This commentary highlights the need for adjusted insulin dosing in patients with renal insufficiency and those on glucocorticoids, suggesting important clinical implications.
To the Editor: I would like to draw attention to two special situations that were not specifically mentioned in the review of management of hyperglycemia in the hospital setting by Dr. Inzucchi (Nov. 2 issue).1 One is the effect of renal insufficiency on determination of the starting dose of insulin. Since insulin clearance is decreased in patients with renal insufficiency, reducing the starting dose of insulin is essential to avoid hypoglycemia. The second situation is the case of patients who are receiving glucocorticoids. Through increasing insulin resistance, glucocorticoids cause hyperglycemia mainly in the postprandial state. Therefore, these patients frequently require higher prandial doses of insulin than basal doses; the rule of a 1:1 ratio between basal and bolus insulin doses frequently does not apply.
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Fadi Nabhan (2007) studied this question.
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