Written by: Raymond Beyda
For the non-emergent, non-ketotic, non-acidotic, uncontrolled hyperglycemic…
Case: A 47 yo M h/o DM with frequent ED visits presents feeling dizzy and lightheaded x 3 days. ROS is positive for polyuria and polydipsia. Vital signs are within the normal range, his exam is unremarkable. Imaging is negative. The following are his lab results:
Na: 140, K: 4.5, Cl: 105, HCO3: 24, AG: 11, BUN: 18, Cr: 1.1, Glucose: 350
You have seen this patient before, the adult patient who presents for a given chief complaint either related to or unrelated to uncontrolled hyperglycemia. In either case, the patient is fully evaluated, intravenous access is obtained, labs are sent off and imaging is or is not performed. The only remarkable finding at the end of the day (and it may be a very long day indeed!) is a serum glucose in the 300 to 400s range or even higher. Notably, there is an anion gap within the normal range, there is no ketosis, the bicarbonate levels are within the normal range, there is no acid-base abnormality (I swear), the patient is not altered, and the disposition decision is to discharge the patient home to follow up with primary care clinic. He or she does not have DKA or HHS! Essentially this just became a visit to the doctor’s office for uncontrolled hyperglycemia. So what are you going to do about it?
Indeed, the emergency department is frequently a place that patients turn to for issues ranging the full gamut of primary care issues; head to toe, not only are we called upon to treat life and limb threatening emergencies, but patients expect and often demand that we treat their everyday less emergent ailments; with limits and barriers to primary care as they are, who’s to blame them? The reality is that we find ourselves playing the role of primary care physicians whether we like it or not. The asthmatic with poor control on only rescue inhalers and the asymptomatic hypertensive sent in for evaluation, are just a few examples of patients we encounter daily.
Another example is, of course, our diabetic patient with uncontrolled hyperglycemia who is about to be discharged. In fact, this patient may not have even known he/she was diabetic and you have just delivered the diagnosis for the first time (pretty bad news with serious consequences); many diabetic patients are unaware of their diagnosis in the first place, and are therefore not equipped to take the first steps at preventing progression of disease in the setting of chronic, uncontrolled hyperglycemia (1). In addition to sending him/her off to follow up with the primary care ambulatory service, are there any other things we can do as physicians to better serve this patient’s immediate and long term needs? Prevention is the best medicine and chronic, uncontrolled hyperglycemia will ultimately invite this patient back to our ED only with more severe health issues, including but not limited to the micro-vascular and macro-vascular complications of prolonged hyperglycemia (1, 2). Remember the MI patient that presented last week with a history of…or the stroke patient with history of…and of course, the chronic kidney disease, dialysis-dependent, hypertensive, atherosclerotic patient who presented last night in acute flash pulmonary edema…what was in his past medical history again ? That’s right, diabetes! So what do we have in our arsenal of diabetes primary care?DIET AND EXERCISE
What about medications?MEDICATIONS
Advantages over insulin-based regimens include less risk of hypoglycemic episodes, something we should strongly consider in the ED environment when we are about to discharge a patient with a new drug regimen to follow up with the PMD. One important adverse reaction to metformin use is GI upset, so consider it when a metformin-naïve patient presents with indigestion or diarrhea a couple days after starting on the drug (2, 5, 6). This occurs with higher doses; so from the ED perspective, start low with 500 mg PO daily or BID (max: 2.5 g/day) and allow for outpatient titration accordingly.
The Bottom Line: Metformin is a safe and fantastic go-to med for starting a diabetic patient on before sending them home to follow up with the PMD and establish chronic diabetes management.
We evaluate primary care patients all the time in the ED, but are we doing the best to ensure that they leave the ED with a plan? Studies have shown that getting hyperglycemic patients the treatment and follow up they need is less than ideal; one study demonstrated that approximately 98% of hyperglycemic patients had no follow up arranged for them following disposition (1). I think we can do better than that! So let’s give an “ounce of prevention.” Diet and exercise can go along way, and if a medication is going to be used, consider metformin as a place to start from in the right patient without contraindications. Then make sure they have a follow up plan with the PMD. While we do specialize in the life and limb threatening, we have plenty of primary care patients we can’t ignore, and if we just pause and take a little bit more time with them, we may be getting close to that “pound of cure.”
Take Home Points:
- Many hyperglycemic patients don’t know they are diabetic, don’t be another MD that overlooks it and doesn’t tell them.
- Tell them to move their bodies and then start them on Metformin 500mg, today.
- Give them follow-up and let the PMD do the rest.
- You just saved a life.
- van Veggel KM, Kruithof MK, Roelandse-Koop E et al. Follow-up of patients with hyperglycemia in the emergency department without a history of diabetes mellitus. Eur J Intern Med. 2014(10):909-13.
- American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes Care. 2014; 37(Supplement 1):S14-S80.
- Tuomilehto, J, Lindstrom, J. et al. Prevention of Type 2 Diabetes Mellitus by Changes in Lifestyle Among Subjects with Impaired Glucose Tolerance. 2001; 344 (18):1343-1350.
- Sigal RJ, Kenny GP, Boule NG et al. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med. 2007; 147: 357-69.
- Katzung, Bertram G. Basic and Clinical Pharmacology 10th Ed. McGraw-Hill Companies, Inc, 2007. Print.
- Kirpichnikov D, McFarlane SI, Sowers JR. Metformin: an update. Ann Intern Med. 2002; 137:25-33.