What adjustments should be made to a treatment regimen for a patient with persistent hyperglycemia on Lantus (insulin glargine) at bedtime and Lispro (insulin lispro) on a sliding scale?

Treatment Adjustments for Persistent Hyperglycemia on Lantus and Lispro Sliding Scale

For patients with persistent hyperglycemia on Lantus at bedtime and Lispro sliding scale, transition to a full basal-bolus insulin regimen with fixed mealtime insulin doses rather than relying on sliding scale alone. 1

Current Regimen Assessment

The current regimen of Lantus (insulin glargine) at bedtime with Lispro (insulin lispro) sliding scale is inadequate for several reasons:

• Sliding scale insulin alone is ineffective as monotherapy and is generally not recommended 2
• This approach lacks proactive insulin coverage for meals, leading to persistent hyperglycemia
• The timing of Lantus at bedtime may contribute to overnight hyperglycemia 3

Recommended Treatment Modifications

Step 1: Optimize Basal Insulin (Lantus)

• Assess adequacy of current Lantus dose (signs of underbasalization include dose >0.5 units/kg/day or elevated fasting glucose) 2
• Consider changing Lantus timing from bedtime to morning, which has shown better glycemic control than bedtime administration 4
• Titrate Lantus dose by 2-4 units every 3 days until fasting glucose reaches target (140-180 mg/dL for most patients) 2, 1

Step 2: Add Structured Mealtime Insulin

• Replace sliding scale with fixed prandial insulin doses 2
• Start with 4 units of Lispro or 10% of basal dose before each meal 2
• Reduce basal insulin dose by approximately 10-20% when adding fixed mealtime doses 2
• Titrate prandial insulin by 1-2 units or 10-15% twice weekly based on post-meal glucose readings 2

Step 3: Calculate Total Daily Insulin Dose

• For patients with severe hyperglycemia, total daily insulin should be 0.3-0.4 units/kg/day 1
• Distribute as approximately 50% basal (Lantus) and 50% bolus (Lispro divided between meals) 1

Monitoring and Adjustment Protocol

• Monitor blood glucose before meals and at bedtime 1
• Target pre-meal glucose <140 mg/dL and random glucose <180 mg/dL 2
• Adjust insulin doses based on pattern recognition:
  • High fasting glucose → increase basal insulin
  • High pre-lunch glucose → increase breakfast Lispro
  • High pre-dinner glucose → increase lunch Lispro
  • High bedtime glucose → increase dinner Lispro

Special Considerations

• Hypoglycemia risk: Monitor for nocturnal hypoglycemia, especially when adjusting basal insulin. Consider reducing Lantus dose if hypoglycemia occurs between 2-4 AM 5
• Timing of Lantus: Morning administration of Lantus has shown better HbA1c improvement compared to bedtime dosing in some studies 4
• Meal content: Adjust prandial insulin based on carbohydrate content of meals if patient is capable of carbohydrate counting 2

Common Pitfalls to Avoid

1. Relying solely on sliding scale insulin - This reactive approach leads to glucose fluctuations and poor control 1
2. Inadequate total insulin dose - Underdosing is a common cause of persistent hyperglycemia 1
3. Failure to adjust both basal and bolus components - Both components need regular adjustment 1
4. Not considering insulin timing - The timing of insulin administration significantly impacts glycemic control 3

By implementing these structured changes to the insulin regimen, patients with persistent hyperglycemia should achieve improved glycemic control with reduced glucose variability.