Can a type 2 diabetic patient who is insulin-independent be given 6 units of human insulin at bedtime when their blood sugar is severely elevated (hyperglycemia)?

Emergency Insulin Administration for Severe Hyperglycemia in Type 2 Diabetes

Yes, this patient with blood glucose of 435 mg/dL requires immediate insulin therapy, but 6 units is likely insufficient—they need a more aggressive approach with both basal and correctional insulin coverage. 1

Immediate Management Protocol

Initial Insulin Dosing Strategy

For a patient with severe hyperglycemia (blood glucose 435 mg/dL) who is normally insulin-independent, the following approach is recommended:

• Start with 0.1-0.2 units/kg of basal insulin once daily (typically 10 units for most adults, but adjust based on body weight). 1
• Add correctional insulin immediately using rapid- or short-acting insulin every 4-6 hours to address the current hyperglycemia. 1
• For patients with blood glucose ≥300 mg/dL, consider starting with 0.3-0.5 units/kg/day as total daily dose, split between basal and correctional components. 1

Why 6 Units May Be Inadequate

• The current blood glucose of 435 mg/dL indicates severe hyperglycemia requiring both basal coverage and immediate correction. 1
• A single 6-unit dose at bedtime addresses only basal needs but does not correct the current severe elevation. 1
• Sliding scale insulin alone (reactive dosing) is strongly discouraged as the sole treatment approach—a scheduled basal insulin regimen with correctional doses is preferred. 1

Recommended Treatment Algorithm

Step 1: Immediate Correctional Insulin

• Administer rapid-acting insulin (e.g., lispro, aspart) or regular human insulin to correct the current hyperglycemia. 1
• Use correctional doses every 4-6 hours until blood glucose approaches target range (100-180 mg/dL for hospitalized patients, 80-130 mg/dL fasting for outpatients). 1

Step 2: Initiate Basal Insulin

• Start basal insulin (NPH, glargine, or detemir) at 10 units once daily or 0.1-0.2 units/kg/day, administered at bedtime or the same time each day. 1, 2
• For patients with blood glucose ≥180 mg/dL, increase basal insulin by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 1, 2
• If blood glucose is 140-179 mg/dL, increase by 2 units every 3 days. 1, 2

Step 3: Continue Oral Medications

• Metformin should be continued unless contraindicated, even when initiating insulin therapy, as it reduces total insulin requirements. 1
• Other oral agents may need adjustment based on the clinical situation. 1

Critical Considerations for This Patient

Rule Out Hyperglycemic Crisis

• Blood glucose of 435 mg/dL raises concern for hyperglycemic hyperosmolar state (HHS) or diabetic ketoacidosis (DKA). 3, 4
• Check serum osmolality, ketones, and electrolytes to determine if this is a hyperglycemic emergency requiring hospitalization. 3
• HHS typically presents with blood glucose >600 mg/dL, elevated serum osmolality, minimal ketones, and altered mental status. 3

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during insulin titration. 1, 2
• Check blood glucose before meals and at bedtime to guide correctional insulin doses. 1
• If hypoglycemia occurs (blood glucose <70 mg/dL), reduce insulin dose by 10-20% immediately. 1

Common Pitfalls to Avoid

• Do not rely solely on bedtime basal insulin to correct acute severe hyperglycemia—correctional insulin is needed immediately. 1
• Do not use sliding scale insulin alone as the only treatment strategy—this approach is associated with worse outcomes compared to scheduled basal-bolus regimens. 1
• Do not delay insulin therapy in patients with severe hyperglycemia—early intervention improves outcomes. 1, 2, 4
• Avoid underdosing—6 units may be appropriate as basal insulin for some patients, but this patient needs both basal coverage AND immediate correction of the 435 mg/dL reading. 1

When to Escalate Care

• Consider hospitalization if the patient has altered mental status, signs of dehydration, or suspected hyperglycemic crisis. 1, 3
• Intensive care unit admission may be required for patients with HHS or DKA. 1, 3
• If blood glucose remains >300 mg/dL despite initial insulin therapy, reassess the total daily insulin dose and consider basal-bolus regimen (basal insulin plus mealtime rapid-acting insulin). 1