Patients with a history of diabetes and chronic obstructive pulmonary disease have hyperglycemia, what is the best management strategy?

In yesterday’s "Weekly Medical Questions" column, we pushed the latest issue of NEJM Knowledge+ Question of the Week
.

【Weekly Doctor Questions】Patients with a history of diabetes and chronic obstructive pulmonary disease have hyperglycemia, what is the best management strategy? Today, we announce the answer
.

Do you see the answer? Of course, answering right is not the goal, but mastering the essentials and expanding knowledge is the kingly way
.

Answer: Increase mealtime insulin.
Key learning points: In hospitalized patients with type 2 diabetes who use basal insulin therapy, the most effective measure to treat hyperglycemia caused by glucocorticoids is to increase mealtime insulin
.

Knowledge Expansion Patients who have not previously had diabetes may experience glucocorticoid-induced hyperglycemia when receiving glucocorticoid therapy for various reasons, while patients with previous diabetes are at risk of further increase in blood sugar
.

Part of the reason that glucocorticoids cause high blood sugar is that the amount of blood circulating glucose entering the tissues is reduced, and glucocorticoids can directly damage pancreatic β cells
.

Glucocorticoids cause a much higher degree of postprandial blood glucose level increase than fasting blood glucose levels; therefore, increasing mealtime insulin will be the best strategy for dealing with glucocorticoid-induced hyperglycemia patients
.

The usual method of administration of insulin glargine is once a day; dividing the daily dose into two will not improve the patient's blood sugar control
.

Increasing the dose of insulin glargine will not solve the problem of postprandial hyperglycemia, and will also expose patients to the risk of fasting hypoglycemia
.

Generally speaking, for most patients with type 2 diabetes who are not admitted to the ICU, non-insulin drugs should be discontinued; some patients with stable disease and no contraindications can use such drugs
.

The patient’s blood sugar is unstable, and sulfonylurea drugs increase the risk of hypoglycemia in critically ill patients
.

The use of metformin is generally not recommended for hospitalized patients because there may be contraindications to metformin during hospitalization, such as renal insufficiency, hemodynamic instability, the use of contrast agents, and the risk of lactic acidosis
.

Equivalent doses of dexamethasone and prednisone have similar effects on glucose levels
.

【Weekly Medical Questions】will continue to be updated
.

What do you want to see or learn? Please tell us through the comments and look forward to your precious comments and suggestions
.

  References 1.
Baldwin D and Apel J.
Management of hyperglycemia in hospitalized patients with renal insufficiency or steroid-induced diabetes.
Curr Diab Rep 2012 Oct 24; 13:114.
2.
American Diabetes Association.
Diabetes care in the hospital: standards of medical care in diabetes--2021.
Diabetes Care 2021 Jan; 44:S211.
Copyright information This article is a translation of "NEJM Frontiers in Medicine" jointly created by Jiahui Medical Research and Education Group (J-Med) and "New England Journal of Medicine" (NEJM) , Written or commissioned
.

The Chinese translation of the full text and the included diagrams are exclusively authorized by the NEJM Group
.

If you need to reprint, please leave a message or contact nejmqianyan@nejmqianyan.
cn
.

Unauthorized translation is an infringement, and the copyright owner reserves the right to pursue legal liabilities
.