What is the next step for a patient with hyperglycemia on 16 units of Lantus (insulin glargine)?

Management of Hyperglycemia with Fasting Blood Sugar of 207 mg/dL on Lantus 16 Units

The basal insulin dose should be increased by 4 units (to 20 units of Lantus daily) with continued dose titration until fasting blood glucose reaches target range.

Assessment of Current Situation

The patient's fasting blood glucose of 207 mg/dL indicates significant hyperglycemia despite being on 16 units of insulin glargine (Lantus). This level is well above the recommended target range of 80-130 mg/dL for most adults with diabetes, indicating inadequate glycemic control with the current insulin regimen.

Insulin Dose Adjustment Algorithm

Step 1: Increase Basal Insulin Dose

• Current dose is 16 units of Lantus (insulin glargine)
• With fasting blood glucose of 207 mg/dL, an immediate dose increase is warranted
• According to ADA/EASD guidelines, increase basal insulin by 2-4 units or 5-10% of the current dose when hyperglycemia persists 1
• Given the significant hyperglycemia (>200 mg/dL), a 4-unit increase (25% increase) is appropriate

Step 2: Implement Systematic Titration Schedule

• After initial adjustment, continue to titrate insulin dose using this algorithm:
  • Check fasting blood glucose daily
  • Increase dose by 2 units every 3 days until fasting glucose reaches target without hypoglycemia 2
  • If hypoglycemia occurs, reduce dose by 10-20% 2

Step 3: Consider Additional Interventions

• If basal insulin dose exceeds 0.5 units/kg/day with persistent hyperglycemia, consider:
  • Adding prandial insulin coverage for postprandial glucose excursions 1
  • Evaluating for medication adherence issues
  • Assessing for intercurrent illness or other factors affecting insulin sensitivity

Monitoring Recommendations

• Daily fasting blood glucose monitoring is essential during dose titration 2
• Additional pre-meal and bedtime glucose checks to assess 24-hour control
• Monitor for signs and symptoms of hypoglycemia
• Reassess HbA1c after 3 months of therapy adjustment

Important Considerations

• Insulin administration technique: Ensure proper subcutaneous injection into abdomen, thigh, or deltoid with site rotation to prevent lipodystrophy 3
• Timing of insulin: Administer Lantus at the same time each day for consistent effect 3
• Hypoglycemia risk: Increased risk with higher insulin doses, especially in patients with renal impairment or irregular eating patterns 1
• Patient education: Reinforce the importance of consistent carbohydrate intake, physical activity, and glucose monitoring

Common Pitfalls to Avoid

1. Using correction insulin alone: Relying solely on correction or "sliding scale" insulin without adequate basal insulin is discouraged and leads to poor glycemic control 1

2. Insufficient dose adjustment: Fear of hypoglycemia often leads to clinical inertia and persistent hyperglycemia, which increases risk of diabetes complications

3. Overlooking contributing factors: Failure to consider medication adherence, injection technique, dietary changes, or concurrent illness that may affect insulin requirements

4. Delayed intensification: Prolonged periods of uncontrolled hyperglycemia should be avoided as they contribute to diabetes complications 1

By implementing this systematic approach to insulin dose adjustment, the patient's fasting blood glucose should improve toward the target range while minimizing the risk of hypoglycemia.