Does a patient with hyperglycemia (blood glucose 387) require additional insulin after receiving 10 units of insulin lispro (Humalog) and 22 units of insulin glargine (Lantus), following an initial blood glucose reading of 424?

From the Guidelines

The patient should not receive additional insulin at this time, as the current blood glucose of 387 mg/dL indicates a modest reduction from the initial reading, and rapid-acting insulin typically peaks within 1-2 hours. The patient has already received 10 units of insulin lispro (rapid-acting) for the initial high blood glucose of 424 mg/dL, along with 22 units of insulin glargine (long-acting) 1. The current blood glucose of 387 mg/dL indicates a modest reduction from the initial reading but remains significantly elevated. Additional insulin may be needed, but this decision should be based on the patient's established sliding scale protocol, insulin sensitivity factor, and time elapsed since the initial dose. Some key points to consider in the management of this patient's hyperglycemia include:

• The importance of dose titration in insulin therapy, as emphasized in the 2017 American Diabetes Association standards of medical care in diabetes 1.
• The potential benefits and drawbacks of different insulin regimens, including basal insulin plus a single injection of rapid-acting insulin, basal insulin plus a GLP-1–receptor agonist, or twice-daily premixed insulin 1.
• The need to monitor for symptoms of hyperglycemia, ensure adequate hydration, and check for ketones if appropriate while awaiting guidance from the provider. Rapid-acting insulin typically peaks within 1-2 hours, so if less than 2-3 hours have passed since the first dose, there may still be active insulin working to lower the blood glucose. Stacking insulin doses too closely together increases the risk of hypoglycemia. Document the blood glucose trend, and consider consulting with the healthcare provider before administering additional insulin.

From the Research

Patient's Current Condition

• The patient's current blood glucose (BG) level is 387, which is higher than the initial level of 424.
• The patient has already been administered 10 units of insulin lispro and 22 units of glargine.

Considerations for Additional Insulin

• According to the study 2, the combination of insulin glargine with a rapid-acting insulin analogue, such as lispro, can improve overall glycemic control and reduce nocturnal hypoglycemia.
• However, the study 3 suggests that mixing lispro with glargine can flatten the early pharmacodynamic peak of lispro and cause a shift to the right in the glucose infusion rate curve, which may lead to difficulties in controlling meal-related glucose excursions.
• The patient's current BG level is still elevated, and the decision to administer additional insulin should be based on their individual needs and response to the initial insulin doses.

Factors to Consider

• The patient's insulin sensitivity and response to the initial insulin doses
• The timing and amount of the patient's next meal or snack
• The patient's activity level and other factors that may affect their glucose levels
• The study 4 suggests that insulin lispro protamine and glargine can reduce glycemic variability and improve glycemic control, but the patient's individual response to these insulins should be taken into account.

Next Steps

• Monitor the patient's BG levels closely and adjust their insulin doses as needed to achieve optimal glycemic control.
• Consider the patient's individual needs and response to the initial insulin doses when deciding whether to administer additional insulin.
• Take into account the potential effects of mixing lispro with glargine on the patient's glucose control, as noted in the study 3.