What adjustments should be made to a patient's treatment plan with long-acting insulin 24u in the morning and short-acting insulin 24u at bedtime with a Fasting Blood Sugar (FBS) level of 90?

Insulin Regimen Adjustment for Patient with Fasting Blood Sugar of 90

The current insulin regimen should be reversed - the long-acting insulin should be administered at bedtime and the short-acting insulin should be given with meals rather than at bedtime. 1

Current Regimen Assessment

The patient is currently taking:

• Long-acting insulin 24 units in the morning
• Short-acting insulin 24 units at bedtime
• Fasting blood sugar (FBS) is 90 mg/dL

This regimen is problematic for several reasons:

• Short-acting insulin at bedtime increases nocturnal hypoglycemia risk
• Long-acting insulin in morning may not provide adequate overnight coverage
• The FBS of 90 mg/dL is actually at target but may be masking other issues

Recommended Insulin Regimen Modifications

Step 1: Adjust Insulin Timing

• Move long-acting insulin from morning to bedtime administration
• Redistribute short-acting insulin to mealtime doses 1

Step 2: Adjust Dosing

• Maintain total daily insulin dose initially
• For long-acting insulin: Continue with 24 units but administer at bedtime
• For short-acting insulin: Distribute the 24 units across meals (e.g., 8 units with each major meal) 1

Step 3: Monitoring and Further Adjustments

• Monitor pre-meal and bedtime glucose levels for 1 week
• Target pre-meal glucose: 90-150 mg/dL 1
• If pre-meal glucose consistently >150 mg/dL: Increase corresponding pre-meal short-acting insulin by 1-2 units or 10-15% 1
• If pre-meal glucose consistently <90 mg/dL: Decrease corresponding pre-meal short-acting insulin by 10-20% 1

Rationale for Changes

1. Physiologic Insulin Pattern: This adjustment better mimics natural insulin secretion patterns with basal coverage overnight and bolus coverage for meals 1

2. Evidence-Based Timing: Bedtime administration of long-acting insulin has been shown to:

   • Provide better fasting glucose control
   • Reduce nocturnal hypoglycemia risk 2
   • Increase basal metabolic clearance of glucose 2

3. Safety Concerns: Short-acting insulin at bedtime creates significant nocturnal hypoglycemia risk without providing adequate basal coverage 3, 4

Special Considerations

• Hypoglycemia Risk: Monitor closely during transition, especially overnight
• Patient Education: Ensure patient understands proper timing of injections and glucose monitoring
• Do not use rapid-acting or short-acting insulin at bedtime unless specifically indicated for high bedtime glucose 1
• Simplification: If the patient has difficulty managing multiple daily injections, consider a fixed-ratio combination product or premixed insulin 1

Follow-up Recommendations

• Review glucose logs after 1-2 weeks
• Assess for hypoglycemic episodes, especially overnight
• Further adjust insulin doses based on glucose patterns
• Consider HbA1c testing after 3 months to evaluate overall glycemic control

This physiologic approach to insulin administration will likely improve overall glycemic control while reducing hypoglycemia risk and providing more stable glucose levels throughout the day.