What is the recommended adjustment for a patient with persistent hyperglycemia overnight, currently on insulin glargine (glargine insulin) 16 units at bedtime and 4 units of NovoRapid (insulin aspart) with each meal?

Management of Persistent Overnight Hyperglycemia in Insulin-Treated Patient

For a patient with persistent overnight hyperglycemia on insulin glargine 16 units at bedtime and NovoRapid 4 units with meals, the recommended adjustment is to increase the bedtime insulin glargine dose by 2 units to 18 units while maintaining the current mealtime insulin dosing. 1

Assessment of Current Insulin Regimen

The patient's current regimen consists of:

• Basal insulin: Glargine 16 units at bedtime
• Bolus insulin: NovoRapid (insulin aspart) 4 units with each meal

This persistent overnight hyperglycemia indicates inadequate basal insulin coverage during the nighttime hours, which is a common issue requiring dose adjustment.

Recommended Insulin Adjustment Algorithm

1. Basal Insulin Adjustment:

   • Increase insulin glargine from 16 to 18 units at bedtime 1
   • Continue to monitor fasting blood glucose for 3-7 days
   • Target fasting glucose range: 90-150 mg/dL (5.0-8.3 mmol/L) 1

2. Titration Protocol:

   • If 50% of fasting glucose values remain above target after 1 week: Increase by another 2 units 1
   • If any fasting glucose readings are <80 mg/dL (<4.4 mmol/L): Reduce dose by 2 units 1
   • Continue this pattern until target fasting glucose is achieved

3. Maintain Current Prandial Insulin:

   • Continue NovoRapid 4 units with each meal
   • Reassess need for prandial insulin adjustment after basal control is achieved

Rationale for This Approach

The 2024 American Diabetes Association Standards of Care recommends a stepwise approach to insulin titration, with incremental increases of 2 units (or 10-15% for higher doses) when glucose levels remain above target 1. The persistent overnight hyperglycemia suggests inadequate basal insulin coverage, making an increase in the bedtime glargine dose the most appropriate first step.

Important Considerations

• Timing of Glargine: While some evidence suggests morning administration of glargine may provide better overnight coverage 2, the current ADA guidelines support bedtime administration with appropriate dose titration 1

• Overbasalization Risk: Watch for signs of overbasalization if the total daily basal dose exceeds 0.5 units/kg/day or if hypoglycemia develops 1, 3

• Monitoring Requirements:

  • Check blood glucose before breakfast daily during titration
  • Document any hypoglycemic episodes (<70 mg/dL)
  • Consider occasional 3 AM readings to detect nocturnal hypoglycemia

• Alternative Approaches if this adjustment fails after 2-3 weeks:

  1. Consider changing timing of glargine from bedtime to morning 1
  2. Consider adding a GLP-1 receptor agonist if appropriate 1
  3. Consider splitting the basal dose (morning and evening) if persistent overnight hyperglycemia continues despite dose increases 1

Potential Pitfalls

• Delayed Dose Adjustment: Therapeutic inertia can lead to prolonged poor glycemic control 3
• Excessive Basal Insulin: Increasing basal insulin too much can cause nocturnal hypoglycemia 4
• Inadequate Monitoring: Failure to monitor glucose after dose changes can miss hypoglycemia or persistent hyperglycemia 3

This approach prioritizes addressing the overnight hyperglycemia while minimizing hypoglycemia risk, following the most recent evidence-based guidelines for insulin management.