How to manage a patient with recurrent ketosis and impaired glucose control on their current insulin regimen?

From the Guidelines

The most effective approach for managing a patient with type 1 diabetes and recurrent ketosis despite high doses of subcutaneous basal-bolus insulin is to intensify insulin therapy by adjusting both basal and bolus insulin doses based on blood glucose patterns, and consider adding adjunctive medications or alternative insulin delivery methods, such as insulin pump therapy, as supported by the 2017 American Diabetes Association standards of medical care in diabetes 1.

Key Considerations

• Intensify insulin therapy by adjusting basal and bolus insulin doses based on blood glucose patterns, with a focus on achieving optimal fasting and postprandial glucose levels 1.
• Consider switching to a basal-bolus regimen with long-acting insulin (like glargine or detemir) once daily and rapid-acting insulin (like lispro, aspart, or glulisine) before meals, as recommended by the 2016 American Diabetes Association standards of medical care in diabetes 1.
• Implement more frequent blood glucose monitoring, at least 4-6 times daily, including fasting, pre-meal, and bedtime measurements, to inform insulin dose adjustments and prevent ketosis 1.
• Add regular ketone testing, especially when glucose levels exceed 250 mg/dL, to promptly identify and address ketosis 1.
• Evaluate for insulin pump therapy if appropriate, as it can provide more precise and flexible insulin delivery, reducing the risk of ketosis and improving glucose control 1.

Adjunctive Therapies

• Consider adding adjunctive medications like SGLT-2 inhibitors cautiously, as they may increase ketosis risk, but can also improve glucose control and reduce insulin doses, as noted in the 2017 American Diabetes Association standards of medical care in diabetes 1.
• Provide education on sick day management, including never skipping insulin during illness and increasing fluid intake, to prevent ketosis and ensure optimal glucose control 1.

Insulin Dosing

• Start with 0.5 units/kg/day total insulin, with approximately 50% as basal and 50% as bolus, divided among meals, and adjust doses based on blood glucose patterns and ketone levels, as recommended by the 2016 American Diabetes Association standards of medical care in diabetes 1.
• Consider using a basal-bolus regimen with a single injection of rapid-acting insulin analogue before the largest meal, or adding a GLP-1–receptor agonist, as alternative approaches to intensify insulin therapy, as discussed in the 2017 American Diabetes Association standards of medical care in diabetes 1.

From the FDA Drug Label

Individualize the dosage of Insulin Aspart based on the route of administration, the patient’s metabolic needs, blood glucose monitoring results and glycemic control goal. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness

The approach to managing a patient with recurrent ketosis and impaired glucose control on their current insulin regimen involves individualizing the dosage of Insulin Aspart based on the patient's metabolic needs and blood glucose monitoring results.

• Dosage adjustments may be necessary to achieve optimal glycemic control.
• Consider changes in physical activity, meal patterns, renal or hepatic function, or acute illness that may affect insulin requirements.
• Since the patient and family have confirmed accurate administration of insulin, the focus should be on adjusting the insulin regimen rather than addressing administration issues 2.
• It is also important to consider potential drug interactions that may affect blood glucose control 2.

From the Research

Approach to Managing Persistent Hyperglycemia and Recurrent Ketosis

• In patients with type 1 diabetes, persistent hyperglycemia and recurrent ketosis despite higher doses of subcutaneous basal-bolus insulin require a comprehensive approach to management 3.
• The first step is to confirm accurate administration of insulin by the patient and their family, as well as to review the patient's insulin regimen and adjust as needed.
• Consideration should be given to the use of continuous subcutaneous insulin infusion (CSII) as an alternative to multiple daily injections of basal/bolus insulin, especially in patients with frequent or severe hypoglycemia or pronounced dawn phenomenon 3.
• Basal insulin analogues with a reduced peak profile and an extended duration of action are preferred over older basal insulins due to their clinical advantages, including reduced injection burden, better efficacy, lower risk of hypoglycemic episodes, and reduced weight gain 3.

Adjusting Insulin Regimens

• Insulin regimens should be adjusted every three or four days until targets of self-monitored blood glucose levels are reached, with a fasting and premeal blood glucose goal of 80 to 130 mg per dL and a two-hour postprandial goal of less than 180 mg per dL 4.
• The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases, but overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) is not recommended 5.
• Consideration should be given to the use of more concentrated basal insulin preparations and/or short-acting prandial insulin, as well as other glucose-lowering therapies, in patients who are not meeting individual glycemic targets 5.

Education and Monitoring

• Patient education on insulin dosing based on carbohydrate counting, premeal blood glucose, and anticipated physical activity is paramount, as is education on the management of blood glucose under different circumstances 3.
• Frequent blood glucose measurements and continuous glucose monitoring may improve glycemic control irrespective of treatment regimen 3.
• A glycemic target of glycated hemoglobin < 7% (53 mmol/mol) is appropriate for most nonpregnant adults with type 1 diabetes 3.