Insulin Management for Patients with Persistent Hyperglycemia on Hemodialysis

Recommended Insulin Regimen Adjustment

The American Diabetes Association recommends increasing Lantus to 10 units daily as a starting point for patients on continuous enteral nutrition who require basal coverage 2, 3
For continuous tube feeding, basal insulin should be continued or initiated at approximately 5-10 units of glargine daily if the patient was not previously on basal insulin 2, 3
The current 5 units is insufficient given the persistent hyperglycemia and continuous nutritional load from tube feeding plus nutritional supplements 4
Regular insulin should be added every 6 hours OR rapid-acting insulin every 4 hours to cover the nutritional component 2, 3, 4
Approximately 1 unit of insulin per 10-15 grams of carbohydrate in the tube feeding formula should be started 2, 3, 4
Total carbohydrate content from both tube feeding and nutritional supplements should be calculated to determine appropriate nutritional insulin doses 4

Hemodialysis patients are at higher risk for hypoglycemia and typically require lower insulin doses than non-dialysis patients 1
If tube feeding is interrupted, immediately starting 10% dextrose infusion at 50 mL/hour can prevent hypoglycemia while maintaining basal insulin 4, 5

The American Diabetes Association recommends aiming for blood glucose levels of 140-180 mg/dL in non-critically ill hospitalized patients 1, 7

The American Diabetes Association advises against relying on sliding scale insulin alone, as this approach is ineffective as monotherapy and consistently shows worse outcomes than basal-bolus regimens 1, 2, 7
Nutritional insulin coverage should not be forgotten, as tube feeding provides continuous carbohydrate load requiring scheduled insulin, not just correctional doses 2, 3, 4
Basal insulin should not be stopped if feeding is interrupted; instead, dextrose infusion should be started to prevent hypoglycemia 4, 5

Blood glucose should be monitored every 4-6 hours given the continuous feeding schedule 2, 6
Insulin doses should be adjusted daily based on glucose patterns 2, 4