What adjustment should be made to the treatment regimen for a patient with hyperglycemia, currently taking glargine (insulin glargine) 50 units and metformin (possibly referred to as Lipton, assuming it's a typo) 18 units, after consuming a cheeseburger?

From the Guidelines

I recommend increasing the glargine dose to 55 units daily and considering a higher mealtime insulin dose when consuming high-carbohydrate meals like cheeseburgers, as the current regimen is not providing adequate 24-hour coverage, and adjusting the mealtime insulin dose based on the carbohydrate and fat content of the meal, as suggested by the 2024 standards of care in diabetes 1. The morning blood glucose of 219 mg/dL indicates that the current insulin regimen is not providing adequate 24-hour coverage.

• Glargine is a long-acting insulin that controls baseline blood glucose levels, and a modest 10% increase from 50 to 55 units is a reasonable adjustment when fasting numbers are consistently elevated, as individualized meal plans should keep nutrient quality, total calories, and metabolic goals in mind 1.
• For meals high in carbohydrates and fat like cheeseburgers, you may need to increase your mealtime insulin (Lispro, not Lipton) dose or consider taking it 15-20 minutes before eating to better match the glucose rise, and provide education on the glycemic impact of carbohydrate, fat, and protein tailored to an individual’s needs, insulin plan, and preferences to optimize mealtime insulin dosing 1.
• Fat in meals like cheeseburgers can delay carbohydrate absorption, making glucose control more challenging, and emphasizing minimally processed, nutrient-dense, high-fiber sources of carbohydrate can help improve glycemia 1.
• After making these adjustments, continue monitoring blood glucose levels closely, especially for hypoglycemia, and consult with your healthcare provider before implementing these changes to ensure they're appropriate for your specific situation, and consider an eating plan emphasizing elements of a Mediterranean eating pattern, which is rich in monounsaturated and polyunsaturated fats and long-chain fatty acids, to reduce cardiovascular disease risk and improve glucose metabolism 1. It's also important to note that the patient should be aware of the signs and symptoms of hypoglycemia, especially when using insulin or insulin secretagogues, and the importance of monitoring glucose after consuming alcoholic beverages to reduce hypoglycemia risk, as suggested by the consensus recommendations for sick day medication guidance for people with diabetes, kidney, or cardiovascular disease 1.

From the FDA Drug Label

Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), during acute illness, or changes in renal or hepatic function. Dosage adjustments should only be made under medical supervision with appropriate glucose monitoring [see Warnings and Precautions (5.2)].

The patient's blood glucose level is 219 in the morning, and they have had a cheeseburger. Considering the high blood glucose level, dosage adjustments may be necessary. The patient is currently on insulin glargine 50 and Lipton 18.

• The high blood glucose level may indicate that the current insulin dosage is not sufficient to control the patient's blood glucose levels.
• The patient's meal pattern has changed with the consumption of a cheeseburger, which may affect their blood glucose levels.
• Dosage adjustments should be made under medical supervision with appropriate glucose monitoring. 2

From the Research

Patient's Current Situation

• The patient's blood glucose (BG) level is 219 mg/dL in the morning.
• The patient is currently taking 50 units of glargine and 18 units of Lipton (likely a rapid-acting insulin).
• The patient had a cheeseburger, which can affect blood glucose levels.

Considerations for Adjusting Insulin Dose

• According to the study 3, adequate titration of insulin dose is crucial to achieve good glycemic control with minimal hypoglycemia.
• The study 3 suggests that a simple titration regimen can be used to adjust the insulin dose based on fasting plasma glucose levels.
• The study 4 found that glargine reduces A1C levels more than NPH insulin in non-obese patients, and reduces the risk of severe and severe nocturnal hypoglycemia.

Potential Changes to Insulin Regimen

• Consider adjusting the glargine dose based on the patient's fasting plasma glucose levels, as suggested by the study 3.
• Consider switching to a different type of insulin, such as insulin degludec, which has been shown to reduce the risk of hypoglycemia compared to insulin glargine 5.
• Consider adjusting the dose of Lipton (rapid-acting insulin) based on the patient's blood glucose levels after meals, such as after consuming a cheeseburger.

Monitoring and Follow-up

• Regularly monitor the patient's blood glucose levels to assess the effectiveness of any changes made to the insulin regimen.
• Adjust the insulin dose as needed to achieve good glycemic control with minimal hypoglycemia, as suggested by the study 3.