dr.

Rulli Rosandi, SpPD-KEMD

_________________________________________________

Management of Inpatient Hyperglycemia Non-Critically ill Setting

MAT-ID-2000339 – V 1.0 (08/2020)

 Learning Objective

At the end of this lecture, the learner should be able to …

▪ Understand barriers to achieving glycemic control in non-critically ill patients
with diabetes

▪ Discuss glycaemic control issues in different medical conditions in the

hospitalised patient

▪ Manage and matched the specific clinical circumstance of the individual patient
with the inpatient insulin regimen
 Barriers to Achieve Glycemic Target
in Non-critically Ill Patients with Diabetes
System-related Issues

• Fear Of Hypoglycemia • Suggested in patient • Heterogenity of diabetes

• Complexity of patient treatment protocols are phenotype
presentation complex • Associated comorbidities
• Suboptimal knowledge • Glucose is not of can affect glucose
and training for medical quality measure metric metabolism
staff in non-ICU setting • Prescription of medication
• Variable caloric intake

Provider-related Issues Patient-related Issues

A.R. Gosmanov / Journal of Clinical & Translational Endocrinology 5 (2016) 1–6

 Achieving Glycemic Target:
Medical Nutrition Treatment

The goals are to The majority of non- Most patients receive a The majority of
optimize glycemic critically ill hospitalized total of 1500–2000 carbohydrate foods
control, to provide patients receive calories per day, with a should be whole grains,
adequate calories to nutrition support as range of 12–15 fruits, vegetables, and
meet metabolic three discrete meals carbohydrate servings low-fat milk, with
demands with or without restricted amounts of
scheduled snacks each sucrose-containing
day, some require EN or foods
PN support

Umpierrez G. Management of hyperglycemia in hospitalized patients in non-critical care settings:

J Clin Endocrinol Metab. 2012;97:16-38.
 Achieving Glycemic Target:
Oral Anti Diabetes
Therapy
o It is recommended to discontinue Metformin
oral agents in most patients
o Major limitations are side effect
profiles and slow onset of action Insulin secretagogues
• Sulfonylureas, glyburide,
glibenclamide, glipizide,
o Table Advantages and gliclazide, and glimepridie
• Glinides, repaglinide and
Disadvantages of Antidiabetic nateglinide
Drugs for the Inpatient
Thizolidinediones; pioglitazone
Management of Hyperglycemia in
Noncritical Care Settings
• Sodium glucose co-transporter 2
inhibitors: canaglifozin and
dapaglifozin
• α-glucosidase inhibitors:
acarbose and miglitol
• Dipeptidyl peptidase-4 inhibitors:
Umpierrez, Pharmacotherapy for Hyperglycemia in Noncritically sitagliptin, saxagliptin,
Ill Hospitalized Patients. Diabetes Spectrum Volume 27, linagliptin, & alogliptin
Number 3, 2014
Advantages
• Good glucose-lowering effect
• Oral route
• Low cost
• No hypoglycaemia
• Good glucose-lowering effect
• Oral route
• Low cost
• Good glucose-lowering effect
• Oral route
• No hypoglycaemia
• Modest glucose-lowering
effect
• Oral route
• No hypoglycaemia
• Mild glucose-lowering effect
• Oral route
• No hypoglycaemia
• Good glucose-lowering effect
• Oral route
• No hypoglycaemia
Disadvantages
• Risk of lactic acidosis in patients with
impaired kidney function, heart
failure, hypoxemia, alcoholism,
cirrhosis, contrast exposure, sepsis,
and shock
• Gastrointestinal side effects
• Risk of hypoglycaemia
• Significant drug-to-drug interactions
• Risk of cardiovascular events
• Slow onset of action
• Contraindicated in patients with heart
failure, hemodynamic instability, and
hepatic dysfunction
• Increased risk of urinary and genital
tract infections
• Risk of dehydration
• Gastrointestinal side effects
• Contraindicated in patients with
inflammatory bowel disease, partial
bowel obstruction, or severe renal or
hepatic disease
• Concern regarding acute pancreatitis
 Achieving Glycemic Target :
Insulin
140

Illness-Related
120
Correction
Nutritional
100
Prandial
Basal
80

60

40

20

0 * Estimations for illustrative purposes:

Healthy Sick/Eating Sick/NPO requirements may vary widely

Adapted from ADA Technical Review: Management of Diabetes & Hyperglycemia in Hospitals.
Diabetes Care 2004

Magee MF. Subcutaneous insulin therapy in the hospital setting : issues, concerns and implementation.
ENDOCRINE PRACTICE Vol 10 (Suppl 2) March/April 2004
 Inpatient Glycemic Targets

Individualized glycemic goal; depends on patient’s clinical condition

Critically ill Non-critically ill

Preferred route Intravenous Subcutaneous

Glucose target (mg/dl) 140-180 mg/dl Premeal <140 mg/dl
(ADA 2015) (Selected patients* 110 -140 mg/dl) Random <180 mg/dl

Glucose target (mg/dl) Premeal 110-140 mg/dl

(ESC 2012) Random 140-180 mg/dl

Not recommended Acceptable Recommended Not recommended

<110 110-140 140-180 >180
*centers with extensive experience and appropriate nursing support, cardiac surgical patients,
and patients with stable glycemic control without hypoglycemia
American Diabetes Association. Standards of Medical Care in Diabetes—2015. Diabetes Care. 2015 ; 38(1): S1-S93
Umpierrez GE, et al. an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012. 97:16–38.
 Upon Admission
- Acces all patients for a history of diabetes
- Obtain laboratory blood glucose testing

T1DM, insulin requiring T2DM

T2DM received
Newly diagnosed hyperglycemia that is clinically
Diet oral based
significant & sustained

Nothing by mouth Eating Nothing by Mouth Eating

Continue out patient regiment

if glucose well controlled Continued oral agents if
Discontinued oral
(consider modest reduction) if no contraindication &
based
calorie intake as inpatients glucose well controlled
expected to be more restricted

If poorly counted If poorly controlled

Basal Bolus Protocol

1. Inzucchi, Silvio E. Management of Hyperglycemia in the Hospital Setting. The New England Journal of Medicine. 2006; 355: 1903-11.
2. Gangopadhyay, KK. Consensus Evidence Based Guidelines for In-Patient Management of Hyperglycaemia in Non-Critical Care Setting as per Indian Clinical Practice.
 Basal Bolus Reflects Endogenous Insulin

Breakfast Lunch Dinner

RA Analog:
Plasma Insulin

RA Analog RA Analog RA Analog Glulisine, Aspart, Lispro

QD Glargine or
QD to BID Detemir

4 : 00 8 : 00 12 : 00 16 : 00 20 : 00 24 : 00 4 : 00 8 : 00

Time

Wode, Bruce W. Et al. Inpatient Insulin Therapy: Benefits and Strategies for Achieving Glycemic Control. [online[. Published at 2019. [cited 2020 March 1].
Available from: www.medscape.org/viewarticle/544930_4
 Increase of Prandial Insulin Needs
in Stress Hyperglycemia

Supplemental or “stress”
insulin correction

Mealtime Insulin (bolus)

Basal Insulin

Breakfast Lunch Dinner Bedtime

AACE Inpatient Glycemic Control Resource Centre

Pooling -1

Which method of insulin

administration do you use most
What is the often in non-critically ill
recommended hospitalized patient ?
method of a. Basal Bolus Insulin
administering insulin b. Sliding Scale Insulin
in non critically ill c. Premixed Insulin
patients? d. Variable intravenous insulin
drip
e. Other
 Sliding Scale Insulin—Time to Stop Sliding

▪ Insulin administered as monotherapy on an ‘as needed’ basis in an attempt to treat

hyperglycemia after it occurs.

▪ Potential advantages of sliding-scale insulin (SSI)1 :

• Convenience, simplicity, and promptness of treatment.
• The regimen does not depend on locating an attending physician officer concerning the necessary
insulin dosage.

▪ Potential disadvantages of SSI1 :

• Regimen treats hyperglycemia after it has already occurred instead of preventing its occurrence.
• This “reactive” approach can lead to rapid changes in blood glucose levels, exacerbating both
hyperglycemia and hypoglycemia, and can lead to iatrogenic diabetic ketoacidosis.

▪ Most of national societies and consensus statements uniformly recommend against use of
sliding scale insulin for adult inpatient glycemic management in the non-critical care setting2-4

1. Umpierrez. Sliding Scale Insulin Use: Myth or Insanity?. The American Journal of Medicine (2007) 120, 563-567
2. American Diabetes Association. Standards of medical care in diabetes–2019. Diabetes Care. 2019;42(suppl 1):S173-S181.
3. Umpierrez G. Management of hyperglycemia in hospitalized patients in non-critical care settings: J Clin Endocrinol Metab. 2012;97:16-38.
4. Moghissi. American Association of Clinical Endocrinologist and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32:1119-1131
 Basal-bolus (Gla-Glulisine) Regimen Resulted Significant
Improvement in Glycemic Control Compared to Sliding Scale

240

220
*
Blood Glucose (mg/dL)

*
200 * ¶ ¶
¶ ¶
180
SSI
160

140
Gla-Glulisine
120

100
Admit 1 2 3 4 5 6 7 8 9 10
Days of Therapy

Changes in blood glucose concentrations in patients treated with glargine plus glulisine ( )
and with SSI ( ). *P < 0.01; ¶P 0.05.

Umpierrez et al. Diabetes Care 2007. 30:2181–2186.

 Basal-bolus (Gla-Glulisine) Regimen Resulted Significant
Improvement in Glycemic Control Compared to Sliding Scale

300
280
260
Blood Glucose (mg/dL)

240
220
200 Gla-Glulisine
180 SSI
160
140
120
100
Admit 1 2 3 4 1 2 3 4 5 6 7
Days of Therapy

Mean blood glucose concentration in subjects who remained with severe hyperglycemia despite increasing
doses of regular insulin per the sliding-scale protocol ( ). Glycemic control rapidly improved after switching
to the basal-bolus insulin regimen ( ). P < 0.05.
Umpierrez et al. Diabetes Care 2007. 30:2181–2186.
 Basal-bolus and Premixed Comparison in
Hospitalized Patients with T2DM

B 300
• Basal-bolus group: 50% of the total
275
daily dose as glargine and 50% as
glulisine.
Blood Glucose (mg/dL)

250
Mean (SD) HbA 1c(%)

225
Basal-bolus • Premixed insulin group: 2 doses of
200 Premixed premixed insulin (60% of the total daily
175
dose before breakfast and 40% before
dinner)
150
• 94 pts
125
• Treatment with a basal-bolus regimen
100
Pre Post Pre Post Pre Post was associated with lower glycemic
Breakfast Breakfast Lunch Lunch Dinner Dinner
variability compared with treatment
Blood glucose profile with premixed insulin regimen

Bellindo V. Comparison of Basal-Bolus and Premixed Insulin Regimens in Hospitalized Patients With Type 2 Diabetes
Diabetes Care 2015;38:2211–2216
 Which Protocol to Use ?

▪ The critical care setting, a variety of IV insulin protocols have been shown to be
effective1

▪ In the non-critical care setting, the optimal SC insulin regimen is less established 1.

▪ Both from physiologically perspective and based on clinical trial data, basal bolus insulin
is more effective form of insulin replacement to correct hyperglycemia in non critical care
setting1-3

1. Juneja R. Subcutaneous Insulin Therapy in Non-Critical Care Hospital Settings. Postgraduate Medicine, 122 (1), 2010
2. ACE/ADA Task Force on Inpatient Diabetes. AACE /ADA consensus statement on inpatient diabetes and glycemic control. Endocr Pract. 2006;12(suppl 3):4–13
3. Umpierrez GE. Basal versus sliding-scale regular insulin in hospitalized patients with hyperglycemia during enteral nutrition therapy. Diabetes Care. 2009;32(4):751–753
 What is the Starting Dose ?

▪ Consideration : Initial insulin therapy in hospital or transitioning from IV insulin

▪ For pts initiating insulin therapy for the first time, calculates TDD requirement
TDD Estimation Patient Characteristic
0.3 units/Kg Body weight Underweight, older ages, hemodialysis
0.4 units/Kg Body weight Normal weight
0.5 units/Kg Body weight Over weight
≥ 0.6 units/Kg Body weight Obese, insulin resistant, glucocorticoid

▪ Divided equally between basal (50%) and bolus (50%) insulin.

Gangopadhyay KK. Consensus evidence-based guidelines for in-patient management of hyperglycaemia in non-critical care setting as per Indian clinical practice.
The Journal of the Association of Physicians of India, 2014
 Correction Insulin Algorithms (Sample)

Premeal Blood Low Dose Moderate Dose High Dose

Glucose (mg/dl) (0.2-0.4 U/Kg/day) (0.5-0.7 U/Kg/day) ( > 0.7 U/Kgbb/d)

Additional Insulin Additional Insulin Additional Insulin

150-200 1 2 3
201-250 2 4 6
251-300 3 6 9
301-350 4 8 12
351-400 5 10 15
> 400 6 12 18

Ariana R. Management of Hyperglycemia in Hospitalized Patients: Noncritical Care Setting . Basel, 2015
 Transition IV to SC Insulin

▪ Establish 24 hr Insulin Requirement

• Based on previous IV insulin requirement
• Extrapolate from average over last 4 hr if stable
• One should consider decreasing the TDD by 20-30 %
▪ Give One-Half Amount As Basal and One-Half Amount As Bolus
▪ Give the long-acting insulin analog subcutaneous monodose 2 h before the first meal and
the discontinuation of intravenous insulin and intravenous glucose infusions. Example →
give glargine 18 units s.c. 2 h before the first meal and stop intravenous insulin and glucose
infusions at meal
▪ In general, as patients move toward recovery, insulin requirement will usually decrease
▪ It is essential insulin regimens be reevaluated on a daily basis

Juneja. The Nuts and Bolts of Subcutaneous Insulin Therapy in Non-Critical Care Hospital Settings. Post graduate Medicine. 122,(1), 2010
Avanzini F, et al. Diabetes Care. 2011.34:1445-50
 Transition IV to SC Insulin : Example

▪ SC TDD is 80-100 % of 24-h insulin requirement:

1 Unit/h x 24 h = 24 Units 80% x 24 Units = 19 Units

Basal dose is 50% of SC TDD:

• 50% of 19 Units = 10 Units of long-acting insulin
• Give 1-2 hr before discontinuing IV insulin
Bolus total dose is 50% of SC TDD:
• 50% of 19 Units = 10 Units
• Give as ~3 Units with each meal

Konsensus Perkeni 2011,

ADA, Diabetes Care 2010; 33: S11- S61
Bode et al. Endocr Pract. 2004; 10(2): 71-80
 Monitoring Blood Glucose in the Non-
Critical Care Setting

▪ Bedside capillary POC testing as the preferred method

▪ Timing of POC testing match with nutritional intake and the diabetes medication regimen

▪ Patients who are eating: as close as possible to meal time, max 1 hour before meal

Before breakfast Before lunch Before dinner Bedtime

▪ Patients who NPO/continuous enteral nutrition: POCT every 4-6 hours

Umpierezz. Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline
J Clin Endocrinol Metab 97: 16–38, 2012
Management of Diabetes
with COVID-19 in Hospital
Pooling 02

According to your practice, what is the

most common comorbid in Covid-19
patients?
A. Diabetes Mellitus
B. Hypertension
C. Heart Disease
D. Chronic Respiratory Disease
E. Cancer
F. Other Disease
 Komorbid Pasien Covid-19 yang Meninggal Dunia

Diabetes 31,8 %

Hipertensi 24,1 %

Peny Jantung 13,1 %

Lainnya 30,9%

0 5 10 15 20 25 30 35

Data Kementerian Kesehatan RI. Google form Evaluasi kasus kematian di RS 27 Juli 2021
 Importance of good glycemic control in COVID-19

Significant mortality reduction by reducing

glycemic variability

✓ Hyperglycemia is detrimental to the control of viremia and

inflammation, aggravating morbidity and mortality rates1
✓ Overly tight glucose control increases risk of severe
hypoglycemia leading to increased mortality1
✓ >7000 COVID-19 patients with T2D during hospitalization: 10X
lower in-hospital mortality (1.1 vs. 11%) in patients with well-
controlled BG (≤ 180 mg/dL) vs. poor BG control(> 180 mg/dL)2

Good glycemic control improves clinical outcomes in COVID-19 hospitalized patients

Reference:1. Zhu. Association of blood glucose control and outcomes in patients with COVID-19 and pre-existing type 2 diabetes. Cell Metabolism 2020; 31;1068–77. 2. Attri B, Goyal A, Gupta Y, Tandon N. basal-bolus insulin regimen for
hospitalized patients with COVID-19 and diabetes mellitus: A practical approach. Diabetes Ther. 2020 Sep;11(9):2177-94.
 Data From Fatmawati Hospital Jakarta

Diabetes &
Covid-19
CONCLUSION : Diabetes mellitus increases
intensive care admission and mortality in
confirmed cases of COVID-19 during
hospitalization.

Multivariate analysis of the relationship between DM and intensive care Multivariate analysis of the relationship between DM and mortality

26
Mokoagow MI, Harbuwono DS, Kshanti IA. National Endocrine Forum Presentation, 2021
Diabetes Mellitus dan Covid-19 di RSSA Malang

Survivor Non-Survivor
Mean ± SD Variable p
(n = 67) (n = 35)
Sex, n (%) Sex, n (%)
- Male 50 (49.0) - Male 34 (50.7) 16 (45.7) 0.629
- Female 52 (51.0) - Female 33 (49.3) 19 (54.3)
Age (years old) 55.6 ± 10.8 58.7 ± 9.4 0.141
Age, years 56.6 ± 10.4 BMI (kg/m2) 24.5 ± 3.9 24.1 ± 3.9 0.582
BMI, kg/m2 24.4 ± 3.9 Blood glucose at 278.5 ± 154.3 332.4 ± 165.3 0.021
admission
Blood glucose at early 299.9 ± 159.4 HbA1c levels (%) 9.7 ± 2.4 11.1 ± 2.7 0.009
admission HbA1c levels category
<7 8 (11.9) 3 (8.5) 0.496
HbA1c levels (%) 10.2 ± 2.6 7 – 7.4 6 (8.9) 2 (5.7)
7.5 – 10 20 (29.9) 7 (20)
Outcome
> 10 32 (47.8) 22 (62.9)
- Survivors 67 (65.7)
- Non-survivors 35 (34.3)

Rosandi R, Sasiarini L, 2021. Unpublished Data

Management of Diabetes with Covid -19

a. Mild COVID-19:
• both oral anti-diabetic (OAD) and insulin treatment can be maintained and
it is not necessary to adjust original regimen.
b. Moderate COVID-19:
• the original treatment can be maintained if patient’s mental condition,
appetite and glucose control are within normal range.
• Patients who are previously on OAD with obvious COVID-19 symptoms that
cannot eat regularly may be treated with insulin instead.
• Patients with premix insulin regimen may be switched to basal- bolus
regimen or insulin pump to manage glucose more flexibly.
c. Severe and Critical COVID-19:
• hospitalized, intravenous insulin should be the first-line therapy

ISE. Position Statement on How to Manage Patients with Diabetes and COVID-19. JAFES. PUBLISHED ONLINE FIRST | April 27, 2020. Vol. 35 No. 1 May 2020
 Example - Management of Diabetes with Covid -19

Pasquel FJ. Individualizing Inpatient Diabetes Management During the Coronavirus Disease 2019 Pandemic. Journal of Diabetes Science and Technology 2020, Vol. 14(4) 705 –707
 Treatment of
Inpatient Hyperglycemia
Polling 3
In your opinion, which of the following complications of diabetes is
the most difficult to control blood glucose levels?
A. Diabetes with Chronic Liver disease
B. Diabetes with Chronic Kidney disease
C. Diabetes with cerebrovascular disease
D. Diabetes with cardiovascular disease
E. Others
 Treatment of
Inpatient Hyperglycemia
in Patients with Diabetes and Chronic Kidney Disease
 Renal Disease and Diabetes

▪ Renal disease is a frequent microvascular complication of diabetes,

▪ Renal dysfunction adds a layer of complexity to diabetes management as it increases

the risk of hypoglycemia

• Veterans Affair study, when serum creatinine increased by 50% from

baseline, the risk of hypoglycemia after discharge increased by 27%

▪ The management is challenging and modified glucose goals and regimens are
needed

Garla V, Cardozo LY. Current therapeutic approaches in the management of hyperglycemia in chronic renal disease. Rev Endocr
Metab Disord, 2017
 Chronic Kidney Disease and Glucose Homeostasis
Uremia
Increase in Inflamatory Increase in Insulin
Mediators Resistance
Metabolic Acidosis

Lack of Physical
Fitness

Chronic Kidney Secondary HPT Decrease in Insulin Glucose Homeostasis

Disease Secretion

Decrease in Tm Glucose Decrease Glucose

Reabsorbtion

Decrease Clearance of Increased Half Life

Insulin of Insulin

Decrease Renal Decrease Glucose

Gluconeogenesis Production

Garla V, Cardozo LY. Current therapeutic approaches in the management of hyperglycemia in chronic renal disease. Rev Endocr Metab Disord, 2017
 Blood Glucose Goals in Chronic Kidney Disease

Variation of BG goals

▪ ADA, 2018: Less stringent HbA1c goals of less than 8.0% (estimated average
glucose 183 mg/dl)

▪ KDOQI 2012 : ± 7.0 % for most patient, >7% in individuals with comorbidities or
limited life expectancy and hypoglycemia

▪ India consensus:

• GFR > 60 ml/min/1.73 m2 Hba1C < 7%

• dan < 60 : ml/min/1.73 m2 : HbA1c : 7 – 8.5 %

1. Garla V, Cardozo LY. Current therapeutic approaches in the management of hyperglycemia in chronic renal disease. Rev Endocr Metab Disord, 2017
2. Tuttle KR, Diabetic kidney disease: a report from an ADA consensus conference. Diabetes Care 2014;37:2864–83
3. Rajesh R. Consensus statement on insulin therapy in chronic kidney disease. diabetes research and clinical practice 127 (2017)
 Adjustment of Inpatient Insulin
Regimen in CKD

Scenario Adjustment

Stable CKD stage 1 and 2 (GFR 60-89) None

with no hypoglycemia

CKD stage 3 (GFR 30-59) Decrease TDD by 30 %

CKD stage 4 (GFR 15-29) Decrease TDD by 50 %

CKD Stage 5 or ESRD (<15) Decrease TDD by 60 %

Garla V. Current therapeutic approaches in the management of hyperglycemia in chronic renal disease. Rev Endocr Metab Disord, 2017
 Conclusion

▪ In hospitalized noncritically ill patients, both hyperglycemia and hypoglycemia are

associated with poor outcomes

▪ Insulin in the form of long-acting, basal insulin and fast-acting nutritional and corrective
insulin should be used in hospitalized patients with diabetes

▪ Prandial insulin should be considered to cover prandial need when basal insulin is
insufficient

▪ The total daily insulin dose for each patient depends on their outpatient
diabetes regimen, their hemoglobin A1c level before admission,
current mode and state of nutrition, and presence or absence of
corticosteroids
 Case 01
▪ All of the following sentences regarding in - hospital glycemic control are correct, except:

a. According to current guidelines, glycemic control for non critically ill ICU patients should
generally aim at blood glucose levels between 80 and 110 mg/dl
b. Less stringent targets may be appropriate in terminally ill patients or patients with severe
co- morbidities
c. Very strict glycemic control has been associated with increased mortality in the largest
multicenter study conducted to test this association
d. Prolonged therapy with sliding scale insulin as the sole regimen is discouraged
e. Non-insulin antihyperglycemic agents are not appropriate in most hospitalized patients
who require therapy for hyperglycemia
 Case 02
▪ Which of the following sentence(s) is/are correct regarding treatment of hyperglycemia in
hospitalized, non - critically ill patients?

a. In - hospital use of sulfonylureas is contraindicated

b. Basal insulin should not be administered when insulin therapy is implemented in insulin

c. Subcutaneous insulin should not be administered in case of shock

d. Sliding scales depicting short - acting insulin administration should be individualized

e. Portable glucose meters should not be used in order to adjust insulin dose
 Case 03
Mrs. W 56 years old comes to emergency room with severe diarrhoea since 2 days ago, wit
frequencies more that 10 times/day, and much vomiting with frequencies more than 8 times/day. Fever
(+), general weakness (+), chest pain (-), decrease of consciousness (-), breathing difficulties (-),
difficulties to speak or swallow (-), one body side weakness (-). Mrs. W has been diagnosed
with diabetes since 14 years ago, her blood glucose was 400 mg/dL when the doctor
diagnosed her for the first time. She is treated with Metformin 3x500 mg and Glimepiride 1x4 mg.

Mrs. W also has been diagnosed with hypertension since 10 years ago, her blood pressure
was 180 mmHg when the doctor diagnosed her for the first time. She is treated with Valsartan
1x160 mg and HCT 1x25 mg. History of illness: Three times of stroke, full recovered.
 Case 03
From the physical examination, she looks weak, body weight 62 kg, body height 156 cm, BMI
21.3 kg/m2. Vital sign: Blood pressure 170/100 mmHg, heart rate 65x/minutes, regular,
respiration rate 18x/minutes, regular, temperature 380C. From head to toe examination, she has
increased of abdominal sounds. Others are normal.
 Laboratory Examination

Normal Test Normal Test

Test Result Unit Test Result Unit
Result Result
Leucocyte 12.830 /µL 3.500-10.000 Urea 79,9 mg/dl 10-50
Hb 14 g/dl 11-16.5 Creatinine 1,6 mg/dl 0,7-1.5
Electrolyte
131 136-145
Na
Thromb. 321.000 μ/L 150-390.103 4,36 mmol/L 3,5-5,0
K
105 98-105
Cl
Albumin 4,16 g/dl 3,5-5,0 Blood Gas
Arterial
Osm 314 mOsm/kg 280-295 7,42 mmHg 7,35-7,45
pH
88 mmHg 75-100
PaO2
Random 40 mEq/L 35-45
PaCO2
blood 543 mg/dl <200 25 % 22-26
HCO3
glucose 98 99
O2 sat
 How Much is the Blood Glucose Target Therapy
for This Patient?
A. 80-110 mg/dl

B. 140-180 mg/dl

C. 180-200 mg/dl

D. 80 - 180 mg/dl
 Case Discussion
▪ How Much is the Blood Glucose Target Therapy for This Patient?

▪ In this case whether treatment with OAD will still continue?

▪ What treatment is appropriate for the patient? Initiate with insulin? how the dose ?