How to adjust the treatment plan for a patient with hyperglycemia (elevated blood sugars) on 23 units of Humalog 75/25 (insulin lispro protamine/insulin lispro) and 16 units of Lantus (insulin glargine)?

Insulin Regimen Adjustment for Persistent Hyperglycemia

This patient requires immediate intensification to a basal-bolus insulin regimen by consolidating to a single daily dose of basal insulin (approximately 35-40 units of Lantus) and adding rapid-acting insulin (4-8 units) before each meal. 1, 2

Critical Problem Identification

The current regimen is fundamentally flawed because:

• Humalog 75/25 is a premixed insulin (75% intermediate-acting, 25% rapid-acting) that should be given twice daily before meals, not as a single daily dose 3
• The patient is receiving 23 units of a premixed insulin plus 16 units of Lantus (total 39 units/day), but blood sugars remain in the 200s, indicating severe undertreatment 1, 2
• This regimen provides neither adequate basal coverage nor appropriate prandial insulin timing 4, 2

Recommended Insulin Regimen Change

Step 1: Consolidate and Optimize Basal Insulin

• Discontinue the Humalog 75/25 completely 4
• Increase Lantus to 35-40 units once daily (administered at bedtime or same time each day), representing approximately 90-100% of current total daily insulin dose 1, 2
• For a patient requiring more aggressive control with blood sugars consistently >200 mg/dL, consider starting at 0.3-0.4 units/kg/day if weight is known 1

Step 2: Add Prandial Insulin Coverage

• Initiate rapid-acting insulin analog (lispro, aspart, or glulisine) at 4-8 units before each of the three main meals 1, 2
• This represents approximately 10% of the basal insulin dose per meal 1, 2
• Administer immediately before eating (within 15 minutes) 3

Step 3: Titration Protocol

For Basal Insulin (Lantus):

• Check fasting blood glucose daily 1, 2
• If fasting glucose ≥180 mg/dL: increase by 4 units every 3 days 1
• If fasting glucose 140-179 mg/dL: increase by 2 units every 3 days 1
• Target fasting glucose: 80-130 mg/dL 4, 1

For Prandial Insulin:

• Check 2-hour postprandial glucose after each meal 2
• Increase the corresponding meal's insulin dose by 1-2 units (or 10-15%) twice weekly if postprandial glucose >180 mg/dL 1, 2
• Target postprandial glucose: <180 mg/dL 4

Step 4: Hypoglycemia Management

• If blood glucose <70 mg/dL occurs, reduce the corresponding insulin dose by 10-20% 1, 2
• Ensure patient has glucose tablets or fast-acting carbohydrates available 5

Critical Pitfalls to Avoid

Do not continue using Humalog 75/25 as a once-daily injection - this premixed insulin is designed for twice-daily administration before meals and provides suboptimal coverage when given once daily 3

Avoid "overbasalization" - if basal insulin exceeds 0.5 units/kg/day (or approaches 50-60 units) without achieving A1C goals, the problem is inadequate prandial coverage, not insufficient basal insulin 1, 2

Never rely on sliding-scale insulin alone - this reactive approach is strongly discouraged and has been shown to be ineffective in achieving glycemic control 2, 6

Do not delay insulin intensification - clinical inertia (failure to adjust insulin despite persistent hyperglycemia) is a major barrier to achieving glycemic control 2, 7

Monitoring Requirements

• Daily fasting blood glucose during titration phase 1, 2
• Pre-meal and 2-hour postprandial glucose checks to guide prandial insulin adjustments 2
• Reassess regimen every 3 days during active titration 1
• Check A1C in 3 months to assess overall glycemic control 4

Additional Considerations

Ensure metformin is part of the regimen (unless contraindicated), as it should remain the foundation of type 2 diabetes therapy even when insulin is initiated 2

Patient education is essential - teach carbohydrate counting, recognition of hypoglycemia symptoms, proper injection technique, and the importance of consistent meal timing with the new basal-bolus regimen 5, 8

Consider GLP-1 receptor agonist as an alternative to prandial insulin if the patient is averse to multiple daily injections, though this may be less effective for blood sugars consistently >200 mg/dL 4, 2