68-year-old man with pneumonia and hyperglycemia
A 68-year-old man is admitted to the hospital for community-acquired pneumonia. His medical history is significant for type 2 diabetes, hypertension, and hyperlipidemia. He works overnight shifts as a security guard. He reports a 3-day history of productive cough, fever, and mild shortness of breath. For the past two days, he has had nausea and has been eating poorly. His home medications include metformin, empagliflozin, lisinopril, and atorvastatin. On examination, temperature is 38.4°C (101.1°F), heart rate is 98/min, blood pressure is 134/82 mm Hg, respiratory rate is 20/min, and oxygen saturation is 94% on ambient air. Laboratory studies show a white blood cell count of 14,500/mm³, creatinine of 1.0 mg/dL (baseline 0.9 mg/dL), and a random glucose of 188 mg/dL. Serum bicarbonate is 24 mEq/L. Which of the following is the most appropriate initial step in this patient's glycemic management?
See the answer and explanation below:
Post-Call Recovery Reads
Finished your notes? Time to swap the pager for a crown. Kingdoms of Silent Sorrows is the ultimate 'brain-break', a high-stakes fantasy featuring a Fae princess, a Vampire king, and an enemies-to-lovers arc that will actually make you forget about your rounding list. No p-values, just fated mates and forbidden magic.
View on AmazonThe Correct Answer
B
Explanation
Clinical Pearl:
In hospitalized patients with type 2 diabetes and an acute illness, oral hypoglycemic agents such as metformin and SGLT2 inhibitors should generally be discontinued. A proactive basal-bolus insulin regimen is the preferred method for achieving glycemic control in non-critically ill patients who are eating.
Explanation:
This patient with type 2 diabetes is admitted with an acute illness (pneumonia) and has decreased oral intake, requiring adjustment of his outpatient glycemic regimen. The most appropriate management is to discontinue his oral hypoglycemic agents and initiate a basal-bolus insulin regimen. This approach is recommended by major society guidelines for non-critically ill hospitalized patients to ensure safety and efficacy. Continuing home oral agents, including metformin and the SGLT2 inhibitor empagliflozin, is inappropriate; metformin carries a risk of lactic acidosis and SGLT2 inhibitors increase the risk of euglycemic diabetic ketoacidosis, particularly during acute illness with poor caloric intake. Using only a sliding scale insulin regimen is a reactive strategy that is less effective than a proactive basal-bolus approach and is not recommended as the sole method of glycemic control. While checking for ketones is important if euglycemic DKA were suspected, this patient's normal serum bicarbonate makes this diagnosis unlikely and this action does not constitute a comprehensive management plan. Adding only basal insulin while continuing the oral agents fails to mitigate the risks associated with metformin and empagliflozin in this setting.
See you tomorrow morning!