PD：Poster Presentation- Diabetes (1-21

PD-1 A BETTER QUALITY OF DIABETES CARE BASED ON A SPECIALIST OF ENDOCRINOLOGY AND METABOLISM

CHIN-CHOU YANG

Division of General Medicine, Department of General Psychiatry, Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nantou, Taiwan1

Background: Diabetes is prevalent in many countries and its costs of medical care are increasing. The proportion of diabetes is higher in psychiatric patients than that of general population, and the difficulties of treatment also raises significantly. Most studies about integrated diabetes care were focused on non-psychiatric patients. Our study will analyze the glycemic change in chronic psychiatric patients with type 2 diabetes in a psychiatric center, after a full-time specialist of endocrinology and metabolism participated in the long-term-care team and directly involved in the integrated care.

Methods: Our retrospective study included 56 resident patients in the chronic psychiatric wards. The specialist of endocrinology and metabolism was engaged in the integrated care team since January 2018. We first used paired-t test to analyze the glycemic change between 2016 and 2017 before our interventional care, and then analyze the glycemic change between 2017 and 2018 after our interventional care.

Results: The results showed that this care model has positive impacts on the patient’s eating habits and activity habits. Chi-square test analysis showed significant relationship between the improvement of eating habits and average glycated hemoglobin (HbA1c) level (X2 = 4.487, p = 0.034), and also between the improvement of activity habits and average HbA1c level (X2 = 11.864, p = 0.001). The average HbA1c and fasting blood glucose (AC) of all patients were both significantly improved (p0.05). For male patients, the average HbA1c was significantly improved, but there was no significant change found in average AC (P > 0.05).

Conclusions: To our best knowledge, this is the first study of diabetes care based on a full-time specialist of endocrinology and metabolism, who was directly involved in the long-term care team in a psychiatric center. The results showed that this care model has positive impacts on the patient’s eating habits and activity habits. The average HbA1c and AC were both significantly improved after our intervention. This study not only provides a positive and feasible approach to medical systems of longterm care, but also setup a health promotion measure that deserves attention and should be actively implemented and promoted.

PD-2 CLINICAL EFFICACY AND SAFETY OF CANAGLIFLOZIN IN THE TREATMENT OF TYPE 2 DIABETES UNCONTROLLED WITH MULTIPLE DAILY INSULIN INJECTION THERAPY

CHENG-HAN HAN, WAN-CHI CHUANG, WEI-CHENG CHANG, 1CHIH-HSUN CHU

Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; 1Department of Nursing, School of Nursing, Fooyin University, Kaohsiung, Taiwan.

Background. The objective of this study is to investigate the efficacy and safety of canagliflozin in patients with type 2 diabetes uncontrolled with multiple daily insulin injection therapy.

Methods. subjects (aged 20-80 years old) who meet the criteria after screening period will start 12 weeks treatment of canagliflozin. At the screening period, HbA1C test was performed and those who have inadequate glycemic control (7.0% < HbA1C < 11.0%) was considered as eligible. All eligible subjects were assigned to canagliflozin with fixed dosage for 12 weeks study treatment.

Results. Total of 25 type 2 diabetic subjects (21 male, 5 female) were enrolled in the study. The mean age were 60.1 yr, body weight were 76.6 ± 11.0 kg with BMI 27.3 ± 4.3 kg/m2. All subjects were controlled with premixed insulin. After a period of 12-week treatment of canagliflozin management in those subjects. The mean HbA1c decreased from 8.9 ± 1.0% to 7.9 ± 0.9%, with a difference of -1.0% (P < 0.001). The mean FPG decreased from 167.8 ± 57.0 mg/dl to 129.1 ± 30.5 mg/dl, with a difference of -38.7 mg/dl (P = 0.005). By weight were significantly decreased of 1.2 kg (p < 0.001). The hemoglobin increased significantly. However, the eGFR was not changed. The lipid panel, liver panel were also not changed. No serious adverse event was reported during the study period

Conclusion. The addition of canagliflozin in type 2 diabetes who uncontrolled with multiple daily insulin injection therapy is effective in term of glycemia and body weight reduction. There is no safety concern in liver or renal function and no serious adverse event occurred.

PD-3 FULMINANT AND PROLONGED HYPOGLYCEMIA IN A PATIENT WITH INSULIN GLARGINE U-300 OVERDOSE - A CASE REPORT

1WEI-LIN CHEN, 1CHIA-FEN WANG, 2CHIH-HSUN CHU

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; 2Department of Nursing, School of Nursing, Fooyin University, Kaohsiung, Taiwan.

Background. This case is a 48-year-old woman with a history of major depression who injected a large dose (1,800 units) of insulin glargine U-300.

Results. The patient presented with only mild hypoglycemia symptoms, such as slow response and dizzy while the blood glucose was 33mg/dl. Continuous 10% glucose solution infusion plus frequent 50% glucose bolus injection, however hypoglycemia episodes persisted at emergency department. During hospitalization, 50% glucose solution was continuously given via central line. Besides, dexamethasone was prescribed hope to prevent further hypoglycemia. However, bolus injection of 50% glucose was still needed due to marked hypoglycemia episodes. A total of 7 days intensive management, the blood glucose was eventually stable without hypoglycemia episode.

Conclusion. The case report demonstrates a prolonged hypoglycemic effect with a large dosage of insulin glargine U-300.

PD-4 FAMILIAL CHYLOMICRONEMIA SYNDROME: A CASE REPORT OF 10-YEARS FOLLOW UP

1EDY KORNELIUS, SHIH-CHANG LO, CHIEN-NING HUANG, YI-SUN YANG

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Chung Shan Medical University Hospital, Chung Shan Medical University, Taiwan

This 46-year-old Taiwanese female was first diagnosed with hypertriglyceridemia at age 37 years when she had the first episode of acute pancreatitis. She was diagnosed with diabetes in the same year, and further developed ischemic stroke at age 44 years. She did not drink alcohol, and there was no history of biliary tract disease, hypothyroidism, or prescription of oral contraceptive pills. Her body mass index (BMI) was 22.7 kg/m2. She did not have acanthosis nigricans or xanthomas but had lipemia retinalis on fundoscopic examination. Otherwise, she had severe hepatomegaly and splenomegaly. Her first record of lipid profile was triglyceride: 7389 mg/dl, total cholesterol 930 mg/dl, high-density lipoprotein (HDL): 18 mg/dl, and low-density lipoprotein (LDL): 86 mg/dl.

She had experienced recurrent abdominal pain with referring pain to the back area and had numerous hospitalizations because of acute pancreatitis. She mentioned that her abdominal pain was unpredictable and worsening after fat-diet intake. She had been taking fenofibrate and combination with niacin, omega-3, and statin alternatively. However, the effects were negligible. Her serum triglyceride levels were ranged around 5,000~15,000 mg/dl. Genetic testing was not performed due to not available in our institution.

She had a history of diabetes with severe insulin resistance. She had been taking a basal-bolus insulin regimen with a total daily dose of 2.5 unit/kg and pioglitazone 30 mg/day. Her average HbA1c was 7.5%.

None of her family members has similar symptoms to this patient. However, her mother has type 2 diabetes mellitus, hypertension, and an old cerebrovascular accident. Her mother’s lipid profile was triglyceride: 356 mg/dl, total cholesterol 144 mg/dl, LDL: 54 mg/dl, and HDL: 28.7 mg/dl.

Throughout her clinical course, she has difficulty to remained compliant with her dietary fat restriction. Her renal, liver, and heart function remained stable.

PD-5 ASSOCIATION OF EXERCISE WITH ALL-CAUSE MORTALITY IN THE ELDERLY TAIPEI RESIDENTS

1YUN-JU LAI, 2YUNG-FENG YEN, 3LI-JUNG CHEN, 4PO-WEN KU, 5CHU-CHIEH CHEN, 6YU-KAI LIN

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Puli Branch of Taichung Veterans General Hospital, Nantou, Taiwan; 2Section of Infectious Diseases, Taipei City Hospital, Taipei City Government, Taipei, Taiwan; 3Department of Exercise Health Science, National Taiwan University of Sport, Taichung, Taiwan; 4Graduate Institute of Sports and Health, National Changhua University of Education, Changhua, Taiwan; 5Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan; 6Department of Health and Welfare, College of City Management, University of Taipei, Taiwan

Background: Human life expectancy has increased rapidly in recent decades. Regular exercise can promote health, but the effect of exercise on mortality is not yet well understood.

Methods: We used data from annual health check-ups of the elderly citizens of Taipei in 2006. Participants were interviewed by trained nurses using a structured questionnaire to collect data on demographics and lifestyle behaviors. Overnight fasting blood was collected for measuring blood glucose, liver and renal function, and lipid profiles. Exercise frequency was categorized into no exercise, 1-2 times in a week, and more than 3-5 times in a week. All-cause mortality was ascertained from the National Registration of Death. All participants were followed up until death or December 31 2012, whichever came first. Kaplan-Meier curves and Cox proportional hazard analysis were used to investigate the association between exercise and all-cause mortality.

Results: In total, 42,047 elderly people were analyzed; 22,838 (54.32%) were male and with a mean (SD) age of 74.58 (6.32) years. Kaplan-Meier curves of all-cause mortality stratified by exercise frequency demonstrated significant findings (Log-rank P < 0.01). Multivariate Cox regression analysis showed that elderly people with higher exercise levels had a significantly decreased risk of mortality (moderate exercise HR = 0.74, 95% CI: 0.68-0.81, high exercise HR = 0.65, 95% CI: 0.59-0.70) after adjusting for potential confounders, with a significant trend (P for trend < 0.01).

Conclusions: Elderly people with increased exercise levels had a significantly decreased risk of all-cause mortality.

PD-6 A CASE REPORT OF SECUKINUMAB RELATED DIABETIC KETOACIDOSIS

JUI-HSIANG LI, SU-HUEY LO

Division of Endocrinology and Metabolism, Department of Internal Medicine Tao-Yuan General Hospital

Introduction: Diabetic ketoacidosis (DKA) is hyperglycemia crisis. It occurred mainly in patients with T1D but also affects in T2D. Common causes of DKA by frequency included infection, inadequate insulin treatment or drug noncompliance, newly-onset diabetes, cardiovascular disease, particularly myocardial infarction, selected drug and other causes. Drug related DKA, such as corticosteroid, FK506, interferon and antipsychotic drug was sometimes happened in diabetes. We reported a case with DKA due to secukinumab (cosentyx).

Case report: A 48-year-old male has history of Type 2 DM under insulin control for 15 years with toujeo 8u qhs+ novorspid 5u tid ac+ livalo 1# qhs and psoriasis regularly follow up in TaoYuan General Hospital and Chang Gung Memory Hospital respectively. His blood glucose control is good. (108-1-23 ac:121mg/dl, a1c:5.5%, 108-4-12 ac:133mg/dl, a1c:6.0%). Since April 2019, he received cosentyx for psoriasis according to treatment ptotocol. He noted blood sugar progressively slow elevation (108-7-23 ac:136mg/dl, a1c:6.2%). On October 10, 2019, he was presented to the emergency room because of dizziness and high blood sugar (SMBG pc:510 mg/dl). The lab data showed sugar:426 mg/dl, Na:135mmol/L , serum ketone:3.7mmol/L, urine analysis ketone 4+,aterial blood gass (PH/CO2/ HCO3 /O2/ O2sat/ Be:7.35 /32.7/17.8/63/ 90.3/-6.6), anion Gap:15. This is compatible with DKA. We gave intravenous fluid hydration and intravenous insulin . After these treatment, metabolic acidosis improved. He started insulin therapy with novorapid 16u tidac+ Toujeo 24u qhs. The blood sugar control was good within 100~200mg/dl. He felt better and discharged on 3rd admission day

Discussion: Secukinumab (cosentyx), a human immunoglobulin G1-kappa monoclonal antibody that directly inhibits interleukin (IL)-17A, has been shown to have efficacy in the treatment of psoriasis. We searched FDA reports about Cosentyx and Hyperglycemia by eHealthMe on December 1 2019. There are some reports about cosentyx related hyperglycemia. The frequency of hyperglycemia found among people who take Cosentyx is about 0.05% (24/51846) especially taking the drug for 1 - 6 months. Age and portion of people who have Hyperglycemia when taking Cosentyx is 3039: 7.69 %, 40-49: 15.38 %, 50-59: 23.08 %, 60+: 53.85 %. From this report, we highly suspected secukinumab related DKA in this male. Therefore, we should keep in mind about Secukinumab related hyperglycemia.

PD-7 EFFECT OF LOW-DOSE PIOGLITAZONE ON NONALCOHOLIC STEATOHEPATITIS: A CASE REPORT

1HSUAN-WEN CHOU, 1YE-FONG DU, 1HAO-CHANG HUNG, 1KAI-PI CHENG, 1HORNG-YIH OU

1Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Background: Nonalcoholic fatty liver disease (NAFLD) is common worldwide currently with the prevalence estimated to be 25% in the general population, and that of nonalcoholic steatohepatitis (NASH) about 3% to 5%. NASH may progress to cirrhosis and even liver cancer. Pioglitazone has been proved to improve liver histology in patients with biopsy-proven NASH. The dose of pioglitazone in most of the trials was 30 mg once daily. However, the efficacy of low-dose pioglitazone on NASH remains unclear.

Methods: Here, we report a case of NAFLD successfully treated with low-dose pioglitazone.

Results: A 61-year-old woman with a history of dyslipidemia, atorvastatin-related hepatitis, and prediabetes presented to our out-patient department for dyslipidemia (LDL-cholesterol: 228 mg/dL) and elevated alanine transaminase (ALT) level (269 U/L). The patient reported no habitus of alcohol-drinking. Abdominal sonography showed moderate fatty liver. After excluding other etiology of hepatitis including hepatitis B virus infection, hepatitis C virus infection, Wilson’s disease, hemochromatosis and autoimmune hepatitis, pioglitazone 15 mg once daily was prescribed due to suspected NASH. ALT level decreased to 65 U/L after treatment, but increased again after ceasing pioglitazone due to lower leg edema. Improvement in aminotransferase levels was noted again after adding back pioglitazone at very low dose of 15 mg for alternative day use.

Conclusions: Low-dose pioglitazone may be beneficial for the patients with NAFLD with less side effects. Long-term therapy may be needed to sustain the improvements of inflammation in patients with NASH. However, potential adverse effects should be taken into consideration during therapy.

PD-8 A CASE OF HYPERGLYCEMIC EMERGENCY PRESENTED AS BILATERAL CORTICAL BLINDNESS AND REVIEW OF LITERATURE

MIN-TSUN CHIU, CHEWN-YI YANG, KAI-JEN TIEN, MEI-CHEN YEH, NAI-CHENG YEH, SHANG-GYU LEE

Division of Endocrinology and Metabolism, Department of Internal medicine, Chi Mei Medical Center, Tainan, Taiwan

Background: There is high prevalence of type 2 diabetes mellitus. Diabetic emergencies commonly presented as diabetic ketosis and hyperosmotic hyperglycemic state. Fewer patients presented as hyperglycemic chorea. In chronic complications, visual problems including retinopathies are common, but it is fewer in acute presentation. Here we present a case of previously well controlled diabetes (HbA1c 5.9%) with bilateral cortical blindness, and review the differential diagnosis and treatment option for this condition.

Methods: In this article, one case of previously well controlled diabetes (HbA1c 5.9%) was reviewd. A 63-year-old female was presented to emergent department due to dysarthria, general weakness, and severe impaired visual acuity. Around 3~5 days before arrival, there had been dizziness and then progressively blurred vision of both eyes. Laboratory study showed glucose level 812 mg/dL, but there was negative findings in brain computed tomography and ophthalmology exam. This patient admitted for further treatment under the impression of bilateral cortical blindness.

Results: Basal bolus insulin regimen was given since the acute hyperglycemia with neurologic complications. During admission, neurology surveillance including brain magnetic resonance imaging and nerve conduction velocity showed no abnormal findings but mild polyneuropathy. Her vision gradually recovered after the control of sugar level. After the stabilized of sugar level. There was good recovery in vision while discharged.

Conclusions: It is uncommon presentation of acute hyperglycemia as acute visual impairment without macroscopic structural ophthalmologic abnormal findings (e.g. vitreous hemorrhage, retinal detachment). What ever the causes of acute visual impairment, regain sugar control in patients with hyperglycemia remains important.

PD-9 THE EFFICACY OF GROUP EDUCATION PROGRAMS ON SGLT-2 INHIBITORS IN PATIENTS WITH TYPE 2 DIABETES

1TING-YU CHEN, 1CHUN-SING LIN, 1YA-CHUN LI, 1MAN-NI LU, 1JIA-MEI CHEN, 1BAO-MEI LIN, 1FANG-TING HUANG, 1FANG-YU CHEN, 1CHONG-HUEI WU

1Division of Endocrinology and Metabolism, Department of Medicine,Taipei Veterans General Hospital, Taiwan

Background: SGLT-2 inhibitors inhibit reabsorption of glucose in proximal tubule of the kidney. As a result, SGLT-2 inhibitors have been shown to be effective at lowering hemoglobin HbA1c levels, improving weight loss and lowering blood pressure. But the most common side effects are reproductive and urinary tract infections that make patients afraid of taking medicine. Therefore, We conducted the Group Education Programs to increase the willingness of patients.

Methods: There were 60 volunteers who took SGLT-2 inhibitor for first time introduced to participate this study. We designed “Group Education Programs” as intervention including TheraBand exercise, introducing the mechanism of SGLT-2 and reminding precautions when taking SGLT2 inhibitor. Participants also can share their experience. Each participants’ body composition including visceral fat, whole body fat percentage and skeletal muscle percentage were measured by Karada Scan 701, OMRON before and after intervention. Other measurements included the fasting glucose, HbA1c and body weight were collected before and after study. The outcomes were evaluated after 8-12weeks. Kolmogorov-Smirnov test was applied for statistical analysis.

Results: Two male had itching and peeling of the Penis. One female had urinary tract infections. One participant was afraid of eating drugs because body weight droped too fast. After sharing experience of all symptoms after SGLT-2 inhibitor and more knowledge of SGLT-2 inhibitor, the participants were more willing to continue the medication. There is a significant reduction in HbA1c level and body weight compared with baseline. HbA1c level was decreased from 9.1 ± 1.5% to7.3 ± 1.0% after intervention, body weight was 75.6 ± 16.3kg to 71.6 ± 15.3kg, respectively (Decreased p-value < 0.05). There were 23 participants completed the measurement of body composition and showed a significant reduction in visceral fat was observed (15.2 ± 6.6% before intervention and 14.3 ± 6.0%, Decreased p-value = 0.039). Whole Body fat percentage decreased 0.7%, and skeletal muscle percentage increased 0.3%.

Conclusion: Group Education Programs have positive effect on maintaining the medication adherence and motivation. SGLT-2 inhibitor with this intervention programs significantly reduced HbA1c level, body weight and visceral fat.

PD-10 EFFECTS OF GLP-1RAS INJECTION FOR GLYCEMIC CONTROL AND BODY COMPOSITION IN TYPE 2 DIABETIC PATIENTS

1MAN-NI LU, 1CHUN-SING LIN, 1YA-CHUN LI, 1TING-YU CHEN, 1JIA-MEI CHEN, 1BAO-MEI LIN, 1FANG-TING HUANG, 1FANG-YU CHEN, 1CHONG-HUEI WU

1Division of Endocrinology and Metabolism, Department of Internal Medicine,Taipei Veterans General Hospital, Taiwan.

Background: 2018 American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) stated that one important goal of management of type 2 diabetes is to prevent and delay cardiovascular events. Glucagon like peptide-1 receptor analogues ( GLP-1 RA) have been proved by showing cardiovascular benefit. Throughing GLP-1 RAs injection to change body composition and glycemic control of the Type 2 Diabetic patients.

Methods: This program analysed data from outpatient clinic of Taipei Veterans General Hospital Metabolism Department from April 1, 2019 to July 30,2019. There were included total of 40 type 2 diabetes mellitus patients having poor glycemic control by oral hypoglycemic agents alone.We prescribed GLP-1 RA injection after collection of their base line characteristic such as body weight, neck and waist circumference,blood pressure, glycated hemoglobin, body fat composition ( using Omron body fat machine: Karada Scan 701, OMRON).Self monitoring of blood glucose and proper injection way were also explained to them. After that, we performed regular phone calling to every patient and confirmed drugs compliance and any injection problems. After eight to twelve weeks of GLP-1 RA injection, we performed post-tests data.

Results: Glycated hemoglobin was reduced 1.9 ± 1.7%, overall weight was -2.9 ± 3.9kg, neck circumference : -0.9 ± 2.7cm, and waist circumferences: -2.3 ± 5.0cm, all of which had significant differences (P < 0.05).Among them, the average value of trunk fat difference before and after completing body composition decrease -2.8 ± 7.1%, the average value of thigh muscle difference was -0.2 ± 3.4%, and the average value of subcutaneous fat difference was -1.4 ± 3.9%.(P < 0.05).

Conclusions: Our study showed that although GLP-1 RAs significantly decreased body weight, neck circumference and waist circumference. They have high percentage of 15 % due to their gastrointestinal side effects such as nausea, vomiting and discomfort.

PD-11 A CASE REPORT OF METFORMIN-ASSOCIATED LACTIC ACIDOSIS

JUI-HSIANG LI, SU-HUEY LO

Division of Endocrinology and Metabolism, Department of Internal Medicine Tao-Yuan General Hospital

Introduction: Metformin is currently the most commonly prescribed oral antihyperglycemia agent in the world and recommended as first-line medication in the guideline of many area such as United States and Taiwan. It is considered cost effective and less hypoglycemia side effect. But lactic acidosis is recognized as rare complication with estimated incidence 6.3 per 100,000 patient-years and high mortality rate around 50%. We presented a case with metformin associated lactic acidosis. He successfully treated and fully recovered.

Case presentation: A 68-year-old man has history of hypertension and diabetes mellitus with medication control in a local medical clinic, Glimet (Glimepiride/Metformin(2/500)) 1# po bid, Diabecon (Pioglitazone/Metformin (15/850)) 1# po bid. The biochemistry study on July 9 2019 was Cr:1.1 mg/dl, A1C:6.6%.

Acute onset of short of breath and urine amount decrease was noted after strenuous exercise and this condtion lasted for one week. He was sent to our emergent department. The lab. exam showed acute renal failure (Bun/Cr: 70/11.5 mg/dl), severe metabolic acidosis (pH/pCO2/ HCO3/BE:6.782/23.9/3.5/31.1), lactic acid:26.1 mmol/L, leukocytosis (WBC:21690m/mm3) and hypoglycemia (sugar:29mg/dl). After admission, emergent continuous venovenous hemofiltration (CVVH) was performed due to ACKD with metabolic acidosis and shock. Emergent intubation was performed on 1st admission day due to severe short of breath. Cr recovered and urine output increased after CVVH. We performed extubation on September 17 2017. We changed diabetic therapy to novorapid 14u tid/ac sc and toujeo 18u hs sc. The blood sugar was around 100~200mg/dl. He discharged on 13th admission days with insulin therapy and shifted to oral hypoglycemic agent (amaryl 1# qd+ trajenta 1#qd) in OPD.

Discussion: Development of metformin associated lactic acidosis involves a combination of lactate overproduction and drug accumulation. Risk factors predisposing to metformin associated lactic acidosis are common, such as hypoxemia, sepsis, alcohol abuse, renal injury, shock and medications such as ACEi or and ARB. Timely diagnosis allows correct treatment that is life saving and every one should keep in mind.

PD-12 CAUSES OF IN-HOSPITAL DEATH IN TYPE 2 DIABETIC PATIENTS WITH MICROVASCULAR COMPLICATION IN TAIWAN

1CHING-LING TU,

1HSING-YI HUANG, 1,2WEI-HAO HSU, 1,2WEI-LUN WEN, 1,3NAI-WEI SHEU, 1,3SHU-HENG HUANG, 1KUAN-HSUAN CHEN, 1I-TING LIN, 1MEI-YUEH LEE

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital; 2Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital; 3Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital

Background: Diabetes mellitus (DM) has become a major cause of death worldwide; it is also the fifth major cause of death in Taiwan in recent three years. We aimed to investigate the causes of inhospital death of type 2 diabetic patients, especially with microvascular complication.

Methods: This case-control study followed 36,477 (12,159 type 2 diabetic patients matched to 24,318 non-diabetic patients) identified from Taiwan National Health Insurance Research Database (NHIRD) from year 1998 to 2013.

Results: The deaths from acute respiratory failure, pneumonia, acute renal failure and septicemia increased in both male and female diabetic patients compared to non-diabetic patients. The disease with the highest risk of in-hospital death in diabetic patients was acute renal failure, with adjusted odds ratio (AOR) of 8.44 (95% confidence interval [CI] 3.35-21.30), 9.07 (95% CI, 1.86-44.22), and 8.10 (95% CI, 2.59-25.35) in total population, male and female, respectively. In diabetic patients with microvascular diseases, the disease with the highest risk of in-hospital death was aspiration pneumonitis (AOR 2.78, 95% CI 1.00-7.71). There was no significant difference of the length of hospitalization between diabetic and non-diabetic patients.

Conclusions: Acute illness such as pneumonia caused septicemia, acute respiratory failure and renal failure and led to in-hospital death in diabetic subjects.

PD-13 ASSOCIATION OF ASPIRIN AND DIPYRIDAMOLE THERAPY WITH RISK OF HEPATOCELLULAR CARCINOMA IN TYPE 2 DIABETES MELLITUS

1HSING-YI HUANG, 1CHING-LING TU, 1,2WEI-HAO HSU, 1,2WEI-LUN WEN, 1,3NAI-WEI SHEU, 1,3SHU-HENG HUANG, 1KUAN-HSUAN CHEN, 1I-TING LIN, 1,4MEI-YUEH LEE

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; 2Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; 3Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; 4Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Background: Studies have shown diabetes mellitus increase cancer risk in liver, pancreas, colon, bladder, endometrial, breast, and non-Hodgkin’s lymphoma. There are also studies have shown aspirin can decrease risk of cancers in esophagus, liver, pancreas, stomach, colon, lung and leukemia, but only few evidence reported the association of aspirin and cancer risk in diabetic population. In this study, we aim to investigate whether aspirin and dipyridamole can decrease the risk of cancer in type 2 diabetic patients.

Methods: A total of 5,308 type 2 diabetic patients were identified from the National Health Insurance from 1998 to 2000 and followed up until 2013. The demographic characteristics between patients using aspirin and dipyridamole were analyzed using the χ(2) test. Cox proportional hazard regression models were used to determine the independent effects of aspirin and dipyridamole in the risks of cancer.

Results: After adjustment with multiple covariates, aspirin decrease risk of lymphoma, liver and any types of cancer with risk ratios of 0.11 (95% confidence interval [CI], 0.01-0.96), 0.46 (95% CI, 0.31-0.69),and 0.72 (95% CI, 0.59-0.89) respectively. Dipyridamole decrease risk of liver cancer with risk ratio of 0.51 (95% CI, 0.32-0.80).Both low and high doses of aspirin and dipyridamole decrease liver cancer with risk ratios of 0.56 (95% CI, 0.37-0.83), 0.14 (95% CI, 0.05-0.39), 0.61 (95% CI, 0.38-0.99) and 0.28 (95% CI, 0.12-0.66) respectively.

Conclusions: Therefore, we conclude both low and high doses of aspirin and dipyridamole decrease risk of liver cancer in type 2 diabetic patients.

PD-14 IMPROVING GLUCOSE CONTROL OF INPATIENTS WITH INTELLIGENT INFORMATION SYSTEM

1CHIA-LIN CHU, 1LI-CHI HUANG

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Cathay General Hospital, Taiwan

Background: During hospitalization, diabetic patients often have high and low blood glucose fluctuations due to unadjusted drugs and dietary treatments. It will be increased the length of hospital stay due to the difficulty in controlling blood sugar especially for treatment of hypoglycemia. Therefore, our diabetes team hopes to give the more immediate and effective intervention for blood glucose control in hospitalized patients.

Methods: The intervention object is “patients with diabetes who have high and low blood glucose levels within 72 hours (hypoglycemia: 250mg/dl), and treated with insulin”, so that the patient’s blood glucose can be stably controlled before discharge.

The information system searches for patients who meet the criteria and the diabetes educators take the initiative to visit the patient in the ward, and builds a file in the system to synchronize the team. Our team members (Physician, personal administrator, nutritionist, pharmacist) will provide interventional care.

Results: 1. After using the blood glucose management prompting mechanism for inpatients, 405 in-patients with diabetes were consulted in 2019, and 81 in-patients with the team’s acceptance criteria, an increase of 2.09 times compared with last year. 2. The patient’s blood glucose was stable before discharge and no hypoglycemia occurred again. 3. Compared with the past, the time spent is reduced from about 72 minutes per day to less than 1 minute.

Conclusions: From the care of inter-professional practice, designing a more comprehensive information system can allow a better and timely interaction and communication mechanism between teams.

PD-15 CLINICAL CHARACTERISTICS AND PROGNOSTIC FACTORS OF GERIATRIC TYPE 2 DIABETIC PATIENTS WITH DKA

1WEN-HSUAN TSAI, 1CHUN-CHUAN LEE, 1CHUN-TA HUANG

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan

Background: Diabetic ketoacidosis (DKA) crisis is a severe, acute metabolic decompensations of diabetic mellitus (DM). Although DKA tends to developed in younger patients with type 1 DM, it can affect type 2 diabetic patients of any age as well. The number of DKA-related hospitalization continues to rise in all age groups but few studies have focused on geriatric population. The aim of this study is to investigate the clinical characteristics, outcomes and prognostic factors of elderly type 2 diabetic patients hospitalized for DKA.

Method: The current study is a sub-study of our SPRING (Structured Protocol for Rapid Inhospital Glycemic Control) Program. Briefly, we conducted a retrospective review of medical records of patients aged 65 or more, who admitted to Mackay Memorial Hospital between January 2016 and December 2019. We used discharge diagnosis to identify subjects admitted primarily for type 2 DM with DKA. Data were retrieved for each patient during the index hospitalization, and only those fulfilling DKA diagnostic criteria proposed by American Diabetic Association (ADA) will then be analyzed. If the same patient is admitted for DKA more than once, only the first event will be included. Our outcome of interest is in-hospital mortality and length of hospital stay. Statistical analysis was done using Mann Whitney U test, X2 or Fisher’s exact test, and binary logistic regression with level of α set at 0.05. Statistical significance was considered for variables with p < 0.05.

Result: Over a three-year period, there were 153 admissions of DKA in 138 patients. After excluding repeated cases, complete data was available in 51 patients. Mean age of patients was 73 ± 6.5 years with slightly more males (54.9%). Infection was the most common precipitating factor (51%), followed by poor compliance (23.5%). The median length of hospital stay was 9 days and only 16 (36.4%) patients could be discharged with 7 days. In-hospital mortality occurred in 7 (13.7%) cases with significant higher probability to occur in those having pre-existing ischemic heart disease, stroke or malignancy. Initial tachycardia (OR = 1.142, CI:1.014-1.285, p = 0.028) was an independent mortality predictor and mortality declined with higher GCS (OR = 0.59, CI:0.367-0.949, p = 0.029). Age, gender, BMI, glucose, pH, osmolality and blood pressure showed no significant efficacy in predicting mortality.

Conclusion: Infection and non-compliance with drug were the most common precipitants for DKA in geriatric type 2 diabetic patients. Length of hospital stay and mortality were high. Our study showed that initial heart rate and coma scale were prognostic factors for elderly patients with DKA.

PD-16 THE EFFECT OF COMBINED GLP-1 ANALOGUE INJECTION THERAPY WITH GROUP EXERCISE COURSES IN PATIENTS OF TYPE 2 DIABETES

1SHI-YU CHEN, 1EI SO, 1TSUNG-LIN HSIEH, 1SU-CHIUNG LIN, 1AI-RU CHEN, 1CHIEH-HUA LU, 1CHANG-HSUN HSIEH

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital

Background: Achieving optimal glycemic control requires medications, diet control, as well as exercise. Research has shown that healthcare providers were often out of practice about exercise guidelines for type 2 diabetic patients, especially with group exercise. Thus, the present study is to evaluate the efficacy of group exercise courses in patients of inadequately controlled T2DM receiving GLP-1 analogue injection therapy.

Methods: In 2018, we included 40 patients receiving GLP-1 analogue injection therapy as control group whereas another group of 40 patients were enrolled in 2019 as experimental group which received GLP-1 analogue injection therapy in collaboration with exercise intervention. GLP1 analogue injection skill and regular group exercise every month intervention were introduced. Health education leaflets with QR code video play about diabetic care were also issued. Biochemical examinations glycemic indices, muscle mass and body fat measurements using Bioimpedance Analysis were collected before and 3 months after therapy.

Results: In this case-control design study, a total of 80 T2DM patients were recruited. The glycated hemoglobin, fasting blood glucose, body weight, body fat, waist and neck circumferences of patients received group exercise courses were decreased significantly in compare with the control group (p < 0.01). Furthermore, the average muscle weight in experimental group increased by 0.4 kg, while it decreased by 0.5 kg in the control group, with significant difference.

Conclusions: Collaborate with group exercise courses with GLP-1 analogue treated patients with poor controlled T2DM, should improve glycemic control and reduced body fat, as well as gaining lean body mass.

PD-17 A SURVEY OF TREATMENT AND COMPLICATIONS OF TYPE 2 DIABETES PATIENTS IN TAIWAN CLINIC

1TSAI KUN-YUAN,

2CHEN MIN-LING, 3CHEN SAMUEL, 4CHOU CHIEN-WEN, 5TZENG THING-FONG, 6LEE YAU-JIUNN

1 重心診所、2 陳敏玲內科診所、3 陳宏麟診所、4 周劍文診所、5 曾競鋒診所、6 李氏聯合診所

Diabetes is a chronic major disease increasing socio-economic burden in Taiwan. More and more people receive treatment for their diabetes in the clinic. Hence, it is necessary to know the quality of treatment in local clinics. In this study, we evaluated the status of diabetes control in 7200 diabetes subjects among 43 local clinics in Taiwan.

The mean age was 62.6 ± 11.9 years (mean ± SD). Male to female ratio was 1:1.016. 60% subjects had obesity and 19.7% subjects were overweight, which based on the definition of WHOAsia Pacific. The percentage of subjects having comorbidity of hypertension and dyslipidemia was 67% and 84%. The percentages of subjects who smoked and have quitted smoking were 17.1% and 4.7%.

The percentage of subjects having HbA1c levels met ADA goals(< 7%) were 52.5%. The percentages with both SBP and DBP less than 130/80 mmHg were 40.9%. The percentages with LDL cholesterol levels less than 100 mg/dl were 79.7%. Therefore, we found only 18.3% of subjects reached all ABC goals.

PD-18 INFLUENCE ON HBA1C AND WEIGHT BY BASELINE BMI WITH ONCE WEEKLY DULAGLUTIDE IN CHINESE T2DM PATIENTS

1YONG QUAN SHI, 2BIN ZHANG, 2HAI YA WU, 3THOMAS LEW (NON-AUTHOR PRESENTER)

1Department of Endocrinology and Metabolism, Changzheng Hospital, Shanghai, China. 2Lilly Suzhou Pharmaceutical Co. Ltd., Shanghai, China. 3Lilly USA, Indianapolis, USA

Objective: To evaluate the efficacy of dulaglutide (1.5mg, 0.75mg) in Chinese T2DM patients with baseline BMI < 25 kg/m2 or ≥ 25 kg/m2, a post-hoc analysis was conducted on two randomized trials at week 26.

Methods: Patients in the dulaglutide versus glimepiride study (AWARD-CHN1, NCT01644500; n = 555) were treatment-naive or discontinued from oral monotherapy; those in the dulaglutide versus glargine study (AWARD-CHN2, NCT01648582; n = 591) continued on metformin and/or sulfonylurea. Analyses were conducted based on mixed-model repeated measures using modified intent-to-treat analysis set with only Chinese population. Changes of HbA1c and weight from baseline were analyzed by individual study.

Results: 45.6% of patients in AWARD-CHN1 and 42.8% in AWARD-CHN2 had a baseline BMI < 25 kg/m2. In patients with BMI < 25 kg/m2 or ≥ 25 kg/m2 of AWARD-CHN1, both doses of dulaglutide were superior to glimepiride for HbA1c reduction from baseline with a least squares mean difference of -0.55% or -0.53% for dulaglutide 1.5mg (both P < 0.001) and -0.32% or -0.35% for dulaglutide 0.75mg (both P < 0.05), while compared to glimepiride, both doses of dulaglutide showed significant weight reduction from baseline with a least squares mean difference of -2.09 kg or -2.75 kg for dulaglutide 1.5mg (both P < 0.001) and -1.76 kg or -1.92 kg for dulaglutide 0.75mg (both P < 0.001). In AWARDCHN2, dulaglutide 1.5mg was superior to glargine for HbA1c reduction from baseline with a least squares mean difference of -0.58% or -0.55% in patients with BMI < 25 kg/m2 or ≥25 kg/m2 of (both P < 0.001), while dulaglutide 0.75mg was superior to glargine for HbA1c reduction from baseline with that difference of -0.29% in patients with BMI < 25 kg/m2 (P < 0.05), but non-inferior to glargine for HbA1c reduction from baseline with that difference of -0.16% in patients with BMI ≥ 25 kg/m2 . Besides, in patients with BMI < 25 kg/m2 or ≥ 25 kg/m2 of AWARD-CHN2, compared to glargine, both doses of dulaglutide showed significant weight reduction from baseline with a least squares mean difference of -2.46 kg or -2.17 kg for dulaglutide 1.5mg (both P < 0.001) and -2.34 kg or -1.51 kg for dulaglutide 0.75mg (both P < 0.001).

Conclusions: Irrespective of baseline BMI, Dulaglutide showed effective reduction of HbA1c and weight in Chinese T2DM patients compared with glimepiride and glargine. For higher BMI patients treated with oral anti-hyperglycemia medicine, dulaglutide 1.5mg could be a better clinical choice.

PD-19 ADHERENCE AND PERSISTENCE FOR DULAGLUTIDE(DU) VS. BASAL INSULIN(BI) IN INJECTION-NAÏVE PATIENTS WITH TYPE 2 DIABETES(T2D): THE DISPELTM STUDY

1REEMA MODY; 2QING HUANG; 3MARIA YU; 2LIYA WANG; 2XIAN ZHANG; 2MICHAEL GRABNER 1HIREN PATEL, 1THOMAS LEW (NON-AUTHOR PRESENTER)

1Eli Lilly and Company, Indianapolis, IN, USA, 2HealthCore, Inc., Wilmington, DE, USA, 3Eli Lilly and Company, Toronto, ON, Canada

Purpose of the study: Adherence and persistence are key considerations in patient-centric treatment selection for T2D management. The objective of this retrospective real-world study was to assess 1-year adherence and persistence using different measures among injection-naïve patients with T2D initiating DU vs. BI.

Methods: A US claims database was used to identify patients with T2D initiating DU or BI between Nov’14–Apr’17 (index date=earliest fill date). Patients ≥ 18 years, with no claim for any antidiabetic injectable in the 6 months pre-index period (baseline), continuous enrollment and ≥ 1 HbA1c result at baseline and 1-year post-index were included. Two widely used measures for assessing persistence of injectables in the real-world were implemented. DU users were propensity-matched 1:1 to BI users.

Summary of the results: Matched cohorts (903 pairs) were balanced in baseline patient characteristics with mean age of 54 years. At 1-year follow-up, DU patients were significantly more likely to be adherent [PDC ≥ 80%, n (%)] than BI patients [516 (57.1%) vs. 262 (29%); p < .001). When measuring persistence as no gap between fills > 45 days [n (%)], more BI [605 (67.0%)] vs. DU [367 (40.6%)] patients discontinued their therapy but more BI [422 (69.8%)] vs. DU [141 (38.4%)] patients restarted their index therapy. More DU [519 (57.5%)] vs. BI [317 (35.1%)] patients discontinued based on the 90th percentile measure, and more DU [320 (61.7%)] vs. BI [126 (39.7%)] patients restarted their index therapy.

Conclusions: In this real-world study, DU demonstrated higher adherence than BI. Given the results, the most appropriate persistence measure may vary for different classes of antidiabetic injectables.

PD-20 DULAGLUTIDE HAS BETTER GLYCEMIC EFFECTIEVNESS VERSUS BASAL INSULIN IN INJECTION-NAÏVE PATIENTS WITH TYPE 2 DIABETES: THE DISPELTM STUDY

1REEMA MODY, 2QING HUANG, 3MARIA YU, 2XIAN ZHANG, 2LIYA WANG, 2MICHAEL GRABNER, 1HIREN PATEL, 1THOMAS LEW (NON-AUTHOR PRESENTER)

1Eli Lilly and Company, Indianapolis, IN, USA. 2HealthCore, Inc., Wilmington, DE, USA. 3Eli Lilly and Company, Toronto, ON, Canada

Background/objectives: 2018 ADA-EASD consensus report recommends GLP-1 RAs over basal insulin (BI) as the first injectable medication in most patients with type 2 diabetes (T2D). Objective of this US retrospective observational study was to compare 1-year real-world glycemic effectiveness among patients with T2D initiating dulaglutide (DU) vs BI.

Design and methods: Patients ≥ 18 years with T2D initiating DU or BI between Nov’14–Apr’17 (index date = earliest fill date), and no claim for any antidiabetic injectable in 6 months pre-index period (baseline), continuous enrollment and ≥ 1 HbA1c result 6 months pre-index and 1-year postindex were identified from a US claims database. DU users were propensity-matched 1:1 to BI users.

Results: Pre-matching mean baseline HbA1c for DU cohort (n = 1,103) was 8.4% vs 9.9% for BI cohort (n = 3,193). Matched cohorts (903 pairs) were balanced in baseline characteristics with mean HbA1c~8.6%, mean age = 54 years, SGLT2 inhibitor use: 24% and DPP-4 inhibitor use~38%. 1-year post-index, 11% of DU cohort used BI and 10% of BI cohort used GLP-1 RAs; DU patients used less rapid-acting insulin (2% vs 16%) and DPP-4 inhibitors (24% vs 39%) and more SGLT2 inhibitors (34% vs 23%) vs BI patients. For the matched cohorts, change (mean; SE) in HbA1c levels from baseline was significantly greater in the DU (-1.12; 0.05) vs the BI cohort (-0.51; 0.05) (p < 0.01). HbA1c level was reduced by ≥ 1% or decreased to < 7% in significantly more number of patients in the DU (65.6%) vs the BI cohort (45.3%) (p < 0.01). Among patients with baseline HbA1c > 9%, change (mean; SE) in HbA1c levels was significantly greater in the DU -2.11; 0.10) vs the BI cohort (-1.52; 0.10) (p < 0.01). Similar observations were made in patients aged ≥ 65 years.

Conclusions: This real-world study, patients with T2D initiating DU demonstrated significantly greater and clinically meaningful HbA1c reduction compared to those initiating BI.

PD-21 CHRONIC KIDNEY DISEASE OUTCOMES WITH DULAGLUTIDE VERSUS INSULIN GLARGINE IN TYPE 2 DIABETES AND MODERATETO-SEVERE CHRONIC KIDNEY DISEASE BY ALBUMINURIA STATUS: AWARD-7

1KATHERINE R. TUTTLE, 2BRIAN RAYNER, 3MARK C. LAKSHMANAN, 3D. BRADLEY WOODWARD, 3ANITA KWAN, 3MANIGE KONIG, 3FADY T. BOTROS; 3THOMAS LEW (NON-AUTHOR PRESENTER)

1Providence Health Care, University of Washington, Spokane, WA, USA; 2Division of Nephrology and Hypertension, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa; 3Eli Lilly and Company, Indianapolis, IN, USA

Background/objectives: In this study, conducted in type 2 diabetes (T2D) and moderate-tosevere chronic kidney disease (CKD), dulaglutide (DU) treatment was associated with slower decline in estimated glomerular filtration rate (eGFR) versus insulin glargine (IG). DU = 1.5mg weekly (1yr treatment) was associated with fewer CKD outcomes, including eGFR decline ≥ 40% or end-stage renal disease (ESRD), versus IG at similar levels of glycemic control and blood pressure. Aim now is to determine risk of CKD outcomes between treatments in albuminuria subgroups.

Design and methods: Participants with T2D and CKD stages 3-4 were randomized (1:1:1) to DU = 0.75mg/DU = 1.5mg weekly versus titrated IG daily, added on to titrated insulin lispro, for 1yr. Composite outcome of eGFR decline ≥ 40% or ESRD was compared between treatments (Coxproportional hazards model time-to-first-event analysis).

Results: At baseline, treatment groups had similar eGFR by albuminuria subgroups; majority of events occurred in macroalbuminuria patients (Table). Compared to IG, incidence rate of composite endpoint was significantly lower for DU = 1.5mg in overall study and macroalbuminuria population.

Conclusions: Risk of ≥ 40% eGFR decline or ESRD outcomes was reduced by > half for DU = 1.5mg versus IG, particularly in macroalbuminuric subgroup.

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