bluuebunny/crossref_metadata_2025_split huggingface dataset:
8269 Euglycemic Diabetic Ketoacidosis Secondary to Rapid Weight Loss in a Patient on Dapagliflozin
Authors: Sridhar Archana , Iqbal Aimen , Kaur Ravleen , Kumar Arathi Prabha , Haider Faryal , Babic Milos 
Published: October 2024

Abstract
Disclosure: A. Sridhar: None. A. Iqbal: None. A. Prabha Kumar: None. F. Haider: None. M. Babic: None.
Background: Euglycemic DKA (eDKA) is a potentially life-threatening complication in patients taking SGLT 2 inhibitors (SGLT2i). Common precipitating factors include strenuous exercise, carbohydrate restriction, starvation, and alcohol use. Clinical case: The patient is a 71-year-old female with past medical history of Type 2 diabetes mellitus (DM), gastro-esophageal reflux disease, hypertension, hyperlipidemia, coronary artery disease and chronic pain syndrome. She presented with complaints of nausea, vomiting, reduced appetite and generalized weakness for the past 4 days. She also reported an intentional weight loss of 35 pounds in the last 6 weeks achieved with daily exercise and a carbohydrate restricted diet. She had been taking Dapagliflozin-Metformin 5-1000 mg twice daily and pioglitazone 30 mg once daily for 2 years and Ozempic subcutaneous injection 1 mg weekly for 6 months. Physical examination in the ED showed normal vital signs, dry mucous membranes, and trace bilateral lower extremity edema. Blood work was significant for venous blood gas pH 7.24, bicarbonate 9 mmol/L, anion gap 30 mmol/L, blood glucose 94 mg/dL, HbA1c 5.8 % and WBC 13.2 K/uL. Urinalysis was positive for glucose and ketones. The patient was admitted for management of eDKA and was started on intravenous 10% dextrose infusion and insulin infusion. Endocrinology was consulted and they recommended following DKA protocol and stopping Dapagliflozin at discharge. She was maintained on insulin infusion for 48 hours after which her anion gap normalized, and she was transitioned to subcutaneous insulin with Lantus 8 units and sliding scale insulin. During this time the patient’s symptoms resolved, and she was able to tolerate oral diet. She eventually resumed her home medications with oral Metformin 1000 mg twice daily and pioglitazone 30 mg once daily. Dapagliflozin and Ozempic were discontinued at discharge. Strenuous exercise and carbohydrate restriction which caused rapid weight loss, were likely the triggers for eDKA in our patient. A diabetes educator was involved at discharge and the patient was counseled to avoid possible triggers and identify warning signs and symptoms in the future. The patient was discharged with a follow up appointment with her Endocrinologist. Conclusion: High index of clinical suspicion is important to promptly diagnose eDKA in patients taking SGLT2i. Patient education on avoiding precipitating factors and early recognition of signs and symptoms is necessary to reduce mortality.
Presentation: 6/3/2024
6660 Euglycemic DKA Induced by SGLT-2 Inhibitor Following Administration ofTirzepatide
Authors: Gurel Kursat , Mathew Shannon , Zeidan Mahmoud , Al Barznji Saman , Alkhankan Fadi 
Published: October 2024

Abstract
Disclosure: K. Gurel: None. S. Mathew: None. M. Zeidan: None. S. Al Barznji: None. F. Alkhankan: None.
Introduction Tirzepatide has side effects of diarrhea, nausea, vomiting, and loss of appetite(2). SGLT-2 inhibitors may cause Euglycemic Diabetic ketoacidosis(EDKA) by inducing carbohydrate starvation and volume depletion(1). Clinical Case A 72-year-old male with a past medical history of T2DM(Hg A1c 8.4[≤ 6%]) on empagliflozin, metformin, hyperlipidemia, obesity on tirzepatide who presents with complaining of nausea, vomiting, and abdominal pain. The patient noted that he started experiencing symptoms two days before admission following receiving tirzepatide dose. He takes Tirzepatide every 10 days and he was started on empagliflozin 1 month ago. The patient started to have a loss of appetite, nausea, and vomiting on the day he received his tirzepatide injection. Over the next two days, the patient’s nausea and vomiting worsened and the patient was not able to tolerate food. On admission, ABG demonstrated pure metabolic acidosis (pH of 7.24[7.30-7.40], bicarb of 11.8 [21 - 28 mmol/L] PCO2 of 27.4[ 41 - 51 mmHg]). BMP showed anion gap of 20(3-15 mmol/L) with glucose level of 145(74-106 mg/dl) . Beta-Hydroxybutyrate level was 6.3(0.0 -0.27 mmol/L). UA was only significant for glucose level of &gt;1000(negative) and ketone level of 40(negative). Lipase level was 539(73-393 U/L). CT abdomen ruled out acute pancreatitis. No infection source was identified. Upon admission to the ICU unit, the patient was started on D5 with KCL 20 mEq and Insulin drip. The patient was followed up with a glucose check every hour and BMP every 4 hours. On day 2 of admission, the Anion gap was normalized and the insulin regimen was transitioned to subcutaneous insulin. The patient was placed on carbohydrate consistent diet. On discharge, the patient was advised to avoid taking SGLT-2 inhibitors including empagliflozin. Conclusion Tirzepatide's potential side effects, including diarrhea, vomiting, and appetite loss, may contribute to volume depletion and carbohydrate starvation(2). Individuals using both SGLT-2 inhibitors and Tirzepatide should be closely monitored for these symptoms. Reference 1-)Baggio LL, Drucker DJ. Glucagon-like peptide-1 receptor co-agonists for treating metabolic disease. Mol Metab. 2021 Apr;46:101090. doi: 10.1016/j.molmet.2020.101090. Epub 2020 Sep 25. PMID: 32987188; PMCID: PMC8085566. 2-)Plewa MC, Bryant M, King-Thiele R. Euglycemic Diabetic Ketoacidosis. [Updated 2023 Jan 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554570/
Presentation: 6/2/2024
7604 Examining Disparities in Diabetes Control and Complications: A Comparative Study of Type 2 Diabetes Mellitus Patients in Rural and Urban Saudi Arabia
Authors: Alqifari Saleh F , Alkomi Omar , Amirthalingam Palanisamy , Alrasheed Tariq , Muqresh Mohamad Ayham , Hamad Heba , Khojah Abdullah , Alshehri Nada , Alhunayhani Budur , AbuAlhasan Bothainah , Alajlan Noura , Alatawi Shahad , Alsabeelah Norah , Wasel Afaf , Alqifari Abdulrahman 
Published: October 2024

Abstract
Disclosure: S.F. Alqifari: None. O. Alkomi: None. P. Amirthalingam: None. T. Alrasheed: None. M. Muqresh: None. H. Hamad: None. A. Khojah: None. N. Alshehri: None. B. Alhunayhani: None. B. AbuAlhasan: None. N. Alajlan: None. S. Alatawi: None. N. Alsabeelah: None. A. Wasel: None. A. Alqifari: None.
Background: The escalating global prevalence of diabetes is also mirrored in Saudi Arabia. Approximately one in four individuals in the country is diagnosed with diabetes, as reported by the World Health Organization (WHO). The Ministry of Health has taken steps to address the needs of patients with diabetes by creating more than 20 specialized diabetes care centers in various regions throughout Saudi Arabia. However, disparities in access and utilization of primary healthcare facilities persist between rural and urban provinces within the country. Highlighting these disparities would bridge healthcare gaps between rural and urban areas to enhance diabetes management, ensure better access to specialized care, and improve the overall well-being of individuals living with Type 2 Diabetes Mellitus (T2DM) in Saudi Arabia. Objectives: This study aims to examine disparities in diabetes control and complications in patients with T2DM in rural and urban Saudi Arabia. Methods: This is an observational retrospective study conducted from November 2022 until May 2023, we collected data from 13 diabetes care centers across Saudi Arabia to assess diabetes control and complications of T2DM among patients who received their care in rural and urban Saudi Arabia. Results: Among 709 patients residing in rural and urban areas, rural area patients' recent HbA1c readings were generally within the range of 7-8%. Among these patients, around 2.6% had a history of heart disease, and 6.08% had experienced cerebrovascular events. Limb numbness was reported by 44.34% of subjects, 47.82% experienced vision complications, and renal impairment was observed in 10.43% of the participants. Additionally, among male patients, 26.41% suffered from erectile dysfunction. Remarkably, 21% of the rural patients reported having been hospitalized due to diabetes complications at least once in the past 12 months. Conclusion: The study findings emphasize the importance of considering regional disparities and socio-environmental factors when managing diabetes and its complications. Additional research is needed to understand the underlying causes and develop targeted interventions for improved diabetes care in rural and urban populations in Saudi Arabia.
Presentation: 6/2/2024
12590 Glp1 Agonists Role On Prediabetes Reversal, A Meta-analysis
Authors: Levy Sitnoveter A , de Azevedo Abrantes G , Carvalhal de Almeida Cordeiro G , Soares Azevedo V , Boccalandro C 
Published: October 2024

Abstract
Disclosure: A. Levy Sitnoveter: None. G. de Azevedo Abrantes: None. G. Carvalhal de Almeida Cordeiro: None. V. Soares Azevedo Junior: None. C. Boccalandro: None.
Introduction: The use of glucagon like peptide 1 (GLP-1) agonists to control type two diabetes(T2DM) is well established. However, their role on prediabetes and T2DM prevention is uncertain.This study aimed to assess GLP-1 agonists role in prediabetic patients and whether it can preventor delay new-onset T2DM in this population. Methods: We performed a systematic review and meta-analysis of randomized control trials(RCT) data on the efficacy of GLP-1 agonists in delaying T2DM in prediabetes patients. Studieswithout prediabetic patients or without GLP-1 agonists as intervention were excluded. Tworeviewers collected the data from a total of 1768 studies, of which 791 were duplicated. At the endof the review there were 41 conflicts, which were analyzed by a third reviewer. After the completereading of 13 studies, 9 were excluded. Results: We included 4 RCT comprising 1717 patients (72% women from baseline). We included4 RCT comprising 1717 patients (72% women from baseline). All patients were obese, and themean follow-up duration was 30 weeks. Overall patient's taking GLP-1 agonists showed asignificant reversal of prediabetes by achieving normoglycemia (MD +5.99 [CI +4.41, 8.12]). Thestudies displayed anConclusion: GLP-1 Agonists appear to be safe and effective in lowering the progression to T2DMin patients with prediabetes and obesity. Further trials should explore the GLP-1 agonist effect onprediabetes beyond the obese population.GLP-1 agonists appeared to be safe and effective in lowering the progression to T2DM inpatients with prediabetes.
Presentation: 6/1/2024
8258 Haptoglobin-related protein (HPR) new role as insulin secretion enhancer
Authors: Viesi Carlos , Tamburini Ian , Bae Hosung , Ilegems Erwin , Velez Leandro , Zhou Mingqi , Nguyen Christy , Johnson Casey , Jang Cholsoon , Nishimura Erika , Seldin Marcus 
Published: October 2024

Abstract
Disclosure: C. Viesi: None.
Type 2 Diabetes (T2D) affects over 530 million people around the globe. Insulin resistance, encompassing tissues such as muscle, adipose, and liver, is the initial step hallmarked by hyperinsulinemia. Coupled with β-cell failure, these coordinated responses progress to T2D, becoming irreversible and medically challenging. Despite the well-established requirement for communication between pancreas and peripheral tissues in T2D progression, this area remains almost entirely unexplored. Here, we performed a human population genetic screening across 310 individuals to search for new endocrine regulators of pancreas function. Specifically, global gene expression from 18 peripheral tissues was analyzed to identify potential endocrine regulators of insulin secretion. This analysis prioritized liver-specific Haptoglobin-related protein (HPR) as genetically-enriched with islet insulin responses. Mouse models using AAV technology and acute protein administration of HPR showed that this newly secreted protein is sufficient to prevent diet-induced insulin resistance through enhanced beta-cell respiration. When mice were administered soluble HPR, then pancreatic tissue subjected to global RNA-sequencing, enhanced respiration pathways were observed. Next, we generated hepatocyte-specific overexpression models using AAV, which were sufficient to rescue whole-body glucose disposal profiles and weight gain in diet-induced insulin-resistant mice. Altogether, these findings highlight HPR as a novel soluble protein which signals from liver to pancreatic islets.
Presentation: 6/3/2024
7437 Harnessing Diabetes Technology for Management of Immune Checkpoint Inhibitor Associated Diabetes
Authors: Knape Anne , Kotwal Anupam , Rohlfsen Dorotha , Patel Anery , Goldner Whitney 
Published: October 2024

Abstract
Disclosure: A. Knape: None. A. Kotwal: None. D. Rohlfsen: None. A. Patel: None. W. Goldner: None.
Background: Immune checkpoint inhibitors (ICIs) are a key treatment modality for many cancers. One percent of patients who receive ICIs can develop insulin deficient ICI associated diabetes (ICI-DM). These patients often have complex oncologic therapy plans making treatment of newly diagnosed insulin deficient diabetes challenging which often results in additional healthcare-related burden for the patient. Methods: This is a retrospective case series of five adults who developed ICI-DM after receiving either PD-1, CTLA-4 or PDL-1 inhibitors or a combination. Data on demographics, medical history and labs were collected in addition to mode of glucose monitoring and treatment after diagnosis of ICI-DM. Results: Patients were age 44-72 at diagnosis of ICI-DM, three were female. Two were admitted to the hospital in DKA, one was diagnosed in the ER with severe hyperglycemia without DKA, two had outpatient hyperglycemia without DKA. Glucose at diagnosis ranged from 215-510 mg/dL. C-peptide was low for all patients. Fingerstick blood sugar (FSBS) monitoring and basal/bolus insulin was immediately initiated for all patients. All were transitioned from FSBS to continuous glucose monitor (CGM) and 2/5 ultimately transitioned to sensor-augmented insulin pump therapy (AID). Time in range on CGM improved in four patients with percent time in range improving between 10-48%. In two patients, hypoglycemia frequency declined by 6% and 3%. Hyperglycemia frequency declined by 13% and 48% in patients on AID therapy and by 14% and 25% in two of those on basal/bolus insulin therapy. All patients preferred CGM over FSBS and remained on CGM therapy. Those who chose AID preferred it over basal/bolus insulin therapy stating it was less complicated than basal/bolus insulin with CGM. Conclusions: We report successful treatment of five cases of ICI-DM with CGM + basal/bolus insulin or AID. 80% demonstrated improved time in range and decreased overall frequency of hyperglycemia. 40% had decreased frequency of hypoglycemia. CGM allows for dynamic adjustment of insulin therapy in a population with complex medical regimens resulting in fluctuating glucose levels. The integrated pump and sensor technology in AID was less burdensome than basal/bolus in those who chose it. Managing ICI-DM is complicated. The burden of this entity can be lessened by harnessing the power of diabetes technology.
Presentation: 6/2/2024
8798 How Low Can You Go: Suspected Methadone-Induced Hyperinsulinemia
Authors: Ravindra L , Fernandez M G , Cheng V 
Published: October 2024

Abstract
Disclosure: L. Ravindra: None. M.G. Fernandez: None. V. Cheng: None.
Background: Studies have shown that methadone use can result in severe hypoglycemia. This is thought to be related to methadone having antagonistic activity at NMDA receptors, resulting in increased pancreatic insulin release, suppressed glucagon and epinephrine, and inhibition of hepatic glycogenolysis. These mechanisms affect the normal physiologic response to hypoglycemia and can result in hyperinsulinemic-induced hypoglycemia. Clinical case: We present a case of a 56-year-old male with complex regional pain syndrome managed with a high daily dose of methadone (345 mg) who presented to the hospital for evaluation of failure to thrive and hypoglycemia. During the hospital admission, evaluation of hypoglycemia included a serum blood glucose level of 41 mg/dL (normal &gt;60 mg/dL), with an inappropriately normal level of insulin 10 (Reference Range (RR) 3-25 mU/L), C-peptide 2.9 (RR 0.5-3.3 ng/ml), Pro-insulin 2.9 (RR 3-20 pmol/L), an undetectable level of Beta-hydroxybutyrate &lt;0.10 (RR 0.02-0.27 mMol/L) negative insulin antibodies &lt;0.4 (RR 0.0 - 0.4 U/mL), and negative sulfonylurea screen. Additional labs included a normal TSH of 2.8 (RR 0.3-5.5 mIU/ml) and appropriate morning cortisol of 23 (RR &gt;14-15 μg/dL). The abdominal CT and follow-up MRI did not reveal any definite abnormalities in the pancreas. Given persistent evidence of hyperinsulinemic-induced hypoglycemia, a PET Dotatate scan was performed, confirming the absence of a neuroendocrine tumor. While admitted, management included nutritional optimization, close glucose monitoring, and an intravenous dextrose infusion. Diazoxide was also initiated and gradually increased to 150 mg three times a day. Addiction Medicine assisted in tapering down the methadone dose from 115 mg to 105 mg three times a day. With these interventions, the patient had no further episodes of hypoglycemia. On discharge, the patient was provided with a continuous glucose monitor. On follow-up, the patient has continued to show improvement and the diazoxide dose has been decreased without recurrent hypoglycemia. Given this, a selective arterial calcium stimulation test was not pursued. Conclusion: Methadone is an uncommon cause of hyperinsulinemic-induced hypoglycemia. Suspicion should arise, particularly in patients on high doses. Current evidence suggests tapering methadone dosage as the primary intervention, as insulin levels can decrease drastically and improve hypoglycemia. This therapeutic approach should be considered before pursuing invasive and costly diagnostic testing.
Presentation: 6/3/2024
6452 Hybrid Closed Loop Insulin Pump Therapy (Omnipod-5, T-Slimx2, Medtronic 780G) in uncontrolled type 1 Diabetes previously treated with multiple daily injections or open loop pumps
Authors: Farhat Ilham , Drishti Shah , Bargman Renee 
Published: October 2024

Abstract
Disclosure: I. Farhat: None. S. Drishti: None. R. Bargman: None.
Background: Type 1 diabetes mellitus (T1DM) poses significant challenges in managing blood glucose levels, especially in adolescents and those from lower socioeconomic backgrounds. Hybrid closed-loop insulin pump systems (HCL) integrating continuous glucose monitoring (CGM) and insulin infusion have shown promise in improving glycemic control in well-controlled patients the utility of these systems is unknown in poorly controlled populations. Objectives: This study aimed to assess real-world glycemic outcomes in children, adolescents, and young adults with uncontrolled T1DM (baseline HbA1c &gt; 9%) using HCL pump systems (Omnipod 5, Tandem t: slim X2, Medtronic 780G) after at least one year on multiple daily injections (MDI) or open loop continuous subcutaneous insulin infusion (CSI) by the impact on HbA1c levels. Methods: Descriptive, retrospective chart review within the NYCHHC hospital system (public hospital system of New York City), of patients aged 3-24 years with T1DM for at least one year. Data on HbA1c, demographics, BMI, emergency room visits, and hospital admissions were collected from the electronic medical records. Statistical analysis using paired T-tests, compared pre-HCL and post-HCL (more than 6 months) periods. Results: A cohort of 66 patients (33 males, 33 females), with average age of16 years were identified. 19 were Hispanic, 32 were Black or African American, and 15 belonged to other racial backgrounds. Baseline average A1C was 10.9. 53 patients were prescribed Omnipod-5, 12 T-slimX2, and 1 Medtronic 780G. Of these individuals, 52 started and stayed on the pump, 14 had not commenced treatment, and 5 patients discontinued the pump system prior to the end of the study. The median follows up period was 10 months and a significant improvement in glycemic control was observed with HbA1c which decreased from 10.9 (pre-HCL initiation) to 9.8 (post-HCL) (p=0.0001, 95% CI: 0.5458-1.5558). Breaking down the group into those who persisted with HCL and those who did not, it is notable that for those who discontinued HCL HbA1c levels increased not significantly from 11.6 to 12.0, (p=0.6144, 95% CI: -2.2042 to 1.4802) while in 46 patients who continued using HCL, HbA1c decreased significantly from 10.7 to 9.5 (p=0.0001, 95% CI: 0.6818-1.7337). Patients who hadn't yet initiated pump treatment displayed an average A1c of 11.9 prior to the prescription and had no further A1C measurements during the study period. Conclusion: The study demonstrates partial efficacy of HCL pump systems in improving glycemic control in individuals with poorly controlled T1DM but fails to achieve good or moderate control. This improvement could potentially reduce long term complications but further improvements are needed to bring this population’s control into target range.
Presentation: 6/2/2024