What to do for a patient with severe hyperglycemia, currently at 500 mg/dL, 1 hour after lunch and 2.5 hours after taking Lispero (insulin lispro) on a sliding scale regimen?

From the Guidelines

For a patient with severe hyperglycemia at 500 mg/dL one hour after lunch and 2.5 hours after taking insulin lispro, immediate intervention is necessary to prevent further complications. Administer a correction dose of rapid-acting insulin (such as insulin lispro) based on the patient's insulin sensitivity factor, typically 1 unit for every 25-50 mg/dL above target, as suggested by recent guidelines 1. Ensure adequate hydration with sugar-free fluids to prevent dehydration. Monitor blood glucose every 1-2 hours until levels decrease below 250 mg/dL, and check for ketones in urine or blood to rule out diabetic ketoacidosis. Contact the healthcare provider to adjust the insulin regimen, as the current sliding scale may be insufficient, considering the recommendations to avoid sliding-scale regular insulin to prevent hypoglycemia and unstable blood glucose levels 1. The high glucose level despite recent insulin administration suggests either insufficient dosing, insulin resistance, excessive carbohydrate intake, or stress-related factors. Once stabilized, review the patient's meal plan, insulin timing, and dosage to prevent future hyperglycemic episodes, taking into account the importance of coordinating food with the type of diabetes medicine for those individuals on medicine 1. If symptoms of severe hyperglycemia (extreme thirst, frequent urination, blurred vision, fatigue) worsen or if ketones are present, emergency medical attention may be required. Key considerations include the patient's overall stability, the effect of hyperglycemia on the clinical condition, and the diabetes treatment method used, such as insulin or oral agents 1. Given the most recent evidence, basal insulin with preprandial correction doses or a basal-bolus insulin regimen may be more effective than sliding-scale insulin alone in achieving glycemic control 1.

From the FDA Drug Label

Instruct patients on handling of special situations such as intercurrent conditions (illness, stress, or emotional disturbances), an inadequate or skipped insulin dose, inadvertent administration of an increased insulin dose, inadequate food intake, and skipped meals. Advise patients that changes in insulin regimen can predispose to hyperglycemia or hypoglycemia and that changes in insulin regimen should be made under close medical supervision [see Warnings and Precautions (5. 2)].

The patient has severe hyperglycemia with a blood glucose level of 500 mg/dL, 1 hour after lunch and 2.5 hours after taking Lispero (insulin lispro) on a sliding scale regimen.

• The patient should be under close medical supervision.
• The patient's insulin regimen may need to be adjusted to prevent further hyperglycemia.
• It is recommended to monitor the patient's blood glucose levels closely and adjust the insulin dose as needed.
• The patient should be instructed on self-management procedures, including glucose monitoring and management of hyperglycemia 2.

From the Research

Patient Assessment

The patient has severe hyperglycemia with a blood glucose level of 500 mg/dL, 1 hour after lunch and 2.5 hours after taking Lispero (insulin lispro) on a sliding scale regimen.

Management Considerations

• The patient's high blood glucose level indicates a need for adjustment in their insulin regimen or other management strategies 3, 4.
• Given the patient's recent lunch and insulin administration, it is essential to monitor their blood glucose levels closely and adjust their insulin doses as needed to prevent further hyperglycemia or potential hypoglycemia 5, 6.
• The use of subcutaneous rapid-acting insulin analogues, such as Lispero, has been studied as an alternative to intravenous insulin infusion for managing diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) 6, 7.
• However, the patient's current situation may require more aggressive management, including intravenous fluids and electrolyte replacement, to address potential dehydration and electrolyte imbalances 4, 5.

Next Steps

• Continue to monitor the patient's blood glucose levels and adjust their insulin regimen as needed to achieve better glycemic control.
• Consider consulting with an endocrinologist or a diabetes specialist to optimize the patient's management plan.
• Evaluate the patient's overall clinical condition, including their hydration status, electrolyte levels, and presence of any complications, to determine the best course of action 3, 4.