What is the best approach to initiate insulin therapy in a 50-year-old female patient with uncontrolled diabetes (A1c of 9.8%, fasting blood glucose of 247 mg/dL) and noncompliance with oral medications, considering her current weight and potential introduction of additional therapies like Mojaro (canagliflozin) in the future?

Initiating Insulin Therapy in Uncontrolled Type 2 Diabetes

Start this patient on basal insulin (Lantus/glargine) at 0.2 units/kg/day (approximately 30 units once daily at bedtime), discontinue oral medications given documented noncompliance, and hold off on rapid-acting insulin (NovoLog/Humalin) until basal insulin is optimized over 2-3 weeks. 1, 2

Rationale for Basal-Only Insulin Initiation

Your patient meets clear criteria for immediate insulin initiation with A1c 9.8% and fasting glucose 247 mg/dL. The American Diabetes Association specifically recommends considering insulin therapy when blood glucose is ≥300 mg/dL or A1C is ≥10%, and your patient is close to these thresholds with documented medication noncompliance. 1

Given her weight of 323 pounds (approximately 147 kg), the starting dose calculation is:

• Starting dose: 0.2 units/kg × 147 kg = 29-30 units of Lantus once daily at bedtime 2, 3
• This conservative 0.2 units/kg approach (rather than 0.1 units/kg) is appropriate given her severe hyperglycemia 1, 4

Why NOT to Start Rapid-Acting Insulin Now

Do not initiate NovoLog or Humalin R (rapid-acting/regular insulin) at this time. Here's why:

• Basal insulin alone is the most convenient initial insulin regimen and should be optimized first before adding prandial coverage 1, 4
• Adding prandial insulin prematurely increases complexity, hypoglycemia risk, and weight gain—all barriers to adherence in an already noncompliant patient 1, 5
• Prandial insulin is only indicated when basal insulin has been titrated to acceptable fasting blood glucose but A1C remains above target 2
• Your patient's fasting glucose of 247 mg/dL indicates inadequate basal control, which must be addressed first 2

Why NOT to Continue Oral Medications

Stop all oral diabetes medications given her documented noncompliance. 1

• Continuing medications she won't take adds unnecessary cost and complexity without benefit
• Once glycemic control improves with insulin and she demonstrates adherence, metformin can be restarted as it reduces all-cause mortality and cardiovascular events 3
• The plan to start Mounjaro (tirzepatide, not "Mojarro"/canagliflozin) in January 2026 is appropriate—at that time, you can transition from insulin-only to combination therapy 1

Titration Protocol

Provide her with this specific self-titration algorithm 1, 2:

• Check fasting blood glucose daily before breakfast
• Target fasting glucose: 80-130 mg/dL 4
• Increase Lantus by 2 units every 3 days until fasting glucose reaches target without hypoglycemia 1, 2
• If hypoglycemia occurs (glucose <70 mg/dL), reduce dose by 10-20% 2
• Recheck A1c in 3 months 2

When to Add Prandial Insulin (Future Consideration)

Only consider adding NovoLog if, after 2-3 months:

• Fasting glucose is controlled (80-130 mg/dL) on optimized basal insulin
• But A1c remains >7% (or her individualized target)
• At that point, start with 4 units or 10% of basal dose before the largest meal 1

Critical Pitfalls to Avoid

Common mistakes that will sabotage this plan:

• Starting with sliding scale insulin alone—this is explicitly not recommended and leads to poor control 2
• Starting both basal and prandial insulin simultaneously—this dramatically increases hypoglycemia risk and complexity in a noncompliant patient 1
• Inadequate titration—most patients require doses >0.5 units/kg eventually; don't undertitrate 1
• Not providing glucagon—prescribe glucagon and educate on hypoglycemia treatment with 15-20g carbohydrate 2

Patient Education Essentials

She must understand these specific points 2:

• Insulin is not a punishment or failure—it's the most effective glucose-lowering therapy available
• Rotate injection sites within one anatomical area (abdomen preferred for consistent absorption)
• Carry fast-acting carbohydrate (glucose tablets, juice) at all times
• Never skip insulin doses, even if not eating well
• Call immediately if glucose <70 mg/dL more than once weekly

Monitoring Requirements

Specific glucose monitoring plan 2:

• Daily fasting glucose checks (before breakfast)
• Random checks if symptomatic
• No need for multiple daily checks until prandial insulin is added
• A1c recheck in 3 months

The Mounjaro Transition Plan

When insurance covers Mounjaro in January 2026 1:

• Start Mounjaro while continuing basal insulin
• Expect to reduce insulin doses by 10-20% as Mounjaro takes effect
• Consider restarting metformin at that time if she demonstrates adherence
• This combination (GLP-1 RA + basal insulin ± metformin) is guideline-preferred for patients with her profile 1