Can a provider give Lispro (insulin lispro) as needed to a patient with hyperglycemia who is not eating?

Can Lispro Be Given to NPO Patients with Hyperglycemia?

Yes, providers can give Lispro as needed for correction of hyperglycemia in patients who are not eating, but it should be part of a scheduled insulin regimen that includes basal insulin, not used as monotherapy. 1

Recommended Approach for NPO Patients with Hyperglycemia

Primary Regimen Structure

• Basal insulin plus correction-dose rapid-acting insulin (like Lispro) is the preferred treatment for hospitalized patients who are not eating or have poor oral intake 1
• For NPO patients, glucose monitoring should be performed every 4-6 hours, with subcutaneous rapid- or short-acting insulin administered as needed to correct hyperglycemia 1
• The combination of scheduled basal insulin with correction doses of Lispro provides both background coverage and reactive treatment for elevated glucose levels 1

Critical Caveat: Avoid Sliding Scale Monotherapy

• Prolonged use of sliding scale insulin (correction doses only) as the sole treatment is strongly discouraged and has been shown to be ineffective in patients with established insulin requirements 1
• Traditional sliding-scale regimens treat hyperglycemia reactively after it occurs rather than preventing it, leading to rapid glucose fluctuations and both hyper- and hypoglycemia 1
• A randomized controlled trial demonstrated that basal-bolus treatment improved glycemic control and reduced hospital complications compared to reactive sliding scale regimens 1

Practical Implementation

For NPO Patients

• Administer basal insulin (glargine, detemir, or degludec) once daily to provide background coverage 1, 2
• Use Lispro every 4-6 hours as correction doses when blood glucose exceeds target (typically >180 mg/dL in hospitalized patients) 1, 2
• A typical correction scale might use 2 units for glucose >250 mg/dL and 4 units for glucose >350 mg/dL, though this should be adjusted based on insulin sensitivity 2

Monitoring Requirements

• Check blood glucose every 4-6 hours in NPO patients 1
• Monitor for hypoglycemia 2-4 hours after Lispro administration, when insulin action peaks 3, 2
• If correction doses are frequently required, increase the scheduled basal insulin dose rather than relying solely on correction insulin 1

Important Safety Considerations

Hypoglycemia Risk

• Lispro has a very rapid subcutaneous absorption and increased potential for hypoglycemia, especially in settings of decreased or absent carbohydrate intake 4
• The risk of hypoglycemia is particularly concerning during overnight hours when it may go undetected 2
• Have hypoglycemia treatment protocols readily available and ensure staff can recognize and treat low blood glucose 2

When Patients Resume Eating

• Once oral intake resumes, transition to a full basal-bolus regimen with prandial Lispro before meals plus correction doses 1
• For patients eating, insulin injections should align with meals, with point-of-care glucose testing performed immediately before meals 1
• If oral intake is poor or unpredictable, administer prandial insulin immediately after the patient eats, adjusting the dose for actual intake 1

Common Pitfalls to Avoid

• Do not withhold basal insulin when giving correction doses of Lispro - this leads to inadequate background coverage and worsening hyperglycemia 2
• Do not rely on Lispro alone without basal insulin - this reactive approach is ineffective and increases glucose variability 1, 2
• Avoid "insulin stacking" by accounting for previously administered correction doses that may still be active (Lispro duration is approximately 3-4 hours) 2
• Do not continue sliding scale insulin indefinitely - reassess and optimize the basal insulin regimen if hyperglycemia persists 1, 2