A dose of primary care for hyperglycemia in the ED: optimizing the discharge.

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

Let’s start out with good old fashion diet and exercise! Lifestyle modification including exercise can improve glycemic control in already established diabetics, and what’s more, it can also prevent the progression to type 2 diabetes in those at risk (3). In a 2001 study published in NEJM, 522 overweight middle-aged patients with impaired glucose tolerance testing were randomly assigned to an intervention group consisting of weight loss, a low saturated and total fat, high fiber diet, and exercise, versus a separate control group (3). The study found, not only that for obvious reasons the intervention group lost more weight, but they also progressed to diabetes at a lower incidence, 11% (6-15 % 95 % CI) versus 23% (17-29%, 95% CI) in the control group (3). So have your patients exert themselves as tolerated, walk around the block a few times per week to get the blood flowing (3, 4).

What about medications?

MEDICATIONS

We can broadly divide anti-hyperglycemics into insulin versus non-insulin based regimens of which there are several (2). Metformin, the first line oral drug of choice is inexpensive, has good efficacy, and is taken by mouth which makes it more palatable to patients compared to insulin therapy; nobody likes injecting themselves daily (2, 5, 6). Caution should be taken with patients with renal or hepatic insufficiency however. Metformin is an insulin-sensitizing biguanide which blocks hepatic gluconeogenesis, decreases GI glucose absorption, and stimulates tissue uptake and glucose utilization (2, 5, 6). As a result, since blockade of hepatic gluconeogenesis leads to lactic acid build up, one of the main side effect concerns is lactic acidosis, making who we give this medication to important. Lactic acidosis is a rare side effect with an incidence of 0.03 cases per 1000 patient years (5, 6). Metformin should not be used in patients with renal and hepatic disease, alcoholism, or diseases that may lead to tissue hypoperfusion e.g. heart failure as these conditions can predispose to lactic acidosis (2, 5, 6).

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.

References:

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.

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jshibata

Editor in Chief of The Original Kings of County
EM/IM PGY4

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3 Comments

jshibata · May 5, 2015 at 8:57 am

Great post Beyda! Every new diabetic should be started on Metformin (unless the kidneys are messed up….). I think we get jaded and think people are not adherent, but like you say, a lot of times people seriously do not know they have diabetes.

I just want to add some tips for the uncontrolled known diabetic:
I’m talking about the patient who’s on metformin 1000 BID and still comes w/ glucose > 500 and has no other abnormalities. She’s smart and doesn’t want to stay in the hospital over the weekend. For this patient, I’m always starting a low dose insulin (0.3mg/kg is safe in Type II diabetics). Although some people say its fine to just start lantus (glargine) 10 units daily (by some people I mean ADA and AAFP). This is a basal or long acting insulin that takes 24 hours and doesn’t peak so it rarely makes people hypoglycemic.

In quadramed, there is an insulin supplies GUI Rx list and you just click on alcohol wipes, lancets, solostar pen, pen needles (just pick the smallest), glucometer and test strips (Truetest is the formulary glucometer at our pharmacy).

We also have care managers 24 hours/day in the ED who will teach patients how to use insulin and make sure an RN visits them at home in a day. I think there is little excuse to admit an uncomplicated pt with only hyperglycemia if they’re intelligent humans and don’t want to stay.

ayk5004 · May 5, 2015 at 12:04 pm

All great points Jackie and, agreed, great job Beyda. I share the above opinion that in the reasonable patient able to comprehend instructions and can get the meds the next day, without any other complicating factors (medical or social), outpatient management should be initiated. My only point is that I don’t think we have care managers 24 hours a day. I haven’t been in the ED in a month, maybe it has changed, or maybe I am wrong all together. However, if you are going to pursue initiating OP treatment with insulin, lets make sure our patients know how to use it and are given appropriate follow up.

Ian deSouza · May 5, 2015 at 12:31 pm

Supposedly there were “diabetes clinics” for a rapid follow-up a few years ago, but I am not sure they exist anymore.