From the FDA Drug Label
The intravenous administration of Humulin R U-100 was tested in 21 patients with type 1 diabetes The patients' usual doses of insulin were temporarily held, and blood glucose concentrations were maintained at a range of 200 – 260 mg/dL for one to three hours during a run-in phase of intravenous Humulin R U-100 followed by a 6-hour assessment phase. During the assessment phase patients received intravenous Humulin R at an initial dose of 0. 5 U/h, adjusted to maintain blood glucose concentrations near normoglycemia (100 to 160 mg/dL).
The patient's blood glucose level is 25, which is significantly lower than the target range. However, the provided study does not directly address treatment for a blood glucose level of 25.
- Key consideration: The study does provide information on intravenous administration of insulin for patients with type 1 diabetes, but it does not provide guidance on treating hypoglycemia (low blood sugar) as severe as 25 mg/dL.
- Clinical decision: Given the severity of the hypoglycemia, immediate treatment with glucose or glucagon is likely necessary, but this is not directly addressed in the provided study 1.
From the Research
For a 61-year-old type 1 diabetic with a blood glucose of 25 mg/dL who is on prednisolone for COPD exacerbation, immediate treatment with 15-20 grams of fast-acting carbohydrates is essential to correct the severe hypoglycemia. The patient's condition requires prompt attention to prevent further complications. According to the most recent and highest quality study 2, the management of type 1 diabetes mellitus involves a regimen of multiple daily injections of basal/bolus insulin, and consideration of continuous subcutaneous insulin infusion for those not meeting individual glycemic targets.
Key Considerations
- Administer 15-20 grams of fast-acting carbohydrates such as 4 ounces of fruit juice, 4-5 glucose tablets, or 1 tablespoon of honey to correct the severe hypoglycemia.
- If the patient is unconscious or unable to swallow safely, administer glucagon - either 1 mg intramuscularly/subcutaneously or use a glucagon nasal spray.
- Recheck blood glucose after 15 minutes and repeat treatment if still below 70 mg/dL.
- Once blood glucose exceeds 70 mg/dL, provide a more substantial snack containing protein and complex carbohydrates.
- The patient should be closely monitored for the next 24 hours as recurrent hypoglycemia is common.
Adjusting Insulin Regimen
The patient's insulin regimen should be reevaluated, potentially reducing basal insulin doses by 20-30% while maintaining meal coverage, with frequent blood glucose monitoring, as prednisolone therapy typically raises blood glucose 3, 2. Consultation with an endocrinologist is advisable to optimize the diabetes management plan during steroid therapy.
Ongoing Management
Continuous glucose monitoring may improve glycemic control irrespective of treatment regimen 2. A glycemic target of glycated hemoglobin < 7% (53 mmol/mol) is appropriate for most nonpregnant adults. Basal insulin analogues with a reduced peak profile and an extended duration of action are preferred. Frequent blood glucose measurements along with patient education on insulin dosing based on carbohydrate counting, premeal blood glucose, and anticipated physical activity is paramount.