Mr. Q, aged 72 years, with a history of type 2 diabetes mellitus (DM,) presented for glycemic optimization prior to elective right-knee replacement, which was scheduled for two weeks later.

The patient’s original surgery date was canceled due to his glucose reading of 322mg/dL upon arrival at the hospital. He had been diagnosed with type 2 DM at age 63 years, has a hemoglobin A1C reading of 6.9% three months earlier.

Mr. Q was concerned about his tendency to experience elevated blood glucose levels before past procedures and was sent by his surgical team for preoperative glycemic optimization.

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The patient’s medical history included hypertension, hyperlipidemia, bilateral knee osteoarthritis, chronic obstructive pulmonary disease (COPD), and asthma. Mr. Q had a history of smoking two packs of cigarettes per day for 30 years until quitting 10 years prior. His surgery history included bilateral knee arthroscopies, left-knee replacement.

The patient’s medication profile included Lantus (insulin glargine) 20 units SC daily, metformin 1 g twice daily, Amaryl (glimepiride) 4 mg daily, prednisone 10 mg daily, Celebrex (celecoxib), Singulair (montelukast), albuterol when necessary, Accupril (quinapril hydrochloride), and Zocor (simvastatin).

Mr. Q denied symptoms of hyperglycemia or hypoglycemia and performs self-glucose monitoring once daily on most days with glucose readings of 86 mg/dL to 130 mg/dL. He reported a sedentary lifestyle limited by arthritic pain and a dietary intake mostly reflective of a diabetic diet with calorie consumption consistent with weight.

Further historical assessment revealed that the patient had been prescribed stress dose steroids with tapering prior to his past surgeries. Mr. Q remembered that he had held all of his antihyperglycemic medications the evening before and day of the procedures.

His preoperative testing labs were done two weeks prior to presentation and revealed the following pertinent results:

  • Hemoglobin A1C: 7%
  • White blood cells: 8,000 mm3
  • Hemoglobin concentration (Hb): 15 g/dL
  • Urinalysis: no pyuria or proteinuria
  • Basic metabolic panel: random glucose, 140 mg/dL
  • Hepatic panel: within normal limits