From the Guidelines
The patient's high glucose level should be managed with a basal-bolus insulin regimen, adjusting the current doses of Lantus and Humalog based on blood glucose monitoring and carbohydrate intake, with a goal of achieving an HbA1c level below 7%. The current insulin administration (11 units of Lantus and 9 units of Humalog) is a good starting point, but adjustments may be necessary to achieve optimal glucose control. According to the 2021 study published in The Lancet Diabetes and Endocrinology 1, for patients with severe hyperglycemia, a basal-bolus regimen is recommended, with basal insulin doses starting at 0.2-0.3 U/kg per day and adjustment of both basal and prandial insulins based on self-monitoring of blood glucose (SMBG) levels.
Immediate Management
For immediate management, the patient should:
- Continue monitoring blood glucose levels every 1-2 hours until stabilized below 200 mg/dL
- Ensure adequate hydration with sugar-free fluids
- Assess for symptoms of hyperglycemia complications
- Receive correction doses of Humalog (rapid-acting insulin) before meals or every 6 hours as needed
Ongoing Management
For ongoing management, a comprehensive diabetes care plan should be established, including:
- Regular insulin therapy with a basal-bolus regimen, typically Lantus once daily and pre-meal Humalog dosed according to carbohydrate intake and correction factor
- Medication adherence and education on proper insulin administration
- Dietary modifications focusing on carbohydrate counting and regular physical activity
- Regular HbA1c monitoring (target <7%) and frequent blood glucose checks to guide therapy adjustments
As noted in the 2016 American Diabetes Association standards of medical care in diabetes 1, insulin therapy should be initiated when patients have severe hyperglycemia, and basal insulin may be initiated at 10 units or 0.1 to 0.2 units/kg of body weight. However, the most recent and highest-quality study 1 provides more specific guidance on the management of hyperglycemia in the hospital setting, which should be prioritized in this case.
From the FDA Drug Label
LANTUS is indicated to improve glycemic control in adults and pediatric patients with type 1 diabetes mellitus and in adults with type 2 diabetes mellitus. The dose of LANTUS must be individualized based on clinical response. Blood glucose monitoring is essential in all patients receiving insulin therapy. Patients adjusting the amount or timing of dosing with LANTUS, should only do so under medical supervision with appropriate glucose monitoring .
The patient's high glucose level should be managed by adjusting the dose of LANTUS and/or humalog under medical supervision with appropriate glucose monitoring.
- Key considerations:
- The patient's current dose of LANTUS is 11 units and humalog is 9 units.
- The patient's blood glucose level is 399, indicating hyperglycemia.
- The dose of LANTUS and/or humalog may need to be adjusted to achieve better glycemic control.
- Blood glucose monitoring is essential to determine the effectiveness of the current insulin regimen and to guide any necessary adjustments.
- Any changes to the insulin regimen should be made cautiously and only under medical supervision 2.
From the Research
Management of High Glucose Level
The patient has a history of uncontrolled type 2 diabetes mellitus (T2DM) and is currently hyperglycemic with a glucose level of 399. The patient was given 11 units of Lantus and 9 units of Humalog.
- The management of the patient's high glucose level should involve careful monitoring and adjustment of their insulin regimen, as well as addressing any underlying factors contributing to their hyperglycemia 3, 4.
- Hyperglycemic crises, such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, can occur in patients with uncontrolled diabetes and require prompt recognition and treatment 4, 5.
- The use of long-acting insulin, such as Lantus, and short-acting insulin, such as Humalog, can help to manage hyperglycemia in patients with T2DM 6.
- However, the management of hyperglycemia in the emergency department (ED) can be challenging, and evidence suggests that better management of hyperglycemia in the ED with proper follow-up can improve clinical outcomes and prevent readmission 5.
Treatment Options
- Treatment options for hyperglycemia in patients with T2DM may include metformin, long-acting insulin, or deferring for close outpatient management 6.
- Glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) may also be used as adjuvant therapies to insulin in the management of T2DM, although their use is not without risks, such as diabetic ketoacidosis (DKA) 7.