Interactive diabetes case 1: Inpatient management in type 1 diabetes – C3

ANSWER — Correct.

The following day, the 6:30 AM blood glucose level was 107 mg/dL (5.9 mmol/L). The patient was able to eat her meals completely. This time, she received her usual morning doses of NPH and regular insulin before breakfast, and the 11:00 AM blood glucose was 129 mg/dL (7.2 mmol/L).

The patient's hyperglycemia, with a blood glucose of 286 mg/dL (15.9 mmol/L), was due to overtreatment of the preceding episode of hypoglycemia. A very common cause of hyperglycemia in patients with diabetes is excessive treatment of hypoglycemia. Hypoglycemia is the most important limiting factor in the glycemic management of type 1 and insulin-treated type 2 diabetes.

Treatment of symptomatic hypoglycemia or a blood glucose of <70 mg/dL (3.9 mmol/L) requires ingestion of glucose or food containing carbohydrates. Glucose (15 to 20 g) is the preferred treatment for the conscious individual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. If the blood glucose level remains below 70 mg/dL (3.9 mmol/L) at 15 minutes, the treatment should be repeated. Four ounces of full-strength (not light) orange juice contains approximately 15 g of carbohydrate. Commercial glucose tablets contain 4 to 5 g of carbohydrate, depending on the brand. The treatment of hypoglycemia is reviewed in more detail elsewhere. (See "Hypoglycemia in adults with diabetes mellitus".)

Patients with type 1 diabetes need a basal (intermediate or long-acting) insulin at all times to prevent diabetic ketoacidosis (DKA). The basal insulin should not be withheld when a patient with type 1 diabetes is in the hospital (unless the patient will receive a continuous infusion of intravenous insulin). If the patient is unable to eat, prandial doses of a short- or very short-acting insulin may be omitted, and intravenous glucose should be provided to prevent hypoglycemia until the patient is able to eat a full meal. (See "Management of diabetes mellitus in hospitalized patients".)

The reader is urged to return to the case at the beginning of this sequence in order to explore the consequences of the alternative choices. (See "Interactive diabetes case 1: Inpatient management in type 1 diabetes".)

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