Should I give Lantus (insulin glargine) to a patient with hyperglycemia who is NPO and has a dose due?

Management of Lantus in NPO Patient with Hyperglycemia

Yes, you should administer the scheduled Lantus dose for a patient with a blood glucose of 360 mg/dL who is NPO, as maintaining basal insulin is essential to prevent further hyperglycemia and potential metabolic decompensation. 1

Rationale for Continuing Basal Insulin

When patients are NPO (nothing by mouth), it's critical to maintain basal insulin coverage while adjusting other components of their insulin regimen:

• Basal insulin (like Lantus/insulin glargine) provides background insulin coverage that helps control hepatic glucose production
• Withholding basal insulin can lead to worsening hyperglycemia, ketosis, and potential diabetic ketoacidosis (DKA)
• The current high blood glucose (360 mg/dL) indicates a need for continued insulin therapy

Dosing Considerations

For NPO patients, the American Diabetes Association recommends the following approach 1:

• Continue basal insulin (Lantus) but consider a dose reduction:
  • Give 60-80% of the usual long-acting insulin analog dose
  • For example, if the patient's usual Lantus dose is 40 units, consider giving 24-32 units
• Monitor blood glucose at least every 4-6 hours while NPO
• Supplement with correctional (sliding scale) short-acting insulin as needed

Monitoring Protocol

After administering the reduced Lantus dose:

• Check blood glucose every 4-6 hours 1
• Watch for signs of hypoglycemia, which is more concerning in NPO patients
• Administer correctional doses of short-acting insulin if blood glucose remains elevated
• Document the patient's response to the adjusted insulin regimen

Special Considerations

Risk of Hypoglycemia

• NPO status increases hypoglycemia risk due to lack of carbohydrate intake
• Insulin glargine (Lantus) has a lower risk of nocturnal hypoglycemia compared to NPH insulin 2
• The midnight timing of the dose may require special attention to overnight monitoring

Avoiding Common Pitfalls

1. Never completely withhold basal insulin in patients with type 1 diabetes - this can rapidly lead to DKA
2. Don't maintain full dose without adjustment - this increases hypoglycemia risk in NPO patients
3. Don't rely solely on sliding scale insulin - basal-bolus regimens have been shown to provide better glycemic control than sliding scale alone 1
4. Don't forget to reassess - the insulin requirements may change based on the patient's clinical condition and when oral intake resumes

Algorithm for Decision-Making

1. Confirm the patient's diabetes type and usual insulin regimen
2. Assess current blood glucose (360 mg/dL indicates significant hyperglycemia)
3. Reduce Lantus dose to 60-80% of usual dose
4. Implement frequent monitoring (every 4-6 hours)
5. Add correctional insulin as needed for persistent hyperglycemia
6. Reassess when patient resumes oral intake

By maintaining a reduced basal insulin dose while the patient is NPO, you provide essential background insulin coverage while minimizing the risk of hypoglycemia, ultimately supporting better glycemic control and patient outcomes.