Do we hold Lantus (insulin glargine) when a patient is Nil Per Os (NPO)?

Management of Lantus (Insulin Glargine) in NPO Patients

Basal insulin (Lantus) should be continued even when a patient is NPO (nil per os) to prevent hyperglycemia and potential metabolic decompensation. 1

Rationale for Continuing Basal Insulin

• Basal insulin provides essential background insulin levels needed to prevent hyperglycemia and ketosis, even when patients are not eating 1
• The American Diabetes Association recommends a basal plus correction insulin regimen as the preferred treatment for noncritically ill hospitalized patients who are NPO 2
• Discontinuing basal insulin in NPO patients can lead to significant hyperglycemia and metabolic decompensation 1
• Sole use of sliding scale insulin without basal coverage is strongly discouraged in the hospital setting 2

Recommended Approach

• For NPO patients, continue the scheduled basal insulin (Lantus) but consider reducing the dose to 60-80% of the usual dose 2
• Monitor blood glucose every 4-6 hours while the patient remains NPO 2
• Add correction insulin (short-acting) as needed based on blood glucose monitoring results 1
• If DKA resolution is the goal, continue intravenous insulin and fluid replacement if the patient remains NPO 2, 3

Special Considerations

For Surgical Patients

• For perioperative patients, administer 60-80% of the usual dose of long-acting insulin analog (Lantus) 2
• Monitor blood glucose at least every 4-6 hours while NPO and dose with short-acting insulin as needed 2

For Patients with Diabetic Ketoacidosis (DKA)

• Once DKA is resolved (glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3), if the patient remains NPO, continue intravenous insulin and fluid replacement 2, 3
• Supplement with subcutaneous regular insulin as needed every 4 hours 2

For Patients on Enteral/Parenteral Nutrition

• For patients on continuous enteral feedings who become NPO, continue prior basal insulin or calculate from total daily dose 2
• For patients on parenteral nutrition who become NPO, consider adding regular insulin to TPN solution 2

Avoiding Common Pitfalls

• Do not withhold basal insulin (Lantus) completely when a patient is NPO, as this can lead to significant hyperglycemia 1
• Do not rely solely on sliding scale insulin for glycemic control, as this reactive approach can lead to rapid changes in blood glucose levels 2
• Do not administer oral medications until a swallowing screen has been completed and found normal for NPO patients 2
• Do not mix insulin glargine (Lantus) with other forms of insulin due to the low pH of its diluent 2

Monitoring After Administration

• Continue monitoring blood glucose every 4-6 hours while the patient remains NPO 2, 1
• Assess for signs of hypoglycemia, especially in patients with renal or liver disease, malignancy, infection, or sepsis 2
• Consider adjusting the basal insulin dose if persistent hyperglycemia or hypoglycemia occurs 1

By maintaining basal insulin coverage while a patient is NPO, you provide essential background insulin levels needed to prevent hyperglycemia and ketosis while minimizing the risk of hypoglycemia through appropriate dose adjustment and monitoring.