From the Guidelines
For a patient with uncontrolled hyperglycemia on Basaglar 40 units twice daily, I recommend adding a single injection of rapid-acting insulin analogue before the largest meal, as this approach has been shown to be noninferior to basal insulin plus a GLP-1–receptor agonist or 2 daily injections of premixed insulins 1. When considering treatment intensification, it's essential to understand the pharmacodynamic profile of each insulin formulation and adjust dosing accordingly.
- The patient's current regimen of Basaglar 40 units twice daily may not be providing adequate control, and adding a rapid-acting insulin analogue can help address postprandial glucose spikes.
- The choice of rapid-acting insulin analogue, such as lispro, aspart, or glulisine, should be based on the patient's individual needs and preferences.
- Dosing adjustments should be made gradually, with careful monitoring of blood glucose levels to avoid hypoglycemia.
- Alternative options, such as switching to a premixed insulin or adding a GLP-1–receptor agonist, may also be considered, but the addition of a rapid-acting insulin analogue is a more straightforward and evidence-based approach 1.
- Comprehensive management should also include reviewing and optimizing the patient's diet, physical activity, and stress management to achieve better glycemic control.
From the FDA Drug Label
2.2 General Dosing Instructions Administer Insulin Glargine subcutaneously once daily at any time of day but at the same time every day. Individualize and adjust the dosage of Insulin Glargine based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal. 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 is currently taking Basaglar (insulin glargine) 40 units twice daily, which is not the recommended dosing regimen. The recommended dosing regimen is once daily. To control blood sugar, consider adjusting the dosage regimen to once daily and individualize the dosage based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal under medical supervision 2.
From the Research
Uncontrolled Hyperglycemia on Basaglar
For a patient with uncontrolled hyperglycemia on Basaglar (insulin glargine) 40 units twice daily, several options can be considered:
- Adjusting the dosage of Basaglar: The current dosage may not be sufficient to control the patient's blood sugar levels, and an increase in dosage may be necessary 3.
- Switching to a different basal insulin: Insulin degludec has been shown to have a more stable and longer-lasting glucose-lowering effect compared to insulin glargine, and may be a suitable alternative 3, 4.
- Adding a rapid-acting insulin: The use of a rapid-acting insulin, such as insulin aspart, in combination with a basal insulin, can help to control postprandial glucose excursions 3, 5.
- Considering a co-formulation: Co-formulations, such as insulin degludec/insulin aspart, can provide both basal and prandial insulin coverage, and may be a convenient option for patients who require multiple injections per day 3, 4.
Factors to Consider
When making changes to a patient's insulin regimen, several factors should be considered, including:
- The patient's lifestyle and dietary habits
- The presence of any comorbidities or complications
- The patient's preference for injection frequency and timing
- The potential for hypoglycemia and other adverse effects
Alternative Insulin Regimens
Alternative insulin regimens, such as biphasic insulin aspart or insulin glulisine, may also be considered for patients with uncontrolled hyperglycemia on Basaglar 5, 6. A comprehensive evaluation of the patient's individual needs and circumstances can help to determine the most suitable insulin regimen.