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Case Study: The Recipe for Diabetes Success in the Hospital

	Presentation

 
N.D., a 48-year-old, obese, African-American man, was admitted to intensive care unit with crushing, substernal chest pain. This was associated with dizziness, nausea, vomiting, and diaphoresis. The electrocardiogram on admission revealed T wave inversions in the anterior and lateral leads. He ruled in for a myocardial infarction (MI) by serial cardiac enzymes. His glucose level on admission was 203 mg/dl with a bicarbonate of 24 mg/dl. A hemoglobin A_1c (HbA_1c) performed in the hospital revealed a value of 8.1%.

The patient’s father had a history of heart disease and had suffered a heart attack at the age of 52 years. His grandmother had a history of type 2 diabetes controlled with insulin. N.D. stated that for a few months before admission, he had been feeling fatigued and had been experiencing increased urination, especially at night.

N.D. is a computer programmer and had led a sedentary lifestyle, without a regular exercise regimen. He had steadily gained weight over the years, to his present weight of 220 lb. He does not smoke and occasionally drinks beer on the weekend. He consistently drinks more heavily during an annual Super Bowl party in January of each year.

	Commentary

 
Ingredients for diabetes success

• Regardless of whether this patient has "stress hyperglycemia" or unrecognized diabetes, treat aggressively with intravenous rather than subcutaneous insulin coverage.
  
• Understand that definitive diabetes is not necessary to demonstrate improved outcomes by controlling glucose as close to normal as possible.
  
• Realize that morbidity and mortality from stroke, MI, and bypass surgery are affected most by glucose levels in the hospital.
  

Does controlling hyperglycemia in the hospital really matter?
The data on the importance of controlling glucose in the hospital span diverse disciplines of medicine. Studies in the areas of stroke, MI, bypass surgery, and wound and nosocomial infections all point to the tremendous potential to reduce morbidity and mortality among hospitalized patients with hyperglycemia. . . . [Full Text of this Article]

Diabetes is the secondary, not primary, problem.
Is hyperglycemia caused by stress or diabetes? It doesn’t matter—treat it.
Is the hospital really the time to consider diabetes? Yes.
Where is the best place to find unrecognized diabetes? In the hospital.
What if the hyperglycemia is caused by medication? Treat it like diabetes.
Is there a diagnostic role for HbA_1c? Maybe.
Diabetes isn’t the reason for admission, so why treat it? Hyperglycemia DOES impact the primary medical problem.
Shouldn’t the MI be managed first? Treat the hyperglycemia aggressively and sequentially with the MI.
Summary and clinical keys

	Footnotes

 

	References

 

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