How to manage hyperglycemia in a patient with diabetes, hypertension, and impaired renal function on Lantus (Insulin Glargine) and Humulin R (Regular Insulin)?

Management of Hyperglycemia in a Patient with Diabetes and Stage III CKD

This patient requires immediate intensification of the current insulin regimen with increased basal insulin doses, addition of structured prandial insulin coverage, and discontinuation of the sliding scale approach in favor of a basal-bolus regimen. 1

Immediate Insulin Regimen Adjustment

The current sliding scale insulin approach must be replaced with a scheduled basal-bolus insulin regimen, as sliding scale insulin alone is explicitly discouraged by multiple guidelines for patients with poor glycemic control. 1

Basal Insulin Optimization

• Increase the total daily Lantus dose based on fasting glucose targets, titrating by 2-8 units every 3 days depending on fasting blood glucose levels 2
• The FDA label for insulin glargine recommends dosing adjustments under medical supervision with appropriate glucose monitoring, particularly when glycemic control is inadequate 3
• Target fasting blood glucose of 100-120 mg/dL to achieve better overall glycemic control 4
• For patients with stage III CKD (eGFR 30-59 mL/min), lower basal insulin doses may be required due to reduced renal clearance 1

Prandial Insulin Addition

Add scheduled rapid-acting insulin (Humulin R or preferably a rapid-acting analog) before each meal rather than relying on correction doses alone. 1

• Start with 4 units of regular insulin before each meal (breakfast, lunch, dinner) to address postprandial hyperglycemia 4
• The current approach of using only sliding scale correction insulin fails to provide adequate prandial coverage, which explains the persistent postprandial glucose elevations 1
• Regular insulin should be administered 30 minutes before meals according to FDA labeling 5

Calculating Total Daily Insulin Requirements

For patients with HbA1c increases and persistent hyperglycemia:

• Consider total daily insulin requirements of 0.3-0.4 units/kg/day, divided approximately 50% basal and 50% prandial 4
• In the presence of stage III CKD, start conservatively at the lower end (0.3 units/kg/day) to minimize hypoglycemia risk 1

Critical Medication Management Considerations

Renal Function Impact

Stage III CKD significantly affects insulin pharmacokinetics and increases hypoglycemia risk. 1

• Insulin clearance is reduced with declining renal function, necessitating more frequent glucose monitoring 1
• Increase blood glucose monitoring to before each meal and at bedtime (minimum 4 times daily) during dose adjustments 1
• The eGFR value should guide the aggressiveness of titration—be more conservative with lower eGFR values 1

Avoiding Common Pitfalls

Do not continue relying on sliding scale insulin as the primary treatment strategy—this approach is inadequate for patients with elevated HbA1c and consistently elevated fasting glucose. 1

Key errors to avoid:

• Never delay insulin intensification when HbA1c is rising and fasting glucose remains elevated 4
• Do not mix or dilute Lantus with other insulins or solutions 3
• Ensure injection site rotation within the same region to prevent lipodystrophy, which can cause erratic insulin absorption 3
• Administer Lantus at the same time each day to maintain consistent basal coverage 3

Hypoglycemia Prevention Protocol

Given the presence of CKD, establish a rigorous hypoglycemia prevention and management plan. 1

• Review and adjust the insulin regimen whenever blood glucose falls below 70 mg/dL 1
• Educate the patient on recognition and treatment of hypoglycemia with 15-20 grams of fast-acting carbohydrate 1
• Consider prescribing glucagon for emergency use, particularly given the increased hypoglycemia risk with renal impairment 4
• More frequent glucose monitoring (every 4-6 hours initially) may be needed during the titration phase 1

Structured Titration Algorithm

Implement a systematic titration approach rather than ad hoc adjustments:

For basal insulin (Lantus):

• If mean fasting glucose over 3 days is ≥180 mg/dL: increase by 6-8 units 2
• If mean fasting glucose is 140-179 mg/dL: increase by 4 units 2
• If mean fasting glucose is 120-139 mg/dL: increase by 2 units 2
• If mean fasting glucose is 100-119 mg/dL: increase by 0-2 units 2
• Hold increases if any glucose reading <72 mg/dL 2

For prandial insulin:

• Adjust based on pre-meal and 2-hour post-meal glucose readings 1
• Increase the pre-meal dose by 1-2 units if post-meal glucose consistently exceeds 180 mg/dL 1

Blood Pressure and Comorbidity Management

Optimize blood pressure control to <130/80 mmHg, as hypertension accelerates progression of diabetic kidney disease. 6

• ACE inhibitors or ARBs are preferred antihypertensive agents in diabetic patients with CKD for renoprotection 6
• Adequate blood pressure control is as important as glycemic control for preventing progression to end-stage renal disease 6

Monitoring and Follow-up

Schedule follow-up within 2-4 weeks to assess response to intensified insulin therapy and make further adjustments. 4

• Reassess HbA1c in 3 months to evaluate overall glycemic control 1
• Monitor renal function (BUN, creatinine, eGFR) every 3-6 months given stage III CKD 1
• Document all hypoglycemic episodes (glucose <70 mg/dL) for quality improvement tracking 1