A 66-year-old woman was admitted to the hospital 24 hours ago with community-acquired pneumonia. Since admission, she has been confused and her oral intake has been poor. Appropriate antibiotics, intravenous fluids, and oxygen have been initiated. She has no other known medical problems.
On physical examination, temperature is 39 °C (102.2 °F), blood pressure is 142/88 mm Hg, pulse rate is 98/min, and respiration rate is 20/min. Oxygen saturation is 98% on oxygen, 2 L/min by nasal cannula. Crackles are evident in the right posterior thorax.
Laboratory studies show glucose values of 185 to 215 mg/dL (10.3-11.9 mmol/L) and a hemoglobin A1c level is 5.5%.
A chest radiograph demonstrates a right lower lobe infiltrate.
Which of the following is the most appropriate management of this patient's hyperglycemia?
A. Empagliflozin and sliding-scale insulin
B. Metformin and sliding-scale insulin
C. Scheduled basal insulin and correction insulin
D. Sliding-scale insulin only
MKSAP Answer and Critique
The correct answer is C. Scheduled basal insulin and correction insulin. This item is available to MKSAP 18 subscribers as item 27 in the Endocrinology and Metabolism section. More information about MKSAP 18 is available online.
The most appropriate management of this patient's hyperglycemia is to initiate scheduled basal insulin and correction insulin. Inpatient hyperglycemia, defined as consistently elevated plasma glucose values above 140 mg/dL (7.8 mmol/L), is associated with poor outcomes. Attempts to decrease morbidity and mortality with tight glycemic control (80-110 mg/dL [4.4–6.1 mmol/L]) have not consistently demonstrated improvements in adverse outcomes and, in some settings, have shown increased rates of severe hypoglycemic events and mortality. As a result, revised inpatient glycemic targets are less stringent than outpatient glucose targets to avoid both hypoglycemia and severe hyperglycemia that can lead to volume depletion and electrolyte abnormalities. Dietary modifications should be made once glucose levels exceed 140 mg/dL (7.8 mmol/L). At persistent glucose levels of 180 mg/dL (10.0 mmol/L) and higher, the American Diabetes Association recommends initiation of scheduled insulin with a blood glucose target of 140 to 180 mg/dL (7.8-10.0 mmol/L) for most critically ill and noncritically ill patients to decrease the risk of adverse outcomes. Scheduled basal insulin or basal insulin plus correction insulin is appropriate for patients who are fasting or who have poor oral intake, such as this patient, with frequent bedside point-of-care monitoring every 4 to 6 hours for insulin adjustments. Scheduled basal and prandial insulin plus correction insulin are appropriate for patients who are eating.
The safety of oral antihyperglycemic agents, including empagliflozin, in the hospital setting has not been fully studied or established. In addition, sodium-glucose transporter-2 (SGLT2) inhibitors have been associated with diabetic ketoacidosis and should be avoided in situations that may produce ketone bodies, such as severe illness or prolonged fasting. Scheduled insulin therapy is the recommended treatment regimen for hyperglycemia in the hospital setting.
The safety of oral antihyperglycemic agents, including metformin, in the hospital setting has not been fully studied or established. Scheduled insulin therapy is the recommended treatment regimen for hyperglycemia in the hospital setting.
The sole use of correction insulin for the management of hyperglycemia is not recommended. It is a reactive approach to hyperglycemia that can lead to large fluctuations in glucose levels coupled with the near universal lag time between measurement of glucose and injection of insulin that occurs in most hospitals.
- To manage in-patient hyperglycemia, scheduled basal insulin or basal insulin plus correction insulin is appropriate for patients who are fasting or who have poor oral intake.