What is the best course of action for a patient with persistent hyperglycemia despite being on insulin?

Management of Persistent Hyperglycemia Despite Insulin Therapy

For a patient with persistent hyperglycemia (blood glucose 416 mg/dL) despite being on insulin for 3 days, the most appropriate action is to implement a basal-bolus insulin regimen with proper dose adjustment rather than continuing with the current ineffective insulin approach.

Assessment of Current Insulin Regimen

When a patient remains significantly hyperglycemic despite insulin therapy, several factors need to be evaluated:

1. Current insulin regimen assessment:

   • Determine if the patient is on a basal-bolus regimen or just sliding scale insulin
   • Sliding scale insulin alone is strongly discouraged as monotherapy 1
   • Check timing of insulin administration relative to meals

2. Insulin dosing evaluation:

   • Calculate if the total daily dose is appropriate (typically 0.3-0.4 U/kg/day for severe hyperglycemia) 1
   • Assess distribution between basal and bolus insulin components
   • Verify administration technique and insulin storage

Recommended Approach

Step 1: Implement Proper Insulin Regimen

• For severe hyperglycemia (>300 mg/dL): Implement a basal-bolus insulin regimen 1
• Total daily dose: Start with 0.3-0.4 U/kg/day for severe hyperglycemia 1
• Distribution: 50% as basal insulin, 50% as prandial insulin divided between meals 1

Step 2: Set Appropriate Glycemic Targets

• Target blood glucose range of 140-180 mg/dL 1
• Initiate insulin therapy for persistent hyperglycemia starting at threshold ≥180 mg/dL 1

Step 3: Insulin Administration Schedule

• Basal insulin: Administer once daily at same time each day 2
• Prandial insulin: Administer 5-10 minutes before meals 3
• Correction insulin: Add supplemental correction doses to address pre-meal hyperglycemia 1

Step 4: Titration Protocol

• Basal insulin: Increase by 2-4 units every 1-2 days until fasting glucose is at target 2
• Bolus insulin: Adjust based on pre-meal and post-meal glucose values 2
• Correction factor: Use the 1800 rule (1800 ÷ total daily insulin dose = mg/dL drop per 1 unit) 4

Special Considerations

For Hospitalized Patients

• Consider consulting with specialized diabetes or glucose management team 1
• Use validated written or computerized protocols for insulin dosage adjustments 1
• Monitor glucose before meals and every 4-6 hours if not eating 1

Common Pitfalls to Avoid

1. Relying solely on sliding scale insulin - This reactive approach fails to provide basal coverage and leads to glucose fluctuations 1
2. Inadequate total insulin dose - Underdosing is common when hyperglycemia persists 1
3. Failure to adjust both basal and bolus components - Both components need regular adjustment 1
4. Not accounting for insulin resistance - Severe hyperglycemia may require higher initial doses 1
5. Overlooking medication adherence issues - Verify insulin is being administered as prescribed

Monitoring Response

• Monitor blood glucose before meals and at bedtime
• Evaluate pattern of glucose values to determine which component of insulin regimen needs adjustment
• Consider more frequent monitoring during dose titration phase
• Target pre-meal glucose <140 mg/dL and random glucose <180 mg/dL 1

By implementing a structured basal-bolus insulin regimen with appropriate dose titration, most patients with persistent hyperglycemia will achieve target glucose levels within several days.