Is a regimen of sliding scale bedtime insulin lispro and insulin glargine twice daily sufficient for adequate glucose control in a patient with hyperglycemia?

Sliding Scale Bedtime Lispro with BID Lantus is NOT Appropriate

This regimen is fundamentally flawed and should be replaced with a proper basal-bolus insulin regimen consisting of once-daily Lantus (glargine) plus scheduled mealtime rapid-acting insulin (lispro) with correction doses, rather than relying on sliding scale alone. 1

Why This Regimen Fails

Sliding Scale Insulin is Ineffective as Monotherapy

• Sliding scale insulin regimens have been demonstrated to be ineffective when used as the sole prandial insulin strategy in patients with established insulin requirements 1
• This "reactive" approach treats hyperglycemia after it has already occurred instead of preventing it, leading to rapid fluctuations between hyper- and hypoglycemia 1
• A glucose of 209 mg/dL indicates inadequate glycemic control that requires scheduled insulin, not just correction doses 1

Lantus BID is Unnecessary and Non-Standard

• Lantus (insulin glargine) is designed as a once-daily basal insulin with a duration of action of 20-24 hours 1, 2
• FDA-approved dosing and clinical trials consistently demonstrate Lantus administered once daily at bedtime (or at other consistent times) 2
• While some patients may require twice-daily dosing if glargine doesn't last 24 hours, this is anecdotal and not the standard approach 1
• The twice-daily dosing in this case appears arbitrary rather than based on documented inadequate duration of action

The Correct Approach: Basal-Bolus Regimen

Recommended Insulin Regimen

Replace the current regimen with:

• Basal insulin: Lantus once daily at bedtime (or consistent time of day), typically 50% of total daily insulin dose 1
• Prandial insulin: Scheduled lispro before each meal based on carbohydrate counting using insulin-to-carbohydrate ratios 1
• Correction insulin: Additional lispro doses for pre-meal hyperglycemia using insulin sensitivity factors 1, 3

Evidence Supporting Basal-Bolus Over Sliding Scale

• A landmark study demonstrated that basal-bolus insulin therapy achieved glycemic control (mean glucose <140 mg/dL) in 68% of patients versus only 38% with sliding scale insulin alone, with no difference in hypoglycemia rates 1
• The basal-bolus regimen using long-acting analogs (glargine) combined with rapid-acting analogs (lispro) results in stable glycemic control and less hypoglycemia compared to older regimens 1

Practical Implementation

Initial Dosing Strategy

• Total daily dose: Start with 0.4-0.5 units/kg/day for obese patients with type 2 diabetes, or 0.1-0.25 units/kg/day for patients with renal impairment or type 1 diabetes 1, 3
• Distribution: 50% as basal (Lantus once daily), 50% divided among three meals as lispro 1

Timing Considerations

• Administer Lantus at bedtime as the standard approach 2
• Give lispro 15 minutes before meals for optimal postprandial glucose control 1
• If bedtime Lantus causes early-night hyperglycemia, consider lunch-time or dinner-time administration 4

Monitoring and Titration

• Adjust basal insulin (Lantus) based on fasting and pre-meal glucose patterns 3
• Adjust prandial insulin (lispro) using insulin-to-carbohydrate ratios if post-meal glucose is consistently out of target 1
• Adjust correction doses using insulin sensitivity factors if corrections don't bring glucose into range 1
• Target fasting glucose of 90-150 mg/dL for most patients 5

Critical Pitfalls to Avoid

Common Errors

• Never rely on sliding scale alone when a patient has established insulin requirements and persistent hyperglycemia 1
• Don't continue ineffective regimens unchanged throughout hospitalization—the current glucose of 209 mg/dL demands regimen modification 1
• Avoid using rapid-acting insulin at bedtime alone without adequate basal coverage, as this increases nocturnal hypoglycemia risk 5

Special Considerations

• If the patient has renal impairment, use lower initial doses (0.1-0.25 units/kg/day) due to 4-6 times higher hypoglycemia risk 3
• Ensure adequate basal insulin coverage before adding or increasing prandial doses 1, 3
• Document all glucose readings and insulin doses to guide systematic adjustments 3