Should I administer additional insulin (NovoRapid, insulin aspart) to a patient with type 2 diabetes mellitus (DM) and hyperglycemia, who showed no response to an initial dose of 4 units of NovoRapid (insulin aspart)?

Management of Hyperglycemia in a Patient with Asthma Exacerbation on Steroids

You should administer an additional dose of NovoRapid (insulin aspart) since the patient's blood glucose remains elevated at 21 mmol/L after one hour of the initial dose. 1, 2

Rationale for Additional Insulin Dose

When managing steroid-induced hyperglycemia in a patient with type 2 diabetes, particularly during an acute illness like asthma exacerbation:

• The initial dose of 4 units was insufficient to lower the blood glucose level
• Steroids significantly increase insulin resistance and postprandial hyperglycemia
• Persistent hyperglycemia (21 mmol/L) requires prompt intervention to prevent metabolic complications

Recommended Approach

1. Administer an additional 4-6 units of NovoRapid immediately

   • The American Diabetes Association recommends titrating prandial insulin by 1-2 units or 10-15% when blood glucose remains elevated 1
   • For steroid-induced hyperglycemia, more aggressive dosing is often required

2. Monitor blood glucose again in 1-2 hours

   • If still elevated, consider additional correction doses
   • Target glucose range should be 80-130 mg/dL (4.4-7.2 mmol/L) 2

3. Adjust insulin regimen for ongoing steroid therapy

   • Consider implementing a sliding scale insulin protocol during the asthma exacerbation
   • For persistent hyperglycemia, may need to add basal insulin (such as NPH or long-acting analog) 1

Important Considerations

• Low ketones are reassuring but persistent hyperglycemia still requires treatment to prevent progression to diabetic ketoacidosis
• Steroid effect: Glucocorticoids significantly increase postprandial hyperglycemia and insulin requirements 1
• Insulin aspart (NovoRapid) pharmacokinetics: Onset of action is 10-20 minutes with peak effect at 1-3 hours 3
• Risk of stacking insulin doses: While there is a risk of hypoglycemia with multiple rapid-acting insulin doses, the current situation with persistent hyperglycemia and steroid effect warrants additional dosing

Monitoring Plan

• Continue to monitor blood glucose every 1-2 hours until stable
• Assess for symptoms of hyperglycemia (polyuria, polydipsia)
• Monitor for hypoglycemia after insulin administration
• Consider more frequent monitoring overnight as steroid effect continues

Long-term Management During Asthma Exacerbation

If the patient will remain on steroids for the asthma exacerbation:

• Implement a basal-bolus insulin regimen with pre-meal rapid-acting insulin and basal insulin
• Consider NPH insulin in the morning for steroid-induced hyperglycemia 1
• Adjust insulin doses daily based on glucose patterns

Remember that steroid-induced hyperglycemia often requires higher insulin doses than usual, and the effect may persist for the duration of steroid therapy.