC. Methods: A dynamic cohort design with time-varying exposures was employed using electronic health records linked...

Introduction & Objective: Guideline-directed care of people with type 2 diabetes (T2D) and high risk of cardiovascular disease (CVD) is informed by robust outcome trials. Little is known about the impact of T2D drugs in adults with T2D with moderate CVD risk, particularly on key kidney outcomes. Methods: We used claims data from OptumLabs® Data War...

Background:There is a need for accurate glycemic control metrics in patients with diabetes and end-stage kidney disease (ESKD). Hence, we assessed the relationship of continuous glucose monitoring (CGM) metrics and laboratory-measured hemoglobin A1c (HbA1c) in patients with type 2 diabetes (T2D) treated by hemodialysis. Methods: This prospective ob...

Context Glucose tolerance during an oral glucose tolerance test (OGTT) is affected by variations in glucose effectiveness (GE) and glucose absorption and thus affects minimal model calculations of insulin sensitivity (SI). The widely used OGTT SI by Dalla Man et al. does not account for variances in GE and glucose absorption. Objective To develop...

Background Major adverse cardiovascular events (MACE) are a leading cause of morbidity and mortality among adults with type 2 diabetes. Currently, available MACE prediction models have important limitations, including reliance on data that may not be routinely available, narrow focus on primary prevention, limited patient populations, and longtime...

The American Society of Anesthesiologists (ASA) Task Force recently recommended discontinuing glucagon-like peptide-1 receptor agonist (GLP-1 RA) agents before surgery because of the potential risk of pulmonary aspiration. However, there is limited scientific evidence to support this recommendation, and holding GLP-1 RA treatment may worsen glycemi...

Introduction Limited longitudinal research is available examining how American adults make dietary changes after learning they have diabetes. We examined the associations between diabetes awareness and changes in dietary quality and food intake in a prospective cohort from the Coronary Artery Risk Development in Young Adults (CARDIA) study. Resear...

This mixed-methods study sought to identify pharmacotherapy preferences among 40 noninsulin-treated adults with type 2 diabetes receiving care at two U.S. health care systems. Participants ranked by relative importance various health outcomes and medication attributes and then contextualized their rankings. Most participants ranked blindness (63%),...

Following the discovery of insulin in 1921 by Frederick Banting and Charles Best, the approach to inpatient diabetes care has evolved over time to optimize patient outcomes. Newer insulin formulations, modernized tools to quantify glycemia, advanced diabetes technologies, and research trials supporting a shift in clinical practice have marked impor...

Rationale Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods. Objectives The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Me...

OBJECTIVE To explore whether insulin resistance, assessed by estimated glucose disposal rate (eGDR), is associated with cardiorenal risk and whether it modifies finerenone efficacy. RESEARCH DESIGN AND METHODS In FIDELITY (N = 13,026), patients with type 2 diabetes, either 1) urine albumin-to-creatinine ratio (UACR) of ≥30 to <300 mg/g and estimat...

In the primary care setting providers have more tools available than ever before to impact positively obesity, diabetes, and their complications, such as renal and cardiac diseases. It is important to recognise what is available for treatment taking into account diabetes heterogeneity. For those who develop type 2 diabetes (T2DM), effective treatme...

OBJECTIVE Patients with diabetes and end-stage kidney disease (ESKD) may experience “burnt-out diabetes,” defined as having an HbA1c value <6.5% without antidiabetic therapy for >6 months. We aim to assess glycemic control by continuous glucose monitoring (Dexcom G6 CGM) metrics and glycemic markers in ESKD patients on hemodialysis with burnt-out d...

Background Few studies have reported the adherence to and efficacy of continuous glucose monitoring (CGM) for 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 bet...

Background: Sodium-glucose co-transport-2 (SGLT2) inhibitors have been shown to reduce clinical events and improve health status (symptoms, function, and quality of life) in patients with HF across the range of EF. Baseline kidney dysfunction is common in HF, complicates HF management, and is strongly linked to worse health status. Aim: The study o...

Objective Trends in use and continuity of use of diabetes‐specific and non‐diabetes weight‐reducing (WR), weight‐inducing (WI), and weight‐neutral (WN) medications were examined among US adults with diabetes and overweight/obesity. Methods Serial cross‐sectional data from Medical Expenditure Panel Surveys (2010–2019) for adults (≥18 years) with di...

BACKGROUND Heart failure with preserved ejection fraction is associated with significant functional limitations, yet treatments for improving exercise performance have been elusive. We sought to explore the association between prespecified patient characteristics and changes in 6-minute walk distance that constitute a clinically significant respons...

Continuous glucose monitors (CGMs) have increasingly been used in ambulatory and inpatient or hospital settings to improve glycemic outcomes for people with diabetes. Given their capacity to aid individuals in avoiding hypo- and hyperglycemia, they may also be useful when transitioning from hospital to home by reducing rates of hospital readmission...

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...

Rationale & Objective In FIDELITY, finerenone improved cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes. This analysis explores the efficacy and safety of finerenone in Hispanic patients. Study Design Post hoc analysis of the FIDELITY prespecified pooled analysis of the FIDELIO-DKD and FIGARO-DKD randomized co...

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...