What adjustments should be made to a diabetes treatment plan for a patient with consistently elevated blood glucose levels, currently taking 46 units of Humalog (insulin lispro) and 10 units of Lantus (insulin glargine)?

Insulin Regimen Adjustment for Poorly Controlled Type 2 Diabetes

The patient requires a significant increase in basal insulin (Lantus) dose and adjustment of mealtime insulin (Humalog) to achieve better glycemic control.

Current Regimen Assessment

• The patient is currently on 46 units of Humalog (rapid-acting insulin lispro) and only 10 units of Lantus (long-acting insulin glargine) with persistently elevated blood glucose levels in the 200-300 mg/dL range 1
• This regimen shows a significant imbalance between basal and bolus insulin components, with inadequate basal insulin coverage 1, 2
• For most patients with type 2 diabetes, basal insulin requirements are typically higher, often approaching 0.3-0.5 units/kg/day 2

Recommended Insulin Adjustments

Step 1: Increase Basal Insulin (Lantus)

• Increase Lantus from 10 units to 20-25 units once daily, administered at the same time each evening 1, 2
• Titrate Lantus by adding 2-4 units every 3-4 days until fasting blood glucose consistently reaches 100-130 mg/dL 1
• The goal is to establish adequate 24-hour basal insulin coverage to control hepatic glucose production between meals and during sleep 1, 2

Step 2: Optimize Mealtime Insulin (Humalog)

• Distribute the 46 units of Humalog across three meals based on carbohydrate content of each meal 1
• Typical distribution: 30-40% breakfast, 30-40% lunch, 30-40% dinner (adjust based on meal patterns) 1
• Consider using an insulin-to-carbohydrate ratio for more precise dosing if the patient can count carbohydrates 1

Step 3: Implement Correction Factor

• Add a correction factor of 1 unit of Humalog for every 50 mg/dL above target pre-meal glucose 1
• Pre-meal targets should be <140 mg/dL and random glucose <180 mg/dL 1, 3

Monitoring and Further Adjustments

• Monitor blood glucose before meals and at bedtime daily during adjustment period 1
• Assess for patterns of hyperglycemia or hypoglycemia to guide further adjustments 2
• If fasting glucose is at target but post-meal glucose remains elevated, focus on increasing mealtime insulin 1
• If post-meal glucose is controlled but fasting glucose remains elevated, continue increasing basal insulin 1

Important Considerations

• The total daily insulin requirement for patients with type 2 diabetes is often around 1 unit/kg/day, with approximately 50% as basal insulin 2, 4
• The current regimen has an inappropriate ratio with only 18% as basal insulin (10 units Lantus out of 56 total units) 1
• Hypoglycemia risk increases with insulin adjustment - educate patient on recognition and treatment of hypoglycemia 5
• Consider adding or optimizing oral agents such as metformin if not contraindicated 1

When to Consider Further Treatment Modifications

• If blood glucose remains poorly controlled despite optimized basal-bolus insulin therapy (total daily dose >0.5 units/kg), consider:
  • Adding a GLP-1 receptor agonist to improve postprandial control and potentially reduce insulin requirements 1
  • Switching to premixed insulin formulations (e.g., 70/30 or 75/25) if adherence to multiple daily injections is an issue 1, 6
  • Referral to an endocrinologist for consideration of insulin pump therapy in appropriate candidates 1

Pitfalls to Avoid

• Relying solely on sliding-scale insulin adjustments without addressing inadequate basal insulin 1, 3
• Failing to adjust mealtime insulin when basal insulin is increased 2
• Neglecting to educate the patient on proper insulin administration technique and timing 4
• Not considering other factors affecting glucose control such as diet, physical activity, stress, or concurrent medications 1