From the Guidelines
For this 72-year-old incarcerated male with uncontrolled diabetes, I recommend optimizing his insulin regimen by splitting the Lantus dose to twice daily and implementing a more structured Humulin R dosing protocol, as the most recent and highest quality study suggests that adjusting insulin therapy is crucial for achieving glycemic control 1. Given his weight of 248 pounds and current limitations, his basal insulin could be increased gradually to 0.3-0.4 units/kg/day (approximately 34-45 units total daily), divided into morning and evening doses to provide more consistent 24-hour coverage.
- Key considerations for adjusting his insulin regimen include:
- Splitting the Lantus dose to twice daily to prevent potential gaps in coverage at the 24-hour mark
- Implementing a more structured Humulin R dosing protocol, with a fixed pre-meal dose (starting at 6-8 units before each meal) plus the sliding scale component
- Ensuring consistent timing of insulin administration relative to meals, ideally 30 minutes before eating for Humulin R
- Regular blood glucose monitoring before meals and at bedtime to guide these adjustments These changes leverage the pharmacokinetics of both insulins more effectively, addressing predictable mealtime glucose excursions rather than just reacting to high readings, as supported by the American Diabetes Association standards of medical care in diabetes 1. Additionally, it is essential to consider the patient's overall health, nutritional intake, and lifestyle when making adjustments to his insulin regimen, as emphasized in the guidelines for lifestyle management and nutrition therapy recommendations for the management of adults with diabetes 1. By prioritizing these adjustments and considering the patient's individual needs, we can work towards achieving better glycemic control and improving his overall quality of life, while minimizing the risk of hypoglycemia and other complications, as highlighted in the most recent standards of care in diabetes 1.
From the FDA Drug Label
Your dose of Insulin Glargine may need to change because of: a change in level of physical activity or exercise, weight gain or loss, increased stress, illness, change in diet, or because of the medicines you take.
DOSAGE Your doctor has told you which insulin to use, how much, and when and how often to inject it. Because each patient's diabetes is different, this schedule has been individualized for you. Your usual dose of Humulin R may be affected by changes in your diet, activity, or work schedule. Carefully follow your doctor's instructions to allow for these changes
The patient's dose of Insulin Glargine or Humulin R may need to be adjusted due to various factors such as changes in physical activity, weight, stress, illness, or diet. To adjust the treatment going forward, consider the following options:
- Increase or decrease the dose of Insulin Glargine: The patient is already at a max basal dose of 23 units each morning, so further increases should be done with caution and under close monitoring.
- Adjust the dose of Humulin R: The patient's dose of Humulin R may need to be adjusted based on changes in diet, activity, or work schedule.
- Monitor blood sugar levels closely: Regular monitoring of blood sugar levels is crucial to determine the effectiveness of the current treatment regimen and make any necessary adjustments.
- Consider alternative treatment options: If the patient's diabetes is not well-controlled with the current regimen, alternative treatment options may need to be considered, such as adding another medication or adjusting the patient's diet and exercise plan 2 3.
From the Research
Adjusting Diabetes Treatment for a 72-year-old Male with Uncontrolled Diabetes
Given the patient's current treatment with Lantus (insulin glargine) and Humalin R, and considering the limitations of insulin and other therapies due to incarceration, potential adjustments to the treatment plan could include:
- Increasing the basal dose of Lantus, although the patient is already at a high dose of 23 units each morning 4
- Considering alternative basal insulins, such as insulin degludec, which may offer improved glycemic control with reduced risk of hypoglycemia 5
- Optimizing the use of Humalin R through adjustments to the sliding scale regimen to better match the patient's insulin needs
- Monitoring the patient's response to treatment and adjusting the regimen as needed to achieve better glycemic control
Considerations for Patients with Cardiovascular Risk Factors
The patient's treatment plan should also take into account the presence of cardiovascular risk factors, which may impact the choice of insulin therapy:
- Insulin glargine has been shown to be effective in patients with cardiovascular risk factors, with reduced risk of hypoglycemia compared to other insulin therapies 6
- The choice of insulin therapy should be individualized based on the patient's specific needs and risk factors
Dietary Considerations
Dietary factors, such as carbohydrate intake, may also impact the patient's response to treatment:
- A low-carbohydrate diet may impair the effectiveness of glucagon in treating hypoglycemia 7
- The patient's dietary plan should be tailored to their individual needs and insulin regimen to optimize glycemic control
Postprandial Glucose Control
Postprandial glucose control is an important aspect of diabetes management:
- The choice of postprandial insulin, such as Humalin R, should be based on the patient's individual needs and response to treatment
- Adjustments to the sliding scale regimen may be necessary to optimize postprandial glucose control 8