How to manage a patient with uncontrolled diabetes mellitus (DM) already on insulin therapy?

From the Guidelines

The management of uncontrolled diabetes in a patient already on insulin therapy should prioritize optimization of the insulin regimen, with consideration of adding basal or prandial insulin, and adjunctive non-insulin medications, as outlined in the most recent guidelines from 2025 1. To manage a patient with uncontrolled diabetes mellitus (DM) already on insulin therapy, the following steps should be taken:

• Evaluate the current insulin regimen and consider intensification by adding basal insulin (like glargine or detemir) at 0.1-0.2 units/kg/day if not already prescribed, or adjusting the dose by 10-20% based on fasting glucose patterns, as recommended by the 2025 standards of care in diabetes 1.
• For patients already on basal insulin, consider adding prandial insulin (lispro, aspart, or glulisine) starting at 4 units or 10% of basal dose before meals.
• Consider switching to a basal-bolus regimen with carbohydrate counting if the patient is capable, or fixed-dose mealtime insulin if not.
• Evaluate for insulin resistance and consider adding adjunctive non-insulin medications such as metformin, GLP-1 receptor agonists (like semaglutide), or SGLT-2 inhibitors, as suggested by previous guidelines 1.
• Review the patient's blood glucose monitoring frequency and technique, ensuring they monitor at least 3-4 times daily, and assess for hypoglycemia, which may prevent appropriate insulin dose escalation.
• Consider continuous glucose monitoring to identify glucose patterns and guide therapy adjustments, as this approach can provide valuable insights into the patient's glucose control and inform treatment decisions. Some key points to consider when managing uncontrolled diabetes in patients already on insulin therapy include:
• The importance of timely dose titration and adjustment of both basal and prandial insulins based on self-monitoring of blood glucose (SMBG) levels 1.
• The potential benefits of using GLP-1 receptor agonists or prandial insulin to reduce postprandial glucose excursions 1.
• The need to evaluate and address potential barriers to glycemic control, such as insulin resistance, hypoglycemia, and non-adherence to therapy.

From the Research

Management of Uncontrolled Diabetes in Patients Already on Insulin

To manage a patient with uncontrolled diabetes mellitus (DM) already on insulin therapy, several strategies can be employed:

• Adjusting the insulin regimen to better match the patient's needs, as a one-size-fits-all approach is often inadequate 2.
• Implementing a treatment plan that minimizes disruption to the patient's lifestyle, is cost-effective, and yields good results 2.
• Frequently assessing glucose levels and adjusting therapy as needed, following the principle of "Recheck often and change PRN" 2.
• Considering the use of analogue insulin, which is associated with less postprandial hyperglycemia and delayed hypoglycemia compared to human insulin 3.

Insulin Regimen Adjustment

Adjusting the insulin regimen may involve:

• Initiating multiple daily injections for patients with type 1 diabetes mellitus (T1DM) 3.
• Using a combination of short-acting or rapid-acting insulin analogue and intermediate or long-acting insulin for T1DM patients 3.
• For patients with type 2 diabetes mellitus (T2DM), starting with a long-acting (basal) insulin or once-daily premixed/co-formulation insulin, alone or in combination with other oral antidiabetic drugs (OADs) or a glucagon-like peptide-1 receptor agonist (GLP-1 RA) 3.
• Adding rapid-acting or short-acting insulin at mealtime if glucose targets are not met 3.

Patient Education and Empowerment

Empowering patients to manage their diabetes involves:

• Teaching patients to count carbohydrates, select foods with a low glycemic index, and adjust their insulin regimen using sliding scales based on the 1500 or 1800 rule 4.
• Encouraging regular exercise and providing solid emotional support from family and friends 4.
• Using algorithms to adjust insulin dosage based on patient-determined blood glucose measurements 5.
• Utilizing dedicated software to adjust insulin dosage between clinic visits, which can rely solely on glucose readings to make effective and safe adjustments 6.

Monitoring and Safety

Effective management also includes:

• Regular blood glucose monitoring to assess the effectiveness of the insulin regimen and make adjustments as needed 3.
• Avoiding intramuscular (IM) injections, especially with long-acting insulins, to prevent severe hypoglycemia 3.
• Rotating injection sites correctly to prevent lipohypertrophy, a frequent complication of insulin therapy that can distort insulin absorption 3.