What adjustments should be made to the medication regimen of an 82-year-old patient with hyperglycemia, currently taking Novolog FlexPen (insulin aspart) U-100 Insulin and glipizide (glyburide) extended release 24hr; 10 mg?

Management of Severe Hyperglycemia in an 82-Year-Old Patient

For an 82-year-old patient with blood glucose levels in the 300-400 mg/dL range on Novolog FlexPen and extended-release glipizide 10 mg, immediate intensification of insulin therapy is required with addition of basal insulin and possible discontinuation of glipizide.

Current Situation Assessment

• Blood glucose levels in the 300-400 mg/dL range indicate severe hyperglycemia requiring prompt intervention 1
• The current regimen of Novolog FlexPen (rapid-acting insulin) without basal insulin coverage and extended-release glipizide is inadequate for glycemic control 1
• At this advanced age (82 years), the patient falls into the category of older adults requiring careful medication management to avoid hypoglycemia while addressing severe hyperglycemia 1

Immediate Medication Adjustments

• Add basal insulin (such as insulin glargine, detemir, or degludec) at a starting dose of 0.1-0.2 units/kg/day or 10 units daily 1
• Consider temporarily discontinuing glipizide (extended-release) as sulfonylureas increase hypoglycemia risk, especially during periods of poor oral intake or illness 1, 2
• Continue Novolog FlexPen for prandial coverage but adjust dosing based on carbohydrate intake and pre-meal glucose readings 1

Titration Protocol

• Increase basal insulin dose by 2 units every 3 days until fasting glucose reaches target range of 90-150 mg/dL for older adults 1
• If hypoglycemia occurs (glucose <80 mg/dL), reduce basal insulin dose by 10-20% 1
• For prandial insulin (Novolog), start with 4 units per meal or 10% of the basal dose 1
• Adjust prandial insulin by 1-2 units or 10-15% twice weekly based on postprandial glucose readings 1

Special Considerations for Older Adults

• Set less stringent glycemic targets for this 82-year-old patient (90-150 mg/dL fasting, <180 mg/dL postprandial) 1
• Monitor for symptoms of hypoglycemia, which may be atypical or unrecognized in older adults 1
• Consider simplifying the insulin regimen once control is achieved to reduce complexity and risk of errors 1

Sick Day Management

• During periods of acute illness, the patient should:
  • Continue insulin therapy but may need increased doses (10-20%) if glucose remains elevated 1
  • Temporarily discontinue glipizide to avoid hypoglycemia 1, 2
  • Increase fluid intake and monitor glucose levels every 4-6 hours 1
  • Seek medical attention if unable to maintain fluid intake or if symptoms persist beyond 72 hours 1

Monitoring Recommendations

• Check blood glucose 4 times daily (before meals and at bedtime) during the adjustment period 1
• Obtain HbA1c after 3 months to assess overall glycemic control 3
• Monitor for signs of hypoglycemia, especially at night or between meals 1
• Assess renal function periodically as both advanced age and diabetes increase risk of kidney impairment 1

Long-term Strategy

• Once glucose levels are stabilized below 180 mg/dL, consider simplifying the regimen 1:
  • If using multiple daily insulin injections, consider transitioning to a once-daily basal insulin in the morning 1
  • If prandial insulin doses are ≤10 units/dose, consider discontinuing and adding a non-insulin agent 1
  • If continuing sulfonylurea therapy, use with caution and at reduced doses 1

Common Pitfalls to Avoid

• Delaying insulin intensification when blood glucose remains significantly elevated increases risk of complications 3
• Using sliding scale insulin alone without basal insulin is ineffective for persistent hyperglycemia 1, 4
• Failing to adjust insulin doses frequently enough during the titration period 1
• Setting overly aggressive glycemic targets in older adults, which increases hypoglycemia risk 1
• Continuing sulfonylureas during periods of poor oral intake 1, 2