Inadequate Insulin Dosing or Timing: The patient's high fasting blood glucose (BG) and high A1c despite being on basal and rapid-acting insulin suggest that the current insulin regimen may not be adequately addressing her glucose needs, possibly due to insufficient dosing or inappropriate timing of insulin administration.

Insulin Resistance: Given the patient's obesity, insulin resistance is a likely contributor to her high fasting BG and A1c. Insulin resistance makes it harder for glucose to enter cells, leading to higher blood glucose levels.
Poor Dietary Control: Consuming high-carbohydrate or high-sugar foods, especially before bedtime, can lead to elevated morning glucose levels. The patient's obesity suggests that dietary factors may be contributing to her glucose control issues.
Inadequate Physical Activity: Lack of regular physical activity can contribute to insulin resistance and poor glucose control. As an obese individual, increasing physical activity could help improve insulin sensitivity.

Cushing's Syndrome: Although rare, Cushing's syndrome can cause significant glucose dysregulation due to excess cortisol production. It's crucial to consider this diagnosis because it requires specific treatment and can have serious consequences if left untreated.
Pituitary or Adrenal Tumors: Tumors affecting the pituitary or adrenal glands can lead to an overproduction of hormones that counteract insulin's effects, such as cortisol or growth hormone. These conditions are rare but critical to diagnose due to their potential impact on glucose control and overall health.
Pancreatic Insufficiency or Other Endocrinopathies: Conditions affecting the pancreas or other endocrine glands can impair glucose regulation. While less common, these conditions are important to rule out, especially if the patient's glucose control does not improve with adjustments to her insulin regimen and lifestyle.

Somatostatinoma: A rare tumor of the pancreas that produces excess somatostatin, which can inhibit insulin secretion and lead to diabetes. This condition is extremely rare but should be considered in cases of unexplained glucose dysregulation.
Glucagonoma: A rare tumor of the pancreas that produces excess glucagon, leading to increased glucose production by the liver and resulting in hyperglycemia. Like somatostatinoma, this is a rare cause of diabetes but is important to diagnose due to its specific treatment requirements.