What adjustments should be made to the Lantus (insulin glargine) dose, carb ratio, and correction scale for an 84-year-old type 2 diabetes patient with elevated overnight blood glucose levels?

Insulin Adjustment for 84-Year-Old Type 2 Diabetes Patient

For this 84-year-old type 2 diabetes patient with persistent hyperglycemia (BG 239 and 233), the Lantus dose should be increased from 25 to 29 units, the carb ratio should remain at 1:15, and the correction scale should be increased to high. 1

Lantus Dose Adjustment

• The current basal insulin dose of 25 units is inadequate as evidenced by consistently elevated blood glucose readings (239 and 233 mg/dL) 1
• For patients with persistent hyperglycemia on basal insulin, the American Diabetes Association recommends increasing the dose by 2-4 units 1
• Given the patient's weight (74 kg), the current dose of 25 units equals approximately 0.34 units/kg/day, which is within the typical range of 0.1-0.4 units/kg/day for type 2 diabetes patients 1
• Increase Lantus dose to 29 units (increase of 4 units) to improve overnight glycemic control 1

Carbohydrate Ratio Considerations

• The current carbohydrate ratio of 1:15 (1 unit of insulin for 15g of carbohydrates) is reasonable for an elderly patient 2
• In older adults, maintaining the current carbohydrate ratio is appropriate when making adjustments to basal insulin to minimize complexity and reduce risk of hypoglycemia 2
• For patients receiving enteral bolus feedings, approximately 1 unit of insulin per 10–15g carbohydrate is recommended, confirming the current ratio is within appropriate range 2

Correction Scale Adjustment

• The patient is currently on a "medium" correction scale but has persistent hyperglycemia 1
• Increase to a "high" correction scale to provide more aggressive correction of elevated blood glucose levels 1
• This adjustment will help address the current hyperglycemia while the increased basal insulin dose takes effect 3

Monitoring and Further Adjustments

• After implementing these changes, monitor fasting blood glucose daily 1
• If fasting glucose remains >150 mg/dL for 3 consecutive days, consider further increasing Lantus by 2 units 1
• If any hypoglycemia occurs (glucose <70 mg/dL), reduce Lantus dose by 2-4 units 1
• Special consideration for this 84-year-old patient: avoid aggressive titration to reduce risk of hypoglycemia 2

Age-Specific Considerations

• For older adults (>80 years), glycemic targets are often less stringent (fasting glucose 90-150 mg/dL) to minimize hypoglycemia risk 2
• In older adults with diabetes, insulin simplification is preferred when possible, supporting the decision to adjust basal insulin while maintaining the current carbohydrate ratio 2
• The American Diabetes Association recommends cautious insulin adjustments in older adults, with a focus on avoiding hypoglycemia 2

Pitfalls to Avoid

• Avoid excessive dose increases (>10% at once) as this increases hypoglycemia risk, particularly important in elderly patients 1
• Don't delay insulin adjustments when blood glucose levels are consistently elevated, as prolonged hyperglycemia increases risk of complications 2
• Be cautious of overbasalization - if fasting glucose normalizes but overall glycemic control remains poor, consider adding or adjusting prandial insulin rather than further increasing basal insulin 1
• For elderly patients, avoid complex insulin regimens that may lead to administration errors and increased hypoglycemia risk 2