Question of the Week

For December 28, 2021

A 60-year-old man with a history of type 2 diabetes and chronic obstructive pulmonary disease (COPD) is hospitalized for a COPD exacerbation. His medications include insulin glargine 40 units daily, metformin 1000 mg twice daily, and inhaled fluticasone plus salmeterol. He reports that a recent glycated hemoglobin level was 7.0% (reference range, 4.3–5.6).

On examination, he is in mild respiratory distress. His temperature is 37.9°C, his blood pressure is 146/90 mm Hg, his heart rate is 102 beats per minute, his respiratory rate is 22 breaths per minute, and his oxygen saturation is 90% while he receives 4 liters of supplemental oxygen by nasal cannula. He is 165.1 cm tall, weighs 79 kg, and has a BMI of 29. A respiratory examination reveals diffuse wheezing, but no signs of consolidation.

The patient is started on levofloxacin, oral prednisone 60 mg daily, and nebulized albuterol plus ipratropium. His home insulin glargine dose is continued, and the metformin is discontinued.

On the second hospital day, several random glucose levels are between 200 and 300 mg/dL (reference range, <140).

Which one of the following strategies is best for managing this patient’s hyperglycemia?

Divide the insulin glargine dose in half and administer the drug twice daily
Add prandial insulin
Replace prednisone with an equivalent dose of dexamethasone
Start a long-acting sulfonylurea as monotherapy
Increase the insulin glargine dose

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