A 23-year-old man is hospitalized for acute gastroenteritis with mild dehydration. He has type 1 diabetes mellitus that was diagnosed 6 years ago and is managed with a regimen that includes insulin glargine at bedtime and insulin aspart before meals. The patient adjusts the dose of insulin aspart based on the size of his meals and premeal glucose levels. His recent glycemic control has been excellent, with a hemoglobin A1c of 7.0%. The patient had an episode of diabetic ketoacidosis a year ago but has no chronic complications of diabetes. His glucose levels occasionally drop below 70 mg/dL, mainly at night, but he has had no symptoms or loss of consciousness due to hypoglycemia. Temperature is 36.7 C (98.1 F), blood pressure is 114/70 mm Hg, and pulse is 100/min. Oral mucous membranes are dry, but physical examination is otherwise normal. Initial laboratory tests show a normal anion gap and a blood glucose level of 80 mg/dL. Due to frequent vomiting, the patient is able to tolerate only limited amounts of fluids or food orally, and he is started on intravenous fluids. Which of the following is the most appropriate strategy for managing this patient's insulin while he is in the hospital?

Question

A 23-year-old man is hospitalized for acute gastroenteritis with mild dehydration.  He has type 1 diabetes mellitus that was diagnosed 6 years ago and is managed with a regimen that includes insulin glargine at bedtime and insulin aspart before meals.  The patient adjusts the dose of insulin aspart based on the size of his meals and premeal glucose levels.  His recent glycemic control has been excellent, with a hemoglobin A1c of 7.0%.  The patient had an episode of diabetic ketoacidosis a year ago but has no chronic complications of diabetes.  His glucose levels occasionally drop below 70 mg/dL, mainly at night, but he has had no symptoms or loss of consciousness due to hypoglycemia.  Temperature is 36.7 C (98.1 F), blood pressure is 114/70 mm Hg, and pulse is 100/min.  Oral mucous membranes are dry, but physical examination is otherwise normal.  Initial laboratory tests show a normal anion gap and a blood glucose level of 80 mg/dL.  Due to frequent vomiting, the patient is able to tolerate only limited amounts of fluids or food orally, and he is started on intravenous fluids.  Which of the following is the most appropriate strategy for managing this patient's insulin while he is in the hospital?

Quizplus · Accepted Answer

Explanation: 11ec2b69_beb4_c112_8f63_055188bdea53_MD0005_00 In the hospital setting, the American Diabetes Association suggests maintaining glucose at 140-180 mg/dL. Insulin is the mainstay of therapy for treating diabetes in hospitalized patients and has 3 basic components: Basal (intermediate or long-acting insulin) for controlling glucose levels between meals, necessary for all patients with type 1 and most with type 2 diabetes Nutritional boluses (short-acting insulin) for controlling postprandial glucose excursions (not required if the patient is not eating) Correctional boluses (short-acting insulin) for correcting high glucose levels (commonly referred to as "sliding scale") This patient has type 1 diabetes mellitus and requires basal insulin (eg, glargine, detemir, NPH) at all times to prevent ketoacidosis and severe hyperglycemia (Choices C and D). However, hospitalized patients often eat less than normal and are at risk for hypoglycemia. Therefore, the dose of basal insulin should generally be decreased (eg, 25%-50%) from the prehospital dose, especially in patients who have tight glycemic control at baseline or a glucose level below targets at the time of admission (Choice A). In addition, boluses of short-acting insulin (eg, aspart, lispro, glulisine) should be used to cover meals and correct hyperglycemia. If the hospitalization is prolonged and the patient frequently experiences glucose levels outside the target range, the basal and bolus doses may need to be adjusted. (Choice E) Insulin infusion is an effective option for patients with complex insulin needs, such as those with critical illness, diabetic ketoacidosis or hyperglycemic hyperosmolar state, perioperative status, or uncontrolled hyperglycemia despite subcutaneous insulin. However, insulin infusion carries a risk of hypoglycemia and requires strict monitoring (often not possible on a general medical ward); it is not needed in this stable patient with good baseline glycemic control, no metabolic abnormalities, and likely transiently impaired oral intake due to gastroenteritis. Educational objective: Basal insulin must be continued at all times in type 1 diabetes to prevent diabetic ketoacidosis and severe hyperglycemia. Most hospitalized patients require reduced insulin doses. References: Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/22223765) Glycemic management in the inpatient setting. (http://www.ncbi.nlm.nih.gov/pubmed/22615078)

A 23-Year-Old Man Is Hospitalized for Acute Gastroenteritis with Mild