How to manage a patient with hyperglycemia on Lantus (insulin glargine) 22 units twice a day?

Management of Patient with A1C 11.6% on Lantus 22 Units Twice Daily

The patient with an A1C of 11.6% on Lantus 22 units twice daily requires immediate insulin intensification with addition of prandial insulin in a basal-bolus regimen to achieve glycemic control.

Current Situation Assessment

The patient's A1C of 11.6% indicates severe hyperglycemia despite being on a substantial dose of basal insulin (Lantus 22 units twice daily, totaling 44 units daily). This suggests:

• Inadequate insulin coverage for the patient's needs
• Possible insulin resistance requiring higher doses
• Lack of mealtime insulin coverage for postprandial glucose excursions

Recommended Management Approach

Step 1: Optimize Basal Insulin

• Continue Lantus but consider consolidating to once-daily dosing (if not already optimized)
• Ensure the total daily basal insulin dose is appropriate (typically 0.1-0.5 U/kg/day as a starting point) 1
• Verify the patient is actually taking all prescribed insulin as directed

Step 2: Add Prandial Insulin

• Initiate prandial insulin (rapid-acting insulin analog) before meals 2, 1
• Start with 4-6 units before each meal or approximately 10-15% of total daily basal dose per meal
• Instruct patient to titrate prandial insulin based on pre-meal and post-meal glucose readings
• The need for prandial insulin is evident when basal insulin exceeds 0.5 U/kg/day, especially as it approaches 1 U/kg/day 2

Step 3: Adjust Insulin Doses

• Titrate basal insulin to target fasting blood glucose of 80-130 mg/dL
• Adjust prandial insulin to target postprandial glucose <180 mg/dL
• Consider using insulin-to-carbohydrate ratios for more precise dosing
• Avoid overbasalization, which can lead to hypoglycemia 1

Step 4: Consider Additional Medications

• Maintain metformin if not contraindicated (renal function, heart failure, liver failure) 1
• Consider adding an SGLT2 inhibitor for additional glycemic control, weight management, and cardio-renal protection 1
• GLP-1 receptor agonists may be beneficial for additional glucose lowering and weight management 2, 1

Monitoring and Follow-up

• Instruct patient on frequent self-monitoring of blood glucose (before meals and at bedtime)
• Review blood glucose logs and adjust insulin doses weekly until stable
• Reassess A1C in 3 months after treatment modification 1
• Evaluate for hypoglycemia, especially nocturnal episodes (advantage of insulin glargine is reduced risk of hypoglycemia compared to NPH insulin) 3, 4

Lifestyle Modifications

• Reinforce diet and exercise as foundational components of treatment 1
• Consider referral to diabetes education program
• Recommend 150 minutes/week of moderate-intensity physical activity 1
• Encourage consistent carbohydrate intake at meals to match insulin dosing

Common Pitfalls to Avoid

1. Delayed intensification of therapy - Don't wait to add prandial insulin when A1C is this elevated 1
2. Overbasalization - Simply increasing basal insulin without adding prandial coverage will not address postprandial excursions 1
3. Inadequate patient education - Ensure patient understands insulin administration, hypoglycemia management, and glucose monitoring 1
4. Ignoring comorbidities - Assess for cardiovascular disease, kidney disease, and other complications 1

This approach follows the American Diabetes Association recommendations for insulin intensification when patients are not meeting glycemic targets despite basal insulin therapy 1. The high A1C of 11.6% indicates a need for more aggressive intervention beyond simply adjusting the current basal insulin regimen.