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Answer 3
  1. Insulin glargine and insulin lispro. This patient with no prior history of diabetes presents with DKA. Physical examination is consistent with insulin resistance as evidenced by his obesity and significant acanthosis nigricans. The very high HbA1c level indicates that the patient has been extremely hyperglycemic for some time. Based on current guidelines, patients with diabetes who are naive to therapy with an HbA1c level greater than 10% should be started primarily on insulin therapy.5 The most effective means of treating hyperglycemia in an insulin-deficient patient recovering from DKA is to start both basal and prandial insulin to mimic physiologic insulin release. Overestimating the patient’s basal or prandial insulin requirements can result in hypoglycemia. Many patients with severe insulin resistance also benefit from an insulin sensitizer such as metformin or pioglitazone. However, these therapies would not be sufficient to treat this patient’s extreme glucose toxicity. Metformin is a well-tolerated insulin sensitizer, but its use is limited by renal insufficiency and the risk of lactic acidosis and should be avoided during recovery from DKA. Glyburide has little role in treating this patient at this time. Although DKA is commonly seen in patients with type 1 diabetes, this patient most likely has type 2 diabetes given that he has a phenotype consistent with insulin resistance and negative titers of glutamic acid decarboxylase and islet cell antibodies.

    5. Jellinger PS, Davidson JA, Blonde L, et al. Road maps to achieve glycemic control in type 2 diabetes mellitus. ACE/AACE Diabetes Road Map Task Force. Endocr Pract 2007;13:260–8.

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