What is the immediate management for a 55‑year‑old man with insulin‑dependent diabetes who missed insulin for two days and has probable obstructive sleep apnea, given his frustration with waiting for a sleep study?

Immediate Management of Missed Insulin and Probable OSA

This patient requires immediate intervention for his missed insulin doses before addressing the sleep study—the acute diabetes management takes absolute priority over the sleep apnea workup. 1

Urgent Diabetes Crisis Management

Address the insulin non-adherence immediately as a medical emergency. This patient has gone 2 days without insulin, placing him at risk for diabetic ketoacidosis or hyperosmolar hyperglycemic state. 1

Immediate Actions Required:

• Check blood glucose immediately and assess for signs of hyperglycemic crisis (polyuria, polydipsia, altered mental status, Kussmaul respirations, fruity breath odor) 1
• If blood glucose >250 mg/dL or patient symptomatic: Check urine or serum ketones and consider emergency department referral 1
• Resume insulin immediately with appropriate dosing based on current blood glucose 2
• Implement intensive glucose monitoring every 2-4 hours until stable, targeting 100-180 mg/dL 2

Addressing the Behavioral Crisis:

The patient's frustration about waiting represents a critical barrier to care that must be addressed urgently. 1 His statement about refusing to wait in line for insulin suggests:

• Immediate pharmacy/clinic access issues that require same-day problem-solving
• Potential depression or diabetes distress requiring mental health screening 1
• Risk of continued non-adherence if barriers aren't removed

Contact the patient within 24 hours (phone call, not waiting for next appointment) to:

• Ensure insulin has been resumed
• Arrange expedited insulin access (clinic samples, emergency prescription, social work intervention for financial barriers) 1
• Screen for depression and diabetes distress 1
• Provide glucagon prescription and caregiver training given his demonstrated risk of severe glycemic excursions 2

Sleep Apnea Management (Secondary Priority)

Once diabetes is stabilized, expedite the sleep study given his high-risk presentation. His symptoms (snoring, witnessed gasping, sleep complaints) combined with insulin-dependent diabetes place him at extremely high cardiovascular risk. 1

Risk Stratification:

This patient has multiple high-risk features warranting urgent evaluation:

• Age 55 with insulin-dependent diabetes (4-10 fold increased OSA prevalence) 1
• Classic triad: Snoring, witnessed apnea, sleep complaints 1
• Cardiovascular risk amplification: OSA in diabetics increases stroke risk (HR 2.87 for untreated patients) and recurrent cardiovascular events 3

Expedited Pathway Options:

Prioritize this patient for sleep study scheduling based on:

• Cardiovascular comorbidity (diabetes) qualifies for expedited evaluation per American Geriatrics Society guidelines 1
• Consider home sleep apnea testing if available to reduce wait time, as it's appropriate for patients with high pretest probability and no significant cardiopulmonary comorbidity 1
• If wait exceeds 4-6 weeks: Consider empiric CPAP trial given high pretest probability, though this is off-label 1

Set Realistic Expectations About OSA Treatment:

Counsel the patient that CPAP will improve his quality of life and blood pressure, but evidence for direct diabetes benefit is mixed. 1, 3

• CPAP benefits: Reduces blood pressure (1.4-7.2 mmHg), improves quality of life, reduces stroke recurrence (14% vs 32% untreated over 7 years) 3
• Diabetes effects: Evidence for glycemic improvement is inconsistent—some studies show modest HOMA-IR improvement, but A1C changes are unreliable 1, 3, 4
• Weight loss is the primary metabolic intervention: If BMI ≥27 kg/m², consider GLP-1 agonist therapy (tirzepatide is FDA-approved specifically for OSA with obesity, producing 20.9% weight loss) 5

Interim Management While Awaiting Sleep Study:

• Avoid alcohol and sedative-hypnotics which worsen OSA 1
• Optimize sleep position: Elevate head of bed, avoid supine sleeping 1
• Aggressive cardiovascular risk reduction: Ensure statin therapy, blood pressure control (target <130/80 mmHg), and optimal diabetes management regardless of CPAP status 3
• Screen for and treat comorbidities: Hypertension (especially resistant hypertension), nocturia, cognitive impairment, depression 1

Critical Follow-Up Plan

Schedule follow-up within 1 week (not routine 3-month interval) to:

• Verify insulin adherence and glycemic stability 1
• Confirm sleep study has been scheduled with specific date 1
• Reassess barriers to care and patient engagement 1
• Consider diabetes education referral and social work consultation 1

Document this encounter as a patient safety event given the missed insulin and abrupt departure, triggering care coordination protocols. 1