What is the appropriate dose of regular insulin for a 112 kg patient with type 2 diabetes mellitus and hyperglycemia, presenting to the Emergency Department (ED)?

From the Guidelines

For a 112 kg patient with type 2 diabetes presenting with hyperglycemia (glucose 297 mg/dL) in the ED, I would recommend administering 11-12 units of regular insulin intravenously, based on the standard initial insulin dosing of approximately 0.1 units/kg for moderate hyperglycemia without ketoacidosis, as suggested by the most recent guidelines 1. This dose is chosen to effectively manage the patient's hyperglycemia while minimizing the risk of hypoglycemia.

• The patient's glucose level is 297 mg/dL, indicating moderate hyperglycemia.
• The patient's weight is 112 kg, and using the guideline-recommended dose of 0.1 units/kg, the calculated dose would be approximately 11.2 units.
• After administration, blood glucose should be monitored every hour, with additional insulin given as needed according to a correction scale.
• Intravenous fluids should also be started, typically normal saline at a moderate rate.
• The elevated HbA1c of 8.7% indicates poor long-term glycemic control, suggesting the need for adjustment of the patient's outpatient diabetes regimen.
• The chest x-ray findings of mild vascular congestion should be monitored, but with the normal BNP (<10) and troponin (0.01), heart failure is less likely as a cause.
• The normal D-dimer (0.27) also rules out pulmonary embolism.
• Once the acute hyperglycemia is controlled, transition to subcutaneous insulin or the patient's home diabetes medications should be planned prior to discharge, with clear follow-up instructions for diabetes management, as outlined in the standards of medical care in diabetes 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. The patient weighs 112 kg and has a glucose level of 297. To calculate the dose:

• 0.18 units/kg * 112 kg = 20.16 units However, this is the total daily dose, and the label does not provide a clear indication of how to administer this dose in the ED setting for acute management. Given the information provided, it is not possible to determine the exact dose of insulin regular to administer in this scenario. The FDA label does not provide sufficient guidance for calculating an initial dose of insulin for acute management of hyperglycemia in the ED setting. Therefore, clinical judgment and consultation with a specialist are recommended. 2 2

From the Research

Management of Hyperglycemia in the Emergency Department

• The patient has a glucose level of 297 and an HbA1c of 8.7%, indicating hyperglycemia 3.
• The management of hyperglycemia in the emergency department (ED) is crucial to improve clinical outcomes and prevent readmission 3.

Insulin Therapy for Type 2 Diabetes

• Insulin therapy is recommended for patients with type 2 diabetes mellitus and an initial A1C level greater than 9 percent, or if diabetes is uncontrolled despite optimal oral glycemic therapy 4.
• For a 112 kg patient, the initial insulin dose can be calculated as 0.3 unit per kg, which would be approximately 33.6 units of regular insulin 4.
• However, the American Association of Clinical Endocrinologists and the American Diabetes Association recommend considering insulin administration for people with type 2 diabetes with HbA1c levels exceeding 9.0% and 10%, respectively 5.

Considerations for Insulin Dosing

• The patient's HbA1c level is 8.7%, which is below the recommended threshold for insulin therapy 5.
• The patient's glucose level is 297, which indicates hyperglycemia, but the insulin dose should be titrated based on the patient's response to treatment 4.
• The use of insulin in patients with type 2 diabetes should be individualized, taking into account the patient's glucose control, adverse effects, cost, adherence, and quality of life 4.

Calculation of Insulin Dose

• Based on the study by 4, the initial insulin dose for a 112 kg patient can be calculated as 0.3 unit per kg, which would be approximately 33.6 units of regular insulin.
• However, this dose may need to be adjusted based on the patient's response to treatment and other factors, such as glucose levels and presence of ketones 3.