Should a patient with hyperglycemia and type 2 diabetes mellitus, currently on insulin glargine, receive short-acting insulin?

Management of Hyperglycemia in Hospitalized Patient with COPD and Type 2 Diabetes

Short-acting insulin should be added to the patient's regimen to manage hyperglycemia, as the patient has a blood glucose of 20.9 mmol/L (376 mg/dL) and is only on basal insulin (glargine 6 units). 1

Assessment of Current Situation

• The patient is a 91-year-old male with COPD exacerbation and type 2 diabetes with severe hyperglycemia (20.9 mmol/L) 1
• Currently only on 6 units of glargine (basal insulin) in the morning 1
• Has elevated blood pressure (164/99), respiratory rate (22-24), and requires oxygen support (3L) 1

Rationale for Adding Short-Acting Insulin

• For hospitalized patients with severe hyperglycemia (>300 mg/dL or >16.6 mmol/L), a basal-bolus insulin regimen is indicated 1
• The patient's current blood glucose of 20.9 mmol/L (376 mg/dL) falls into the severe hyperglycemia category requiring more aggressive management 1
• Basal insulin alone is insufficient for managing severe hyperglycemia in hospitalized patients, especially those with acute illness like COPD exacerbation 1

Recommended Insulin Regimen

• Continue basal insulin (glargine) but consider increasing the dose to 0.2-0.3 units/kg/day based on weight 1
• Add rapid-acting insulin before meals (or every 4-6 hours if not eating) 1
• For severe hyperglycemia (>300 mg/dL), implement a basal-bolus regimen with approximately half the total daily dose as basal and half as prandial insulin 1
• Initial prandial insulin dose can start at 4 units, 0.1 units/kg, or 10% of the basal dose before meals 1

Special Considerations for This Patient

• The patient's COPD exacerbation represents a significant physiologic stress that can worsen hyperglycemia 1, 2
• Advanced age (91 years) increases hypoglycemia risk, so careful monitoring is essential 1
• The patient is on antibiotics (azithromycin and amoxiclav) for COPD exacerbation, which may affect glucose levels 1
• Implement a hypoglycemia prevention and management protocol 1

Monitoring and Adjustment

• For hospitalized patients who are eating, monitor blood glucose before meals 1
• For patients not eating, monitor every 4-6 hours 1
• Adjust insulin doses based on blood glucose patterns 1
• Watch for signs of overbasalization (basal dose exceeding 0.5 units/kg/day, significant bedtime-to-morning glucose differential, hypoglycemia) 1

Common Pitfalls to Avoid

• Using sliding scale insulin alone is strongly discouraged as it treats hyperglycemia reactively rather than preventively 1
• Failure to adjust insulin doses based on nutritional intake can lead to hypoglycemia 1
• Not considering the impact of COPD exacerbation and steroid treatment (if used) on glucose levels 1
• Overlooking the need to monitor for hypoglycemia, especially in elderly patients 1

Transition Planning

• Have a protocol for resuming oral medications 1-2 days before discharge if applicable 1
• Ensure proper education and follow-up plans are in place before discharge 1
• Consider long-term management needs based on pre-hospitalization diabetes control 1