36
Treatment
Table 4. Endocrine Toxicities
G2: Moderate symptoms, able
to perform ADL; T2DM with
fasting glucose value >160
to 250 mg/dL (>8.9–13.9
mmol/L). No ketoacidosis or
metabolic derangements but
other evidence of CIADM at
any glucose level.
• May hold ICPi until glucose control is obtained.
• Urgent endocrine consultation for any patient with
new-onset CIADM.
• Initiate insulin for CIADM (or as default therapy if
there is any question about the diagnosis).
• Referral to ED or hospital admission if unable
to initiate therapy, urgent outpatient specialist
evaluation is not available, developing ketoacidosis
or other concern for CIADM.
G3–4: Severe symptoms,
medically significant or life-
threatening consequences,
unable to perform ADL;
G3: >250–500 mg/dL
(>13.9–27.8 mmol/L);
G4: >500 mg/dL (>27.8
mmol/L). Ketoacidosis or
other metabolic abnormality.
• Hold ICPi until glucose control is obtained with
reduction of toxicity to ≤G1.
• Admit for inpatient management of DKA, volume
and electrolyte resuscitation and insulin initiation.
• Endocrine consultation for all patients.
• Insulin therapy appropriate for all patients.
Additional considerations:
• Insulin therapy should be used in any case with significant hyperglycemia pending
additional diagnostic work up if mechanism of DM is not known.
• Long-acting insulin therapy alone is not sufficient for CIADM because of the
absence of pancreatic function after beta-cell destruction.
▶ Starting total daily requirement can be estimated at 0.3–0.4 units/kg/day.
▶ Half of daily requirements are typically given in divided doses as prandial coverage
while half should be administered as a once daily long-acting homologue. This
requires self-monitoring 4 or more times daily or the use of a continuous glucose
monitor.
▶ Sliding scale insulin can be used in conjunction with multiple daily injection
regimens to accommodate the variability in glucose levels.
▶ Decreased requirements after the initial acute admission for DKA are commonly
seen in the so-called honeymoon period.
▶ Education is critical to learn skills like responding to hypoglycemia, anticipating
exercise, monitoring for DKA, or carbohydrate counting and to transition to
technologies such as insulin pumps. Early endocrinolog y consultation is a high
priority for all patients.
• T2DM patients will need to increase the frequency of self-monitoring as therapy
intensifies and agents that can cause hypoglycemia are added to their regimen.
• Steroids can exacerbate post-prandial hyperglycemia and endocrinolog y consult
should be considered for initiating or managing insulin in patients with T2DM being
started on high dose steroids. If insulin is used, the doses generally need to be adjusted
again as steroids are tapered down.
(cont'd)
