MKSAP: 78-year-old man with poor glycemic control

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 78-year-old man is evaluated in the hospital for poor glycemic control before undergoing femoral-popliteal bypass surgery. He has been on the vascular surgery ward for 3 weeks with a nonhealing foot ulcer.

The patient has an extensive history of arteriosclerotic cardiovascular disease, including peripheral vascular disease, and a 20-year history of type 2 diabetes mellitus. His most recent hemoglobin A1c value, obtained 2 months before admission, was 8.9%. His diabetes regimen consists of glipizide, 40 mg/d. During his hospitalization, his plasma glucose levels have generally been in the 200 to 250 mg/dL (11.1 to 13.9 mmol/L) range. He is eating well.

In addition to stopping glipizide, which of the following is the most appropriate treatment for this patient?

A. Basal insulin and rapid-acting insulin before meals
B. Insulin infusion
C. Neutral protamine Hagedorn (NPH) insulin twice daily
D. Sliding scale regular insulin

MKSAP Answer and Critique

The correct answer is A. Basal insulin and rapid-acting insulin before meals. This item is available to MKSAP 15 subscribers as item 26 in the Endocrinology section. Part A of MKSAP 16 was released on July 31. More information is available online.

This patient has uncontrolled diabetes mellitus during an acute medical illness requiring hospitalization. Although there are no data demonstrating improved clinical outcomes with better glycemic control in patients on general hospital wards, such treatment likely improves outcomes in the intensive care unit. Accordingly, national consensus guidelines recommend attempting to improve glycemic control in all hospitalized patients (premeal glucose level <140 mg/dL [7.8 mmol/L] and random glucose level <180 mg/dL [10.0 mmol/L]). Thus, a basal-bolus insulin regimen consisting of a long- or intermediate-acting insulin and a rapid-acting insulin analogue before meals is recommended for this hospitalized patient with diabetes mellitus. Such an approach allows for a more easily titratable regimen and can conveniently be held during diagnostic testing or procedures when nutritional intake is interrupted.

Insulin infusions are difficult to administer outside the intensive care unit in most hospitals; therefore, initiating one is not the best treatment for this patient and may not even be necessary to obtain good glycemic control.

A regimen of neutral protamine Hagedorn (NPH) insulin twice daily will likely improve glycemic control but is not as easily titratable as a basal-bolus correction and does not provide for premeal coverage to prevent postprandial glucose spikes.

Sliding scale regular insulin has been associated with increased hyperglycemic and hypoglycemic excursions and has been found to result in inferior glycemic control compared with a basal-bolus correction regimen in hospitalized patients. Initiating this approach is therefore inappropriate.

Key Point

  • There are no data demonstrating improved clinical outcomes after treatment to achieve better glycemic control in patients on general hospital wards, but such treatment has been shown to improve outcomes in critically ill patients in the intensive care unit.

Learn more about ACP’s MKSAP 16.

This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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