Intervention and outcome
The patient’s antihyperglycemic regimen was revised to insulin detemir 30 units twice daily, insulin aspart 20 units with each meal, and aspart supplemental scale which would give him insulin starting with glucose of 150 mg/dL at two units of insulin for every additional 30 mg/dL of glucose.
The patient had noted glycemic improvement to 122 to 167 mg/dL 24 hours after initiation of the revised antihyperglycemic regimen. The patient was weaned off steroids with consequent decrease in overall insulin requirement.
Upon hospital discharge on postoperative day 5, the patient was on insulin detemir 25 units twice daily, aspart 15 units with each meal, and his aspart supplemental scale went unchanged with a glucose range of 110 to 159 mg/dL.
The patient was discharged, his last hospital regimen included insulin detemir 25 units twice daily, aspart 15 units with each meal (which he was instructed to hold if he was not eating meal) and aspart supplemental sliding scale with emphasis on self-glucose monitoring prior to each insulin dose, four times daily (before each meal and at bedtime).
The patient was advised to schedule a follow-up with the glycemic management NP within two weeks of hospital discharge and to call the NP if glucoses remain elevated at or above 180 mg/dL for one day.
When a patient with diabetes’ routine changes, as in the case of hospitalization, his or her antihyperglycemic medication requirements may also change. In creating an inpatient diabetes management plan, the patient’s outpatient usage should be considered, but not necessarily replicated.
This case highlighted the need for a diabetes specialist consultation in a patient who was on a highly complex outpatient diabetes regimen.
The patient’s review of systems was significant for polyuria and polydipsia, which are symptoms of hyperglycemia consistent with his presented glycemic trend.
His physical exam was notable for acanthosis nigricans, a skin condition characterized by areas of dark, velvety discoloration in body folds and creases found at armpits, groin, and neck in people who are obese or have diabetes,1 which indicated a tendency of glucose resistance, creating a need for an above average outpatient insulin daily dose. Lastly, the use of high-dose steroids during his inpatient stay further elevated the patient’s baseline glucoses.
A closer analysis of his outpatient antihyperglycemic regimen revealed duplicate functions. Insulin detemir is along acting insulin used for management of glucose for basal metabolic needs. Insulin aspart protamine suspension 70%, insulin aspart 30% is a premix insulin with an intermediate-acting and rapid-acting component used for basal and nutritional purposes.
This rapid-acting insulin is used for nutritional and correctional purposes. Liraglutide is a glucagon-like peptide 1 agonist indicated for nutritional glucose control. The insulin regimen and reported usage was mismatched when compared with the patient’s report of two meals daily. It is important to recognize that such a regimen can be — and should be — simplified.