What adjustments are needed for a diabetic patient with an elevated Hemoglobin A1c (HbA1c) level, currently taking Toujeo (insulin glargine) Max U-300 38 units daily and Humlin (human insulin) 10 units three times a day?

From the Guidelines

For a diabetic patient with an elevated Hemoglobin A1c (HbA1c) level of 10.2, currently taking Toujeo (insulin glargine) Max U-300 38 units daily and Humlin (human insulin) 10 units three times a day, I recommend increasing the Toujeo dose to 42 units daily while maintaining the Humalin dose at 10 units three times daily, as the current insulin regimen is not providing adequate glycemic control over time 1.

Key Considerations

• The patient should monitor blood glucose levels more frequently, ideally 4 times daily (before meals and at bedtime), for at least two weeks to assess the effectiveness of this adjustment.
• If fasting blood glucose remains above 130 mg/dL after one week, the Toujeo dose can be further increased by 2-4 units, following the titration guidelines which suggest increasing the dose by 1–2 units or 10–15% twice weekly 1.
• Toujeo, as a long-acting basal insulin, primarily controls fasting and background glucose levels, while Humalin, a short-acting insulin, manages post-meal glucose spikes.
• Increasing the basal insulin first is typically safer as it reduces the risk of hypoglycemia compared to adjusting mealtime insulin.
• The patient should also be vigilant for signs of hypoglycemia (shakiness, sweating, confusion) and always have fast-acting carbohydrates available.
• Lifestyle modifications including consistent carbohydrate counting, regular physical activity, and stress management should complement this medication adjustment, as emphasized in the standards of care for diabetes management 1.

Additional Recommendations

• Consideration should be given to adjusting the insulin regimen further if the patient's HbA1c level remains above target, potentially including the addition of prandial insulin or a self-mixed/split insulin regimen 1.
• The importance of coordinating food intake with diabetes medication, particularly for those on insulin, should be emphasized to the patient, including the benefits of portion control, choosing nutrient-dense foods, and avoiding sugar-sweetened beverages 1.

From the Research

Adjustments for Diabetic Patient with Elevated HbA1c

The patient's current regimen consists of Toujeo (insulin glargine) Max U-300 38 units daily and Humlin (human insulin) 10 units three times a day, with an HbA1c level of 10.2%.

• The American Diabetes Association suggests the use of long-acting (basal) insulin to augment therapy with one or two oral agents or one oral agent plus a glucagon-like peptide 1 receptor agonist when the A1C level is 9% or more, especially if the patient has symptoms of hyperglycemia or catabolism 2.
• Insulin regimens should be adjusted every three or four days until targets of self-monitored blood glucose levels are reached, with a fasting and premeal blood glucose goal of 80 to 130 mg per dL and a two-hour postprandial goal of less than 180 mg per dL 2.
• The patient's current HbA1c level of 10.2% indicates that adjustments to their insulin regimen may be necessary to achieve better glycemic control.

Considerations for Insulin Therapy

• Insulin therapy is considered to be the most effective therapy for the reduction of high glucose levels, and should be administrated when patients cannot be regulated with the combination of oral hypoglycemic agents 3.
• The algorithms and guidelines of the American Association of Clinical Endocrinologists and the American Diabetes Association recommend that insulin administration be strongly considered for people with type 2 diabetes with HbA1c levels exceeding 9.0% and 10%, respectively 4.
• However, studies comparing basal insulin directly with glucagon-like peptide-1 (GLP-1) receptor agonists suggest that the latter agents may offer superior benefit, particularly in terms of HbA1c reduction and weight loss 4.

Alternative Insulin Therapies

• Prandial premixed therapy (PPT) and basal/bolus therapy (BBT) are two alternative insulin therapies that have been compared in type 2 diabetic patients previously treated with insulin glargine plus oral agents 5.
• While BBT was found to be more effective in reducing HbA1c levels, PPT may be considered as an alternative option for patients who require fewer injections.
• Glucose-sensitive insulin, such as NNC2215, is a new development that may offer improved glycemic control while lowering the risk of hypoglycaemia 6.