How to transition and manage hyperglycemia in a patient with Type 2 Diabetes Mellitus (T2DM) on Lantus (insulin glargine) who underwent Coronary Artery Bypass Grafting (CABG) and is currently on insulin drip (gtt) with elevated blood sugars?

From the Guidelines

For a patient with T2DM previously on 66 units of Lantus who underwent CABG and now has blood sugars in the 300s on an insulin drip in the ICU, I recommend implementing a structured transition plan based on the most recent evidence from 2023 1.

Key Considerations

• Continue the insulin infusion until blood glucose levels stabilize between 140-180 mg/dL for at least 4-6 hours, as recommended by recent guidelines 1.
• Restart the patient on 80% of their home Lantus dose (approximately 50-55 units) the evening before discontinuing the insulin drip, considering the patient's pre-admission regimen and inpatient response to therapy 1.
• The morning after Lantus administration, if glucose levels remain stable, the insulin drip can be discontinued, and a correctional insulin scale using rapid-acting insulin (like Novolog or Humalog) can be added for any glucose readings above 180 mg/dL, as suggested by recent studies 1.

Monitoring and Adjustments

• Monitor blood glucose every 4 hours initially, then adjust to every 6 hours if stable, taking into account the patient's nutritional status and potential steroid use, which may increase insulin requirements 1.
• If the patient begins eating, add mealtime insulin at 0.1 units/kg per meal, considering the patient's individual needs and response to therapy 1.

Discharge Planning

• A structured discharge plan should be tailored to the individual patient, including diabetes education and support, to achieve blood glucose targets and avoid long-term complications 1.
• Pharmacotherapy adjustment at the time of discharge should take into account the patient's home regimen before admission, cardiorenal risk, inpatient response to therapy, and recent HbA1c measurements, as recommended by recent guidelines 1.

From the FDA Drug Label

During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring [see Warnings and Precautions (5. 2)]. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), during acute illness, or changes in renal or hepatic function. Dosage adjustments should only be made under medical supervision with appropriate glucose monitoring [see Warnings and Precautions (5.2)].

To transition and manage hyperglycemia in a patient with Type 2 Diabetes Mellitus (T2DM) on Lantus (insulin glargine) who underwent Coronary Artery Bypass Grafting (CABG) and is currently on insulin drip (gtt) with elevated blood sugars,

• Monitor blood glucose levels frequently to assess the patient's glycemic control.
• Adjust the insulin dosage as needed under medical supervision, taking into account changes in the patient's physical activity, meal patterns, and renal or hepatic function.
• Consider the patient's current insulin regimen, including the insulin drip, and adjust the Lantus dosage accordingly to avoid hypoglycemia or hyperglycemia.
• Use caution when switching insulin therapies, as this may affect glycemic control and predispose to hypoglycemia 2.

From the Research

Transitioning from Insulin Drip to Subcutaneous Insulin

• When transitioning a patient with Type 2 Diabetes Mellitus (T2DM) from an insulin drip to subcutaneous insulin, such as Lantus (insulin glargine), after a Coronary Artery Bypass Grafting (CABG) surgery, it is essential to consider the patient's current insulin requirements and blood glucose levels 3, 4.
• The patient's insulin drip should be adjusted to achieve a blood glucose level between 140 mg/dL and 180 mg/dL, as recommended by recent consensus guidelines 3, 4.
• Once the patient's blood glucose levels are stable, the insulin drip can be discontinued, and subcutaneous insulin can be initiated 3, 4.

Managing Hyperglycemia

• Hyperglycemia in hospitalized patients, including those undergoing CABG surgery, is a significant concern and can lead to increased morbidity, mortality, length of stay, and readmissions 5.
• Insulin remains the most appropriate agent for managing hyperglycemia in hospitalized patients, and intravenous insulin infusion is preferred during and immediately after surgery 3, 4.
• After the immediate post-operative period, subcutaneous basal insulin analogs, such as Lantus, with prandial or correction doses, should be used to manage hyperglycemia 3, 4.
• Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels and preventing hypoglycemia 3, 4.

Considerations for Lantus (Insulin Glargine)

• Lantus is a long-acting basal insulin analog that can be used to manage hyperglycemia in patients with T2DM 3, 6.
• The dosage of Lantus should be adjusted based on the patient's individual needs and blood glucose levels, and it is essential to consider the patient's previous insulin regimen and dosage when transitioning to Lantus 6, 7.
• A study found that taking 60%-87% of the normal evening dose of insulin glargine the evening before surgery can help achieve target blood glucose levels and reduce the risk of hypoglycemia in ambulatory surgery patients with T2DM 7.