What adjustments should be made to the treatment plan for a patient with poorly controlled type 2 diabetes (A1C of 12), currently on Novolog (insulin aspart) 6 units 3 times a day and Lantus (insulin glargine) 26 units twice a day, who has not been taking metformin (biguanide) 1000 mg twice a day as prescribed?

Management of Poorly Controlled Type 2 Diabetes with A1C of 12%

For a patient with an A1C of 12% who has not been taking prescribed metformin but is on insulin therapy (Novolog and Lantus), you should immediately restart metformin 1000 mg twice daily and optimize the insulin regimen by increasing the Novolog dose to 8-10 units three times daily while maintaining the current Lantus dose. 1, 2

Assessment of Current Therapy

• The patient has severely uncontrolled diabetes (A1C of 12%) despite being on a basal-bolus insulin regimen (Lantus 26 units twice daily and Novolog 6 units three times daily) 1
• Non-adherence to metformin 1000 mg twice daily is contributing to poor glycemic control 1
• The current insulin regimen is insufficient to achieve glycemic targets, particularly for postprandial glucose control 2, 3

Recommended Treatment Plan

Step 1: Restart Metformin

• Immediately restart metformin 1000 mg twice daily as it is the preferred first-line agent and should be continued when used in combination with insulin therapy 1
• Metformin will help improve insulin sensitivity and may allow for more effective insulin action 1
• Counsel the patient about the importance of medication adherence and potential vitamin B12 deficiency with long-term metformin use 1

Step 2: Optimize Insulin Therapy

• Increase the Novolog (prandial insulin) dose from 6 units to 8-10 units three times daily to better control postprandial glucose excursions 1, 2
• Maintain the current Lantus (basal insulin) dose of 26 units twice daily initially, as it provides 24-hour coverage of basal insulin needs 4
• Instruct the patient to self-monitor blood glucose before meals and at bedtime to guide further insulin adjustments 1

Step 3: Titration Schedule

• Adjust Novolog dose by 1-2 units or 10-15% every 3-7 days based on postprandial glucose readings 1, 2
• If fasting blood glucose remains elevated after optimizing prandial control, consider increasing Lantus by 2 units every 3 days until fasting glucose is in target range 2
• Target fasting glucose of 70-130 mg/dL and postprandial glucose <180 mg/dL 1

Step 4: Consider Additional Therapy

• If A1C remains above goal after optimizing insulin and metformin, consider adding a GLP-1 receptor agonist, which can improve glycemic control while potentially reducing insulin requirements 1, 2
• The combination of insulin with GLP-1 receptor agonists has shown greater A1C reduction than insulin alone in patients with poorly controlled diabetes 1

Monitoring and Follow-up

• Schedule follow-up within 2 weeks to assess response to therapy and make further adjustments 2
• Check A1C every 3 months until target is achieved 1
• Evaluate for hypoglycemia, especially as insulin doses are increased 1, 4
• Provide comprehensive diabetes self-management education to improve adherence and self-care behaviors 1

Potential Pitfalls to Avoid

• Avoid excessive increases in basal insulin without adequate prandial coverage, which can lead to hypoglycemia between meals while still having postprandial hyperglycemia 2, 3
• Be cautious about rapid increases in insulin doses; incremental adjustments are safer to prevent hypoglycemia 2
• Don't overlook the importance of lifestyle modifications including diet and physical activity, which should continue alongside pharmacologic therapy 1
• Remember that insulin aspart (Novolog) has a faster onset and shorter duration of action than regular human insulin, so timing of administration immediately before meals is important 5