Should I add a one-time dose of long-acting insulin to a patient's current regimen of short-acting insulin (SSI) three times a day, with 20 units before each meal, to improve glucose control?

Management of Severe Hyperglycemia in a Patient on SSI and Prandial Insulin

Yes, you should add a one-time dose of long-acting insulin to address the severely elevated morning blood glucose of 452 mg/dL. 1

Assessment of Current Regimen

• The patient is currently on sliding scale insulin (SSI) three times daily with 20 units of prandial insulin before meals, but this regimen is clearly insufficient as evidenced by the severely elevated morning blood glucose of 452 mg/dL 1
• This glucose level indicates a need for basal insulin coverage in addition to the prandial insulin already prescribed 1
• The current regimen lacks 24-hour basal insulin coverage, which is essential for controlling fasting hyperglycemia 1

Recommended Approach

Step 1: Add Basal Insulin

• Add a one-time dose of basal insulin (long-acting) to provide 24-hour glucose control 1
• For insulin-naïve patients, the recommended starting dose would be 0.1-0.2 units/kg or 10 units once daily 2
• However, since this patient is already on insulin therapy with significant hyperglycemia, consider:
  • Starting with 0.2 units/kg of basal insulin (for a 70kg patient, approximately 14 units) 1
  • Alternatively, calculate as 30-50% of the total daily insulin requirement 1

Step 2: Adjust Current Insulin Regimen

• Maintain the prandial insulin coverage (20 units before meals) 1
• Consider adjusting the sliding scale insulin (SSI) protocol to better address postprandial excursions 1
• For subsequent days, titrate basal insulin by increasing 2 units every 3 days until fasting plasma glucose reaches target without hypoglycemia 1

Monitoring and Follow-up

• Check blood glucose more frequently after adding basal insulin to monitor response and avoid hypoglycemia 2
• Assess the adequacy of the insulin dose at the next visit 1
• Look for clinical signals of overbasalization (elevated bedtime-to-morning differential, hypoglycemia, high glucose variability) 1

Important Considerations

• Morning hyperglycemia (dawn phenomenon) often requires adequate basal insulin coverage overnight 1
• If the patient continues to have poor control after adding basal insulin, consider:
  • Converting to a twice-daily NPH regimen (distributing as 2/3 in morning, 1/3 in evening) 1
  • Adding a GLP-1 receptor agonist if not contraindicated 1

Cautions and Pitfalls

• Monitor closely for hypoglycemia, especially overnight; if it occurs, reduce the basal dose by 10-20% 1
• Avoid using rapid-acting or short-acting insulin at bedtime without food intake 1
• For patients with very high glucose (>300 mg/dL), insulin is the preferred injectable therapy rather than waiting for oral agents to take effect 1
• Remember that clinical inertia (delay in intensifying therapy) is a common barrier to achieving glycemic control in hospitalized patients 3

By adding basal insulin to the current regimen, you provide 24-hour coverage that addresses the fundamental physiologic need for both basal and prandial insulin, which should help bring the severely elevated glucose under control.