What adjustments should be made to a diabetic patient's insulin regimen who is non-compliant with blood sugars in the range of hyperglycemia and is self-administering 40 units of insulin twice daily?

Immediate Insulin Regimen Restructuring Required

This patient requires immediate discontinuation of their self-prescribed 40 units BID regimen and transition to a properly structured basal-bolus insulin program with comprehensive diabetes education and close monitoring. 1, 2

Critical Safety Concerns

The current situation presents multiple red flags:

• Self-dosing without medical supervision creates significant risk for both severe hypoglycemia and inadequate glycemic control 3
• Blood glucose consistently in the 250s indicates the current regimen is failing, with A1C likely >10% 1, 2
• Unknown insulin type and timing makes assessment of appropriateness impossible 4
• Non-compliance suggests inadequate diabetes education and lack of structured follow-up 2

Recommended Insulin Regimen Restructuring

Step 1: Clarify Current Insulin Type and Establish Baseline

• Determine what insulin product the patient is actually using (basal vs rapid-acting) 4
• If using 40 units BID of a basal insulin like glargine, this represents massive overbasalization (likely >0.5 units/kg/day) 5
• If using rapid-acting insulin BID, the patient has no basal coverage, explaining persistent hyperglycemia 1

Step 2: Initiate Proper Basal-Bolus Regimen

For blood glucose consistently >250 mg/dL, start with:

• Basal insulin: Insulin glargine 0.3-0.4 units/kg once daily (approximately 20-30 units for average-weight adult) 2, 4
• Prandial insulin: Rapid-acting insulin 4 units before each meal OR 10% of basal dose 1, 2
• This represents a total daily dose of approximately 0.4-0.5 units/kg/day, split 50% basal and 50% prandial 2

Step 3: Titration Protocol

Basal insulin adjustment:

• Increase by 2 units every 3 days until fasting glucose reaches 80-130 mg/dL 1, 5
• If hypoglycemia occurs, reduce dose by 10-20% 1, 5
• Monitor for overbasalization if dose exceeds 0.5 units/kg/day 5

Prandial insulin adjustment:

• Increase by 1-2 units or 10-15% twice weekly based on postprandial glucose readings 1, 2
• Target postprandial glucose <180 mg/dL 1

Essential Concurrent Interventions

Add or Optimize Oral Agents

• Continue or restart metformin if not contraindicated—this improves insulin sensitivity and is the foundation of type 2 diabetes therapy 1, 2
• Consider adding GLP-1 receptor agonist once basal insulin is optimized, especially if cardiovascular disease is present 1, 5

Implement Structured Monitoring

• Self-monitor blood glucose before each meal and at bedtime during titration 2
• Check A1C every 3 months until target achieved 2
• Increase monitoring frequency during dose adjustments to detect hypoglycemia early 2

Provide Comprehensive Diabetes Education

• Proper injection technique: 90-degree angle, rotate sites within same anatomical area 2, 4
• Hypoglycemia management: Carry 15-20g fast-acting carbohydrate at all times 2
• Glucagon prescription for emergency use with family member training 1, 2
• Address medication adherence barriers and provide diabetes self-management education 2

Critical Pitfalls to Avoid

Do not continue the current 40 units BID regimen:

• If this is basal insulin BID, it represents dangerous overbasalization without prandial coverage 5
• If this is rapid-acting insulin BID, the patient has no basal coverage and will remain hyperglycemic 1

Do not delay insulin restructuring:

• Blood glucose in the 250s represents severe hyperglycemia requiring immediate intervention 1, 2
• Prolonged hyperglycemia increases risk of complications and should be specifically avoided 1

Do not use sliding scale insulin alone:

• Scheduled basal-bolus regimen with fixed prandial doses is superior to reactive sliding scale approaches 2

Watch for rapid insulin requirement changes:

• If patient has been on glucocorticoids, insulin needs may decline rapidly when steroids are stopped—reduce doses by 20-30% immediately 6
• Illness, changes in oral intake, or other medications can dramatically alter insulin requirements 4

Follow-Up Requirements

• Weekly contact (phone or in-person) during initial titration phase 1
• Reassess regimen if blood glucose falls below 100 mg/dL or modify if <70 mg/dL 2
• Consider referral to endocrinology if targets not achieved within 3-6 months or if recurrent hypoglycemia occurs 2