Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
A 67-year-old man is evaluated in the hospital for hyperglycemia 3 days after admission for a COPD exacerbation. Appropriate treatment was initiated with antibiotics, bronchodilators, supplemental oxygen, and systemic glucocorticoids. The patient's oral intake remains good. Since the initiation of systemic glucocorticoids, fasting blood glucose levels have been consistently greater than 180 mg/dL (10.0 mmol/L) and postprandial levels occasionally greater than 250 mg/dL (13.9 mmol/L).
On admission, hemoglobin A1c was 5.3%.
Treat hyperglycemia in a hospitalized patient who has good oral intake.
Point-of-care glucose measurement is important to identify hyperglycemia in hospitalized patients prescribed glucocorticoids. The most appropriate management of this patient's hyperglycemia is the initiation of basal, prandial, and correctional insulin (Option B). The American Diabetes Association (ADA) recommends initiation of insulin therapy for treatment for persistent hyperglycemia starting at a threshold of 180 mg/dL (10.0 mmol/L). After insulin therapy is started, a target glucose range of 140 to 180 mg/dL (7.8-10.0 mmol/L) is recommended for most critically ill and non-critically ill patients. Basal insulin is long-acting insulin given once daily; prandial insulin is scheduled short-acting insulin given three times daily with each meal; and correctional insulin is dosing in response to continued elevated glucose rather than preemptively. A correctional dose of short-acting insulin should be given in addition to the scheduled prandial insulin to correct for hyperglycemia before eating. This approach leads to improved outcomes and avoids large fluctuations in glucose values through the day. A randomized controlled trial has shown that basal-prandial insulin treatment improved glycemic control and reduced hospital complications compared with use of only correctional insulin (“sliding scale insulin”) regimens in general surgery patients with type 2 diabetes mellitus.
The ADA notes that basal insulin, or a basal plus correction regimen (Option A), is the preferred treatment for non-critically ill hospitalized patients with poor oral intake or those with oral intake restriction. Because this patient's oral intake is good, the preferred management of hyperglycemia is basal, prandial, and correctional insulin.
The sole use of correctional insulin (Option C) for the management of inpatient hyperglycemia is not recommended. This approach to hyperglycemia is reactive and can cause large fluctuations in glucose values and lag times between of measurement and insulin injection. The use of correctional insulin in hospitalized patients as the only means to control hyperglycemia is strongly discouraged by the ADA.
Research on the safety of oral hypoglycemic drugs in the hospital setting is ongoing, and conclusive findings have not yet been established. Harm is also a concern, particularly in patients who may experience changes in volume status, exposure to contrast agents, and unpredictable meals because of testing or clinical status changes. Initiating metformin (Option D) is not the best choice for this patient.
Basal, prandial, and correctional insulin is the recommended treatment for hyperglycemia in non-critically ill hospitalized patients who have good oral intake.
The use of correctional insulin in hospitalized patients as the only means to control hyperglycemia is strongly discouraged by the American Diabetes Association.
American Diabetes Association. 15. Diabetes care in the hospital: standards of medical care in diabetes-2021. Diabetes Care. 2021;44:S211-S220. PMID: 33298426 doi:10.2337/dc21-S015
Copyright 2019, American College of Physicians.
A 73-year-old woman is evaluated for a 10-year history of osteoarthritis affecting multiple joints over the years, including the distal joints of her fingers, bases of the thumbs, knees, and cervical and lower lumbar spines. She has chronic daily pain in at least one joint. She has tried nonpharmacologic measures, and she had minimal benefit from intra-articular glucocorticoid and hyaluronic acid injections to her knees. She was recently diagnosed with peptic ulcer disease. History is also significant for coronary artery disease, diabetes mellitus, and hypertension. Medications are enalapril, carvedilol, metformin, atorvastatin, pantoprazole, and low-dose aspirin.
On physical examination, vital signs are normal. Heberden nodes and squaring of the bilateral carpometacarpal joints are present. Crepitus and limited extension of the cervical spine are noted. Bilateral knee varus deformity and bony enlargement are present, with crepitus on range of motion.
Treat osteoarthritis with duloxetine.
Duloxetine, a serotonin and norepinephrine reuptake inhibitor with central nervous system effects, is a good treatment option for this patient with generalized osteoarthritis (OA). Duloxetine is FDA approved for chronic musculoskeletal pain and has been shown to have analgesic efficacy for chronic low back pain and knee OA pain, implicating the role of central sensitization in OA pain modulation. This patient has already tried multiple nonpharmacologic measures, as well as intra-articular glucocorticoid and hyaluronic injections, all with insufficient symptomatic relief. Duloxetine is a reasonable choice given the patient's comorbidities and generalized musculoskeletal pain.
Gabapentin and pregabalin are more effective than placebo in the treatment of neuropathic pain conditions such as postherpetic neuralgia and diabetic neuropathy. These drugs are expensive and both are associated with dose-dependent dizziness and sedation. There is no evidence of their effectiveness specifically for chronic OA pain.
NSAIDs inhibit cyclooxygenase (COX) enzymes, blocking the generation of the lipid prostaglandin E2 (PGE2). PGE2 stimulates inflammation, vasodilation, smooth muscle contraction, pain, and fever. However, PGE2 also maintains gastric mucosa and promotes kidney sodium excretion and glomerular filtration. Other COX products include thromboxane A2, a prothrombotic regulator of platelets, and prostacyclin, an antithrombotic and vasodilatory lipid. Because NSAIDs inhibit all of these, the consequences of COX inhibition are complex and accompanied by multiple potential side effects. Side-effect risk is increased in older patients and those with preexisting comorbidities. Therefore, ibuprofen is not an advisable choice in an elderly patient with peptic ulcer disease, hypertension, and heart disease.
Topical capsaicin may benefit localized OA (for example, knee only) but is impractical in this case given the multiple areas of involvement. Furthermore, duloxetine is more likely to be efficacious given how many treatments this patient has tried and failed.
Duloxetine is FDA approved for chronic musculoskeletal pain and has been shown to have analgesic efficacy for chronic low back pain and knee osteoarthritis pain.
McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22:363-88. PMID: 24462672 doi:10.1016/j.joca.2014.01.003
Copyright 2018, American College of Physicians.