Should I adjust the Lantus (insulin glargine) dose for a patient with hyperglycemia on hemodialysis (HD) and receiving feeding through a tube with Juven (nutritional supplement) shakes?

Yes, you should increase the Lantus dose for this patient with persistent hyperglycemia on hemodialysis receiving tube feeding nutrition.

This patient's blood glucose range of 180-370 mg/dL is well above target, and the current Lantus dose of 5 units is inadequate for someone receiving continuous nutritional support through tube feeding. The current regimen relies too heavily on sliding scale insulin alone, which is explicitly discouraged as monotherapy in hospitalized patients 1.

Recommended Insulin Regimen Adjustment

Basal Insulin Dosing for Tube Feeding

• Increase Lantus to 10 units daily as a starting point, which aligns with guideline recommendations for patients on continuous enteral nutrition who require basal coverage 1
• For continuous tube feeding, basal insulin should be continued or initiated at approximately 5-10 units of glargine daily if the patient was not previously on basal insulin 1
• The current 5 units is insufficient given the persistent hyperglycemia and continuous nutritional load from tube feeding plus Juven shakes 1

Add Scheduled Nutritional Insulin Coverage

Critical addition: This patient needs nutritional insulin, not just basal insulin and sliding scale 1. For continuous enteral feeding:

• Add regular insulin every 6 hours OR rapid-acting insulin every 4 hours to cover the nutritional component 1
• Start with approximately 1 unit per 10-15 grams of carbohydrate in the tube feeding formula 1
• Calculate total carbohydrate content from both tube feeding and Juven shakes to determine appropriate nutritional insulin doses 1

Maintain Correctional Insulin

• Continue sliding scale (correctional) insulin every 4-6 hours using rapid-acting insulin for hyperglycemia 1
• This should supplement, not replace, the basal and nutritional insulin components 1

Special Considerations for Hemodialysis Patients

Dose Adjustment Rationale

• Hemodialysis patients are at higher risk for hypoglycemia and typically require lower insulin doses than non-dialysis patients 1
• However, this patient's blood glucose levels of 180-370 mg/dL indicate significant under-treatment despite dialysis 2
• Research specifically in hemodialysis patients shows insulin glargine can safely improve glycemic control when properly titrated 2

Safety Monitoring

• If tube feeding is interrupted, immediately start 10% dextrose infusion at 50 mL/hour to prevent hypoglycemia while maintaining basal insulin 1
• Monitor blood glucose every 4-6 hours given the continuous feeding schedule 1
• Adjust insulin doses daily based on glucose patterns 1

Target Blood Glucose Range

Aim for blood glucose levels of 140-180 mg/dL in this non-critically ill hospitalized patient 1. The current range of 180-370 mg/dL significantly exceeds this target and increases risk of complications 1.

Common Pitfalls to Avoid

• Do not rely on sliding scale insulin alone - this approach is ineffective as monotherapy and consistently shows worse outcomes than basal-bolus regimens 1
• Do not forget nutritional insulin coverage - tube feeding provides continuous carbohydrate load requiring scheduled insulin, not just correctional doses 1
• Do not stop basal insulin if feeding is interrupted - instead, start dextrose infusion to prevent hypoglycemia 1
• Account for dialysis timing - insulin requirements may fluctuate around dialysis sessions, requiring dose adjustments 2

Titration Strategy

• Increase Lantus by 2-4 units every 1-2 days if fasting/pre-dialysis glucose remains >140 mg/dL 3
• Adjust nutritional insulin doses daily based on glucose patterns throughout the day 1
• In hemodialysis patients, more conservative titration may be warranted, but the current severe hyperglycemia justifies more aggressive initial adjustment 2