In the Journals

Inpatient hypoglycemia predicts major amputation in diabetic foot disease

Patients hospitalized with acute diabetic foot are more likely to undergo any or major amputations when experiencing a hypoglycemic event, independent of other amputation risk factors, according to an analysis of electronic medical records data.

Avivit Cahn

“This study is the first to assess the impact of glycemic control on patients with acute diabetic foot in the inpatient setting,” Avivit Cahn, MD, a senior physician at Hadassah Hebrew University Medical Center in Jerusalem, told Endocrine Today. “The study found an important association between inpatient glycemic control and amputations, with a stronger association of hypo- rather than hyperglycemia with adverse outcomes.”

In a retrospective study, Cahn and colleagues analyzed EMR data from 418 patients hospitalized with acute diabetic foot admitted to the diabetic foot unit of Hadassah Hebrew University Medical Center for at least 3 days from 2015 to 2017 (mean age, 65 years; 74.4% men; 92.6% with type 2 diabetes; 65.3% using insulin at admission; 33% with a previous amputation). Per protocol beginning in 2010, all patients admitted to the unit are transitioned to basal-bolus insulin therapy; patients already taking basal insulin are additionally started on prandial insulin. Glucose and insulin values are reviewed by a diabetes specialist and diabetes nurse weekly, according to researchers. Primary outcomes were any or major amputation during hospitalization. Secondary outcomes included length of hospitalization and in-hospital mortality.

During the study period, patients underwent 45,496 glucose measurements, for a mean of 108.8 measurements per hospitalization and 4.7 measurements per day. Median hospitalization length was 17 days, and in-hospital mortality was 6% (26 patients).

During hospitalization, 229 patients (55%) underwent amputation. Of those, 108 patients (47%) had a major amputation. The researchers found that patients experiencing any hyperglycemia and any or severe hypoglycemia were more likely to undergo any or major amputations during hospitalization.

Researchers found that independent predictors of amputation included peripheral vascular disease (OR = 2.31; 95% CI, 1.36-3.92), high Wagner’s diabetic foot ulcer classification score (OR = 2.93; 95% CI, 1.77-4.88) and hypoglycemia (OR = 2.08; 95% CI, 1.24-3.49). Independent predictors of major amputations included peripheral vascular disease (OR = 3.16; 95% CI, 1.46-6.83), previous amputation (OR = 1.98; 95% CI, 1.13-3.46), elevated white blood cell count (OR = 1.05; 95% CI, 1-1.11), high Wagner’s score (OR = 3.48; 95% CI, 1.71-7.12) and hypoglycemia (OR = 1.98; 95% CI, 1.08-3.64).

High glycemic variability was associated with increased mortality (P = .04); however, the association with hypoglycemia was of borderline significance (P = .07), according to researchers.

“Although causation cannot be inferred from an associative study, this is the first study to highlight the importance of glycemic control in inpatients with acute diabetic foot,” Cahn said. “Future studies should aim for interventional protocols in this population assessing whether tighter glycemic control will improve outcomes.” – by Regina Schaffer

For more information:

Avivit Cahn, MD, can be reached at Hadassah Hebrew University Medical Center, Diabetes Unit, Department of Endocrinology and Metabolism, P.O. Box 12000, Jerusalem, Israel 91120; email: avivit@hadassah.org.il.

Disclosures: The authors report no relevant financial disclosures.

Patients hospitalized with acute diabetic foot are more likely to undergo any or major amputations when experiencing a hypoglycemic event, independent of other amputation risk factors, according to an analysis of electronic medical records data.

Avivit Cahn

“This study is the first to assess the impact of glycemic control on patients with acute diabetic foot in the inpatient setting,” Avivit Cahn, MD, a senior physician at Hadassah Hebrew University Medical Center in Jerusalem, told Endocrine Today. “The study found an important association between inpatient glycemic control and amputations, with a stronger association of hypo- rather than hyperglycemia with adverse outcomes.”

In a retrospective study, Cahn and colleagues analyzed EMR data from 418 patients hospitalized with acute diabetic foot admitted to the diabetic foot unit of Hadassah Hebrew University Medical Center for at least 3 days from 2015 to 2017 (mean age, 65 years; 74.4% men; 92.6% with type 2 diabetes; 65.3% using insulin at admission; 33% with a previous amputation). Per protocol beginning in 2010, all patients admitted to the unit are transitioned to basal-bolus insulin therapy; patients already taking basal insulin are additionally started on prandial insulin. Glucose and insulin values are reviewed by a diabetes specialist and diabetes nurse weekly, according to researchers. Primary outcomes were any or major amputation during hospitalization. Secondary outcomes included length of hospitalization and in-hospital mortality.

During the study period, patients underwent 45,496 glucose measurements, for a mean of 108.8 measurements per hospitalization and 4.7 measurements per day. Median hospitalization length was 17 days, and in-hospital mortality was 6% (26 patients).

During hospitalization, 229 patients (55%) underwent amputation. Of those, 108 patients (47%) had a major amputation. The researchers found that patients experiencing any hyperglycemia and any or severe hypoglycemia were more likely to undergo any or major amputations during hospitalization.

Researchers found that independent predictors of amputation included peripheral vascular disease (OR = 2.31; 95% CI, 1.36-3.92), high Wagner’s diabetic foot ulcer classification score (OR = 2.93; 95% CI, 1.77-4.88) and hypoglycemia (OR = 2.08; 95% CI, 1.24-3.49). Independent predictors of major amputations included peripheral vascular disease (OR = 3.16; 95% CI, 1.46-6.83), previous amputation (OR = 1.98; 95% CI, 1.13-3.46), elevated white blood cell count (OR = 1.05; 95% CI, 1-1.11), high Wagner’s score (OR = 3.48; 95% CI, 1.71-7.12) and hypoglycemia (OR = 1.98; 95% CI, 1.08-3.64).

High glycemic variability was associated with increased mortality (P = .04); however, the association with hypoglycemia was of borderline significance (P = .07), according to researchers.

“Although causation cannot be inferred from an associative study, this is the first study to highlight the importance of glycemic control in inpatients with acute diabetic foot,” Cahn said. “Future studies should aim for interventional protocols in this population assessing whether tighter glycemic control will improve outcomes.” – by Regina Schaffer

For more information:

Avivit Cahn, MD, can be reached at Hadassah Hebrew University Medical Center, Diabetes Unit, Department of Endocrinology and Metabolism, P.O. Box 12000, Jerusalem, Israel 91120; email: avivit@hadassah.org.il.

Disclosures: The authors report no relevant financial disclosures.