MKSAP: 57-year-old man with substernal chest pain

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

A 57-year-old man is admitted to the hospital for evaluation of substernal chest pain. His medical history is significant for type 2 diabetes mellitus, coronary artery disease, hypertension, and hyperlipidemia. He manages his diabetes as an outpatient with diet, exercise, and metformin. His other medications are aspirin, metoprolol, atorvastatin, and sublingual nitroglycerin as needed. His inpatient plasma glucose values are 170 to 210 mg/dL (9.4-11.6 mmol/L). Results of all other laboratory studies are normal.

Which of the following is the most appropriate treatment for this patient’s diabetes while hospitalized?

A. Basal and prandial insulin
B. Glipizide
C. Metformin
D. Sliding-scale insulin

MKSAP Answer and Critique

The correct answer is A. Basal and prandial insulin.

The most appropriate treatment for this patient’s diabetes mellitus while hospitalized is a weight-based treatment plan that includes basal and prandial insulin. Hyperglycemia in the hospital is associated with poor outcomes. According to the American Diabetes Association and American Association of Clinical Endocrinologists, glucose goals in hospitalized patients in a non-ICU setting are premeal values less than 140 mg/dL (7.8 mmol/L) and random values less than 180 mg/dL (10 mmol/L). The American College of Physicians recommends avoiding values less than 140 mg/dL (7.8 mmol/L) to decrease the risk of hypoglycemic complications. The patient’s plasma glucose values exceed the recommended guidelines and require treatment.

Oral agents do not have safety or efficacy data for use in the hospital. Glipizide is an insulin secretagogue that can potentially induce hypoglycemia in the hospital setting, particularly with unpredictable changes in oral intake.

With metformin use, hospitalized patients can develop poor organ perfusion, which can increase the risk of lactic acidosis. Intravenous contrast dye can also impair kidney function in the setting of metformin use in the hospital. Reinitiation of the patient’s home regimen of metformin at or near the time of discharge is most appropriate after all procedures have been completed and organ function is stable and glucose levels have returned to baseline values.

Sliding-scale insulin is nonphysiologic and can result in large fluctuations in blood glucose levels. Sliding-scale insulin is not recommended as the sole insulin therapy in the hospital setting.

Key Point

  • For non-critically ill hospitalized patients with diabetes mellitus and hyperglycemia, a weight-based treatment plan that includes basal and prandial insulin is recommended.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 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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