Insulin Management for Patient with Kidney Disease, Diabetes, and Hypertension
For a patient with kidney disease, diabetes, and hypertension who experiences glucose spikes despite an A1c of 5.5, a basal-plus-correction insulin regimen is more appropriate than sliding scale insulin alone. 1, 2
Assessment of Current Situation
- Patient has kidney disease, diabetes, and hypertension with reported glucose spikes up to 200 mg/dL 1
- A1c of 5.5% indicates good overall glycemic control, but intermittent hyperglycemia still occurs 2
- Previously on metformin but discontinued, likely due to kidney disease 1
- Renal impairment is a significant factor in medication selection and dosing 1
Recommended Insulin Approach
Basal-Plus-Correction Regimen (Preferred)
- A basal-plus approach consisting of a single dose of basal insulin along with correction doses of rapid-acting insulin is preferred for patients with renal failure and mild hyperglycemia 1
- For patients with renal failure, use a lower total daily insulin dose (0.1-0.25 U/kg per day) of basal insulin 1, 2
- Add correction doses of rapid-acting insulin (NovoLog) for pre-meal hyperglycemia 1, 3
- This approach provides better glycemic control than sliding scale insulin alone 1, 4
Correction Insulin Scale (Modified for Renal Impairment)
For a patient with kidney disease, a lower-dose correction scale is appropriate 1, 2:
- Pre-meal glucose <100 mg/dL: no insulin
- 100-150 mg/dL: 1 unit
- 151-200 mg/dL: 2 units
- 201-250 mg/dL: 3 units
- 251-300 mg/dL: 4 units
300 mg/dL: 5 units and contact provider
Why This Approach Is Superior to Sliding Scale Alone
- Sliding scale insulin alone (without basal insulin) is ineffective as monotherapy and is generally not recommended by clinical guidelines 1, 5
- Studies show sliding scale insulin alone is associated with a 3-fold higher risk of hyperglycemic episodes compared to other regimens 6
- Randomized trials consistently demonstrate better glycemic control with basal-plus-correction approach than with sliding scale insulin alone 2, 7
- The American Diabetes Association strongly discourages the use of sliding scale insulin as the sole treatment of hyperglycemic patients 3, 8
Special Considerations for Kidney Disease
- Metformin should be discontinued if eGFR is less than 30 mL/min per 1.73 m² 1
- Patients with renal failure are at higher risk for hypoglycemia and require lower insulin doses 1
- The risk of hypoglycemia with basal-bolus insulin is about 4-6 times higher than with sliding scale insulin therapy alone, requiring careful dosing in renal impairment 1
- Monitor blood glucose more frequently in patients with kidney disease to avoid hypoglycemia 3
Monitoring and Follow-up
- Monitor blood glucose before meals and at bedtime 2
- Adjust basal insulin dose based on fasting and pre-meal glucose patterns 3
- Have a clear plan for treating hypoglycemia 1
- Document all glucose readings and insulin doses administered 3
- Consider transitioning to oral agents if appropriate for the patient's renal function once stable 1
Common Pitfalls to Avoid
- Using sliding scale insulin alone without basal insulin leads to poor glycemic control and glucose variability 5, 8
- Failing to reduce insulin doses in patients with renal impairment increases hypoglycemia risk 1, 2
- Premixed insulin therapy (70/30) has been associated with unacceptably high rates of hypoglycemia and is not recommended in patients with renal disease 1, 3
- Continuing metformin in patients with severe renal impairment (eGFR <30 mL/min) increases risk of lactic acidosis 1