Glycemic Control Teacher
Glycemic Control Teacher
Glycemic Control Teacher
Training problems
A. Rationale:
Type 2 diabetes is a complicating factor in approximately 20% of hospital admissions. An
additional 12% of hospitalized patients may have previously unrecognized diabetes (1). An
understanding of diabetes management in the hospital setting is essential for the safe and
appropriate delivery of health care to this population, especially since there is a move toward
tighter inpatient glycemic control, but it is also known that insulin has been associated with a
great frequency of medication errors.
B. Prerequisite:
- History taking and physical examination (CDIM/SGIM curriculum clinical core competency
#3)
- Test interpretation (CDIM/SGIM curriculum clinical core competency #5)
- Communication and relationships with colleagues (CDIM/SGIM curriculum clinical core
competency #4)
- Therapeutic decision making (CDIM/SGIM curriculum clinical core competency #
6)
- Diabetes mellitus (CDIM/SGIM curriculum training problem # 14)
b) Understand the co-morbid conditions that affect diabetic control such as infections,
renal and hepatic insufficiency, myocardial infarction
c) Recognize the effects of non-diabetic medications such as steroids and pentamidine on
glycemic control
d) Understand the rationale behind good glycemic control, and to recognize that this is a
goal not only for outpatient care but for inpatient as well
e) Understand the pharmacology and adverse effects of commonly used diabetic
medications (insulin, sulfonylureas, metformin, glitinides, alpha-glucosidase inhibitors,
and thiazolidinedione agents)
f) Recognize the different insulin preparations and the differences in their time of onset,
peak and duration of action
g) Understand the rationale for giving insulin to cover basal and nutritional requirements
h) Understand the indications for discontinuation or initiation of diabetic medications
during a hospital admission
Kohn LT, Corrigan JM, Donaldson MS, Eds.: To Err Is Human: Building a Safer
Health System. Committee on Quality of Health Care in America, Institute of
Medicine. Washington, D.C., National Academy Press, 1999.
Case 1:
The resident calls you to the emergency room to see a patient brought in by her friends.
They found her unconscious a few minutes ago and say she has diabetes.
1) What 3 acute metabolic complications of diabetes are in your differential diagnoses given
just the above information?
Diabetic ketoacidosis
Hyperglycemic hyperosmolar syndrome
Hypoglycemia
2) What would you like to assess quickly (physical exam and/or lab) in the patient even
before you obtain a detailed history?
Vital signs
Blood glucose
3) You then learn from her friends that the patient is 20 years old, has been using insulin, and
has been having fever and cough the past 3 days. She is a thin white female and shows
deep slow breathing. Her blood glucose is 280mg/dL.
Diabetic ketoacidosis
c) What are the two general treatment measures that have to be instituted right away?
This is controversial, but in general, hydration and insulin treatment alone can
reverse the acidosis. For pH < 6.9, bicarbonate has been recommended if initial
hydration and insulin do not reverse the acidosis.
Case 2:
A 55 year old obese male with no history of diabetes came in to the Emergency Room
with chest pain and was subsequently diagnosed to have a myocardial infarction. He had
complications necessitating intubation and was admitted to the intensive care unit. His
random blood glucose was 195 mg/dL and on repeat was 210 mg/dL.
2) A few days later he was extubated and was transferred to the regular floor. His blood
glucoses remained in the 160-180mg/dL range fasting. You tell him you suspect he
has underlying diabetes and would like to start a treatment plan for him. You start him
on an anti-diabetes pill while hospitalized but want to make sure he is ready for
discharge. What information/education on diabetes would he need?
Case 3:
A 63 year old female was brought to the Emergency Room unconscious. Her husband
says she has diabetes and hypertension. He has brought in her pill bottles, consisting of
amlodipine 10 mg qd and glimepiride (Amaryl) 4 mg qd. You do a pill count and it seems
there are fewer pills in the bottle than there should be. She does not have a glucometer at
home.
1) What would you like to assess quickly (physical exam and/or lab) in the patient even
before you obtain a detailed history?
Vital signs
Blood glucose
2) Labs show a blood glucose level of 32 mg/dL. What immediate steps will you take?
3) After the immediate steps above, how else will you address her hypoglycemia and her
diabetes?
She would need maintenance intravenous fluids containing dextrose (usually D10). This is
generally given until the effect of the sulfonylurea is gone and until the patient is awake
and can have p.o. intake. A single I.V. push of D50 will not be sufficient.
The patient and spouse have to be educated on hypoglycemia prevention, detection and
treatment. A glucose meter should be prescribed and blood glucose monitoring has to be
taught. Consider changing her medication to those that do not usually produce
hypoglycemia, such as thiazolidinediones and metformin.
Garber AJ, Moghissi ES, Bransome ED, Jr., et al. American College of Endocrinology
position statement on inpatient diabetes and metabolic control. Endocr
Pract 2004;10(1):77-82