Should additional Humalog (insulin lispro) be administered for a patient with a current blood glucose level of 306 mg/dL after an initial dose given for a level of 465 mg/dL?

Additional Humalog for Blood Glucose of 306 mg/dL After Previous Dose

Yes, additional Humalog (insulin lispro) should be administered for the current blood glucose of 306 mg/dL, as this remains significantly above the recommended target range of 140-180 mg/dL for hospitalized patients. 1

Assessment of Current Situation

• The patient received Humalog at 9 PM for a blood glucose of 465 mg/dL, and now at 12:30 AM (3.5 hours later), the blood glucose has decreased to 306 mg/dL 2
• While there has been improvement (159 mg/dL reduction), the current level of 306 mg/dL remains significantly elevated and requires additional correction 1
• Insulin lispro (Humalog) has a rapid onset of action (15-30 minutes) and short duration (3-5 hours), meaning the previous dose's effect may be diminishing 3, 4

Dosing Considerations

• For blood glucose levels ≥300 mg/dL, additional rapid-acting insulin therapy is warranted, especially if the patient is symptomatic 2
• The American Diabetes Association recommends a protocolized approach to blood glucose management, targeting an upper blood glucose level ≤180 mg/dL 1
• When administering additional doses of rapid-acting insulin like Humalog, consider:
  • The remaining activity of the previous dose (given 3.5 hours ago) 5
  • Risk of insulin stacking and potential for hypoglycemia 1
  • The need to achieve target blood glucose range of 140-180 mg/dL 1

Recommended Approach

• Administer a reduced correction dose of Humalog, approximately 50-75% of what would normally be given for this blood glucose level, to account for potential remaining insulin activity from the previous dose 2
• For a blood glucose of 306 mg/dL, a typical correction dose might be 2-4 units of Humalog, depending on the patient's insulin sensitivity 2
• Monitor blood glucose again in 2-3 hours to assess the effectiveness of this additional dose and determine if further correction is needed 1

Important Considerations and Pitfalls

• Avoid excessive insulin administration that could lead to hypoglycemia, especially during overnight hours when hypoglycemia may go undetected 1
• Be aware that point-of-care glucose testing may not always accurately reflect true blood glucose levels, particularly in critically ill patients 1
• Consider underlying causes for persistent hyperglycemia, such as:
  • Infection or inflammatory process 6
  • Steroid administration 1
  • Inadequate basal insulin coverage 1
  • Carbohydrate intake not covered by previous insulin dose 1

Follow-up Actions

• After administering the additional Humalog dose, continue monitoring blood glucose every 2-4 hours until stable 1
• Reassess the overall insulin regimen if hyperglycemia persists, considering whether basal insulin adjustments are needed 1
• Document the response to the additional insulin dose to help guide future insulin administration 1