QUESTION FOR INTERNISTS

[quickfeet]

When and how do you manage hyperglycemia in inpatients?

Simple question but I have read Harrison's, UpToDate, and multiple other resources without finding a straight answer.

Recent real-life example: On my sub-i, had 50 something year old admitted for NSTEMI. Prior to admission, he took NO medications. Had no diagnosis of T2DM. His CMP glucose was 368.

So in my mind, the first step was to take 24 hours of POC glucose and do a HbA1c.

His POC glucose readings were in the low 300s/high 200s for the first day of admission.

• Question 1: Do you just start him on Lantus at night? How do you know how many units to start?
• Question 2: When does hyperglycemia need to be treated in inpatients?

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[Rekt]

You'll probably get better answers here;

http://forums.studentdoctor.net/forums/internal-medicine-and-im-subspecialties.41/

 

[Psai]

I wouldn't start him on insulin. I figure the hyperglycemia is secondary to a stress response.

I would only treat in someone with known diabetes.

 

[HelpPleaseMD]

check his HgA1c, Lipid profile
start him on low dose lantus. .15 (if you are really coservative) per kg
-insulin sliding scale for coverage

ask him when he last went to a pmd.

 

[Instatewaiter]

When and how do you manage hyperglycemia in inpatients?

Simple question but I have read Harrison's, UpToDate, and multiple other resources without finding a straight answer.

Recent real-life example: On my sub-i, had 50 something year old admitted for NSTEMI. Prior to admission, he took NO medications. Had no diagnosis of T2DM. His CMP glucose was 368.

So in my mind, the first step was to take 24 hours of POC glucose and do a HbA1c.

His POC glucose readings were in the low 300s/high 200s for the first day of admission.

• Question 1: Do you just start him on Lantus at night? How do you know how many units to start?
• Question 2: When does hyperglycemia need to be treated in inpatients?

Do you start him on Lantau at night?

A) No for a few reasons. You don't know his trajectory. Because these NSTEMIs can heat up overnight, it is best to use shorter acting agents initially lest you make him sicker than he already is going to be by causing hypoglycemia. Hypoglycemia causes a catecholamine surge which is the exact opposite of what you want to happen in an NSTEMI. However after 24 or 48 hours you can estimate his daily dose of insulin needed by what you've given him. You then give a little less than 50% of his total daily insulin requirement as Lantus. And make up the rest with a combination of nutritional and sliding scale short acting insulin.

Depending on his level of sickness, i'd probably start him on sliding scale insulin or if in an ICU an insulin drip. Unless you're at some community shop that puts every healthy NSTEMI in the ICU, if he's in an ICU for an NSTEMI, he's sick. Especially in that case, you'd be an idiot to start lantus on the first night.

When does hyperglycemia need to be treated as inpatients-
A: Above 200 is probably reasonable enough to treat, this is somewhat arbitrary in floor patients