From the Guidelines
For a 112 kg patient with hyperglycemia (glucose 297 mg/dL) in the ED, I recommend starting with a basal insulin dose of 0.2-0.3 U/kg per day, which equals approximately 22-33 units, given the patient's moderate hyperglycemia and insulin-naive status, as suggested by the study published in The Lancet Diabetes and Endocrinology in 2021 1. The patient's glucose level of 297 mg/dL falls into the moderate hyperglycemia category, and according to the guidelines, basal insulin with or without correction doses is recommended.
- The patient's weight is 112 kg, so the calculated basal insulin dose would be 22-33 units per day.
- Since the patient is insulin-naive and has type 2 diabetes, as implied by the elevated HbA1c of 8.7%, starting with a lower dose and adjusting as needed is prudent.
- Correction doses with rapid-acting insulin before meals or every 6 hours can be considered if the patient's glucose levels remain elevated. The patient's chest X-ray shows mild vascular congestion versus peribronchial thickening, but normal cardiac markers (Troponin 0.01, BNP <10) suggest this is not cardiac in origin.
- Ensure adequate IV fluids and monitor electrolytes, particularly potassium, as insulin therapy can cause hypokalemia.
- Once the patient is stabilized, transition to subcutaneous insulin with consideration of basal-bolus regimen based on the patient's weight and insulin sensitivity, as recommended by the study 1.
From the FDA Drug Label
At endpoint, mean (± SD) total daily insulin doses for Humulin R U-100 were 0.18 ± 0. 17 units/kg. With intravenous use, the pharmacologic effect of Humulin R U-100 begins at approximately 10 to 15 minutes and terminates at a median time of approximately 4 hours (range: 2 to 6 hours) after administration of doses in the range of 0. 1 to 0.2 units/kg.
For a 112 kg patient, the total daily insulin dose would be approximately 0.18 units/kg x 112 kg = 20.16 units. However, since this is for intravenous use, a more appropriate dose range would be 0.1 to 0.2 units/kg.
- The initial dose could be 0.1 units/kg x 112 kg = 11.2 units.
- Alternatively, the initial dose could be 0.2 units/kg x 112 kg = 22.4 units, but this may be too high. Given the patient's glucose level of 297, a dose of 11.2 units of insulin (IV) could be considered as a starting point, with adjustments made as needed to achieve normoglycemia 2, 3.
From the Research
Management of Hyperglycemia in the ED
The patient presents with a glucose level of 297 and a hemoglobin A1c (HbA1c) of 8.7, indicating poor glycemic control 4. The management of hyperglycemic crises, including diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS), involves aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events 5.
Insulin Therapy
The American Diabetes Association recommends the use of intravenous insulin in the management of DKA and HHS, with a typical starting dose of 0.1 units/kg/hour 6, 7. For a 112 kg patient, the initial insulin dose would be:
- 0.1 units/kg/hour x 112 kg = 11.2 units/hour
Key Considerations
- The patient's glucose level and HbA1c indicate poor glycemic control, and insulin therapy is necessary to manage hyperglycemia 4.
- The management of DKA and HHS requires careful monitoring of electrolytes, fluid status, and glucose levels 6, 7.
- The prognosis and outcome of patients with DKA or HHS are determined by the severity of dehydration, the presence of comorbidities, and age >60 years 8.
Monitoring and Adjustments
- The patient's glucose level, electrolytes, and fluid status should be closely monitored, and the insulin dose adjusted as needed to achieve glycemic control 6, 7.
- The patient's HbA1c level indicates poor glycemic control over the past 2-3 months, and adjustments to their long-term diabetes management plan may be necessary 4.