Is 20 units of Glargine (insulin glargine) adequate for a patient with hyperglycemia who is NPO (nothing by mouth) and on a sliding scale regimen?

From the Guidelines

A fixed dose of 20 units of insulin glargine is not adequate as the sole treatment for a hospitalized NPO patient with hyperglycemia, and a combination of basal insulin and correctional sliding scale insulin regimen is recommended. The patient needs both basal insulin (glargine) and a correctional sliding scale insulin regimen to manage their hyperglycemia effectively. For NPO patients, the total daily insulin dose should typically be reduced by 20-30% from their usual requirements, with about 50-80% given as basal insulin and the remainder as correctional doses 1. The appropriate glargine dose depends on the patient's weight, prior insulin requirements, kidney function, and severity of illness. Without knowing these patient-specific factors, 20 units might be too high or too low.

According to the American Diabetes Association (ADA) and other guidelines, basal, prandial, and correction insulin are recommended for non-critically ill patients, and the treatment should be individualized based on the patient's circumstances 1. Additionally, the sliding scale should use rapid-acting insulin (like lispro or aspart) administered every 4-6 hours based on blood glucose readings. Close monitoring with frequent blood glucose checks is essential, as NPO status increases hypoglycemia risk. The regimen should be reassessed daily and adjusted based on the patient's glycemic patterns to maintain blood glucose between 140-180 mg/dL for most hospitalized patients.

The patient's current FSBS of 155mg/dl indicates mild hyperglycemia, and according to the guidelines, consideration should be given to low-dose basal insulin or oral antidiabetic agents, along with correction doses of rapid-acting insulin 1. However, since the patient is NPO, oral antidiabetic agents may not be suitable, and insulin therapy should be prioritized. The patient's glargine dose of 20 units due tonight should be reassessed, and a sliding scale insulin regimen should be initiated to manage their hyperglycemia effectively.

Key considerations in managing this patient's hyperglycemia include:

• Close monitoring of blood glucose levels
• Adjustment of the insulin regimen based on the patient's glycemic patterns
• Use of rapid-acting insulin for correctional doses
• Individualization of the treatment plan based on the patient's weight, prior insulin requirements, kidney function, and severity of illness
• Maintenance of blood glucose levels between 140-180 mg/dL for most hospitalized patients.

From the Research

Determining Adequate Insulin Dosing

To determine if 20 units of Glargine (insulin glargine) is adequate for a patient with hyperglycemia who is NPO (nothing by mouth) and on a sliding scale regimen, several factors must be considered:

• The patient's current blood glucose level, which is 155mg/dl
• The patient's insulin regimen, including the use of Glargine and a sliding scale
• The patient's overall health status and any other medications they may be taking

Considerations for Insulin Dosing

The following points should be considered when determining adequate insulin dosing:

• According to the study 2, adequate titration of the insulin dose can help patients reach treatment goals, including HbA(1c) <7% and FBG <5.5 mmol/L (<100 mg/dL)
• The study 3 recommends an initial daily insulin dose of 0.5 units/kg bodyweight if not on insulin, and a greater than 30% increase in pre-prednisolone insulin dose for patients with prednisolone-induced hyperglycaemia
• The use of a standardized protocol for sliding scale insulin can help decrease medication errors and adverse events related to hyperglycemia and hypoglycemia, as shown in the study 4
• The study 5 found that sliding scale insulin regimens were associated with a 3-fold higher risk of hyperglycemic episodes compared to individuals following no pharmacologic regimen

Sliding Scale Insulin Regimens

The following points should be considered when using sliding scale insulin regimens:

• The study 5 found that suboptimal glycemic control is common in medical inpatients with diabetes mellitus, and that the risk of suboptimal control is associated with selected demographic and clinical characteristics
• The study 6 found that adding insulin glargine is more likely to achieve a lower HbA(1c) level than conventional therapy with oral agents
• The use of insulin glargine in combination with a sliding scale regimen may be effective in achieving glycemic control, as shown in the study 2

Conclusion Not Provided

As per the instructions, no conclusion will be provided. The information above is intended to provide a summary of the relevant studies and considerations for determining adequate insulin dosing.