What is the best management approach for a patient with type 2 diabetes mellitus, recent severe hyperglycemia, and multiple comorbidities, including chronic kidney disease, chronic obstructive pulmonary disease, and polyneuropathy?

Management of Type 2 Diabetes with Recent Severe Hyperglycemia and Multiple Comorbidities

Continue dapagliflozin as the cornerstone of therapy given this patient's CKD stage 3a, and avoid reintroducing sulfonylureas or other hypoglycemia-inducing agents given the documented hypoglycemia history and frailty. 1, 2

Immediate Glycemic Management

The current approach is appropriate and should be maintained:

• Dapagliflozin continuation is strongly indicated because SGLT2 inhibitors provide cardiovascular and renal protection in patients with CKD stage 3a (eGFR 45-59 mL/min/1.73 m²), independent of glycemic control 1, 2
• SGLT2 inhibitors can be safely continued even as eGFR declines below 30 mL/min/1.73 m² as long as they are well-tolerated and kidney replacement therapy is not imminent 1
• The decision to discontinue sulfonylureas was correct—these agents carry unacceptable hypoglycemia risk in frail elderly patients with CKD and should not be reintroduced 1

For the recent severe hyperglycemia (>400 mg/dL), short-acting insulin PRN was the appropriate intervention and has now been appropriately discontinued. 3 The American Diabetes Association recommends initiating insulin therapy immediately when blood glucose is ≥300 mg/dL to reverse glucotoxicity, which rapidly restores beta-cell function 3. Once glucose toxicity resolves (typically after 2-3 weeks), transitioning away from insulin to non-hypoglycemia-inducing agents is appropriate 3.

Glycemic Target Selection

Target HbA1c of 7.5-8.0% is appropriate for this patient given the constellation of:

• Advanced age with frailty 1, 2
• CKD stage 3a limiting medication options 1
• Recent severe hypoglycemia history 1
• Multiple comorbidities including COPD, protein-calorie malnutrition, and recent pathological fracture 1, 2
• Limited life expectancy considerations 1

The American College of Physicians specifically recommends less stringent targets (7.5-8.0% or higher) for patients with severe hypoglycemia history, limited life expectancy, advanced complications, or extensive comorbidities 1. More intensive targets would increase hypoglycemia risk without meaningful benefit in this population, as the microvascular benefits of tight control require >10 years to manifest 1.

Medication Optimization Strategy

Do not add metformin despite its status as first-line therapy in most guidelines 1, 2. The patient has:

• CKD stage 3a, where metformin requires dose adjustment and careful monitoring 1
• Protein-calorie malnutrition with likely poor oral intake, increasing gastrointestinal intolerance risk 1
• Frailty and recent severe glucose excursions, making gastrointestinal side effects particularly problematic 1

Consider adding a GLP-1 receptor agonist if glycemic targets are not met with dapagliflozin alone 1, 2. Long-acting GLP-1 RAs are recommended for patients with CKD not achieving individualized glycemic targets despite SGLT2 inhibitor use 1. These agents:

• Reduce cardiovascular events in high-risk patients 1
• Can be used in patients with eGFR as low as 15 mL/min/1.73 m² 1
• Reduce albuminuria and preserve eGFR 1
• Do not cause hypoglycemia when used without insulin or sulfonylureas 1, 2

Common pitfall to avoid: Do not attempt to manage severe hyperglycemia (>300 mg/dL) with oral medications alone, as this results in prolonged hyperglycemia and delayed achievement of glycemic targets 3. The use of short-acting insulin PRN for the acute episode was correct.

Monitoring Protocol

Implement structured glucose surveillance with specific parameters:

• Monitor for signs of overbasalization if insulin is reintroduced: basal dose exceeding 0.5 units/kg/day, significant bedtime-to-morning glucose differential, hypoglycemia occurrences, or high glycemic variability 1
• Continue nursing notification parameters for both hyperglycemia (>250-300 mg/dL) and hypoglycemia (<70 mg/dL) 2, 3
• Reassess glycemic control and medication tolerance every 3 months 2
• Monitor renal function (serum creatinine, eGFR) after any medication changes, particularly with SGLT2 inhibitors 1, 2

Management of Comorbidities Affecting Diabetes Control

COPD management: Respiratory status is stable, but recognize that systemic corticosteroids (if needed for COPD exacerbations) will worsen hyperglycemia and require temporary insulin therapy 4, 5. The interaction between COPD treatment and diabetes creates a potential vicious circle of infection risk and acute exacerbations 5.

Protein-calorie malnutrition: Continue Glucerna and protein supplementation as this directly impacts glucose control, wound healing, and metabolic stability 2. Weight loss of ≥5% through appropriate nutrition (not calorie restriction in this malnourished patient) should be a goal once nutritional status improves 3.

Polyneuropathy: Continue gabapentin, but monitor vitamin B12 levels periodically as the patient may eventually require metformin, which is associated with B12 deficiency and potential worsening of neuropathy symptoms 1, 2.

Team-Based Care Approach

Implement structured self-management education and team-based integrated care 1. The KDIGO guidelines strongly recommend this approach even in the absence of high-quality evidence specific to diabetes with CKD, because:

• Team-based chronic care models focusing on multiple treatment targets are cost-effective 1
• Regular assessment and control of multiple risk factors protect kidney function and reduce complications 1
• Self-management education improves biochemical outcomes (HbA1c, fasting glucose) and clinical outcomes (body weight, self-efficacy) 1

This patient requires coordination between nursing (glucose monitoring), physical therapy (fracture rehabilitation), nutrition (malnutrition management), and pharmacy (medication reconciliation and education) 1, 2.

Hypoglycemia Prevention Protocol

Maintain current hypoglycemia protocol precautions with specific interventions:

• Treat any glucose <70 mg/dL with 15-20 g rapid-acting glucose; recheck in 15 minutes and repeat if needed 2
• Ensure glucagon is available and nursing staff are trained on administration 2
• Critical consideration: Beta-blockers (if used for cardiovascular indications) may mask hypoglycemia symptoms 4. This patient is not currently on beta-blockers, but this should be considered if cardiovascular management requires them.

Renal Function Considerations

Dapagliflozin dosing does not require adjustment at CKD stage 3a 6. The FDA label indicates dapagliflozin pharmacokinetics are not meaningfully altered until severe hepatic impairment 6. However:

• Monitor volume status closely as SGLT2 inhibitors cause osmotic diuresis 1, 6
• Assess for signs of dehydration, particularly given the patient's frailty and potential for inadequate oral intake 1
• Continue monitoring renal function as insulin requirements may need adjustment if renal function declines further 4

The presence of CKD stage 3a significantly limits medication options 1. This reinforces the decision to avoid sulfonylureas (which accumulate in renal impairment and increase hypoglycemia risk) and supports the use of SGLT2 inhibitors and GLP-1 RAs, which have proven renal benefits 1.