What adjustments should be made to the treatment plan for a patient with Diabetes Mellitus type 2 (DM2) who is currently taking Lantus (insulin glargine) 44 units at bedtime and has elevated blood glucose levels?

Management of Inadequate Glycemic Control on Basal Insulin

Immediately increase the Lantus dose by 4-6 units (approximately 10-15%) and add rapid-acting insulin before the largest meal, as blood glucose levels in the 200s mg/dL indicate both inadequate basal coverage and insufficient mealtime insulin. 1

Immediate Basal Insulin Dose Adjustment

Your patient's fasting glucose is likely elevated given the 200s mg/dL readings, requiring aggressive basal insulin titration:

• Increase Lantus by 4 units every 3 days if fasting glucose remains ≥180 mg/dL, or by 2 units every 3 days if fasting glucose is 140-179 mg/dL, until reaching the target of 80-130 mg/dL 2, 1
• The current dose of 44 units is approaching 0.5 units/kg/day (assuming ~88 kg body weight), which signals the need for prandial insulin rather than continuing to escalate basal insulin alone 2, 1
• Continue daily fasting blood glucose monitoring during this titration phase 2, 1

Critical Addition of Prandial Insulin Coverage

Blood glucose in the 200s mg/dL reflects not just inadequate basal coverage but also significant postprandial excursions requiring mealtime insulin:

• Start with 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before the largest meal or the meal causing the greatest glucose excursion 2, 1
• Alternatively, use 10% of the current basal dose (approximately 4 units in this case) as the starting prandial dose 2, 1
• Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on pre-meal and 2-hour postprandial glucose readings 1
• If A1C remains elevated after 3-6 months despite controlled fasting glucose, add prandial insulin before additional meals sequentially 2

Foundation Therapy Verification

• Ensure the patient is on metformin unless contraindicated, as it remains the foundation of type 2 diabetes therapy and should be continued when intensifying insulin 2, 1
• Consider adding a GLP-1 receptor agonist to the regimen to improve A1C while minimizing weight gain and hypoglycemia risk 2, 1

Critical Pitfalls to Avoid

Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to suboptimal control, increased hypoglycemia risk, and overbasalization 2, 1:

• Signs of overbasalization include: basal dose >0.5 units/kg/day, high bedtime-to-morning glucose differential (≥50 mg/dL), hypoglycemia episodes, and high glucose variability 2, 1
• Scheduled basal-bolus insulin regimens are strongly preferred over relying solely on correction (sliding scale) insulin 2, 3
• When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, adding mealtime insulin becomes necessary rather than further basal escalation 2, 1

Patient Education Requirements

Provide comprehensive education on:

• Proper insulin injection technique and site rotation to prevent lipodystrophy 4
• Recognition and treatment of hypoglycemia, including keeping a source of sugar readily available 2, 1
• Self-monitoring of blood glucose at critical times: fasting, pre-meals, and 2 hours post-meals during titration 2, 1
• "Sick day" management rules and when to contact the healthcare provider 1
• Insulin storage and handling, ensuring Lantus is administered at the same time daily 4

Monitoring and Follow-up

• Reassess every 3 days during active titration and every 3-6 months once stable 2, 1
• If hypoglycemia occurs, determine the cause and reduce the corresponding insulin dose by 10-20% 2, 1
• Target fasting glucose of 80-130 mg/dL and A1C <7% for most patients 2