es-dpp4i-eligibility-check

name	es-dpp4i-eligibility-check
description	This skill determines whether a hospitalized adult with type 2 diabetes is eligible for DPP4i initiation based on recent HbA1c <7.5%, blood glucose <180 mg/dL, and, if insulin‑treated pre‑admission, a total daily insulin dose <0.6 units/kg/day. It is triggered by questions such as "Does this patient meet criteria for DPP4i consideration?"

Assess eligibility for DPP4i use based on HbA1c, blood glucose, and pre-admission insulin dose

STEP 1 — Gather Information

• Confirm diagnosis of type 2 diabetes (T2D)
• Obtain most recent HbA1c (within past 3 months)
• Measure current point‑of‑care blood glucose (BG)
• Record patient weight (kg)
• If the patient was on insulin before hospitalization, calculate total daily insulin dose (units/kg/day) from pre‑admission regimen

STEP 2 — Rule In / Rule Out

• Is the patient diagnosed with type 2 diabetes?
  • No → Rule out DPP4i eligibility (not appropriate for T1D or other insulin‑dependent diabetes)
  • Yes → proceed to next step

STEP 3 — Classify or Stratify

• Is HbA1c <7.5% and BG <180 mg/dL?
  • No → Not eligible for DPP4i (glycemic control outside target range)
  • Yes → proceed
• If the patient was on pre‑admission insulin:
  • Calculate total daily insulin dose (units/kg/day)
  • Is dose <0.6 units/kg/day?
    • No → Not eligible (high insulin requirement suggests need for scheduled insulin)
    • Yes → proceed to decision

STEP 4 — Decide

• Eligible for DPP4i consideration (meets all criteria) → suggest DPP4i with correction insulin or consider initiating DPP4i as part of a coordinated transition plan
• Not eligible → continue or initiate scheduled insulin therapy per glycemic management protocol

Clinical Guardrails / Mimics / Pitfalls

• Do not apply to patients with type 1 diabetes or other forms of insulin‑dependent diabetes
• Avoid DPP4i if the patient has a history of pancreatitis or severe renal impairment (eGFR <30 mL/min/1.73 m²) unless dose‑adjusted per drug labeling
• If BG remains ≥180 mg/dL after DPP4i initiation, discontinue and start scheduled insulin therapy
• DPP4i is not recommended for patients with significant risk of hyperglycemia (e.g., active infection, high‑dose glucocorticoids)

Concrete Clinical Example

A 68‑year‑old woman with T2D admitted for community‑acquired pneumonia has weight 70 kg, recent HbA1c 7.2%, admission BG 150 mg/dL, and was on glargine 16 units nightly pre‑admission (total daily dose 0.23 units/kg/day). She meets all criteria (HbA1c <7.5%, BG <180 mg/dL, insulin dose <0.6 units/kg/day) and is deemed eligible for DPP4i consideration.

Source: Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2022, https://doi.org/10.1210/clinem/dgac278

TODO: consider adding scripts/calc.py for the es-dpp4i-eligibility-check calculator