How often should a postpartum type 2 diabetic patient on Lantus (insulin glargine) AM and PM check fingersticks in the hospital and when should she resume half of her pre-pregnancy Lantus dose?

Postpartum Glucose Monitoring and Insulin Management for Type 2 Diabetes

Fingerstick Monitoring Frequency in Hospital

Check fingersticks every 4-6 hours while the patient remains NPO or has poor oral intake, and before each meal (breakfast, lunch, dinner) plus at bedtime once regular eating resumes. 1

Specific Monitoring Schedule:

• If NPO or poor oral intake: Blood glucose monitoring every 4-6 hours is the standard recommendation 1
• Once eating regular meals: Point-of-care glucose testing should be performed immediately before meals (0700,1200,1700 hours) and at bedtime (2100 hours) 1, 2
• Target range: 100-180 mg/dL for noncritically ill hospitalized patients, though 140-180 mg/dL is acceptable for most 1

Important Monitoring Considerations:

• Traditional four-times-daily fingerstick monitoring (preprandial and bedtime) provides a reasonable approximation of mean daily glucose but underestimates postprandial hyperglycemia (missing 31% of excursions) and hypoglycemia (missing 90% of episodes <72 mg/dL) 2
• Any glucose result that does not correlate with clinical status should be confirmed through conventional laboratory testing 1

Resuming Lantus After Delivery

Start at 50-80% of the pre-pregnancy Lantus dose immediately postpartum, with 60-80% being the most conservative and recommended approach given the rapid fall in insulin requirements after placental delivery. 1, 3

Specific Dosing Algorithm:

• Immediate postpartum period: Reduce total daily Lantus dose to 60-80% of pre-pregnancy dose 3
• Rationale: After delivery of the fetus and placenta, maternal insulin requirements fall rapidly due to removal of placental hormones that cause insulin resistance 1
• Timing: Begin reduced-dose Lantus at the next scheduled administration time (either AM or PM depending on when delivery occurred) 1

Critical Monitoring During Transition:

• Check capillary blood glucose every 4-6 hours initially to detect hypoglycemia risk 1
• If blood glucose falls below 100 mg/dL, decrease the glargine dose by an additional 10-20% 3
• Increase monitoring frequency during breastfeeding, as there is additional risk of hypoglycemia 1

Dose Titration Strategy:

• After 3 days of stable glucose readings, adjust basal insulin by 2-4 units every 3 days based on fasting glucose values 4
• Target fasting glucose of 80-130 mg/dL once stable 1, 4
• If fasting glucose ≥180 mg/dL, increase by 4 units every 3 days 4
• If fasting glucose 140-179 mg/dL, increase by 2 units every 3 days 4

Special Postpartum Considerations

Gestational Diabetes vs. Pre-existing Type 2 Diabetes:

• If gestational diabetes: Discontinue all diabetes therapy postpartum and monitor for resolution, as most cases resolve after delivery 1
• If pre-existing type 2 diabetes: Resume modified insulin regimen as outlined above 1

Breastfeeding Impact:

• Breastfeeding increases hypoglycemia risk and requires continued close monitoring 1
• Metformin and glibenclamide are safe during breastfeeding for type 2 diabetes patients 1
• Consider adding back metformin as foundation therapy once oral intake is established 1, 4

Common Pitfalls to Avoid:

• Do not resume full pre-pregnancy insulin doses immediately postpartum - this will cause severe hypoglycemia given the rapid fall in insulin resistance 1, 3
• Do not rely solely on correction insulin - maintain scheduled basal insulin with appropriate dose reduction 1, 4
• Do not delay dose adjustments - titrate every 3 days based on glucose patterns rather than waiting weeks 4
• Do not ignore hypoglycemia signals - any glucose <100 mg/dL requires immediate 10-20% dose reduction 3

Discharge Planning:

• Neonatal glucose monitoring is essential as the infant is at risk for severe hypoglycemia after delivery 1
• Schedule follow-up within 1-2 weeks for dose optimization 1
• Provide education on hypoglycemia recognition and treatment, especially during breastfeeding 1, 4
• If HbA1c <8% at discharge, continue current regimen with outpatient follow-up 1