Post-Quiz: Hyperglycemia in Hospitalized Patients IM 101

You are a clinical pharmacist reviewing the medication chart of a 63-year-old female patient with Type 2 diabetes who was admitted with dehydration secondary to gastroenteritis. Her home regimen of diabetes management includes NPH insulin in the morning and at bedtime, with regular insulin before meals. Given her current condition, she is on a clear liquid diet, and her blood glucose levels are being monitored every 4 hours.

The nursing staff asks for your guidance on insulin administration, specifically concerning the expected duration of action of the patient’s regular and NPH insulin, to prevent hypoglycemic events while she’s on a reduced caloric intake.

What information would you provide regarding the duration of action for regular and NPH insulin in this clinical scenario?

Regular insulin: 2-4 hours, NPH insulin: 6-8 hours
Regular insulin: 5-8 hours, NPH insulin: 18-24 hours
Regular insulin: 8-12 hours, NPH insulin: 12-16 hours
Regular insulin: 4-6 hours, NPH insulin: 10-16 hours

A 52-year-old woman with a history of Type 1 diabetes is admitted to the ICU with septic shock. She is on an insulin pump at home. Considering her critical illness, what would be the most appropriate glycemic target for her?

80-110 mg/dL, to minimize infection and facilitate recovery.
110-140 mg/dL, to balance the risk of hypoglycemia with the benefits of glycemic control.
140-180 mg/dL, to prevent hypoglycemia while avoiding significant hyperglycemia.
No specific target, but keep glucose below 250 mg/dL.

You are the clinical pharmacist on duty when a 47-year-old male patient with a history of Type 2 diabetes is admitted for elective surgery. The patient’s diabetes is managed with subcutaneous regular insulin and metformin. His last dose of regular insulin was administered 4 hours prior to admission. The nursing staff is concerned because his blood glucose level is 250 mg/dL upon admission. You are asked for your input regarding the patient’s insulin management.

Understanding the pharmacokinetics of regular insulin, what would you suggest as the most likely reason for the patient’s elevated blood glucose level and what immediate action would you recommend?

The patient is likely experiencing the peak effect of regular insulin, and no additional insulin should be administered at this time.
The patient's blood glucose level is high because the regular insulin is likely at its trough, having been administered 4 hours prior. An additional dose of regular insulin should be given.
The patient's elevated blood glucose may be due to stress or other factors unrelated to the insulin's pharmacokinetics. A correction dose of rapid-acting insulin should be given.
The regular insulin is still in its onset phase; thus, the patient's blood glucose level hasn't decreased yet. A supplemental dose of regular insulin is recommended.

You are a clinical pharmacist consulting on the case of a 58-year-old female patient with Type 1 diabetes, admitted for an acute kidney infection. She manages her diabetes with NovoLog (insulin aspart) before meals and a long-acting insulin analog at bedtime. She took her usual dose of NovoLog 3 hours before lunch, but now, 4 hours post-injection, her blood glucose is reported as 275 mg/dL. The medical team is seeking your advice on the next steps for her diabetes management.

Given your understanding of the pharmacokinetics of NovoLog, what is the most likely explanation for the patient’s hyperglycemia, and what would you recommend?

The patient's hyperglycemia is likely due to the peak effect of NovoLog, suggesting that her pre-meal dose was insufficient. A correction dose of NovoLog should be administered.
Since NovoLog is still in its onset phase, the patient's blood glucose hasn't decreased yet. It's advisable to wait another hour before making any adjustments.
NovoLog likely reached its peak approximately an hour ago, and its effects are now diminishing, contributing to the rise in blood glucose. A correction dose of rapid-acting insulin should be given.
The patient's hyperglycemia is probably unrelated to the pharmacokinetics of NovoLog and may be due to her acute illness or other factors. Her insulin regimen should remain unchanged.

You are a clinical pharmacist and have been asked to conduct a training session for new healthcare staff. During the session, a question arises about the appropriate timing of insulin administration in relation to meal times. The staff is particularly interested in understanding the differences in onset of action among several insulin types to optimize glycemic control in diabetic patients.

How would you instruct the staff regarding the typical onset of action for the following insulins: regular insulin (Humulin R), insulin aspart (NovoLog), insulin lispro (Humalog), and insulin glargine (Lantus)?

Humulin R: 10-30 minutes, NovoLog: 30-60 minutes, Humalog: 15-30 minutes, Lantus: 1-2 hours
Humulin R: 30-60 minutes, NovoLog: 10-20 minutes, Humalog: 15-30 minutes, Lantus: 3-4 hours
Humulin R: 15-30 minutes, NovoLog: 5-10 minutes, Humalog: 10-15 minutes, Lantus: 1-1.5 hours
Humulin R: 1-2 hours, NovoLog: 2-4 hours, Humalog: 30-60 minutes, Lantus: 5-6 hours

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