What is the significance of hyperglycemia persisting after insulin administration?

From the Guidelines

Hyperglycemia persisting after insulin administration is a significant concern that requires immediate attention, as it may indicate insufficient insulin dosing or an underlying acute illness, and a target glucose range of 140–180 mg/dL is recommended for the majority of patients. According to the standards of medical care in diabetes-2020 1, insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dL. The study suggests that a more stringent goal, such as 110–140 mg/dL, may be appropriate for selected patients if they can be achieved without significant hypoglycemia. However, the findings from the NICE-SUGAR trial, as mentioned in the study 1, indicate that tight glycemic control may increase mortality compared to more moderate glycemic targets and generally causes higher rates of hypoglycemia.

Some key points to consider in managing hyperglycemia include:

• Monitoring blood glucose levels regularly to assess the effectiveness of insulin therapy
• Adjusting insulin dosing as needed to achieve the target glucose range
• Ensuring the patient is well-hydrated, as dehydration can worsen hyperglycemia and insulin resistance
• Considering the potential for underlying acute illness or stress response that may be driving up blood glucose levels
• Being cautious of the risk of hypoglycemia, particularly when aiming for more stringent glucose targets, as evidenced by the NICE-SUGAR trial 1.

In clinical practice, it is essential to balance the benefits of glycemic control with the risks of hypoglycemia, and the recommended target glucose range of 140–180 mg/dL 1 provides a reasonable goal for most patients. By prioritizing this target range and carefully monitoring blood glucose levels, healthcare providers can minimize the risks associated with hyperglycemia and hypoglycemia, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Changes in an insulin regimen (e.g., insulin strength, manufacturer, type, injection site or method of administration) may affect glycemic control and predispose to hypoglycemia [see Warnings and Precautions (5. 3)] or hyperglycemia. Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia;

The significance of hyperglycemia persisting after insulin administration is that it may indicate a problem with the insulin regimen or injection site, such as lipodystrophy or localized cutaneous amyloidosis, which can affect glycemic control.

• Key factors to consider include changes in insulin regimen, injection site, or method of administration.
• Monitoring blood glucose levels is essential to identify and manage hyperglycemia. 2 2

From the Research

Significance of Hyperglycemia Persisting After Insulin Administration

• Hyperglycemia persisting after insulin administration can be a significant concern, as it may indicate inadequate insulin dosage or ineffective insulin therapy 3, 4.
• In some cases, hyperglycemia may persist despite insulin administration due to various factors such as infection, which was found to be a common precipitating condition for hyperglycemic crisis in a study published in 2020 3.
• The significance of hyperglycemia persisting after insulin administration can be evaluated by monitoring blood glucose levels and adjusting insulin dosage accordingly 5.
• Effective insulin therapy requires frequent adjustments to insulin dosage, and glucose readings can be sufficient to adjust insulin dosage provided that adjustments are made every 1-4 weeks 5.

Factors Contributing to Hyperglycemia Persisting After Insulin Administration

• Infection can be a major contributing factor to hyperglycemia persisting after insulin administration, as it can lead to increased glucose production and decreased insulin sensitivity 3.
• Inadequate insulin dosage or ineffective insulin therapy can also contribute to hyperglycemia persisting after insulin administration 4.
• Other factors such as glucose toxicity, contraindications to or failure to achieve goals with oral antidiabetic medications, and a need for flexible therapy can also contribute to hyperglycemia persisting after insulin administration 4.

Management of Hyperglycemia Persisting After Insulin Administration

• Adjusting insulin dosage based on glucose readings can be an effective way to manage hyperglycemia persisting after insulin administration 5.
• Using rapid-acting insulin analogues such as insulin lispro and insulin aspart can help to improve glycemic control and reduce the risk of hypoglycemia 6, 7.
• Individualizing insulin regimens and adopting a treatment plan that closely resembles a natural physiologic state can also help to manage hyperglycemia persisting after insulin administration 4.