What adjustments should be made to the treatment regimen of a patient with an A1C of 9.0%, experiencing hyperglycemia, currently on a sliding scale insulin regimen and taking 60 units of Lantus (insulin glargine)?

Insulin Regimen Adjustment for Patient with A1C 9.0% and Hyperglycemia

For a patient with an A1C of 9.0% and blood glucose in the 200's currently on sliding scale insulin and 60 units of Lantus, the most effective approach is to intensify insulin therapy by optimizing the basal insulin dose and adding structured prandial insulin coverage.

Current Regimen Assessment

• The patient's A1C of 9.0% indicates inadequate glycemic control, suggesting the current regimen of sliding scale insulin with 60 units of Lantus (insulin glargine) is insufficient 1
• The current basal insulin dose of 60 units may be appropriate or even high, suggesting potential issues with insulin timing, adherence, or inadequate prandial coverage 1
• Sliding scale insulin alone is not recommended as an effective strategy for glycemic management and should be replaced with a more structured approach 1

Basal Insulin Optimization

• Assess the adequacy of the current basal insulin dose by evaluating fasting glucose patterns; if consistently elevated, consider a modest increase of 10% (6 units) 1
• If the patient experiences nocturnal hypoglycemia or morning hyperglycemia, consider splitting the Lantus dose into morning and evening injections 1, 2
• Look for signs of overbasalization (basal dose >0.5 units/kg/day, elevated bedtime-morning glucose differential, or hypoglycemia), which may indicate need for dose reduction rather than increase 1

Adding Structured Prandial Insulin

• Replace sliding scale with scheduled mealtime insulin, starting with one injection at the largest meal 1
• Initial prandial dose should be 4 units or 10% of the basal insulin dose (6 units) with the largest meal 1, 3
• Titrate the prandial insulin dose by 1-2 units or 10-15% twice weekly based on 2-hour post-meal glucose readings 1
• If A1C remains above target after adding one prandial dose, progressively add prandial insulin to other meals until full basal-bolus coverage is achieved 1

Monitoring and Adjustment Protocol

• Set fasting plasma glucose target (typically 80-130 mg/dL) and adjust basal insulin by 2 units every 3 days until target is reached without hypoglycemia 1
• For prandial insulin, target 2-hour postprandial glucose <180 mg/dL 1
• If hypoglycemia occurs, identify the cause and reduce the corresponding insulin dose by 10-20% 1
• Reassess the regimen every 3-6 months and adjust as needed 1

Special Considerations

• Consider adding a GLP-1 receptor agonist if not already on one, which can improve glycemic control while potentially reducing insulin requirements 1, 3
• Insulin glargine (Lantus) has been shown to have a lower risk of hypoglycemia compared to NPH insulin, which is beneficial when intensifying therapy 4, 5
• For patients with cardiovascular risk factors, maintaining glycemic control with insulin glargine has shown benefits without excess hypoglycemia 5

Practical Implementation Tips

• Educate the patient on proper insulin injection technique, timing, and storage 3
• Ensure the patient has appropriate blood glucose monitoring supplies and knows how to recognize and treat hypoglycemia 3
• Consider prescription of glucagon for emergency hypoglycemia management 1
• Document the insulin adjustment plan clearly and provide written instructions to the patient 3