How to manage hyperglycemia in a patient on Lantus (insulin glargine) 28 units and Lispro (insulin lispro) 14 units TID?

Management of Hyperglycemia in a Patient on Lantus 28 Units and Lispro 14 Units TID with Blood Sugars 200-350

The patient requires an immediate insulin dose adjustment with a 10-20% increase in both basal and bolus insulin doses to address the persistent hyperglycemia, which poses significant risks for microvascular and macrovascular complications.

Assessment of Current Regimen

The patient is currently on:

• Lantus (insulin glargine): 28 units once daily
• Lispro (insulin lispro): 14 units three times daily (TID) with meals
• Blood glucose readings: 200-350 mg/dL (significantly above target range)

This indicates inadequate glycemic control despite being on both basal and bolus insulin therapy. According to the ADA/EASD guidelines, persistent hyperglycemia with blood glucose levels consistently above 180 mg/dL requires prompt intervention 1.

Step-by-Step Management Approach

1. Immediate Insulin Adjustment

• Basal Insulin (Lantus):

  • Increase by 10-20% (3-6 units) to 31-34 units once daily
  • Consider splitting the dose if dawn phenomenon is suspected 2

• Bolus Insulin (Lispro):

  • Increase by 10-20% (1-3 units per dose) to 15-17 units TID
  • Ensure proper timing (immediately before meals) 1

2. Monitoring Protocol

• Implement intensive blood glucose monitoring:

  • Before meals
  • 2 hours after meals
  • At bedtime
  • Occasionally at 3 AM to detect nocturnal hypoglycemia

• Target blood glucose ranges:

  • Fasting/pre-meal: 80-130 mg/dL
  • Post-meal (2 hours): <180 mg/dL

3. Titration Algorithm

• For Basal Insulin (Lantus):

  • Adjust by 1-2 units (or 5-10% for higher doses) every 3-4 days based on fasting glucose values 1
  • If fasting glucose remains >130 mg/dL for 3 consecutive days, increase dose
  • If any hypoglycemia occurs (<70 mg/dL), reduce dose

• For Bolus Insulin (Lispro):

  • Adjust based on post-meal glucose patterns
  • If post-meal glucose consistently >180 mg/dL, increase pre-meal dose for that specific meal
  • Consider insulin-to-carbohydrate ratios if meal content varies significantly

Important Considerations

Potential Causes of Treatment Failure

1. Insulin Administration Issues:

   • Check injection technique and rotation of sites
   • Verify insulin storage conditions (avoid extreme temperatures)
   • Confirm insulin has not expired

2. Dietary Factors:

   • Assess carbohydrate counting accuracy
   • Evaluate meal timing in relation to insulin administration
   • Consider meal composition (high-fat meals may delay glucose absorption) 3

3. Medication Interactions:

   • Review for medications that may affect glucose control:
     • Corticosteroids, atypical antipsychotics, and sympathomimetics can increase glucose levels 4
     • Beta-blockers may mask hypoglycemia symptoms 4

Avoiding Common Pitfalls

1. Hypoglycemia Risk:

   • Educate patient on hypoglycemia recognition and treatment
   • Ensure patient has fast-acting glucose available at all times
   • Consider timing of insulin glargine administration (bedtime administration may lead to early night hyperglycemia) 5

2. Dawn Phenomenon:

   • If morning glucose levels are disproportionately elevated, consider:
     • Moving Lantus administration to dinner time 2
     • Splitting the Lantus dose (morning and evening)

3. Insulin Stacking:

   • Caution patient about taking additional correction doses too frequently
   • Remind that lispro has a duration of action of 3-5 hours 6

When to Consider Additional Interventions

If blood glucose remains poorly controlled after 1-2 weeks of insulin adjustments:

1. Consider adding non-insulin agents:

   • Metformin (if not contraindicated) as it improves insulin sensitivity
   • Consider GLP-1 receptor agonists to improve postprandial control

2. Evaluate for insulin pump therapy if glucose levels remain erratic despite multiple daily injections

3. Consult endocrinology if blood glucose remains >300 mg/dL despite adjustments or if recurrent hypoglycemia occurs

Remember that insulin requirements may change with illness, stress, changes in physical activity, or weight changes, requiring ongoing adjustments to maintain optimal glycemic control 1.