From the Guidelines
The recommended approach at discharge is to continue with the current insulin regimen (option B). This patient has experienced recurrent diabetic ketoacidosis despite being on metformin, indicating that her diabetes is not adequately controlled with oral medication alone. Although she has type 2 diabetes, her presentation with ketoacidosis suggests significant insulin deficiency that requires exogenous insulin therapy. The low dose of insulin glargine (10 units daily) combined with metformin has achieved adequate glycemic control during her hospitalization. Increasing the metformin dose would not address the underlying insulin deficiency causing ketoacidosis. Adding a thiazolidinedione would be inappropriate as these medications can cause fluid retention and are not effective for treating insulin deficiency severe enough to cause ketoacidosis. Despite the patient's hesitancy about insulin therapy, education about the importance of continuing insulin to prevent further episodes of ketoacidosis is essential, as supported by the American Diabetes Association standards of medical care in diabetes 1. Her recurrent DKA episodes indicate a more severe insulin deficiency than typical type 2 diabetes, possibly representing late-onset type 1 diabetes or severely insulin-deficient type 2 diabetes, making insulin therapy necessary for her safety and health.
Key considerations for her discharge plan include:
- A structured discharge plan tailored to the individual patient, which may reduce length of hospital stay and readmission rates and increase patient satisfaction 1
- Education on the importance of continuing insulin therapy to prevent further episodes of ketoacidosis
- Close monitoring of her blood glucose levels and adjustment of her insulin regimen as needed
- Consideration of a basal-plus-correction insulin regimen, which is the preferred treatment for patients with poor oral intake or those who are receiving nothing by mouth 1
It is crucial to prioritize the patient's safety and health by continuing the current insulin regimen, as discontinuing insulin therapy could lead to further episodes of diabetic ketoacidosis, increasing morbidity and mortality.
From the Research
Patient's Current Condition
The patient is a 52-year-old woman with type 2 diabetes mellitus, dyslipidemia, obesity, and hypertension, who has been re-admitted to the hospital with nausea, vomiting, and evidence of diabetic ketoacidosis. She is currently taking metformin and has been given intravenous fluids and insulin.
Treatment Options
The patient is hesitant about taking the low-dose insulin, and the following options are being considered:
- A. Increase dose of metformin
- B. Continue with current insulin regimen
- C. Add thiazolidinedione to the patient's current metformin regimen
Evidence-Based Recommendations
Based on the studies, the following points can be considered:
- Insulin glargine is a long-acting, human insulin analogue that provides a relatively constant basal level of circulating insulin with no pronounced peak 2.
- The early introduction of insulin in patients with type 2 diabetes is to be encouraged, and insulin glargine can be added to oral hypoglycaemic agents if they are failing 2.
- Combination therapy using metformin or thiazolidinediones and insulin has been shown to improve blood glucose levels and reduce total daily insulin dose 3.
- Thiazolidinediones have been effective in lowering blood glucose levels and total daily insulin dose, but may have adverse effects such as fluid retention and oedema 3, 4.
- Intensifying insulin therapy by adding rapid-acting insulin injections can improve HbA1c levels in patients on maximum doses of basal insulin 5.
Recommended Course of Action
Based on the evidence, it is recommended to:
- Continue with the current insulin regimen, as the patient is experiencing adequate glycemic control on insulin glargine and metformin 2, 3.
- Monitor the patient's blood glucose levels and adjust the insulin dose as needed to maintain adequate glycemic control 2, 5.
- Consider the potential benefits and risks of adding thiazolidinediones to the patient's regimen, but this may not be necessary given the patient's current response to metformin and insulin 3, 4.