How to adjust Lantus (insulin glargine) 35u and Aspart (insulin aspart) 10u for HbA1c of 10?

Insulin Adjustment Strategy for HbA1c of 10% with Lantus 35u and Aspart 10u

For a patient with HbA1c of 10% on Lantus 35u and Aspart 10u, increase the Aspart dose to 14 units per meal (starting with the largest meal) and maintain the current Lantus dose, then titrate based on blood glucose monitoring.

Current Regimen Assessment

The patient's current regimen consists of:

• Lantus (insulin glargine) 35 units daily - basal insulin
• Aspart (rapid-acting insulin) 10 units - prandial insulin
• HbA1c of 10% - indicating poor glycemic control

Recommended Insulin Adjustment Strategy

Step 1: Prandial Insulin Intensification

• Increase Aspart dose from 10 units to 14 units (40% increase) with the largest meal or meal with greatest postprandial glucose excursion 1
• Maintain current Lantus dose of 35 units daily
• This approach follows the ADA guidelines for patients with HbA1c >10% who require intensification of prandial insulin 1

Step 2: Monitoring and Further Titration

• Monitor blood glucose at least 4 times daily, with particular attention to:
  • Fasting glucose (to assess Lantus adequacy)
  • Postprandial glucose (to assess Aspart adequacy)
• Titrate Aspart dose by 1-2 units or 10-15% twice weekly based on postprandial glucose values 1
• If hypoglycemia occurs, determine cause and lower corresponding dose by 10-20% 1

Step 3: Progressive Intensification (if needed after 3-6 months)

If HbA1c remains above target after 3-6 months:

• Consider stepwise addition of Aspart to other meals (add to second, then third meal) 1
• For each additional meal, start with 4 units or 10% of basal dose 1
• Progress to full basal-bolus regimen if needed

Rationale for This Approach

1. HbA1c of 10% indicates significant hyperglycemia requiring prompt intensification of insulin therapy 1

2. Prandial insulin intensification is appropriate because:

   • The patient is already on basal insulin (Lantus)
   • The current Aspart dose is likely inadequate for postprandial control
   • ADA guidelines recommend increasing prandial insulin when HbA1c remains elevated despite basal insulin 1

3. Starting with one meal allows for gradual intensification while minimizing hypoglycemia risk 1

Important Considerations

• Hypoglycemia risk: Monitor closely during dose adjustments, especially in the first few weeks
• Injection technique: Ensure proper rotation of injection sites to prevent lipohypertrophy, which can affect insulin absorption 2
• Meal consistency: Encourage consistent carbohydrate intake at meals to match insulin dosing
• Self-monitoring: Patient self-titration with a simple algorithm (adjusting dose every 3-4 days based on glucose readings) improves glycemic control 2

Common Pitfalls to Avoid

• Overbasalization: Increasing basal insulin beyond 0.5 units/kg/day without addressing prandial needs can lead to nocturnal hypoglycemia without improving overall control 1
• Therapeutic inertia: Delaying intensification of insulin therapy when HbA1c is significantly elevated (>10%) can prolong exposure to hyperglycemia 1
• Inadequate monitoring: Failing to check both fasting and postprandial glucose levels makes appropriate dose adjustments impossible 1

By following this structured approach to insulin adjustment, the patient's glycemic control should improve, leading to better long-term outcomes and reduced risk of diabetes complications.