What adjustments can be made to a patient with diabetes' insulin regimen, currently on glargine (insulin glargine) and lispro (insulin lispro), to manage hyperglycemia with morning blood glucose levels of 244 mg/dL?

Management of Persistent Hyperglycemia in Hospitalized Diabetic Patient

You need to increase the basal insulin glargine dose and add scheduled prandial insulin lispro before meals, as the current regimen of half-dose glargine (12.5 units) with only sliding scale insulin is inadequate and explicitly discouraged by current guidelines.

Critical Problem with Current Regimen

• Sliding scale insulin (SSI) alone is strongly discouraged in the inpatient hospital setting and should not be the primary treatment approach 1
• The patient has persistent hyperglycemia (244 mg/dL both evening and morning), indicating the current reduced basal dose and lack of scheduled prandial insulin is insufficient 1
• For hospitalized patients with good nutritional intake, an insulin regimen with basal, prandial, and correction components is the preferred treatment 1

Recommended Insulin Regimen Adjustments

Restore and Optimize Basal Insulin

• Return to full-dose glargine or increase from the current 12.5 units based on the patient's home regimen and current glucose levels 1, 2
• If the patient was previously on 25 units glargine at home (since you're giving half at 12.5 units), consider returning closer to that dose or even increasing it given persistent hyperglycemia 1
• Glargine should be administered once daily at the same time each day to provide consistent 24-hour basal coverage 2

Add Scheduled Prandial Insulin

• Resume scheduled insulin lispro before meals rather than holding it entirely 1
• Start with 4 units of lispro before each meal or 10% of the basal insulin dose per meal if the patient is eating well 1
• If the patient was on 20 units lispro before meals at home, consider starting at a reduced dose (e.g., 10-15 units per meal) and titrate based on response 1

Maintain Correction Insulin

• Continue using correction-dose rapid-acting insulin (lispro) in addition to scheduled prandial doses, not as a replacement 1
• The "low sliding scale" should supplement, not substitute for, scheduled basal-bolus therapy 1

Specific Dosing Algorithm

Initial approach:

• Increase glargine to at least 20 units once daily (80% of likely home dose of 25 units, or higher if needed) 1
• Add lispro 4-6 units before each meal if eating well 1
• Continue correction doses with lispro per sliding scale 1

Titration strategy:

• Increase basal insulin by 2 units every 3 days to target fasting glucose <140 mg/dL 1
• Increase prandial insulin by 1-2 units or 10-15% if pre-meal or 2-hour post-meal glucose remains elevated 1
• For hypoglycemia, reduce the corresponding insulin dose by 10-20% 1

Monitoring Requirements

• Check bedside glucose before meals and at bedtime for patients who are eating 1
• More frequent monitoring (every 4-6 hours) if the patient is NPO or has variable oral intake 1
• Adjust insulin doses based on glucose patterns, not just individual readings 1

Common Pitfalls to Avoid

• Do not rely on sliding scale insulin alone - this approach is ineffective and leads to persistent hyperglycemia 1
• Do not continue withholding scheduled prandial insulin if the patient is eating meals - this leaves postprandial hyperglycemia uncontrolled 1
• Do not under-dose basal insulin - the current 12.5 units is clearly insufficient given persistent fasting hyperglycemia of 244 mg/dL 1
• Avoid "overbasalization" by ensuring prandial insulin is added when basal insulin alone doesn't achieve targets 1

Why This Approach Works

• The persistent morning glucose of 244 mg/dL indicates inadequate basal insulin coverage overnight 1, 2
• The evening glucose of 244 mg/dL suggests inadequate prandial coverage from earlier meals 1
• A basal-bolus regimen addresses both fasting and postprandial hyperglycemia more effectively than sliding scale alone 1
• Studies demonstrate that basal-bolus regimens achieve better glycemic control than sliding scale insulin in hospitalized patients 1