What insulin can I start a 54-year-old female patient with hyperglycemia on?

Insulin Therapy for a 54-Year-Old Female with Blood Sugar of 340 mg/dL

For a 54-year-old female patient with a blood sugar of 340 mg/dL, you should start basal insulin glargine at a dose of 10 units or 0.1-0.2 units/kg at bedtime, combined with metformin if not contraindicated. 1

Initial Assessment and Treatment Decision

With a blood glucose level of 340 mg/dL, this patient requires immediate insulin therapy. This level of hyperglycemia indicates:

• Significant insulin deficiency
• Need for prompt intervention to reduce glucose levels
• Risk of complications if left untreated

Insulin Selection Algorithm:

1. First choice: Basal insulin

   • Insulin glargine (Lantus) is preferred due to:
     • Once-daily dosing (typically at bedtime)
     • Lower risk of nocturnal hypoglycemia compared to NPH insulin
     • More consistent 24-hour coverage without pronounced peaks 2
     • Initial dose: 10 units or 0.1-0.2 units/kg body weight 1

2. Dosing calculation example:

   • For a 70 kg patient: 0.1-0.2 units/kg = 7-14 units
   • Start with 10 units at bedtime as a conservative approach

Titration and Follow-up Plan

After initiating basal insulin, implement this titration schedule:

• Adjust dose every 3-7 days based on fasting blood glucose (FBG) measurements:

  • If FBG ≥100-120 mg/dL: Increase by 2 units
  • If FBG ≥120-140 mg/dL: Increase by 4 units
  • If FBG ≥140-180 mg/dL: Increase by 6 units
  • If FBG ≥180 mg/dL: Increase by 8 units 3
  • If any blood glucose <72 mg/dL: Reduce dose by 2-4 units

• Target FBG: <100 mg/dL to achieve HbA1c <7% 3

Monitoring and Potential Regimen Intensification

• Check HbA1c after 3 months of therapy
• If HbA1c remains >7% despite optimized basal insulin:
  • Consider adding prandial insulin (rapid-acting analog like insulin aspart, lispro, or glulisine) before meals 1
  • Alternative: Consider adding a GLP-1 receptor agonist if postprandial hyperglycemia persists 1

Important Considerations and Precautions

• Patient education is essential:

  • Proper insulin injection technique
  • Blood glucose monitoring (at least fasting and bedtime initially)
  • Recognition and treatment of hypoglycemia
  • Sick day management

• Common pitfalls to avoid:

  • Underdosing: Starting with too low a dose and failing to titrate aggressively enough
  • Delayed intensification: Not adding prandial insulin when basal insulin alone is insufficient
  • Hypoglycemia risk: Particularly nocturnal hypoglycemia when using NPH instead of glargine 4
  • Missing concurrent causes: Not addressing other factors that may be causing hyperglycemia (infection, medications like steroids)

• Metformin consideration:

  • Continue or initiate metformin unless contraindicated (renal dysfunction, heart failure, etc.)
  • Combination of basal insulin with metformin is more effective than insulin alone 1

By following this approach, you can effectively manage this patient's significant hyperglycemia while minimizing the risk of hypoglycemia and working toward optimal glycemic control.