Insulin Regimen Adjustment for Hyperglycemia
The patient's insulin regimen needs to be intensified by increasing the basal insulin dose by 10-20% and adjusting the prandial insulin based on pre-meal glucose values. 1
Current Status Assessment
- Fasting blood sugar: 120-130 mg/dL (slightly elevated)
- Pre-meal glucose: 140-200 mg/dL (significantly elevated)
- Current regimen:
- Long-acting insulin: 22 units twice daily
- Short-acting insulin: 12 units three times daily
- Metformin: 1000mg twice daily
Step-by-Step Insulin Adjustment Plan
1. Basal Insulin Adjustment
- Increase long-acting insulin from 22 units to 25 units twice daily (approximately 10-15% increase)
- This addresses the elevated fasting glucose (120-130 mg/dL)
- Reassess fasting glucose in 3-5 days; target should be 90-110 mg/dL 1
2. Prandial Insulin Adjustment
- Increase short-acting insulin from 12 units to 15 units before each meal (25% increase)
- This addresses the significantly elevated pre-meal glucose values (140-200 mg/dL)
- Consider implementing a correction factor: add 1 unit for every 50 mg/dL above 150 mg/dL 1
3. Metformin Management
- Continue metformin 1000mg twice daily as currently prescribed
- Ensure patient takes with meals to minimize gastrointestinal side effects 2
Monitoring Protocol
- Check blood glucose 4 times daily:
- Fasting (morning)
- Before each meal
- Consider occasional 2-hour post-meal checks to assess prandial control
- Document values for 1 week
- Adjust insulin doses further if needed:
- If fasting glucose remains >130 mg/dL, increase basal insulin by another 10%
- If pre-meal glucose remains >140 mg/dL, increase prandial insulin by 1-2 units 1
Important Considerations
Hypoglycemia Risk
- Educate patient on hypoglycemia symptoms (confusion, sweating, shakiness)
- Ensure patient has glucose tablets or juice available
- If hypoglycemia occurs (<70 mg/dL), reduce the preceding insulin dose by 10-20% 1
Overbasalization Warning Signs
- Watch for nocturnal hypoglycemia
- If basal dose exceeds 0.5 units/kg/day, consider redistributing insulin to more prandial coverage 1
Timing Considerations
- Administer basal insulin at consistent times, 12 hours apart
- Give short-acting insulin 15-30 minutes before meals
- Consider splitting metformin dose with breakfast and dinner to improve tolerability 2
This regimen adjustment follows the basal-bolus approach recommended for patients with significant hyperglycemia, which is more effective than sliding scale regimens alone 1. The adjustments should be made systematically with close monitoring to achieve target glucose levels while minimizing hypoglycemia risk.