What is the appropriate dose of short-acting insulin (e.g. aspart (NovoLog), lispro (Humalog), or glulisine (Apidra)) for a patient with severe hyperglycemia (Blood Glucose Level (BGL) of 20.9 mmol/L)?

Management of Severe Hyperglycemia (BGL 20.9 mmol/L)

For a patient with severe hyperglycemia (BGL 20.9 mmol/L), administer rapid-acting insulin at a dose of 0.1 units/kg body weight as an immediate corrective measure. 1

Initial Assessment and Insulin Dosing

• For severe hyperglycemia (>16.6 mmol/L or >300 mg/dL), a basal-bolus insulin regimen is indicated, with rapid-acting insulin (aspart, lispro, or glulisine) as the immediate intervention 1
• Calculate the initial rapid-acting insulin dose at 0.1 units/kg body weight for immediate correction of the severe hyperglycemia 1
• For ongoing management, a total daily insulin dose of 0.3-0.5 units/kg should be initiated, split 50/50 between basal and bolus (rapid-acting) insulin 1
• Higher starting doses may be warranted in patients with higher baseline HbA1c, pre-existing diabetes, or those on previous diabetes therapy 1

Specific Considerations for Rapid-Acting Insulin

• Rapid-acting insulin analogs (aspart, lispro, or glulisine) are preferred for immediate correction of severe hyperglycemia due to their faster onset of action 1
• These insulins have peak action within 1-2 hours and shorter duration compared to regular human insulin 2
• All three rapid-acting analogs (aspart, lispro, and glulisine) show similar efficacy and safety profiles for acute hyperglycemia management 3
• Insulin glulisine demonstrates slightly greater early insulin exposure and action compared to insulin lispro in some studies 2

Monitoring and Follow-up

• Recheck blood glucose 2 hours after administration of rapid-acting insulin 1
• For persistent hyperglycemia, additional doses may be required based on the response to the initial dose 1
• Monitor for symptoms of hypoglycemia, particularly in elderly patients or those with renal impairment 1
• Consider reducing the initial dose to 0.05 units/kg in elderly patients or those with renal dysfunction 1

Special Circumstances

• If the patient is on corticosteroids, insulin requirements may be higher due to steroid-induced insulin resistance 1
• For patients with type 1 diabetes presenting with severe hyperglycemia, always assess for ketosis and consider diabetic ketoacidosis protocols if ketones are present 1
• In hospital settings, transition to a basal-bolus regimen after initial correction, with basal insulin at 0.2-0.3 units/kg/day and rapid-acting insulin before meals 1

Common Pitfalls to Avoid

• Avoid delaying insulin therapy in patients with severe hyperglycemia, as this can lead to metabolic decompensation 1
• Do not rely solely on sliding scale insulin for ongoing management of severe hyperglycemia 1
• Be cautious about overcorrection, which can lead to hypoglycemia; aim for gradual normalization of blood glucose 1
• Remember that patients with consistent blood glucose levels may represent a group with more predictable insulin responses 4