What is the suggested management approach for a patient with poorly controlled diabetes, hyperglycemia, hyponatremia, and impaired renal function, taking lispro (insulin lispro) 15 units three times a day?

Management of Severe Hyperglycemia in a Poorly Controlled Diabetic Patient

The patient requires immediate hospitalization for intravenous insulin therapy, fluid resuscitation, and electrolyte management due to severe hyperglycemia (blood glucose 798 mg/dL), extremely elevated A1C (19%), and hyponatremia (sodium 123 mmol/L). 1

Initial Assessment and Management

• Evaluate for signs of hyperglycemic crisis (polyuria, polydipsia, nausea, vomiting, abdominal pain, altered mental status) as the patient's blood glucose level of 798 mg/dL indicates severe hyperglycemia 1
• Check for dehydration status, which is likely significant given the hyponatremia (sodium 123 mmol/L) and elevated anion gap (16) 1
• Initiate intravenous fluid therapy with 0.9% sodium chloride to address hyponatremia and dehydration 2
• Start intravenous insulin therapy rather than continuing subcutaneous insulin, as the severity of hyperglycemia warrants more aggressive management 2
• Monitor electrolytes, particularly potassium (currently 4.5 mmol/L), as levels may fluctuate during treatment 1

Inpatient Insulin Management

• Implement intravenous insulin infusion following a nurse-driven protocol with variable rate based on glucose values 2
• Target blood glucose range of 140-180 mg/dL for this non-critically ill patient with severe hyperglycemia 1
• Monitor blood glucose every 1-2 hours initially until stable, then every 4-6 hours 1
• When transitioning from IV to subcutaneous insulin, administer basal insulin 2-4 hours before discontinuing the IV infusion 2
• Convert to subcutaneous insulin at 60-80% of the daily infusion dose when transitioning from IV insulin 2

Long-term Insulin Regimen Adjustment

• The current regimen of lispro insulin 15 units three times daily is clearly inadequate for this patient 2
• Implement a basal-bolus insulin regimen with:
  • Basal insulin (glargine or detemir) once or twice daily 2
  • Prandial insulin (lispro) before meals 2
  • Total daily dose should be increased to 0.3-0.5 units/kg/day given the severe hyperglycemia 1
• Avoid sole use of sliding scale insulin as it is strongly discouraged for inpatient management 2

Addressing Compliance Issues

• Provide comprehensive diabetes education focusing on:
  • Proper insulin storage, injection technique, and timing of dosage 3
  • Importance of adherence to meal planning and regular physical activity 3
  • Regular blood glucose monitoring and recognition of hypo- and hyperglycemia 3
• Consider simplifying the insulin regimen if complexity is contributing to poor compliance 2
• For patients with irregular meal consumption, consider administering insulin after meals to ensure the dose is appropriate for the amount of carbohydrate consumed 2

Monitoring and Follow-up

• Monitor for hypoglycemia (blood glucose <70 mg/dL) which is a risk during aggressive insulin therapy 2
• Implement a hypoglycemia prevention and management protocol 2
• Review treatment regimen if any blood glucose value falls below 70 mg/dL 2
• Schedule follow-up within 1-4 weeks after discharge 2
• Consider referral to diabetes education and endocrinology for ongoing management 2

Special Considerations

• Evaluate for underlying causes of severe hyperglycemia (infection, medication non-adherence) 1
• For patients with poor compliance, consider a less complex insulin regimen that might improve adherence 2
• If the patient continues to have poor compliance, consider more frequent follow-up visits and possibly continuous glucose monitoring to better track glycemic patterns 2
• Address any social determinants of health that may be affecting medication adherence and diabetes self-management 2