Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital – A3

ANSWER — Correct.

On further inquiry, you learn that the patient has type 1 diabetes. She presented with diabetic ketoacidosis (DKA) and had a second episode of DKA six years ago when she had pneumonia. Age is not a criterion for diagnosis of type 1 diabetes, which can have its onset at any age. One cannot assume that an older patient treated with insulin has type 2 diabetes. She needs an intermediate or long-acting insulin at all times.

Her metabolic control was satisfactory at home. It has been rendered unstable in the hospital by the use of an insulin sliding scale as the sole source of insulin. An insulin sliding scale without provision of a basal (intermediate or long-acting) insulin is not a satisfactory method of treatment in a patient with type 1 diabetes and in many insulin-treated patients with type 2 diabetes.

Since the patient is now eating her usual diet and has received regular insulin to treat the blood glucose of 363 mg/dL on the day you see her, it is appropriate to resume her usual insulin regimen before dinner on December 5. The blood glucose is 209 mg/dL before dinner and 171 mg/dL at bedtime. The patient's glucose values are satisfactory the following day, December 6, and she is discharged home.

You may also wish to take this occasion to teach the patient how to estimate the dose of her short-acting insulin. An approach to estimating the dose of short- and very short-acting insulins is reviewed separately. (See "Interactive diabetes case 3: Hypoglycemia in a patient with type 1 diabetes – B2".)

Well done.

For additional information, see the comment at the end of this sequence. (See "Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital – Comment".)

To explore the consequences of the other actions, return to the case at the beginning of this sequence. (See "Interactive diabetes case 5: Insulin management in a 73-year-old patient with diabetes admitted to the hospital".)