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Diabetic Emergencies, Diagnosis and Clinical Management: Sick-Day Rules in Diabetes, Case Studies

Konstantinos Makrilakis, Nikolaos Katsilambros
A 28-year-old man with Type 1 diabetes for 12 years is under treatment with long-lasting insulin (e.g., insulin glargine) 26 IU at bedtime and a rapid-acting insulin analog (e.g., insulin lispro) three times a day before each meal (the dose determined depending on the carbohydrate content of the meal and the preprandial blood glucose level. The usual daily dose of insulin lispro is 22-24 IU). His glycemic control is quite good (recent HbA1c: 6.7%).

The patient calls his physician in the morning because he has been vomiting all night, has developed abdominal pains, and has a temperature of 38° C (100.4° F). His blood glucose level in the morning was 312 mg/dl (17.3 mmol/L). He was out at a party the previous night and was not able to hold anything down this morning, not even water.
The doctor initially asked the patient to check his urine for ketones with a special urine strip (that the patient had been instructed in the past to have at home) and call him back. 

A few minutes later the patient informed the doctor that the urine test was positive for ketones (2+).

Based on the guidelines analyzed above, the doctor recommended the injection of 10 IU of insulin lispro subcutaneously (20% of the total daily dose) and repeat blood glucose measurement and ketones in 2-3 hours. At the same time he asked the patient to try to sip tea slowly (at least one cup every 30-45 minutes), and to call again if urine ketones persisted after 6 hours (or earlier if they increased) or if blood glucose level was persistently higher than 300 mg/dl (16.7 mmol/L), despite the administration of insulin.

Diabetic_EmergenciesTwo and a half hours later the patient had a blood glucose level of 230 mg/dl (12.8 mmol/L) and urine ketones had decreased to 1+. The tea had been relatively well tolerated, with only one episode of vomiting. Nausea had subsided but there had been two diarrheal bowel movements. The fever had subsided with antipyretics and the abdominal pain was much better.

The doctor advised another 10 IU of insulin lispro subcutaneously and the tea to be continued.

Three hours later the patient felt much better. He had another diarrheal bowel movement, his blood glucose level was 170 mg/dl (9.4 mmol/L) and ketones were no longer detected in the urine.

He had a light meal (soup with chicken broth and some rice with a piece of toast) and calculated the preprandial lispro dose as usual with an addition of 5 IU (10% of total daily dose). In the afternoon he felt weak, but diarrhea and vomiting had ceased. Blood glucose level was 135 mg/dl (7.5 mmol/L) and no more insulin was administered. After his (light) dinner he returned to his regular schedule.

Case 8.2 

A 72-year-old woman with Type 2 diabetes for 12 years is being treated with metformin (1000 mg twice a day) and glimepiride (4 mg per day). She lives with her 38-year-old daughter and her daughter ‘s family at home. She also suffers from severe osteoarthritis of the hips, with limited ability to ambulate outside of the house. Her diabetic control is not very good (recent HbA1c: 8.5%) but she has been refusing to start insulin, despite her physician’s advice. Her usual blood glucose measurements range between 170 and 220 mg/dl [9.4-12.2 mmol/L].

She develops intense itching and burning on urination, together with increased thirst and urine production and has had very high blood glucose levels (> 300 mg/dl [16.7 mmol/L]) for the last 2 days. She has had no fevers, chills, nausea, or vomiting. She took the initiative to increase her glimepiride dose to twice a day, but did not see much improvement and called her primary physician for advice.

The doctor advised her to send a urine specimen for urinalysis and culture at an outside laboratory and start antibiotics if there was evidence of an infection from the urinalysis. Regarding blood glucose control, he advised the patient to drink plenty of fluids (at least 2-3 liters per day), discontinue metformin, and start insulin, at least temporarily. He gave the patient the alternative of her or her daughter coming to the clinic for training on proper insulin injection technique or of her being admitted to the hospital for treatment and education.

Since the patient was not vomiting and was able to tolerate fluids and food, and since her ambulation was difficult, she opted for the first choice. Her daughter was trained in insulin administration technique and NPH and regular insulin were prescribed, to be used according to blood glucose levels (which she was advised to check frequently — at least 3 times a day before meals and occasionally 2 hours after a meal).

Urinalysis revealed increased WBC count and nitrite (+) urine. Antibiotics by mouth were started for 3 days for the lower urinary tract infection (UTI), to be changed according to urine culture and sensitivity results and clinical response. NPH insulin was started at an initial dose of 10 IU every night and regular insulin at 8 IU before meals. Metformin was temporarily discontinued.

Blood glucose levels next morning started to subside with treatment of the infection and NPH administration (down to 172 mg/dl [9.5 mmol/L]). Blood glucose levels for the rest of the day were monitored frequently (ranging between 150 and 200 mg/dl [8.3-11.1 mmol/l] preprandially and 180 and 250 mg/dl [10.0-13.9 mmol/L] postprandially) and the dose of regular insulin was adjusted accordingly.

By the second day the symptoms of the UTI had disappeared and the patient felt much better. She realized now that insulin administration was not a great nuisance and agreed to start it permanently. Metformin was restarted, glimepiride discontinued, and a twice-a-day regimen of a mixture of isophane/regular insulin (70/30 mixture) was started, the dose to be adjusted according to blood glucose measurements. The patient did not have to be admitted to the hospital.

Case 8.3 

A 68-year-old man with Type 2 diabetes for 6 years is being treated with metformin (1000 mg twice a day) with adequate glucose control (recent HbA1c: 6.9%). He checks his blood glucose at home 3-4 times per week, with usual levels around 130-160 mg/dl (7.2-8.9 mmol/L).

He has now (since the day before) developed symptoms of a common cold (fever, cough, sneezing, nasal congestion) and calls his physician for advice if anything needs to be changed in his diabetic regimen.

The doctor advises him to drink plenty of fluids and start checking his blood sugar more frequently (at least 3 times a day before meals and also sometimes 2 hours after a meal) and call him back if his levels consistently exceed 200 mg/dl (11.1 mmol/L). He also advises the patient to report to the clinic in case more severe symptoms arise (dyspnea, chest pains, increased thirst, and urination). He was advised to continue his metformin regimen as long as no signs of dehydration were present.

The patient s blood sugars ranged between 150 and 210 mg/dl (8.3-11.7 mmol/L) over the following 3 days and no change in his regimen was needed. He took antipyretics and over-the-counter antitussive cold medicine for his flu-like symptoms, which gradually improved. His blood sugar levels gradually returned to usual levels over the next 3 days.

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Nikolaos Katsilambros, MD, PhD, FACP
SCOPE Founding Fellow
Professor of Internal Medicine
Athens University Medical School
Evgenideion Hospital and Research Laboratory ‘Christeas Hall’
Athens, Greece
Christina Kanaka-Gantenbein, MD, PhD
Associate Professor of Pediatric Endocrinology and Diabetology
First Department of Pediatrics, University of Athens
Agia Sofia Children’s Hospital
Athens, Greece
Stavros Liatis, MD
Consultant in Internal Medicine and Diabetology
Laiko General Hospital
Konstantinos Makrilakis, MD, MPH, PhD
Assistant Professor of Internal Medicine and Diabetology
Athens University Medical School
Laiko General Hospital
Athens, Greece
Nikolaos Tentolouris, MD, PhD
Assistant Professor of Internal Medicine and Diabetology
University of Athens
Laiko General Hospital
Athens, Greece
A John Wiley & Sons, Ltd., Publication This edition first published 2011 © 2011 by John Wiley & Sons, Ltd.
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Diabetic Emergencies: Diagnosis and Clinical Management provides emergency room staff, diabetes specialists and endocrinologists with highly practical, clear-cut clinical guidance on both the presentation of serious diabetic emergencies like ketoacidosis, hyperosmolar coma and severe hyper- and hypoglycemia, and the best methods of both managing the emergencies and administering appropriate follow-up care.
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