How to manage hyperglycemia in a patient with Type 1 diabetes mellitus (T1DM) and multiple comorbidities, including impaired renal function (Chronic Kidney Disease stage 3, CKD3), who is refusing hospital admission?

Management of Severe Hyperglycemia in Type 1 Diabetes Patient Refusing Hospital Admission

This patient requires immediate insulin administration with a correction dose of rapid-acting insulin followed by close monitoring and adjustment of her insulin regimen to address the severe hyperglycemia and prevent diabetic ketoacidosis.

Assessment of Current Situation

• The patient presents with severe hyperglycemia (capillary blood glucose readings of 29.8 mmol/L and 35.0 mmol/L) and moderate ketonuria (1.1 mmol/L), indicating impending diabetic ketoacidosis (DKA) 1
• She has Type 1 diabetes mellitus with multiple comorbidities including CKD3, liver cirrhosis, and primary cerebellar degeneration 2
• The patient is refusing hospital admission despite clinical indications for more intensive monitoring 1
• Recent fall with chest wall pain and possible rib injury may be contributing stressors to the hyperglycemia 1

Immediate Management

1. Administer rapid-acting insulin correction dose immediately

   • Calculate correction dose based on 0.1 units/kg body weight 1
   • For severe hyperglycemia (>300 mg/dL or >16.6 mmol/L), a more aggressive correction is appropriate 1

2. Fluid replacement

   • Encourage oral fluid intake with sugar-free fluids to address dehydration 1
   • Target 1.5 times maintenance requirements if possible 1
   • Monitor for signs of worsening dehydration which would necessitate IV fluids and hospital admission 1

3. Frequent blood glucose monitoring

   • Check capillary blood glucose every 2-4 hours until levels are below 15 mmol/L 1
   • Continue to monitor ketones 1

Adjustment of Insulin Regimen

1. Modify current insulin regimen

   • Increase total daily insulin dose by 20-30% 1
   • Split into basal-bolus regimen with approximately 50% as basal insulin (Tresiba) and 50% as bolus insulin (rapid-acting) 1
   • Consider increasing Tresiba to 24-26 units daily (from current 19 units) 1
   • Replace Humulin M3 (premixed insulin) with rapid-acting insulin before meals 1

2. Implement a structured insulin schedule

   • Rapid-acting insulin before each meal based on carbohydrate intake and correction factor 1
   • Basal insulin (Tresiba) once daily 1
   • Calculate correction factor: approximately 1 unit for every 2-3 mmol/L above target 1

Ongoing Monitoring and Follow-up

1. Arrange for frequent monitoring

   • Home visits by healthcare provider or family member trained in diabetes management every 4-6 hours for the first 24 hours 1
   • Telephone follow-up every 2-4 hours between visits 1

2. Establish clear thresholds for mandatory hospital admission

   • Deteriorating consciousness level 1
   • Worsening ketosis (>3.0 mmol/L) 1
   • Inability to maintain oral hydration 1
   • Blood glucose not improving after two correction doses 1
   • Development of vomiting 1

3. Educate caregiver (son-in-law) on:

   • Signs and symptoms of worsening DKA 1
   • Proper insulin administration technique 3
   • Blood glucose and ketone monitoring 3
   • When to seek emergency care 1

Special Considerations for This Patient

1. CKD3 implications

   • Insulin clearance is decreased in renal impairment, increasing risk of hypoglycemia 3, 4
   • Start with 80% of calculated insulin dose and titrate carefully 3, 4
   • More frequent glucose monitoring to avoid hypoglycemia 3

2. Liver cirrhosis considerations

   • Altered insulin metabolism may lead to unpredictable glucose responses 3
   • Increased risk of hypoglycemia due to impaired gluconeogenesis 3
   • Adjust insulin doses more conservatively 3

3. Poor mobility and fall risk

   • Ensure caregiver assistance with insulin administration and monitoring 3
   • Position glucose monitoring supplies and hypoglycemia treatment within easy reach 1

Hypoglycemia Prevention and Management

1. Provide hypoglycemia treatment supplies

   • Fast-acting glucose (15-20g) readily available 1
   • Glucagon kit for severe hypoglycemia 1
   • Educate caregiver on administration 1

2. Establish hypoglycemia protocol

   • Treat blood glucose <4.0 mmol/L with 15-20g fast-acting carbohydrate 1
   • Recheck in 15 minutes and repeat treatment if still low 1
   • Follow with a small protein-containing snack once glucose normalizes 1

When to Escalate Care

If any of the following develop, immediate hospital admission is required:

• Mental status changes or decreased consciousness 1
• Inability to maintain hydration 1
• Persistent vomiting 1
• Worsening ketosis despite treatment 1
• Failure of blood glucose to decrease after two correction doses 1
• Development of severe acidosis (if measurable) 1

Documentation and Communication

• Document all insulin doses, blood glucose readings, and ketone levels 3
• Ensure clear communication plan between patient, caregiver, and healthcare team 3
• Provide written instructions for insulin dosing and when to seek emergency care 3