What is the best course of action for a 65-year-old patient with hyperglycemia, currently on Lantus (insulin glargine) 44 units?

Management of Inadequate Glycemic Control in a 65-Year-Old on Basal Insulin Monotherapy

This patient requires intensification of her insulin regimen by adding prandial insulin coverage to her existing basal insulin, as basal insulin alone is insufficient when blood glucose levels remain in the 200s mg/dL range. 1

Immediate Assessment and Action

Current Status Analysis

• Blood glucose levels persistently >200 mg/dL indicate inadequate glycemic control despite 44 units of Lantus (insulin glargine) 1
• This represents hyperglycemia requiring intervention, as levels >140 mg/dL should prompt treatment adjustments 1
• The patient is on basal insulin monotherapy without prandial coverage, which is insufficient for comprehensive glucose management 1

Recommended Insulin Regimen Modification

Add prandial insulin to create a basal-bolus regimen 1:

• Continue Lantus 44 units at the current dose (or adjust based on fasting glucose) 1
• Add rapid-acting insulin (lispro, aspart, or glulisine) before each meal 1
• Starting prandial dose: Begin with 4 units of rapid-acting insulin before each meal, or calculate as 10% of total daily basal dose per meal 1
• Alternatively, start with a single prandial dose before the largest meal and expand if needed 1

Titration Strategy for Older Adults

Given the patient's age of 65 years, specific considerations apply 1:

Basal insulin adjustment 1:

• Target fasting glucose: 90-150 mg/dL (5.0-8.3 mmol/L) for older adults 1
• If 50% of fasting values exceed goal: increase by 2 units 1
• If >2 fasting values/week are <80 mg/dL: decrease by 2 units 1

Prandial insulin titration 1:

• Monitor pre-lunch and pre-dinner glucose every 2 weeks 1
• If 50% of premeal values exceed 90-150 mg/dL goal: increase dose or add agents 1
• If >2 premeal values/week are <90 mg/dL: decrease medication dose 1

Alternative: Add Non-Insulin Agents

Consider adding oral agents instead of or alongside prandial insulin 1:

• If eGFR ≥45 mL/min/1.73 m²: Start metformin 500 mg daily, increase every 2 weeks as tolerated 1
• If eGFR <45 mL/min/1.73 m²: Consider GLP-1 receptor agonists, SGLT2 inhibitors, or DPP-4 inhibitors 1
• This approach may be simpler for older adults with self-management limitations 1

Critical Safety Considerations for Older Adults

Hypoglycemia Prevention

• Older adults have increased risk of hypoglycemia due to comorbidities, renal insufficiency, malnutrition, and impaired counterregulatory responses 1
• They may have reduced awareness of hypoglycemic symptoms, delaying recognition and treatment 1
• Avoid overly aggressive targets: More relaxed goals may be appropriate based on overall health status 1

Monitoring Requirements

• Bedside glucose monitoring before meals if eating regularly 1
• Every 4-6 hours if not eating or with poor oral intake 1
• Assess for patterns requiring dose adjustments weekly 1

Timing Considerations for Older Adults

Consider changing basal insulin timing from bedtime to morning 1:

• This reduces nocturnal hypoglycemia risk 1
• Particularly important if patient has unpredictable meal consumption 1
• May give insulin after meals to match actual carbohydrate intake in those with variable eating patterns 1

Common Pitfalls to Avoid

Do Not Use Sliding Scale Insulin Alone

• Sliding scale insulin as sole therapy is strongly discouraged in both inpatient and outpatient settings 1
• It is reactive rather than proactive and leads to poor glycemic control 1
• A simplified sliding scale may be used temporarily while adjusting prandial doses (e.g., 2 units for glucose >250 mg/dL, 4 units for >350 mg/dL) 1

Avoid Complexity Beyond Patient Capability

• Complex multi-injection regimens may exceed self-management abilities in older adults 1
• If patient cannot manage basal-bolus therapy, simplification with addition of oral agents is preferred 1
• Assess cognitive and functional status before intensifying regimen 1

Do Not Delay Intensification

• Basal insulin alone is inadequate when fasting glucose is controlled but overall glucose remains elevated 1
• When basal insulin dose exceeds 0.5 units/kg/day without achieving A1C target, add prandial coverage 1
• At 44 units for a typical 65-year-old, this patient likely needs additional coverage 1

Practical Implementation

Immediate next steps:

1. Add rapid-acting insulin 4 units before each meal (or before largest meal initially) 1
2. Continue Lantus 44 units at current time 1
3. Monitor pre-meal and bedtime glucose daily 1
4. Adjust doses every 2-3 days based on glucose patterns 2
5. Consider adding metformin if not contraindicated 1

Expected outcomes 3, 4:

• Lantus provides relatively constant 24-hour basal coverage without pronounced peaks 3
• Addition of prandial insulin addresses postprandial hyperglycemia 1
• Target A1C <7.0-7.5% for healthy older adults, <8.0% for those with comorbidities 1