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Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital

Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital
Author:
Lloyd Axelrod, MD
Section Editor:
David M Nathan, MD
Deputy Editor:
Katya Rubinow, MD
Literature review current through: Jan 2024.
This topic last updated: May 31, 2023.

CASE — You are asked to see a 73-year-old woman with diabetes who was admitted to the hospital for a non-healing ulcer of the left great toe.

The patient has a 36-year history of diabetes mellitus. At home, she takes NPH insulin 22 units before breakfast and 6 units at bedtime and regular insulin 6 units before dinner. She checks her blood glucose values three to four times a day. The results are as follows: those before breakfast are usually in the 90 to 150 mg/dL (5 to 8.3 mmol/L) range, those before lunch (checked infrequently) are in the 130 to 170 mg/dL (7.2 to 9.4 mmol/L) range, those before dinner are in the 100 to 150 mg/dL (5.6 to 8.3 mmol/L) range, and those at bedtime are in the 140 to 180 mg/dL (7.8 to 10 mmol/L) range. Her most recent glycated hemoglobin (A1C) value was 7.8 percent three weeks ago. She follows the same American Diabetes Association (ADA) 1600-calorie diet that she has followed for the last 30 years. The weight is 155 pounds, height 5' 3", body mass index (BMI) 27.5 kg/m2. She is on lisinopril 10 mg every morning and aspirin 162 mg a day. She will get nothing by mouth the day following admission because she is scheduled for an arteriogram. The admitting clinician holds the NPH insulin and puts the patient on an insulin sliding scale before meals and at bedtime, shown in the table (table 1).

The patient also receives intravenous (IV) fluids with D5W at 80 mL/hour starting at 6 AM on the first full hospital day. The patient's diabetes medication history in the hospital reveals the following, shown in the table (table 2).

The patient resumes her meals on December 3 at dinner, following the same diet as at home. The serum creatinine remains normal following the arteriogram. The patient is angry and tearful because she feels her diabetes has "gone crazy." She wants to resume the insulin regimen she uses at home and go home, where she will be safer. The clinician is reluctant to return to the patient's previous regimen, fearing that the NPH insulin will cause further episodes of hypoglycemia. You are asked to assist with diabetes management. The case manager wants to know whether the patient can be sent home today.

What is your assessment and plan?

The patient has unexplained labile diabetes. You suspect that there is osteomyelitis of the left great toe and that this lesion is intermittently releasing cytokines into the circulation, creating intermittent insulin resistance and hyperglycemia. You recommend an insulin infusion to provide maximum flexibility, transfer to the medical intensive care unit, and consultation with an infectious disease specialist. (See "Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital – A1".)

The default sliding scale ordered on admission is inappropriate for this patient, who appears to need larger doses in the morning and smaller doses at bedtime. You recommend that separate sliding scales be used at different times of day, giving more insulin at all levels of blood glucose before meals, and less insulin at all levels of blood glucose at bedtime. You defer discharge to assess the patient's response to the new regimen. (See "Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital – A2".)

You suspect that the patient has type 1 diabetes despite her age. You attribute the lability of blood glucose values to sole reliance on an insulin sliding scale without any basal intermediate or long-acting insulin in a patient with type 1 diabetes. You agree with the patient that she needs to return to the insulin regimen she uses at home, starting the same day (December 5) at dinner time. You suggest that the patient may be ready for discharge the following day, but you wish to assess the patient's response to her insulin regimen the following day before discharge. (See "Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital – A3".)

You suspect that the patient has type 1 diabetes despite her age. You attribute the lability of blood glucose values to sole reliance on an insulin sliding scale without any basal intermediate or long-acting insulin in a patient with type 1 diabetes. However, you are concerned by the recurrent episodes of hypoglycemia and advise that the patient receive only half of her usual doses of NPH insulin along with the sliding scale of regular insulin. You suggest that the patient may be ready for discharge the following day, but you wish to assess the patient's response to her insulin regimen the following day before discharge. (See "Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital – A4".)

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