What adjustments should be made to a patient's current medication regimen of Lantis (insulin glargine) 25 units at bedtime and Humalog (insulin lispro) 4 units at lunchtime, given stage three renal failure and uncontrolled hyperglycemia with blood glucose levels ranging from 300 to 400 mg/dL?

Insulin Adjustment for Stage 3 Renal Failure with Uncontrolled Hyperglycemia

The patient's insulin regimen requires significant intensification with both increased basal insulin and additional mealtime insulin coverage to address the severely uncontrolled hyperglycemia (300-400 mg/dL), while being cautious due to stage 3 renal failure.

Current Medication Assessment

The patient is currently on:

• Lantus (insulin glargine) 25 units at bedtime
• Humalog (insulin lispro) 4 units at lunchtime only

This regimen is clearly insufficient given the persistent hyperglycemia.

Recommended Insulin Adjustments

Basal Insulin Adjustment

• Increase Lantus from 25 units to 35 units at bedtime (40% increase)
• This conservative increase accounts for reduced insulin clearance in renal failure while addressing the need for better 24-hour glucose control 1

Bolus Insulin Adjustment

• Add Humalog before breakfast: Start with 6 units
• Increase lunchtime Humalog from 4 units to 8 units
• Add Humalog before dinner: Start with 6 units
• This provides coverage for all meals, addressing the significant postprandial hyperglycemia 1, 2

Titration Protocol

• Adjust basal insulin by 2-4 units every 3-4 days based on fasting glucose:

  • If FBG >180 mg/dL: Increase by 4 units
  • If FBG 140-179 mg/dL: Increase by 2 units
  • If FBG 100-139 mg/dL: No change
  • If FBG <100 mg/dL: Decrease by 2 units 2

• Adjust mealtime insulin by 1-2 units every 3 days based on 2-hour postprandial readings:

  • If >200 mg/dL: Increase by 2 units
  • If 140-200 mg/dL: Increase by 1 unit
  • If <140 mg/dL: No change 2

Special Considerations for Renal Failure

• Hypoglycemia Risk: Patients with stage 3 renal failure have increased risk of hypoglycemia due to decreased insulin clearance and impaired renal gluconeogenesis 1
• Monitoring: Increase blood glucose monitoring frequency to at least 4 times daily (before meals and bedtime)
• Nighttime Hypoglycemia: Be particularly vigilant about nocturnal hypoglycemia, which is more common in renal failure 1, 2
• Insulin Accumulation: The half-life of insulin is prolonged in renal failure, requiring more conservative dosing and careful titration 1

Additional Medication Considerations

• SGLT2 Inhibitor: Consider adding an SGLT2 inhibitor (e.g., dapagliflozin 10mg daily) if eGFR ≥30 ml/min/1.73m², which can improve glycemic control and provide cardiovascular and renal benefits 1
• Metformin: If not already on metformin, consider adding it if eGFR ≥30 ml/min/1.73m² at a reduced dose (maximum 1000 mg/day) 1
• GLP-1 Receptor Agonist: Consider as an alternative add-on therapy to reduce insulin requirements and minimize hypoglycemia risk 2

Monitoring Plan

• Blood glucose monitoring: Before meals and at bedtime
• Renal function: Check eGFR every 3 months
• HbA1c: Every 3 months
• Hypoglycemia symptoms education
• Ensure patient carries fast-acting carbohydrates at all times

Cautions and Pitfalls

• Overbasalization: Avoid excessive basal insulin that can lead to nocturnal hypoglycemia
• Medication Timing: Ensure consistent timing of insulin administration relative to meals
• Sick Day Management: Provide specific instructions for insulin adjustment during illness
• Renal Function Decline: Be prepared to further reduce insulin doses if renal function worsens

This approach balances the need for improved glycemic control with the increased risk of hypoglycemia in renal failure, providing a structured framework for safe insulin intensification.