A 64-year-old male is admitted to the hospital to manage a heart failure exacerbation. History is notable for type 2 diabetes mellitus diagnosed 7 years ago and managed with glipizide and metformin. He insists on full compliance with all prescribed medications. The patient is unaware of any microvascular complications. Hemoglobin A1c (HbA1c) checked shortly before admission was 8.5%.
Initial evaluation reveals the patient to be in mild-to-moderate respiratory distress but capable of eating. Weight and height are recorded as 90 kg and 173 cm, respectively. Admission plasma glucose (glc) is 234 mg/dL, and serum creatinine is 1.1 mg/dL. The admitting service writes orders for lispro (LP; Humalog) with meals and glargine (Glarg) at bedtime as presented in Figure 23-1. The night nurse calls the on-call intern to report bedtime capillary blood glucose (CBG) is 254 mg/dL and outside call parameters.
Initial diet and insulin orders.
The patient responds well to therapy with diuretics and vasodilators. His CBG pattern (mg/dL) by the morning of hospital day 2 is shown in Table 23-1.
Table 23-1. Capillary Blood Glucose Measurements |Favorite Table|Download (.pdf)
Table 23-1. Capillary Blood Glucose Measurements
Glycemic control improves after advancing LP doses. However, on hospital day 4, the patient feels sweaty and tremulous in the morning, and CBG before breakfast is measured at 64 mg/dL. At bedtime on hospital day 3, CBG was 95 mg/dL.
1. What is the best approach to manage the patient's type 2 diabetes?
2. How can the patient's unanticipated exacerbation of hyperglycemia on the night of admission be corrected?
3. How should insulin be adjusted on hospital day 2 to improve glycemic control?
4. How should hypoglycemia occurring the morning of hospital day 4 be addressed?
A basal/bolus insulin regimen is the preferred approach to diabetes management on non–critical care hospital services. Typically, a basal insulin analog such as Glarg (Lantus®) is combined with a prandial insulin analog such as LP (Humalog®).
Correction factor (CF) insulin should be dosed as summarized in Figure 23-2. Rapid-acting insulin analogs are preferred as CF insulin. CBG correction target is usually 140 or 150 mg/dL.
Persistently elevated CBG measurements during the day but stable CBG from night to morning indicate a need to increase prandial insulin doses. See Figure 23-3 or Appendix 1 for instructions regarding prandial insulin adjustments. In this case, insulin LP should be increased by 20% at each meal to 11 U.
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