How to manage a patient on Tresiba (insulin degludec) 20 units and Humulin (human insulin) 24 units with hyperglycemia (pre-breakfast glucose 28.4 mmol/L)?

Management of Severe Hyperglycemia in a Patient on Basal-Bolus Insulin

For a patient on Tresiba 20 units and Humulin 24 units with a pre-breakfast glucose of 28.4 mmol/L, immediate intensification of insulin therapy is required, specifically by increasing the basal insulin (Tresiba) dose by 4-6 units and adding prandial insulin coverage before each meal.

Assessment of Current Regimen

The patient's current insulin regimen consists of:

• Tresiba (insulin degludec) 20 units - a long-acting basal insulin
• Humulin 24 units - likely referring to Humulin R (regular human insulin) used as bolus/prandial insulin

The pre-breakfast glucose of 28.4 mmol/L (approximately 511 mg/dL) indicates severe hyperglycemia that requires immediate intervention to reduce the risk of diabetic complications.

Recommended Management Approach

Step 1: Adjust Basal Insulin

• Increase Tresiba (insulin degludec) dose by 4-6 units (20% increase) 1
• Current dose of 20 units appears insufficient to control overnight hepatic glucose production
• Titrate by adding 2 units every 3-4 days until fasting glucose improves 1

Step 2: Optimize Prandial Insulin Coverage

• Ensure Humulin is being administered before meals (not just once daily)
• Implement a structured prandial insulin regimen:
  • Breakfast: 8-10 units (or 30-35% of total daily prandial dose)
  • Lunch: 6-8 units (or 25-30% of total daily prandial dose)
  • Dinner: 8-10 units (or 30-35% of total daily prandial dose) 1
• Consider switching from Humulin R to a rapid-acting insulin analog if available, as it provides better postprandial glucose control 1

Step 3: Implement Self-Monitoring Protocol

• Check blood glucose 4 times daily (before each meal and at bedtime)
• Add occasional 2-hour post-meal checks to assess prandial insulin adequacy
• Consider continuous glucose monitoring if available 1

Step 4: Titration Algorithm

• For basal insulin: Increase by 2 units every 3-4 days until fasting glucose reaches target (<7 mmol/L)
• For prandial insulin: Adjust individual meal doses based on pre-meal and 2-hour post-meal readings
• If pre-breakfast glucose remains >10 mmol/L despite basal insulin increases, assess for the "dawn phenomenon" and consider increasing evening basal dose or adding bedtime intermediate-acting insulin 1

Clinical Considerations

Signs of Overbasalization to Monitor

• Watch for clinical signals that might indicate overbasalization as you increase the basal dose:
  • Large difference between bedtime and morning glucose
  • Hypoglycemia during the night or between meals
  • High glucose variability 1

Potential Pitfalls and Caveats

1. Avoid excessive basal insulin: When basal insulin exceeds 0.5 units/kg/day without achieving target fasting glucose, consider adding more prandial coverage rather than continuing to increase basal insulin 1

2. Rule out intercurrent illness: Severe hyperglycemia may indicate an underlying infection or other acute illness that requires treatment 1

3. Assess injection technique: Ensure proper rotation of injection sites and correct administration technique 1

4. Consider insulin resistance: With such high glucose levels, evaluate for factors contributing to insulin resistance (infection, medications, stress) 1

5. Medication adherence: Verify that the patient is actually taking insulin as prescribed 1

If glucose levels do not improve within 48-72 hours despite these adjustments, or if the patient develops symptoms of diabetic ketoacidosis (nausea, vomiting, abdominal pain), immediate medical attention is required.