What is the most appropriate insulin regimen for a 78-year-old male with type 2 diabetes mellitus (T2DM), currently on semaglutide (semaglutide) and sliding-scale insulin aspart, to minimize finger sticks and control blood glucose levels?

Insulin Regimen Selection for a 78-Year-Old with Type 2 Diabetes

Changing sliding-scale insulin aspart to scheduled insulin glargine 12 units subcutaneously once daily in the morning is the most appropriate treatment plan for this patient to minimize finger sticks while maintaining good glycemic control and quality of life.

Rationale for Basal Insulin Selection

The patient's current situation presents several challenges:

• 78-year-old male with T2DM, CVA, and COPD
• Currently on sliding-scale insulin aspart (averaging 20 units daily) and semaglutide 1mg weekly
• HbA1c of 8.5% indicating suboptimal control
• Multiple medication intolerances (metformin, sulfonylureas, SGLT2 inhibitors, pioglitazone)
• Frustrated by frequent finger sticks (4-5 times daily)
• Cannot tolerate higher doses of semaglutide due to GI upset

Benefits of Once-Daily Basal Insulin

1. Reduced Monitoring Burden: Basal insulin glargine requires significantly fewer finger sticks than sliding-scale insulin, improving quality of life 1.

2. Appropriate for Elderly Patients: The ADA guidelines specifically recommend basal insulin for older adults as it's associated with minimal side effects and reasonable efficacy 1.

3. Simplified Regimen: For elderly patients, simplification of insulin regimens is recommended, with a preference for once-daily basal insulin in the morning rather than multiple daily injections 1.

4. Hypoglycemia Risk Management: Basal insulin glargine has a lower risk of hypoglycemia compared to prandial or premixed insulin regimens, which is particularly important in elderly patients 1.

Why Other Options Are Less Suitable

1. Scheduled insulin aspart before meals and snacks:

   • Would require multiple daily injections
   • Higher risk of hypoglycemia
   • Still necessitates frequent glucose monitoring
   • Increases treatment burden significantly 1

2. NPH/regular insulin 70/30 premixed:

   • Requires twice-daily dosing
   • Less flexible timing
   • Higher hypoglycemia risk than basal insulin
   • Not ideal for elderly patients due to complexity 1, 2

3. Insulin degludec with regular insulin at meals:

   • Most complex regimen of all options
   • Multiple daily injections
   • Highest monitoring burden
   • Highest risk of hypoglycemia 1

Implementation Plan

1. Initial Dosing: Start with insulin glargine 12 units subcutaneously once daily in the morning 1, 3

2. Titration Protocol:

   • Set fasting glucose goal of 90-150 mg/dL (appropriate for elderly patients)
   • Increase dose by 2 units every 3 days if 50% of fasting glucose values are above target
   • Decrease dose by 2 units if >2 fasting values/week are <80 mg/dL 1

3. Monitoring Schedule:

   • Once-daily fasting glucose check (significant reduction from current 4-5 daily checks)
   • HbA1c every 3 months
   • Periodic checks for hypoglycemia symptoms 1, 3

4. Continuation of Semaglutide:

   • Continue semaglutide 1mg weekly as it complements basal insulin
   • GLP-1 RAs like semaglutide have been shown to work well with basal insulin 4, 5
   • Provides postprandial glucose control without additional insulin 4

Important Considerations and Caveats

• Hypoglycemia Awareness: Fortunately, this patient is aware when experiencing hypoglycemia, making basal insulin a safer option 1

• Medication Burden: This regimen reduces both injection burden and finger stick frequency, addressing the patient's frustration 1

• Elderly-Specific Concerns: For patients >75 years, simplicity and hypoglycemia avoidance are paramount considerations 1

• Education: Ensure the patient understands the new regimen and how to recognize/treat hypoglycemia 3

• Reassessment: If HbA1c remains >8% after 3 months of optimized basal insulin therapy, consider adding a non-insulin agent rather than prandial insulin 3

This approach provides the best balance of glycemic control, reduced monitoring burden, and quality of life for this elderly patient with multiple comorbidities.