Insulin Adjustment for Patient with A1c 7.6% on Lantus and Novolog
For a patient with A1c of 7.6% on Lantus 31 units at night and Novolog 30-50 units per day, increase the Lantus dose by 10-15% (3-5 units) while maintaining the current Novolog dosing, then reassess in 1-2 weeks.
Current Situation Assessment
The patient's current regimen:
- A1c: 7.6% (indicating suboptimal control)
- Lantus (insulin glargine): 31 units at night
- Novolog (insulin aspart): 30-50 units per day
Adjustment Strategy
Step 1: Basal Insulin Optimization
- The patient's A1c of 7.6% is above the recommended target of 7.0% for most adults with diabetes 1
- Basal insulin (Lantus) should be titrated first when fasting glucose remains elevated
- Increase Lantus by 10-15% (3-5 units) to 34-36 units at night
- This follows the principle that basal insulin should be optimized before making significant changes to bolus insulin 1
Step 2: Monitor and Reassess
- Patient should monitor fasting blood glucose daily for 1-2 weeks
- Target fasting glucose: 80-130 mg/dL (4.4-7.2 mmol/L)
- If fasting glucose remains elevated after 1-2 weeks, consider additional 10% increase in Lantus
Step 3: Bolus Insulin Adjustment (if needed after basal optimization)
- If A1c remains elevated after basal insulin optimization:
- Review pre-meal and post-meal glucose patterns
- Adjust Novolog doses based on carbohydrate intake and pre-meal glucose values
- Consider adding additional mealtime Novolog injection if specific meals show consistent post-prandial hyperglycemia
Rationale for This Approach
The ADA guidelines recommend a target A1c of 7.0% to prevent or delay progression of microvascular complications 1. With the patient's current A1c at 7.6%, adjustment is needed but should be approached systematically.
Basal insulin optimization is the first step when adjusting insulin regimens. According to the ADA guidelines, "If basal insulin has been titrated to an acceptable fasting blood glucose level, but A1C remains above target, consider advancing to combination injectable therapy to cover postprandial glucose excursions" 1.
The patient is already on a basal-bolus regimen, which is appropriate for their situation. However, the doses need adjustment to achieve target glycemic control. The recommendation to increase basal insulin by 10-15% is based on standard insulin titration algorithms that suggest incremental adjustments to minimize hypoglycemia risk while improving control 1.
Important Considerations
- Hypoglycemia risk: Monitor closely for nocturnal hypoglycemia after increasing Lantus dose 1
- Weight gain: Be aware that insulin dose increases may lead to weight gain (2-4 kg) 1
- Individualization: If the patient is elderly or has comorbidities, consider a less stringent A1c target of 7.5-8.0% 1, 2
- Self-monitoring: "Equipping patients with an algorithm for self-titration of insulin doses based on self-monitoring of blood glucose improves glycemic control" 1
Next Steps if Initial Adjustment is Insufficient
If the patient's glycemic control doesn't improve after basal insulin optimization:
Consider switching to a more concentrated basal insulin formulation like insulin glargine 300 units/mL, which has shown similar efficacy with less nocturnal hypoglycemia compared to glargine 100 units/mL 3
Evaluate the distribution of Novolog doses throughout the day and adjust based on meal patterns and glucose monitoring results
Consider alternative insulin regimens such as premixed insulin twice daily if adherence to multiple daily injections is an issue 4, 5
Remember that regular follow-up and glucose monitoring are essential for successful insulin dose adjustment. Reassess the patient's response to therapy within 2-4 weeks of making changes to the insulin regimen.