Should I adjust the Glargine (insulin glargine) regimen for a type 1 diabetic patient with hyperglycemia (A1c 10.9) and frequent glucose spikes, from 37 units to a split dose of 20 units in the morning and 20 units in the evening?

Insulin Regimen Adjustment for Type 1 Diabetic with Hyperglycemia

Yes, splitting the glargine dose to 20 units in the morning and 20 units in the evening is recommended for this patient with type 1 diabetes experiencing glucose spikes throughout the day. 1, 2

Rationale for Split Dosing

The patient's current regimen of sliding scale insulin plus 37 units of glargine is clearly inadequate, as evidenced by:

• HbA1c of 10.9% (significantly above target)
• Glucose spikes throughout the day
• Current single daily dose may not provide consistent 24-hour coverage

Benefits of Split Dosing

1. More consistent insulin coverage: Splitting the basal insulin provides more stable glucose levels throughout the 24-hour period 2
2. Reduced glucose variability: Twice-daily dosing helps minimize the peaks and troughs in insulin action 2, 3
3. Better control of fasting and pre-meal glucose: Morning dose helps control daytime glucose while evening dose controls overnight levels 1

Implementation Plan

1. Initial dose adjustment:

   • Change from 37 units once daily to 20 units in the morning and 20 units in the evening (total 40 units)
   • The slight increase in total daily dose (3 units) is reasonable given the poor glycemic control 1

2. Monitoring after adjustment:

   • Assess fasting plasma glucose (FPG) daily
   • Monitor pre-meal and post-meal glucose levels
   • Watch for hypoglycemia, especially during the transition period

3. Further titration:

   • Adjust each dose separately based on glucose patterns
   • Morning dose affects daytime glucose control
   • Evening dose affects overnight and early morning glucose control
   • Follow evidence-based titration: increase by 2 units every 3 days until target glucose is reached without hypoglycemia 1

Additional Considerations

• Sliding scale adjustment: The patient's sliding scale insulin should be continued but may need adjustment once the basal insulin regimen is optimized
• Hypoglycemia risk: If hypoglycemia occurs, determine the cause and reduce the corresponding dose by 10-20% 1
• Meal timing: Ensure consistent meal timing relative to insulin administration
• Injection sites: Rotate injection sites within the same region to reduce the risk of lipodystrophy 4

Potential Pitfalls

• Morning hypoglycemia: If morning hypoglycemia occurs, reduce the evening glargine dose
• Pre-dinner hyperglycemia: If pre-dinner glucose remains high, consider increasing the morning glargine dose
• Nocturnal hypoglycemia: Monitor for this common complication when adjusting basal insulin doses 3

Follow-up Plan

• Reassess the effectiveness of the split-dose regimen within 1-2 weeks
• Consider further adjustments based on glucose patterns
• Evaluate the need for additional prandial insulin coverage if postprandial spikes persist despite optimized basal insulin

This approach aligns with current guidelines for insulin management in type 1 diabetes and addresses the specific issue of glucose variability throughout the day that the patient is experiencing.