From the Guidelines
For a patient in primary care with an A1c of 12.8%, blood glucose of 236 mg/dL, symptoms of polydipsia, polyuria, and nocturia, and 3+ glucose in urinalysis, immediate management for new-onset diabetes mellitus is required, starting with metformin and basal insulin therapy as recommended by the most recent guidelines 1. The patient's presentation with marked hyperglycemia (A1C ≥8.5% [69 mmol/mol]) and symptoms such as polyuria, polydipsia, and nocturia indicates the need for prompt initiation of pharmacologic therapy, in addition to lifestyle modifications, as stated in the guidelines 1.
Key Recommendations
- Initiate metformin 500 mg once daily with meals for 1 week, then increase to 500 mg twice daily if tolerated, as it is the initial pharmacologic treatment choice for patients with normal kidney function 1.
- Simultaneously initiate basal insulin at 10 units daily (such as insulin glargine or detemir) given the significantly elevated A1c, as recommended for patients with marked hyperglycemia and symptoms 1.
- Provide a glucometer with testing supplies and instruct the patient to check fasting and pre-meal glucose levels, aiming for targets between 80-130 mg/dL.
- Schedule follow-up within 1-2 weeks to adjust therapy based on home glucose readings.
- The patient needs diabetes education covering diet, exercise, medication administration, hypoglycemia recognition and management, and foot care.
- Order additional labs including comprehensive metabolic panel, lipid profile, and urine microalbumin.
- Consider referrals to diabetes education, ophthalmology for retinal screening, and possibly endocrinology given the severity of presentation. This approach is supported by the most recent guidelines 1, which prioritize the initiation of pharmacologic therapy, in addition to lifestyle modifications, for patients with new-onset diabetes mellitus, and recommend metformin and basal insulin as the initial treatment choices for patients with marked hyperglycemia and symptoms.
From the FDA Drug Label
The main goal of treating diabetes is to lower your blood sugar to a normal level. High blood sugar can be lowered by diet and exercise, and by certain medicines when necessary.
The patient has a high HbA1c level of 12.8%, hyperglycemia with a blood glucose level of 236 mg/dL, and symptoms of polydipsia, polyuria, and nocturia, with glycosuria (3+ glucose) on urinalysis.
- The patient's high blood sugar levels and symptoms suggest that their current treatment plan is not effective.
- The patient may require medication to lower their blood sugar levels, in addition to diet and exercise.
- Insulin therapy may be necessary to control the patient's blood sugar levels, especially if they are experiencing symptoms of hyperglycemia.
- It is essential to monitor the patient's blood sugar levels regularly and adjust their treatment plan as needed to prevent complications of diabetes.
- The patient should be educated on how to manage their diabetes, including recognizing and treating hypoglycemia and hyperglycemia, and proper insulin administration 2, 3, 3.
From the Research
Patient Assessment and Diagnosis
- The patient's HbA1c level of 12.8% and hyperglycemia of 236 mg/dL indicate poor glycemic control 4.
- Symptoms of polydipsia, polyuria, and nocturia, along with glycosuria (3+ glucose) in the urinalysis, are consistent with uncontrolled diabetes mellitus 4.
Treatment and Management
- Point-of-care HbA1c testing can help inform the provider and patient of likely prior glycemic status and emphasize the importance of timely diabetes self-management education and medication management 4.
- The patient's HbA1c target should be set based on individualized factors, and the "a priori" or "a posteriori" approach can be used to determine the target and prescribe antidiabetic medication 5.
- It is essential to consider the limitations of point-of-care HbA1c testing and follow correct testing procedures to ensure accurate results 6.
Considerations and Caveats
- The patient's HbA1c level may be affected by other clinical conditions, such as anemia, which can impact the accuracy of the diagnosis and treatment plan 7, 8.
- Screening for anemia and correcting it before setting the treatment goal of optimal HbA1c control is crucial, especially when the level is in the diagnostic threshold 8.