What is the appropriate management for a 70-year-old diabetic female with hyperglycemia (HbA1c 11.1), scheduled for orthopedic metal implant surgery on her left leg due to a fracture, who was started on Lantus (insulin glargine) and Apidra (insulin glulisine) as part of a hyperglycemic protocol?

From the Guidelines

I recommend continuing the current insulin regimen with Lantus 30 units subcutaneously at 7 PM and Apidra according to the sliding scale protocol, but with modifications for the perioperative period. For a 70-year-old diabetic patient with an HbA1c of 11.1% undergoing orthopedic surgery, withholding oral hypoglycemics (metformin and gliclazide) was appropriate, as per the guidelines for managing hyperglycemia in hospitalized patients 1. When the patient becomes NPO for surgery, changing to CBG monitoring every 6 hours is reasonable, as recommended for inpatient glucose monitoring 1. Target blood glucose levels should be 140-180 mg/dL during the perioperative period, as suggested by the American Diabetes Association standards of medical care in diabetes 1. Consider reducing the Lantus dose by 20-25% the night before surgery to prevent hypoglycemia during the fasting period, and on the day of surgery, hold the Apidra and use IV insulin if blood glucose exceeds 180 mg/dL, as recommended for perioperative glucose management 1. After surgery, resume the basal-bolus insulin regimen when the patient starts eating, with potential dose adjustments based on nutritional intake and activity levels, to provide glycemic control while minimizing hypoglycemia risk during the perioperative period, which is particularly important for wound healing and infection prevention in orthopedic implant surgery 1. This approach is supported by the most recent guidelines for diabetes care in the hospital, which emphasize the importance of individualized glucose targets and insulin regimens for hospitalized patients 1. Additionally, consideration of the patient's age, comorbidities, and nutritional status is crucial in determining the optimal insulin regimen, as highlighted in the standards of medical care in diabetes for older adults 1.

From the FDA Drug Label

Insulin Glargine is a long-acting man-made-insulin used to control high blood sugar in adults and children with diabetes mellitus. Your dose of Insulin Glargine may need to change because of: a change in level of physical activity or exercise, weight gain or loss, increased stress, illness, change in diet, or because of the medicines you take. Dosage reductions and increased frequency of glucose monitoring may be required when Insulin Glargine is coadministered with these drugs.

The patient is a 70-year-old female with diabetes, and her dose of Insulin Glargine may need to be adjusted due to her medical condition and other factors.

• The patient's HbA1c level is 11.1, indicating poor blood sugar control.
• The patient is undergoing orthopedic metal implant surgery, which may affect her blood sugar levels.
• The patient's metformin and gliclazide were withheld, and Lantus (Insulin Glargine) was started at 30 units SQ at 7 pm, with Apidra as part of the hyperglycemic protocol.
• The patient's CBG is being monitored, and the dose of Insulin Glargine may need to be adjusted based on the results. It is essential to closely monitor the patient's blood sugar levels and adjust the dose of Insulin Glargine as needed to maintain good blood sugar control 2 2.

From the Research

Patient Profile

• 70-year-old female patient with a history of diabetes
• Admitted to the hospital since May 1 as a charity case and transferred to a private room yesterday
• Scheduled to undergo ortho metal implant on her left leg due to a fracture
• Initial HbA1c result: 11.1

Glycemic Control

• The patient's HbA1c result indicates poor glycemic control 3
• Studies suggest that maintaining good glycemic control is essential to prevent complications in diabetic patients 4, 5
• The patient's current glycemic control protocol includes withholding metformin and gliclazide, and starting Lantus 30 units SQ at 7pm, with Apidra as part of the hyperglycemic protocol

Insulin Therapy

• The patient is currently on insulin therapy, with a protocol that includes adjusting insulin doses based on blood glucose monitoring results 5
• Studies suggest that rapid-acting insulin analogs, such as glulisine, may provide better glycemic control than regular insulin in hospitalized patients with type 2 diabetes 6
• The patient's insulin therapy protocol includes adjusting doses to obtain target blood glucose concentrations of <130 mg/dl before meals and at bedtime, while avoiding hypoglycemia

Hypoglycemia Risk

• The patient is at risk of hypoglycemia, particularly given her age and history of diabetes 7
• Studies suggest that frequent hypoglycemia is common in older adults with poor glycemic control, and that raising HbA1c goals may not be adequate to prevent hypoglycemia in this population 7
• The patient's current protocol includes monitoring blood glucose levels every 6 hours once on NPO to minimize the risk of hypoglycemia

Blood Glucose Monitoring

• The patient's blood glucose monitoring results will be used to adjust her insulin therapy and prevent hypoglycemia 5
• Studies suggest that blood glucose monitoring is essential for glycemic control, and that HbA1c results should be used in conjunction with blood glucose monitoring to guide insulin therapy 4, 5