What is the next best step for an 81-year-old male with Diabetes Mellitus type 2 (DM2), dementia, Giant Cell Arteritis (GCA), Polymyalgia Rheumatica (PMR), stenosis of the vertebral artery, Hypertension (HTN), and Benign Prostatic Hyperplasia (BPH) on a sliding scale insulin regimen with Humalog (insulin lispro) and a basal insulin dose of Glargine (insulin glargine) 5 units every morning, who has a current blood glucose level of hyperglycemia?

From the Guidelines

The next best step for this 81-year-old male with hyperglycemia and multiple comorbidities is to increase his basal insulin glargine dose from 5 units to 7-8 units every morning while maintaining his sliding scale Humalog regimen, as suggested by the most recent guidelines 1. This approach aims to balance the need for better glycemic control with the risk of hypoglycemia, particularly in elderly patients with dementia.

Key Considerations

• The patient's current blood glucose level of 24.1 mg/dL indicates the need for adjustment in his insulin regimen.
• Given his age and cognitive impairment, a caregiver should be involved in insulin administration and glucose monitoring to ensure safety and adherence to the treatment plan.
• The patient's complex medical history, including GCA and PMR, which may involve steroid treatment that can worsen hyperglycemia, requires careful glycemic management.
• A less aggressive target blood glucose range of 100-180 mg/dL is appropriate for this elderly patient with multiple comorbidities to balance diabetes control with safety concerns, as indicated by recent clinical practice guidelines 1.

Management Strategy

• Increase basal insulin glargine to 7-8 units every morning.
• Maintain the sliding scale Humalog regimen.
• Increase blood glucose monitoring to at least 3-4 times daily for the next few days to assess the effectiveness of this adjustment.
• Reassess glucose readings after one week on the adjusted regimen to determine if further adjustments are needed, considering the principles outlined in recent studies 1.

Safety and Efficacy

• The adjustment is based on the most recent and highest quality evidence available, prioritizing the patient's morbidity, mortality, and quality of life outcomes.
• The approach considers the potential risks and benefits of insulin therapy in elderly patients with dementia, as discussed in recent literature 1.

From the FDA Drug Label

2.2 General Dosing Instructions • Individualize and adjust the dosage of Insulin Glargine-yfgn based on the patient’s metabolic needs, blood glucose monitoring results and glycemic control goal.

The patient's current blood glucose level is 24.1, which is above the threshold of 20 in the sliding scale.

The next best step is to administer 6 units of Humalog, as indicated by the sliding scale for a blood sugar measurement of 20 or higher, and consider adjusting the dosage of Insulin Glargine-yfgn based on the patient's metabolic needs and blood glucose monitoring results, under medical supervision with appropriate glucose monitoring 2.

From the Research

Patient's Current Condition

The patient is an 81-year-old male with Diabetes Mellitus type 2 (DM2), dementia, Giant Cell Arteritis (GCA), Polymyalgia Rheumatica (PMR), stenosis of the vertebral artery, Hypertension (HTN), and Benign Prostatic Hyperplasia (BPH). He is currently on a sliding scale insulin regimen with Humalog (insulin lispro) and a basal insulin dose of Glargine (insulin glargine) 5 units every morning. His current blood glucose level is 24.1.

Next Best Step

Given the patient's current blood glucose level of 24.1, which is above the threshold of 20 specified in his sliding scale regimen, the next best step would be to administer the corresponding dose of Humalog as per the sliding scale protocol, which in this case would be 6 units 3. However, it is crucial to consider the patient's overall clinical condition, including his dementia and other comorbidities, when making decisions about his insulin therapy.

Considerations for Insulin Therapy

• The use of sliding scale insulin has been associated with a large number of medication errors and adverse events, including hypoglycemia and hyperglycemia 3.
• A basal-bolus insulin strategy might result in better short-term glycemic control but could increase the risk for severe hypoglycemic episodes 4.
• Adopting a proactive approach to managing diabetes, such as using supplemental insulin in conjunction with basal insulin, may be a more effective and safer means of improving glycemic control in hospital 5.

Management of Comorbidities

• The patient's GCA and PMR should be managed with glucocorticoids, and consideration should be given to steroid-sparing adjuvant therapies, such as leflunomide, especially in cases of difficult-to-treat disease 6.
• The patient's stenosis of the vertebral artery, HTN, and BPH should be managed according to standard clinical guidelines, taking into account the patient's overall clinical condition and any potential interactions with his diabetes therapy.

Monitoring and Adjustments

• The patient's blood glucose levels should be closely monitored, and adjustments made to his insulin therapy as needed to maintain adequate glycemic control 3, 4.
• The patient's response to therapy should be regularly assessed, and adjustments made to his treatment regimen as needed to optimize his outcomes.