What is the appropriate insulin dose for a critically ill patient with hyperglycemia?

From the Guidelines

Insulin therapy should be initiated for critically ill patients with hyperglycemia at a threshold of ≥180 mg/dL, with a target glucose range of 140–180 mg/dL.

Key Considerations

• The target glucose range of 140–180 mg/dL is recommended for the majority of critically ill patients, as it balances the benefits of glycemic control with the risks of hypoglycemia 1.
• More stringent goals, such as 110–140 mg/dL, may be appropriate for selected patients, such as those undergoing cardiac surgery, if they can be achieved without significant hypoglycemia 1.
• The NICE-SUGAR trial and subsequent meta-analyses have shown that intensive glycemic control increases mortality and causes higher rates of hypoglycemia compared to more moderate glycemic targets 1.
• Clinical judgment and ongoing assessment of clinical status should guide day-to-day decisions regarding insulin dosing, taking into account factors such as illness severity, nutritional status, and concomitant medications 1.
• The recommended target glucose range may vary depending on the patient's condition, with higher glucose ranges (up to 250 mg/dL) potentially acceptable in patients with severe comorbidities or short life expectancy 1.

Insulin Dosing

• The specific insulin dose will depend on the individual patient's needs and response to therapy, but the goal is to achieve a glucose range of 140–180 mg/dL without causing significant hypoglycemia.
• Regular monitoring of blood glucose levels is essential to adjust insulin dosing and prevent hypoglycemia 1.

From the FDA Drug Label

The intravenous administration of Humulin R U-100 was tested in 21 patients with type 1 diabetes ... During the assessment phase patients received intravenous Humulin R at an initial dose of 0.5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL).

The appropriate insulin dose for a critically ill patient with hyperglycemia is not directly stated in the provided drug labels. However, based on the information provided, an initial dose of 0.5 U/h of intravenous Humulin R U-100 was used in a study to maintain blood glucose concentrations near normoglycemia in patients with type 1 diabetes 2.

• The dose was adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL).
• It is essential to note that the dose may need to be individualized and adjusted based on the patient's response and blood glucose levels.
• The provided information does not specifically address the treatment of critically ill patients with hyperglycemia, and therefore, the dose may not be directly applicable to this population 2.

From the Research

Insulin Dose for Critically Ill Patients with Hyperglycemia

• The optimal insulin dose for critically ill patients with hyperglycemia is not clearly established, but several studies provide guidance on glycemic targets and insulin therapy 3, 4, 5, 6, 7.
• According to a study published in 2020, continuous intravenous insulin infusion is the best method for achieving glycemic targets in critically ill patients, with a target glucose range of 110-180 mg/dL 5.
• Another study published in 2019 recommends treating hyperglycemia after two consecutive glucose levels >180 mg/dL, with target levels of 140-180 mg/dL for most patients 4.
• A 2016 review suggests that in critically ill patients, intravenous insulin is most appropriate, with a starting threshold no higher than 180 mg/dL, and a maintenance target of 140-180 mg/dL 6.
• A landmark study published in 2001 demonstrated that intensive insulin therapy to maintain blood glucose at or below 110 mg/dL reduces morbidity and mortality among critically ill patients in the surgical intensive care unit 7.
• However, more recent studies have raised concerns about the risks of hypoglycemia associated with tight glycemic control, and suggest that a more moderate target range of 140-180 mg/dL may be more appropriate for most critically ill patients 3, 4, 5, 6.

Glycemic Targets and Insulin Therapy

• The optimal glycemic target for critically ill patients is still a matter of debate, but most studies suggest a target range of 140-180 mg/dL 3, 4, 5, 6.
• Insulin therapy is the most appropriate method for controlling glycemia in hospitalized patients, but it is associated with an increased risk of hypoglycemia 5.
• Continuous intravenous insulin infusion and scheduled basal-bolus-correction insulin are the preferred modalities for glycemic control in critically and noncritically ill hospitalized patients, respectively 5.
• The use of continuous or near-continuous glucose monitoring combined with computerized insulin titration algorithms may be required to achieve complex glycemic targets in critically ill patients 3.