Clnical question

[NightOwl]

Hi i just started working not too long. I have some questions and could use u guys guidance on:

 

What is the guideline for managing pt with hyperglycemia in clinic ( random=300+)

 

How to deal with asx pt with very high bp?

 

Any tips for insulin adjustment? This issue really is stressing me out

 

Thanks in advance for helping this newbie

[d2305]

I always start with metformin, and see how they tolerate it. Start with 500mg qd.

[SocialMedicine]

sounds like this guy has some issues .... he has diabetes with that random blood sugar(unless he is on steroids or a not so typical scenario).... get fasting labs and hemoglobin a 1 c ..... you do not treat diabetes entirely based on symptoms, rather lab values.... often metformin is dosed BID at 500mg initially in a type 2 scenario..... people typically do not initially start insulin in an adult with "Type 2" diabetes ...... you need to discuss this case with your supervisor and not on a forum .... someone should be giving advice knowing the full picture of this patient .... for example certain medications might be better if someone has underlying GI issues or kidney disease etc. Nobody can give you useful advice with the above information. Also, DO NOT MAKE patient care decisions based on what someone tells you on a forum. I could be a medical student or an accountant for all you know. If my mom went to her doctor and they checked a website forum to figure out how to treat her I might have a cardiac arrest hah. There is ALOT I do not know .... and I give myself the same advice every day .... but you need to go home and READ about diabetes management for several hours. If you treat a lot of Diabetes patients check out the Joslin diabetes center text.

[Acebecker]

UpToDate will help you a lot. Review that. In known diabetic Pts, 300+ is actually not something I get worked up about (I'm very accustomed to having DMII Pts who don't give a crap and never take their meds, so 300+ is high but not scary high). Bump the meds and if on high doses of Metformin already, insulin is probably needed at that point. Make sure Creatinine is good when upping metformin and doesn't bump up when you increase the met. Close follow-up is the name of the game. They need to be back in your office the next day.

 

Regarding your question about a Pt with no Sx who has a really high BP... Think about the question and you'll know the answer. Which is to get their BP under control. If they're already on max doses of 4 meds, need renal artery U/S to r/o stenosis. Should also check renin/aldosterone ratio. Electrolytes will help clue you in on this one - Na will be high, K will be low in hyperaldosteronism (which is the cause of resistant HTN in up to 1 in 5 Pts).

 

Finally, insulin adjustment is always tricky. The guideline I use for Lantus (glargine) is start with 10U subcu @HS and increase by 1 unit for every 3 days that FBS is >120 mg/dL. As soon as your FBS is <120, you're at goal and that dose is where you'll need to stay. Conversely, need to decrease the dose of Lantus by 1 unit if FBS is <70-80. For the fast acting insulins, carb counting is the key. The Pt needs to know how much they're eating and have experimented with a carb ratio per unit of insulin. I think a good starting point is 1 unit of Novolog for every 15g of CHO (carbohydrate) in the meal. Sliding scales don't work well - you're just chasing your highs and lows - unless you have a set dose and you slide it up or down based on the CHO in the meal. A caveat: make sure the Pt does NOT take their insulin until the meal is sitting in front of them. Novolog has a 15min onset time (IIRC) and if the meal is delayed even 5 minutes a profound hypoglycemia can result.

 

Hope that helps.

 

 

Andrew

[cbrsmurf]

I agree with Acebecker

Check uptodate. The american diabetes association has a good algorithm to follow.

metformin 500 1/2 tab BID (metformin can cause diarrhea/gi upset) and titrate up, full labs to start

high BP - ask about caffiene, smoking, etoh, drug use. labs, start acei/arb or thiazides if electrolyte is ok, f/u in 1 wk

 

diabetes and htn are very common in primary care, make sure you do plenty of reading. also suggest your read UKPDS, ACCORD and ALLHAT trials.