What is the recommended insulin dosing regimen for a patient with an HbA1c of 9.3 who is taking metformin and currently using insulin aspart, insulin glargine (Lantus), and other insulins?

From the Guidelines

For a patient with an HbA1c of 9.3% on metformin and multiple insulin types, I recommend intensifying the basal-bolus insulin regimen while continuing metformin, with a focus on adjusting the basal insulin dose to 0.1-0.2 units/kg/day based on body weight and degree of hyperglycemia, as suggested by the 2021 standards of medical care in diabetes 1. The patient should maintain metformin at the maximum tolerated dose and adjust the insulin regimen as follows: continue insulin glargine (Lantus) once daily, typically 0.2-0.4 units/kg as the basal component, and use insulin aspart before meals at an initial dose of 0.1-0.2 units/kg/day divided across meals.

• Key considerations for the insulin regimen include:
  • Starting doses estimated based on body weight and degree of hyperglycemia
  • Individualized titration over days to weeks as needed
  • Principal action of basal insulin to restrain hepatic glucose production and limit hyperglycemia overnight and between meals
  • Control of fasting glucose can be achieved with human NPH insulin or a long-acting insulin analog, with long-acting basal analogs (U-100 glargine or detemir) demonstrated to reduce the risk of symptomatic and nocturnal hypoglycemia compared with NPH insulin 1. Blood glucose should be monitored 4 times daily (fasting and before meals), with target fasting glucose of 80-130 mg/dL and postprandial glucose below 180 mg/dL.
• Adjustments to the insulin regimen should be made based on:
  • Fasting glucose readings for basal insulin
  • Pre-meal and post-meal readings for mealtime insulin
  • Carbohydrate counting (typically 1 unit per 10-15g carbohydrates) for mealtime insulin dose adjustments This intensified approach is necessary because the HbA1c of 9.3% indicates poor glycemic control, and a basal-bolus regimen provides better 24-hour coverage by addressing both fasting hyperglycemia with glargine and postprandial spikes with aspart, as supported by the 2021 standards of medical care in diabetes 1.

From the FDA Drug Label

2.3 Initiation of Insulin Glargine Therapy Recommended Starting Dosage in Patients with Type 2 Diabetes The recommended starting dosage of Insulin Glargine in patients with type 2 diabetes who are not currently treated with insulin is 0.2 units/kg or up to 10 units once daily.

The recommended insulin dosing regimen for a patient with an HbA1c of 9.3 who is taking metformin and currently using insulin aspart, insulin glargine (Lantus), and other insulins is to individualize and adjust the dosage of Insulin Glargine based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal.

• The patient's current insulin regimen is not specified in the provided drug label, so dosage adjustments should only be made under medical supervision with appropriate glucose monitoring.
• For a patient with type 2 diabetes who is not currently treated with insulin, the recommended starting dosage of Insulin Glargine is 0.2 units/kg or up to 10 units once daily 2. However, since the patient is already on insulin, this information may not be directly applicable. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns, during acute illness, or changes in renal or hepatic function. It is essential to monitor the patient's blood glucose levels closely and adjust the insulin dosage accordingly. The patient's current dosage of five units three times daily before meals may need to be adjusted based on their individual needs and response to treatment. Medical supervision and glucose monitoring are crucial in determining the optimal insulin dosing regimen for this patient 2.

From the Research

Insulin Dosing Regimens

The patient in question has an HbA1c of 9.3 and is currently taking metformin and using insulin aspart, insulin glargine (Lantus), and other insulins. The recommended insulin dosing regimen for this patient is not explicitly stated in the provided studies, but we can look at the following points:

• A study comparing exenatide with mealtime insulin lispro in patients with type 2 diabetes inadequately controlled by insulin glargine and metformin found that exenatide resulted in similar glycemic control as mealtime insulin lispro, with a mean HbA1c change of -1.13% and -1.10%, respectively 3.
• Another study suggested that insulin may not be the preferred treatment for patients with HbA1c >9%, and that other treatments such as metformin, incretin-based treatments, SGLT2 inhibitors, and thiazolidinediones may be more effective 4.
• A comparison of insulin intensification strategies with insulin lispro low mixture twice daily versus basal insulin glargine and prandial insulin lispro once daily found that both strategies improved glycemic control in patients with type 2 diabetes not adequately controlled on insulin glargine plus metformin and/or pioglitazone 5.
• A study comparing the addition of insulin glargine versus NPH insulin to metformin found that both treatments reduced fasting blood glucose levels and postprandial beta-cell load, but insulin glargine reduced beta-cell stress more effectively at dinner and with a trend at lunch 6.
• A comparison of mealtime insulin aspart and human insulin in combination with metformin found that insulin aspart resulted in a significant reduction in HbA1c and blood glucose area under the curve (AUC) compared to human insulin 7.

Key Points to Consider

• The patient's current insulin regimen includes insulin aspart, insulin glargine, and other insulins, but the specific dosing regimen is not provided.
• The patient's HbA1c level is 9.3, which is above the target range for most patients with type 2 diabetes.
• The studies suggest that a combination of metformin and insulin, such as insulin aspart or insulin glargine, may be effective in improving glycemic control.
• The optimal insulin dosing regimen for this patient will depend on various factors, including their individual response to different insulins, their lifestyle and diet, and their overall health status.

Possible Insulin Dosing Regimens

• Insulin aspart before meals, with a dose of 5 units three times daily, as mentioned in the patient's current regimen.
• Insulin glargine at bedtime, with a dose that is titrated to achieve a fasting blood glucose level within the target range.
• A combination of insulin aspart and insulin glargine, with the insulin aspart dose adjusted based on the patient's pre-meal blood glucose levels and the insulin glargine dose adjusted based on the patient's fasting blood glucose level.