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I worry about the algorithm for the management of uncontrolled diabetes in in-patients (figure 1), even despite the fact that it carries the imprimatur of Barts NHS Health Trust. Whilst a glucose of >/= 20 mmol/L may be an appropriate stimulus to action in type 2 diabetes, by the time glucose reaches this level in a patient with type 1 diabetes they could be in well established diabetic ketoacidosis. In fact, because the parameter of principal concern in type 1 diabetes is the blood ketone level, and not glucose, it is difficult to define a level of the latter that should trigger concern, but I would suggest 15 mmol/L is a safer level particularly if on an upward trend .
Other problems with this algorithm include the fact that diabetic ketoacidosis is defined by a pH <7.30, rather then 7.35, and that the algorithm does not indicate what should be done for the not overtly unwell patient with blood ketones >/=1.5 but < 3 mol/L with pH in the normal range.
No competing interests
26 June 2017
Jeremy A Fletcher
Diabetes Centre, Broomfield Hospital, Chelmsford, CM1 7ET