Should a diabetic patient with severe hyperglycemia, neuropathy, and non-adherence to insulin therapy be sent to the hospital or can they be restarted on long-acting insulin (e.g. glargine)?

Management Decision: Hospital Admission Required

This patient requires immediate hospital admission for evaluation and management of severe hyperglycemia (551 mg/dL) in the setting of insulin non-adherence. 1, 2

Rationale for Hospitalization

Critical Hyperglycemia Threshold

• Blood glucose of 551 mg/dL exceeds the threshold requiring urgent medical evaluation, as the American Diabetes Association recommends hospital admission when blood glucose persistently exceeds 250-500 mg/dL (Grade 3-4 hyperglycemia) 3
• This level of hyperglycemia requires assessment for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), both life-threatening conditions that necessitate immediate medical care 3

Risk Assessment for Acute Complications

You must rule out DKA/HHS before considering outpatient management. The patient needs:

• Immediate evaluation for ketones (blood or urine) 3
• Assessment for signs of DKA: drowsiness, flushed face, thirst, loss of appetite, fruity breath odor, heavy breathing, rapid pulse 4
• Evaluation for HHS symptoms: severe dehydration, altered mental status, or coma 3
• Even if asymptomatic now, marked hyperglycemia accompanied by ketosis requires immediate interaction with a diabetes care team 3

Non-Adherence as a Red Flag

• The history of not taking insulin indicates a high-risk situation requiring supervised initiation of therapy 1
• Non-adherent patients are at increased risk for recurrent hyperglycemic crises and require structured discharge planning with diabetes education 3
• Infection or dehydration is more likely to necessitate hospitalization in diabetic patients than non-diabetic patients 3

Hospital Management Protocol

Initial Assessment

Upon admission, the following should be obtained:

• Comprehensive metabolic panel to assess for electrolyte abnormalities, renal function, and acid-base status 3
• Ketone measurement (serum beta-hydroxybutyrate preferred over urine ketones) 3
• HbA1c if not available from previous 2-3 months 3, 1
• Assessment for precipitating factors: infection, myocardial infarction, stroke 3

Insulin Initiation Strategy

If DKA/HHS is present:

• Continuous intravenous insulin infusion is the standard of care for critically ill patients with DKA or severe hyperglycemia 3, 1
• Target blood glucose 140-180 mg/dL using validated IV insulin protocols 1
• Transition to subcutaneous insulin requires administration of basal insulin 2-4 hours before stopping IV insulin to prevent rebound hyperglycemia 3

If DKA/HHS is ruled out:

• Initiate basal-bolus-correction insulin regimen 1, 5
• Starting total daily dose: 0.3-0.5 units/kg/day for insulin-naive patients 1
• Divide as 50% basal insulin (glargine or detemir once daily) + 50% prandial insulin (lispro, aspart, or glulisine) divided before three meals 1
• Add correction doses of rapid-acting insulin for blood glucose >180 mg/dL 1

Monitoring Requirements

• Blood glucose monitoring before meals and at bedtime 1
• Target premeal glucose <140 mg/dL and random glucose <180 mg/dL 1, 5
• Track all hypoglycemic episodes (blood glucose <70 mg/dL) 1

Why Outpatient Management is Inappropriate

Safety Concerns

• Severe hyperglycemia (>500 mg/dL) without immediate assessment for metabolic decompensation poses significant mortality risk 3
• Observational studies demonstrate that patients with blood glucose >220 mg/dL have significantly higher infection rates and in-hospital mortality 3
• The presence of neuropathy suggests long-standing poorly controlled diabetes, increasing risk for autonomic dysfunction and hypoglycemia unawareness 3, 6

Need for Supervised Insulin Initiation

• Restarting insulin in a non-adherent patient requires education, dose titration, and monitoring that cannot be safely accomplished in the outpatient setting at this glucose level 3
• The patient needs "survival skills education" and a structured discharge plan before safe outpatient management 3
• Sliding scale insulin alone (outpatient correction-only approach) is inappropriate and associated with poor outcomes 5

Discharge Planning (After Stabilization)

Pre-Discharge Requirements

• Resume or initiate appropriate insulin regimen 1-2 days before discharge 1
• For patients with HbA1c >10%, discharge on basal-bolus regimen or 80% of hospital basal insulin dose plus previous oral agents 1
• Provide diabetes education including insulin administration technique, hypoglycemia recognition and treatment, and glucose monitoring 3
• Schedule outpatient follow-up within 1 week to 1 month 1

Addressing Non-Adherence

• Assess barriers to adherence: cost, complexity of regimen, competing demands, depression 3
• Simplify regimen if possible while maintaining glycemic control 3
• Ensure access to medications and supplies before discharge 3

Common Pitfalls to Avoid

• Do not attempt outpatient management of glucose >500 mg/dL without ruling out DKA/HHS - this is a potentially fatal error 3
• Do not restart long-acting insulin alone - this patient likely needs a basal-bolus regimen given the severe hyperglycemia and history of non-adherence 1, 5
• Do not discharge without structured education and follow-up - non-adherence will recur without addressing underlying barriers 3
• Do not use sliding scale insulin as monotherapy - this approach is ineffective and associated with poor outcomes 3, 5

The neuropathy mentioned is a marker of chronic poor control 6, 7 but does not change the acute management decision - this patient needs hospital admission for safe evaluation and insulin initiation.