Should I upgrade the insulin regimen for a patient who is NPO (nothing by mouth) and experiencing hyperglycemia?

From the Guidelines

Yes, you should upgrade the insulin regimen for an NPO patient with hyperglycemia. For patients who cannot eat, discontinue or reduce prandial (mealtime) insulin while maintaining or increasing basal insulin coverage. Consider implementing a basal-correction regimen with long-acting insulin like glargine (Lantus) or detemir (Levemir) at their usual dose, plus regular sliding scale insulin with rapid-acting insulin (lispro, aspart, or glulisine) every 4-6 hours based on blood glucose readings, as recommended by the American Diabetes Association standards of medical care in diabetes 1.

Key considerations for managing hyperglycemia in NPO patients include:

• Monitoring blood glucose every 4-6 hours and adjusting the insulin regimen accordingly, aiming for target ranges of 140-180 mg/dL for most hospitalized patients
• Addressing any underlying causes of hyperglycemia, such as stress, steroids, or infection
• Considering IV insulin infusion for severe hyperglycemia (>300 mg/dL) or in critically ill patients, as insulin is the preferred therapy for persistent hyperglycemia 1
• Avoiding the sole use of sliding-scale insulin, as it is strongly discouraged in the inpatient hospital setting 1

By taking a proactive approach to managing hyperglycemia in NPO patients, you can help reduce the risk of complications and improve patient outcomes, as supported by the evidence from the American Diabetes Association standards of medical care in diabetes 1.

From the FDA Drug Label

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 is NPO and experiencing hyperglycemia, upgrading the insulin regimen may be necessary. However, changes to the insulin regimen should be made under close medical supervision to avoid predisposing the patient to further hyperglycemia or hypoglycemia 2.

From the Research

Insulin Regimen for NPO Patient with Hyperglycemia

• The patient's condition of being NPO (nothing by mouth) and experiencing hyperglycemia requires careful consideration of their insulin regimen 3.
• According to the study "Insulin Therapy in Hospitalized Patients" published in the American journal of therapeutics, hyperglycemia is prevalent in hospitalized patients and is associated with increased morbidity and mortality 3.
• The study suggests that insulin therapy is the most appropriate method for controlling glycemia in the hospital setting, but it is associated with an increased risk of hypoglycemia 3.
• A basal-bolus insulin strategy is recommended for non-critically ill patients, as it results in better glycemic control and lower risk of hypoglycemia compared to sliding scale insulin or premixed insulin regimens 3.

Considerations for Insulin Upgrade

• The decision to upgrade the patient's insulin regimen should be based on their individual needs and response to current therapy 4, 5.
• The study "Insulin therapy for type 2 diabetes: rescue, augmentation, and replacement of beta-cell function" published in the American family physician suggests that indications for exogenous insulin therapy in patients with type 2 diabetes include acute illness or surgery, pregnancy, glucose toxicity, and failure to achieve goals with oral antidiabetic medications 4.
• The study "Addition of neutral protamine lispro insulin or insulin glargine to oral type 2 diabetes regimens for patients with suboptimal glycemic control: a randomized trial" published in the Annals of internal medicine found that the addition of long-acting insulin to oral regimens improved glycemic control in patients with type 2 diabetes 5.

Glycemic Targets and Insulin Therapy

• The ideal glucose goals for non-critically ill patients remain undefined and must be individualized according to the patient's characteristics 3.
• A target glucose range of 110-180 mg/dL may be appropriate for most critically ill patients and non-critically ill patients 3.
• The study "EADSG Guidelines: Insulin Therapy in Diabetes" published in Diabetes therapy recommends that an insulin regimen should be adopted and individualized to closely resemble a natural physiologic state and avoid wide fluctuating glucose levels 6.