What is the recommended dose adjustment for a patient with an HbA1c level of 8.4% who is currently taking Lantus (insulin glargine) 30 units and Novolog (insulin aspart) 3 units?

Insulin Dose Adjustment for Patient with HbA1c 8.4%

For a patient with HbA1c of 8.4% currently on Lantus 30 units and Novolog 3 units, I recommend increasing the Lantus (basal insulin) dose by 4 units to 34 units daily and the Novolog (bolus insulin) dose by 1 unit to 4 units per meal.

Assessment of Current Control

The patient's HbA1c of 8.4% indicates suboptimal glycemic control:

• This falls between 8-9%, suggesting the need for therapy intensification 1
• Current regimen of Lantus 30 units (basal) and Novolog 3 units (bolus) is insufficient
• Target HbA1c should be between 7-8% for most patients with diabetes 1

Insulin Adjustment Algorithm

Step 1: Evaluate Basal Insulin (Lantus)

• Current dose: 30 units daily
• For HbA1c between 8-9%, increase basal insulin by 10-15% 1
• 30 units × 0.15 = 4.5 units increase (round to 4 units)
• New Lantus dose: 34 units daily

Step 2: Evaluate Bolus Insulin (Novolog)

• Current dose: 3 units per meal
• With HbA1c >8%, prandial insulin should be increased 1
• Recommend increasing by 1 unit per meal (33% increase)
• New Novolog dose: 4 units per meal

Rationale for Adjustment

1. Basal-Bolus Balance:

   • When HbA1c remains above target despite optimized basal insulin, combination injectable therapy should be intensified 1
   • Both basal and prandial insulins need adjustment based on blood glucose levels

2. Proportional Adjustment:

   • The total daily insulin dose is currently 39 units (30 + 3×3)
   • Increasing both components maintains the appropriate basal-bolus ratio
   • This approach addresses both fasting and postprandial hyperglycemia

3. Safety Considerations:

   • Modest incremental increases (10-15% for basal, 33% for bolus) minimize hypoglycemia risk
   • Gradual titration is preferred over aggressive adjustment 1

Monitoring and Follow-up

• Check fasting blood glucose daily to assess basal insulin efficacy
• Monitor pre-meal and 2-hour post-meal glucose to evaluate bolus insulin effectiveness
• Return for follow-up in 2 weeks to reassess control and make further adjustments if needed
• Target fasting glucose: 90-130 mg/dL
• Target post-meal glucose: <180 mg/dL

Important Precautions

• Instruct patient on recognizing and managing hypoglycemia
• Ensure proper insulin administration technique and site rotation
• Advise on consistent carbohydrate intake with meals
• Consider checking blood glucose more frequently during dose adjustment period

Alternative Considerations

If this adjustment doesn't achieve target HbA1c within 2-3 months:

1. Consider further intensification of insulin therapy
2. Evaluate for basal-bolus ratio issues (typical ratio is 50:50)
3. Consider adding a GLP-1 receptor agonist if appropriate 1
4. Assess for other factors affecting glycemic control (illness, medications, adherence)

This stepwise approach to insulin adjustment prioritizes achieving better glycemic control while minimizing the risk of hypoglycemia, which directly impacts patient morbidity and mortality.