Treating New-Onset Catabolic Type 2 Diabetes With Glargine and Lispro

N.D., a 38-year-old African-American woman, was admitted to the hospital with a plasma glucose level of 793 mg/dl and 2+ urine ketones. She had no history of diabetes and last saw her primary care provider 6 months ago for her annual examination. Her plasma glucose level was normal at that time. She had lost 30 lb in the past 8 weeks, and she reported having had polyuria and polydipsia for 2 weeks. She reported anorexia with very little oral intake for the past 2 days. Her weight was 220 lb (100 kg). Physical examination showed acanthosis nigricans and morbid obesity.She had been given 10 units of regular insulin subcutaneously and 2 l of normal saline intravenously in the emergency department, resulting in a plasma blood glucose of 525 mg/dl. Results of a basic chemistry panel were:1. Sodium: 134 mg/dl2. Potassium: 3.9 mg/dl3. Bicarbonate: 20 mg/dl4. Chloride: 100 mg/dl5. Creatinine: 1.0 mg/dlOvernight, she was given “sliding scale” insulin, 10 units every 6 hours, for glucose levels consistently > 400 mg/dl. The next morning, an insulin drip was started. During the next 24 hours, 100 units of intravenous lispro in a drip resulted in a fasting plasma glucose of 120 mg/dl. Her hemoglobin A1c (A1C) was 12.2%.The next evening, she was given 50 units of glargine with premeal supplements of lispro to a total of 50 units (15 units at breakfast, 15 units at lunch, and 20 units at dinner). Her blood glucose levels now were well controlled without initial hypoglycemia.During the next …