What is the appropriate management for a patient with uncontrolled diabetes mellitus (DM), presenting with hyperglycemia, symptoms of polydipsia, polyuria, and nocturia, and glycosuria, who lacks insurance coverage?

From the Guidelines

For this uninsured patient with uncontrolled diabetes mellitus, presenting with hyperglycemia, symptoms of polydipsia, polyuria, and nocturia, and glycosuria, I recommend starting with metformin 500 mg twice daily with meals, along with lifestyle modifications, rather than sending them to the ED. This approach is based on the most recent and highest quality study available, which suggests that metformin is the initial pharmacologic treatment choice for individuals with type 2 diabetes, especially when kidney function is normal 1. The patient's symptoms, such as polydipsia, polyuria, and nocturia, are classic signs of uncontrolled diabetes, but there are no indications of diabetic ketoacidosis or hyperosmolar hyperglycemic state, which would require emergency intervention. Some key points to consider in the management of this patient include:

• Metformin is the most cost-effective first-line medication, available for as little as $4 per month at many pharmacy discount programs.
• The patient should also be counseled on dietary changes, such as reducing carbohydrate intake, especially simple sugars, regular physical activity, and adequate hydration.
• They should be taught to monitor blood glucose at home using an affordable meter, with testing at least once daily initially.
• A follow-up appointment should be scheduled in 2-4 weeks to assess response and potentially adjust therapy.
• If symptoms worsen, particularly if vomiting, severe abdominal pain, confusion, or extreme fatigue develop, the patient should seek emergency care immediately. This approach balances medical effectiveness with cost considerations while addressing the patient's significant hyperglycemia, and is supported by the most recent guidelines for the management of type 2 diabetes 1. It's worth noting that other studies, such as those from 2017 and 2002, provide additional guidance on the management of diabetes, but the most recent and highest quality study should take precedence in guiding clinical decision-making 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Uncontrolled Diabetes Mellitus

The management of a patient with uncontrolled diabetes mellitus (DM) presenting with hyperglycemia, symptoms of polydipsia, polyuria, and nocturia, and glycosuria, who lacks insurance coverage, requires a comprehensive approach.

• The patient's condition is a public health problem and presents a clinical challenge, as hyperglycemia in the emergency department (ED) increases mortality and morbidity associated with the primary condition 2.
• The presence of hyperglycemia, polydipsia, polyuria, and nocturia suggests that the patient may be experiencing diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS), which are hyperglycemic emergencies that commonly present to the ED 2.
• A standardizing ED management protocol, such as a DKA pathway, can improve adherence to treatment guidelines, reduce variability, and improve safety 3.
• For patients with type 2 diabetes, the use of GLP-1 receptor agonists as first-line therapy may be considered, as they have been shown to provide a sustained benefit on the disease process by correcting the underlying pathogenic disturbances 4.
• In patients who have failed metformin, GLP-1/DPP-IV inhibitors may be considered as second-line therapy, as they have been shown to be effective in achieving glycaemic targets, promoting weight loss, and having a favourable impact on surrogate markers of cardiovascular outcomes 5.
• It is essential to evaluate and manage the underlying etiology of the patient's condition, including the potential for euglycemic diabetic ketoacidosis (EDKA), which can be misdiagnosed due to a serum glucose <250 mg/dL 6.

Considerations for Patients with Limited Insurance Coverage

• Patients with limited insurance coverage may face challenges in accessing necessary medications and healthcare services.
• Healthcare providers should be aware of available resources and programs that can help patients access necessary care, such as patient assistance programs or community health clinics.
• A multidisciplinary approach, including coordination with social workers and case managers, can help address the patient's social determinants of health and ensure that they receive comprehensive care.