What adjustments should be made to a patient with Type 2 Diabetes Mellitus (T2DM) on Humalog (insulin lispro) and Lantus (insulin glargine) with hyperglycemia and normal ketone levels?

Management of Hyperglycemia in a T2DM Patient with Normal Ketones

For a patient with Type 2 Diabetes Mellitus on insulin therapy (Humalog and Lantus) with blood glucose readings of 21 mmol/L (378 mg/dL) followed by 17 mmol/L (306 mg/dL) and normal ketones, the insulin regimen should be intensified by increasing the basal insulin dose by 10-20% and adding supplemental rapid-acting insulin to address the persistent hyperglycemia.

Assessment of the Current Situation

This patient presents with:

• Type 2 Diabetes Mellitus
• Current insulin regimen: Humalog (rapid-acting) with meals and Lantus (basal) in the evening
• Significant hyperglycemia: blood glucose readings of 21 mmol/L and 17 mmol/L
• Normal ketone levels (ruling out diabetic ketoacidosis)

Immediate Management

1. Increase basal insulin (Lantus):

   • Increase evening Lantus dose by 10-20% 1
   • For example, if current dose is 20 units, increase to 22-24 units

2. Adjust prandial insulin (Humalog):

   • Increase mealtime Humalog doses by 10-15% 1
   • Consider adding correction doses based on pre-meal glucose readings

3. Add supplemental insulin:

   • If pre-meal glucose >14 mmol/L (250 mg/dL), add correction doses using the formula:
     • Correction dose = (Current glucose - Target glucose) ÷ Correction factor
     • Typical correction factor: 1 unit lowers glucose by 2-3 mmol/L (36-54 mg/dL)

Titration Algorithm

1. For basal insulin (Lantus):

   • Titrate by 2-4 units every 3-7 days until fasting glucose is 4.4-7.2 mmol/L (80-130 mg/dL) 1
   • Maximum dose should generally not exceed 0.5 units/kg/day to avoid overbasalization 1

2. For mealtime insulin (Humalog):

   • Adjust doses based on pre-meal and 2-hour post-meal glucose readings
   • Target post-meal glucose <10 mmol/L (180 mg/dL) 1

Monitoring Protocol

1. Immediate monitoring:

   • Check blood glucose every 4-6 hours until readings are <14 mmol/L (250 mg/dL)
   • Monitor for symptoms of hypoglycemia

2. Ongoing monitoring:

   • Check fasting glucose daily
   • Check pre-meal and 2-hour post-meal glucose at least once daily
   • Rotate testing times to capture different meal responses

Important Considerations

Avoid Common Pitfalls

1. Avoid overbasalization:

   • Don't rely solely on increasing basal insulin when postprandial hyperglycemia is the issue 1
   • If basal dose exceeds 0.5 units/kg/day, consider redistributing insulin to bolus doses

2. Rule out insulin administration issues:

   • Check for lipohypertrophy at injection sites 2
   • Ensure proper injection technique and site rotation
   • Verify insulin storage conditions (avoid extreme temperatures)

3. Consider insulin resistance factors:

   • Infection or illness
   • Medication effects (steroids, etc.)
   • Stress or recent surgery

Alternative Approaches

If the patient struggles with multiple daily injections or complex regimens:

1. Consider premixed insulin:

   • Switch to twice-daily premixed insulin (70/30 or 75/25) 3, 1
   • Starting dose: Calculate total daily insulin and divide into 2/3 morning, 1/3 evening

2. Consider adding non-insulin agents:

   • Metformin (if not contraindicated) can reduce insulin requirements 2
   • GLP-1 receptor agonists can improve glycemic control with less hypoglycemia risk 1

Education Points for Patient

1. Ensure consistent meal timing and carbohydrate content
2. Teach proper blood glucose monitoring techniques
3. Review hypoglycemia recognition and treatment
4. Emphasize the importance of injection site rotation

By implementing these adjustments systematically and monitoring closely, the patient's blood glucose levels should improve while minimizing the risk of hypoglycemia.