Scenario 1
| A 67-year-old woman with poorly controlled type 2 diabetes (glycated haemoglobin 90 mmol/mol) is admitted to the medical admissions unit with a community-acquired pneumonia and acute kidney injury (AKI; creatinine 300 μmol/L). Her diabetes is normally managed with metformin 1,000 mg twice daily, sitagliptin 100 mg once daily (OD) and dapagliflozin 10 mg OD. A random capillary blood glucose (CBG) was elevated at 20 mmol/L, calculated serum osmolality was 300 mosmol/kg and she did not fulfil the diagnostic criteria for diabetic ketoacidosis (pH 7.36, HCO3 20 mmol/L and capillary ketones 0.7 mmol/L). How should her hyperglycaemia be managed? This patient is acutely unwell and although she has not presented with a hyperglycaemic emergency, she is at risk if the high blood glucose levels are not addressed. All three of her regular oral hypoglycaemic agents should be discontinued given the AKI. Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, further increases the possibility of ketoacidosis and should be withheld during this acute illness. A stat dose of 4 units NovoRapid should be prescribed; CBGs should be repeated 2-hourly and a further dose of NovoRapid should be considered if hyperglycaemia persists after 4 hours, bearing in mind the risk of prolonged insulin effect given the AKI. If despite this the patient remains hyperglycaemic or there is evidence of clinical deterioration a variable rate insulin infusion (VRII) should be considered. Although NovoRapid and/or a VRII will help with the hyperglycaemia in the short term, the patient should be considered for regular subcutaneous insulin therapy given her poor pre-existing control and the withdrawal of her usual medications. As such, a referral to the specialist diabetes team should be made. Upon recovery from this acute illness, re-introduction of oral diabetes agents should be considered. |