What is the optimal inpatient management plan for a 37‑year‑old Filipino man with severe methamphetamine dependence, marked hyperglycemia (capillary glucose 289–576 mg/dL, fasting ~319 mg/dL), elevated blood urea nitrogen, hypocalcemia, and otherwise normal laboratory studies, during his admission before transfer to a therapeutic community?

Inpatient Management of Severe Hyperglycemia in Methamphetamine Dependence

Initiate insulin therapy immediately with a basal-bolus regimen targeting glucose 140–180 mg/dL, provide aggressive hydration and electrolyte repletion, correct hypocalcemia, and establish close glucose monitoring every 4–6 hours until metabolic stabilization is achieved. 1

Immediate Insulin Initiation

Your patient presents with severe hyperglycemia (capillary glucose 289–576 mg/dL, fasting 318.6 mg/dL) requiring urgent intervention. Insulin therapy must be started immediately for persistent hyperglycemia ≥180 mg/dL. 1 The sliding-scale-only approach is strongly discouraged and should never be used. 1

Recommended Insulin Regimen

• Start a basal-bolus insulin regimen as the preferred treatment for non-critically ill hospitalized patients with good nutritional intake 1
• Calculate total daily insulin dose at 0.3–0.4 units/kg/day 1
• Administer 50% as long-acting basal insulin (once daily) and 50% divided as prandial rapid-acting insulin before meals 1
• For a 70 kg patient, this translates to approximately 21–28 units total daily: 10–14 units basal + 3–5 units before each meal 1
• Add correction insulin doses on top of scheduled insulin for glucose >180 mg/dL 1

Target glucose range: 140–180 mg/dL for this non-critically ill patient, which balances efficacy with hypoglycemia risk. 1 More stringent targets of 100–140 mg/dL may be considered once stable, but only if achievable without significant hypoglycemia. 1

Glucose Monitoring Protocol

• Monitor capillary glucose before each meal (3 times daily) since the patient is eating 1
• If oral intake becomes poor or NPO status is required, monitor every 4–6 hours 1
• Document all glucose values and notify the physician immediately for values <50 mg/dL or >350 mg/dL 1

Critical caveat: Methamphetamine withdrawal may paradoxically cause hypoglycemia after the acute intoxication phase resolves, as one study demonstrated decreased fasting glucose in methamphetamine abusers after discontinuation. 2 This makes close monitoring during the first 48–72 hours of admission particularly important.

Fluid and Electrolyte Management

Hydration Strategy

Your patient's elevated BUN (27.4 mg/dL) with normal creatinine suggests prerenal azotemia from dehydration, commonly seen in methamphetamine intoxication. 3

• Initiate aggressive IV crystalloid therapy with normal saline or lactated Ringer's solution 4
• Target urine output >0.5 mL/kg/hour to ensure adequate renal perfusion 3
• Monitor for resolution of elevated BUN as a marker of adequate hydration 3

Calcium Correction

The patient's calcium of 1.26 mmol/L (normal ~2.1–2.6 mmol/L) represents significant hypocalcemia requiring immediate correction:

• Administer IV calcium gluconate 1–2 grams over 10–20 minutes if symptomatic (tetany, paresthesias, QT prolongation)
• Follow with oral calcium supplementation 1–2 grams daily in divided doses
• Recheck calcium levels daily until normalized
• Consider checking magnesium and phosphate, as abnormalities can impair calcium correction

Methamphetamine-Specific Considerations

Metabolic Complications to Monitor

Methamphetamine toxicity creates several metabolic risks that compound diabetes management:

• Rhabdomyolysis occurs in 44% of methamphetamine-intoxicated patients with AKI 3
• Check creatine kinase (CK) levels; if elevated >1000 U/L, increase IV fluid rate and monitor for myoglobinuric renal injury 3, 4
• Hepatotoxicity is common; your patient's normal transaminases are reassuring but should be rechecked if clinical deterioration occurs 2, 4
• DKA risk is significantly elevated in insulin-dependent diabetics using methamphetamine (66.7% vs 6% in general diabetic population) 5

Assess for DKA

Given the severe hyperglycemia and methamphetamine use, immediately check:

• Serum or urine ketones
• Venous blood gas for pH and bicarbonate
• Anion gap calculation

If ketones are present with pH <7.3 or bicarbonate <18 mEq/L, this represents DKA requiring IV insulin infusion rather than subcutaneous insulin. 1, 5

Nutritional Management

• Implement a consistent carbohydrate diet with 45–60 grams carbohydrate per meal 1
• Provide carbohydrate content labeling to facilitate patient education 1
• Ensure adequate caloric intake; methamphetamine withdrawal may suppress appetite initially but increase it later 2

Hypoglycemia Prevention Protocol

Given the risk of hypoglycemia during methamphetamine withdrawal 2:

• Ensure glucose tablets (15–20 grams) are immediately available at bedside 6
• Train nursing staff to recognize hypoglycemia symptoms (confusion, diaphoresis, altered mental status) 1
• Treat any glucose ≤70 mg/dL immediately with 15–20 grams oral glucose, recheck in 15 minutes, and repeat if needed 6
• Have glucagon available (injectable or intranasal) for severe hypoglycemia with altered consciousness 6

Discharge Planning and Transition

Before transfer to the therapeutic community:

• Simplify the insulin regimen if possible; consider basal insulin alone if glucose control is achieved and oral intake is uncertain 1
• Provide written instructions with specific insulin doses, timing, and glucose monitoring schedule
• Ensure follow-up within 1–2 weeks with primary care or endocrinology given the new diabetes diagnosis 1
• Document HbA1c if not already obtained to distinguish stress hyperglycemia from pre-existing diabetes 1
• Communicate medication changes and glucose targets clearly to the receiving therapeutic community 1

Key pitfall to avoid: Do not discharge on sliding-scale insulin alone, as this is ineffective and strongly discouraged. 1 The patient requires a structured basal insulin regimen at minimum.