What is the next adjustment needed for glycemic control in a type 2 diabetic patient with brittle diabetes on 10u (units) glargine (insulin glargine) in the morning and sliding scale insulin, with an A1C (hemoglobin A1C) of 11 and variable blood glucose levels?

Insulin Regimen Adjustment for Brittle Type 2 Diabetes with Poor Glycemic Control

The patient requires immediate intensification of insulin therapy with a basal-bolus regimen due to consistently elevated blood glucose levels and an A1C of 11%.

Current Status Assessment

• The patient shows a pattern of low morning blood glucose (80-144 mg/dL) with significant hyperglycemia throughout the day (consistently >250 mg/dL) and evening (>300 mg/dL) 1
• Current regimen of 10 units glargine in the morning with sliding scale insulin is clearly insufficient, as evidenced by the A1C of 11% 1
• The blood glucose pattern suggests inadequate basal insulin coverage and insufficient prandial insulin dosing 1
• Sliding scale insulin alone is ineffective as monotherapy for patients with established insulin requirements 1

Recommended Insulin Regimen Changes

Basal Insulin Adjustment

• Increase basal insulin (glargine) from 10 units to 20 units daily 1, 2
• Consider splitting the basal dose to twice daily or switching to evening administration due to early morning hypoglycemia pattern 1, 3
• Titrate basal insulin by 2 units every 3 days until fasting glucose reaches target (90-130 mg/dL) without hypoglycemia 1, 2

Addition of Structured Mealtime Insulin

• Add scheduled mealtime (prandial) insulin with meals using rapid-acting insulin 1, 2
• Start with 4 units or 10% of the total daily basal dose before each meal 1, 2
• Titrate mealtime insulin doses individually based on pre-meal and 2-hour post-meal glucose values 1, 2

Discontinue Sliding Scale Only Approach

• Replace the current sliding scale-only approach with a structured basal-bolus regimen plus correction doses 1, 4
• Sliding scale insulin as monotherapy is ineffective and potentially dangerous as it treats hyperglycemia reactively rather than preventatively 1, 5

Implementation Strategy

Initial Dosing

• Calculate total daily insulin dose: 0.4-0.5 units/kg/day for this patient with brittle diabetes and A1C of 11% 1, 2
• Distribute as approximately 50% basal and 50% prandial insulin 1, 2
• Example for a 70kg patient: ~28-35 units total daily dose
  • Basal: 20 units glargine (consider evening administration)
  • Prandial: 4 units rapid-acting insulin before each meal 1, 2

Monitoring and Titration

• Monitor blood glucose 4 times daily (before meals and at bedtime) 1, 6
• Adjust basal insulin to target fasting glucose of 90-130 mg/dL 1, 7
• Adjust prandial insulin to target post-meal glucose <180 mg/dL 1
• Reassess the entire regimen every 3-7 days until stable 1, 2

Special Considerations for Brittle Diabetes

• Consider potential causes of glucose variability:
  • Inconsistent carbohydrate intake or timing 5, 6
  • Variable physical activity 6
  • Insulin timing errors relative to meals 5, 4
• Provide comprehensive diabetes education on:
  • Carbohydrate counting 1, 2
  • Proper insulin administration technique 7
  • Hypoglycemia recognition and management 2, 8

Pitfalls to Avoid

• Continuing with sliding scale insulin alone, which has been shown to be ineffective in 84% of cases 4
• Insufficient basal insulin dosing - current 10 units is inadequate given the consistently elevated glucose levels 1
• Delayed intensification of insulin therapy despite clear evidence of poor control 1, 2
• Failure to address the significant post-meal glucose excursions evident in the monitoring data 1, 6

Expected Outcomes

• Target A1C of <7% within 3-6 months with proper insulin adjustment 1
• Reduced glycemic variability with smoother 24-hour glucose profiles 9
• Decreased risk of diabetes complications through improved overall glycemic control 1, 6