What adjustments should be made to a patient's Lantus (insulin glargine) and metformin regimen with an HbA1c level of 11.8?

Medication Adjustment for Poorly Controlled Type 2 Diabetes

With an HbA1c of 11.8% on Lantus 30 units and metformin 2000 mg, you should increase Lantus to 45-50 units daily and maintain the current metformin dose. 1

Assessment of Current Control

The HbA1c of 11.8% indicates severely uncontrolled diabetes despite being on a moderate dose of basal insulin (Lantus 30 units) and a maximal dose of metformin (2000 mg). This level of hyperglycemia significantly increases the risk of both microvascular and macrovascular complications, requiring prompt intervention.

Medication Adjustment Algorithm

1. Basal Insulin (Lantus) Adjustment

• Current dose: 30 units daily
• Recommended adjustment: Increase to 45-50 units daily (50% increase)
• Titration method: Increase by 2-4 units every 3-4 days until fasting blood glucose reaches 72-90 mg/dL (4.0-5.0 mmol/L) 1, 2

The FDA label for insulin glargine indicates that dosage adjustments should be individualized based on the patient's metabolic needs and blood glucose monitoring results 2. With an HbA1c >11%, significant insulin dose escalation is warranted.

2. Metformin

• Current dose: 2000 mg daily
• Recommendation: Maintain current dose as this is already at the maximum recommended daily dose

3. Consider Additional Therapy

According to the ADA/EASD consensus report, when HbA1c levels exceed 10% (86 mmol/mol), consideration should be given to adding a third agent or transitioning to a more complex insulin regimen 1:

• Option A: Add a GLP-1 receptor agonist if postprandial hyperglycemia is significant
• Option B: Consider transitioning to basal-bolus insulin therapy if severe hyperglycemia persists after basal insulin optimization

Monitoring Recommendations

1. Blood glucose monitoring: Increase frequency to at least twice daily (fasting and post-dinner)
2. HbA1c: Recheck in 3 months
3. Hypoglycemia awareness: Educate patient on recognition and management
4. Follow-up: Schedule within 2-4 weeks to assess response to therapy

Important Considerations

• Hypoglycemia risk: The risk increases with higher insulin doses, but this must be balanced against the serious risks of continued severe hyperglycemia 1
• Insulin titration: Self-titration by the patient (increasing by 1-2 units every 3 days if fasting glucose remains above target) can be effective 3
• Adherence assessment: Verify that the patient is taking medications as prescribed and using proper injection technique

Common Pitfalls to Avoid

1. Insufficient insulin dose adjustment: Many providers increase insulin too cautiously, leading to prolonged hyperglycemia
2. Failure to consider insulin resistance: At HbA1c >11%, significant insulin resistance may be present, requiring higher doses than expected
3. Overlooking the need for prandial coverage: If fasting glucose improves but HbA1c remains elevated, postprandial hyperglycemia may require additional intervention
4. Delaying specialist referral: If glycemic targets are not achieved within 3-6 months despite appropriate adjustments, consider endocrinology referral 1

The evidence clearly supports that with an HbA1c of 11.8%, more aggressive therapy is needed. Increasing the Lantus dose by approximately 50% while maintaining the maximum metformin dose represents the most evidence-based approach to improve glycemic control and reduce the risk of diabetes-related complications.