What about when these patients present hypoglycemic? Are there any special considerations? (Ex: Recurrent hypoglycemia with the longer acting glimpiride type meds)
Thanks for the question. If a patient presents hypoglycemic with one of the longer acting meds, we should expect it could last about 24 hours. This could be the result of an overdose, an extra dose, or taking the medication without eating. Subcutaneous octreotide should be used (I recommend q6 hours), with supplemental glucose if needed, until the hypoglycemia resolves.
i can imagine it may be a bit difficult to resist CT- scanning a middle aged or older male with significant abdominal pain but only mildly elevated ketones and acidemia. Even if i saw that he was on a SGLT2 inhibitor, it'd be tricky to start treating as a dKA without first imaging? Any thoughts?
Luke - always challenging in any patient with DKA to know if the abdominal pain is from the ketosis or something else. I don't think anyone would blame you if you scanned particularly since infection is the number 1 (or 2 depending on your population) cause of DKA and intra-abdominal infection can easily be missed. If I'm not impressed with the tenderness on my initial exam, I'll often treat and do serial abdominal exams. If the pain is worsening or not improving, I have a low threshold to scan. Hope that helps
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James C. - June 15, 2019 6:53 AM
What about when these patients present hypoglycemic? Are there any special considerations? (Ex: Recurrent hypoglycemia with the longer acting glimpiride type meds)
Bryan H. - June 17, 2019 6:35 AM
Thanks for the question. If a patient presents hypoglycemic with one of the longer acting meds, we should expect it could last about 24 hours. This could be the result of an overdose, an extra dose, or taking the medication without eating. Subcutaneous octreotide should be used (I recommend q6 hours), with supplemental glucose if needed, until the hypoglycemia resolves.
Miguel N. - June 18, 2019 8:20 PM
Typo on the insulin infusion dose. You probably meant insulin infusion rate of 0.1 units/kg/hr instead of 1 unit/kg/hr.
Anand S., M.D. - June 19, 2019 5:41 AM
Thanks for catching this! We will be fixing the written summary shortly
Luke T., Dr - July 2, 2019 10:26 PM
i can imagine it may be a bit difficult to resist CT- scanning a middle aged or older male with significant abdominal pain but only mildly elevated ketones and acidemia. Even if i saw that he was on a SGLT2 inhibitor, it'd be tricky to start treating as a dKA without first imaging? Any thoughts?
Anand S., M.D. - July 3, 2019 1:05 PM
Luke - always challenging in any patient with DKA to know if the abdominal pain is from the ketosis or something else. I don't think anyone would blame you if you scanned particularly since infection is the number 1 (or 2 depending on your population) cause of DKA and intra-abdominal infection can easily be missed.
If I'm not impressed with the tenderness on my initial exam, I'll often treat and do serial abdominal exams. If the pain is worsening or not improving, I have a low threshold to scan.
Hope that helps