How to manage hyperglycemia in a type 1 diabetic patient on insulin?

Management of Hyperglycemia in Type 1 Diabetes

Type 1 diabetic patients with hyperglycemia should be treated with a basal-bolus insulin regimen using long-acting basal insulin analogs (once or twice daily) combined with rapid-acting insulin analogs before each meal, with doses adjusted based on carbohydrate intake, premeal glucose levels, and anticipated physical activity. 1, 2

Initial Insulin Dosing Strategy

Calculate total daily insulin dose (TDD) at 0.5 units/kg/day for metabolically stable patients, with a range of 0.4-1.0 units/kg/day depending on individual factors. 1, 2 Higher doses are required during puberty, pregnancy, and acute illness. 1, 2

• Split the TDD equally: 50% as basal insulin and 50% as prandial insulin (divided among three meals). 1, 2
• For example, a 70 kg patient would receive approximately 35 units total daily: ~17-18 units basal insulin and ~17-18 units prandial (roughly 6 units before each meal). 1

Basal Insulin Selection and Administration

Use long-acting insulin analogs (glargine, detemir, or degludec) rather than NPH insulin because they provide a flatter action profile with lower risk of hypoglycemia, especially nocturnal hypoglycemia. 2, 3

• Administer once daily (typically at bedtime) or twice daily depending on the specific analog chosen and individual patient response. 2
• Adjust basal insulin dose based on fasting and premeal glucose levels. 2

Prandial Insulin Selection and Dosing

Administer rapid-acting insulin analogs (aspart, lispro, or glulisine) before each meal to reduce hypoglycemia risk compared to regular human insulin. 1, 2

• Educate patients to adjust prandial doses based on three factors: carbohydrate content of the meal, premeal blood glucose level, and anticipated physical activity. 1, 2
• Faster-acting insulin aspart (Fiasp) offers even better postprandial glucose coverage if available. 2, 3

Alternative Delivery Method

Consider continuous subcutaneous insulin infusion (insulin pump) for patients who fail to achieve glycemic targets or experience frequent/severe hypoglycemia with multiple daily injections. 1, 2 Pump therapy provides modest advantages in lowering A1C (approximately 0.3% reduction) and reducing severe hypoglycemia rates. 1

Monitoring and Dose Adjustment

Implement frequent glucose monitoring, preferably with continuous glucose monitoring (CGM), to guide insulin adjustments and reduce hypoglycemia risk. 2, 3

• Target HbA1c <7% (53 mmol/mol) for most nonpregnant adults. 3
• Adjust basal insulin based on fasting glucose patterns. 2
• Adjust prandial insulin based on pre- and postprandial glucose measurements. 2

Critical Pitfalls to Avoid

Never use sliding-scale insulin alone in type 1 diabetes—this approach fails to provide basal insulin coverage and leads to dangerous metabolic decompensation including ketoacidosis. 1

• Hyperglycemia itself worsens insulin resistance, creating a vicious cycle that requires prompt correction. 4
• Rotation of injection sites within the same anatomical area (rather than rotating between different body regions) reduces day-to-day absorption variability. 1
• The abdomen has the fastest absorption rate, followed by arms, thighs, and buttocks. 1

Special Considerations for Hospitalized Patients

Maintain basal insulin even if the patient is not eating, adding correction doses of rapid-acting insulin every 4-6 hours. 1, 2

• When transitioning from intravenous to subcutaneous insulin, administer the subcutaneous basal dose 2-4 hours before discontinuing the IV infusion. 2
• For patients eating in the hospital, add prandial insulin before meals to the basal-correction regimen. 1, 2

Adjunctive Therapy Option

Pramlintide (an amylin analog) may be considered in adults as adjunctive therapy to improve postprandial glucose control and reduce glycemic variability, though it carries an FDA black box warning for increased risk of severe hypoglycemia within 3 hours of injection. 5, 6 This requires careful patient selection and insulin dose reduction when initiated. 5

Hypoglycemia Prevention

Review and adjust the insulin regimen whenever blood glucose falls below 70 mg/dL to prevent recurrent episodes. 1

• Patients must carry at least 15 grams of fast-acting carbohydrate at all times. 1
• Family members and close contacts should be trained in glucagon administration. 1
• Medical identification (bracelet or card) is mandatory for all insulin users. 1