What adjustments should be made to the current insulin regimen of long-acting (basal) insulin 28 units daily and short-acting (prandial) insulin 20 units three times a day for a patient with an A1c level of 6.2%?

Insulin Dose Reduction Recommended for A1c 6.2%

With an A1c of 6.2%, which is below the target of <7% for most patients, you should reduce your insulin doses by 10-20% to prevent hypoglycemia while maintaining adequate glycemic control. 1

Current Situation Analysis

Your current regimen consists of:

• Long-acting insulin: 28 units daily
• Short-acting insulin: 20 units three times daily (60 units total)
• Total daily insulin: 88 units

Your A1c of 6.2% indicates you are below the recommended target of <7% for most adults with diabetes, suggesting potential overtreatment. 1 More stringent targets like <6.5% are only appropriate for selected patients if achievable without significant hypoglycemia or adverse effects. 1

Recommended Insulin Adjustments

Basal (Long-Acting) Insulin Reduction

• Reduce from 28 units to approximately 22-25 units daily (10-20% reduction) 1
• Monitor fasting plasma glucose to ensure it remains within target of 80-130 mg/dL 2
• If hypoglycemia occurs, reduce by an additional 10-20% 1

Prandial (Short-Acting) Insulin Reduction

• Reduce from 20 units to approximately 16-18 units three times daily (10-20% reduction) 1
• This represents a total prandial reduction from 60 to approximately 48-54 units daily
• Adjust each meal dose individually based on postprandial glucose readings 2

Clinical Rationale

The 2025 American Diabetes Association guidelines specifically state that when A1c is <8% and patients are meeting glucose targets, consider lowering the basal dose by 4 units per day or 10% of basal dose. 1 Your A1c of 6.2% is well below this threshold, indicating clear need for dose reduction.

Key concern: Maintaining an A1c this low on high insulin doses significantly increases your risk of hypoglycemia, which can cause serious morbidity including cardiovascular events, falls, and impaired quality of life. 1

Monitoring Strategy

Essential Glucose Monitoring

• Check fasting glucose daily to guide basal insulin adjustments 2
• Check pre-meal glucose before each meal 2
• Check 2-hour postprandial glucose after the largest meal to guide prandial adjustments 2
• Increase monitoring frequency during dose adjustments to detect hypoglycemia early 2

Follow-Up Timeline

• Recheck A1c in 3 months 1
• Target A1c range: 6.5-7.0% for optimal balance of glycemic control without excessive hypoglycemia risk 1

Hypoglycemia Prevention

• Carry 15-20 grams of fast-acting carbohydrate at all times to treat blood glucose <70 mg/dL 2
• If hypoglycemia occurs despite dose reduction, decrease the corresponding insulin dose by an additional 10-20% 1
• Consider glucagon prescription for emergency use 2

Additional Considerations

Evaluate for Overbasalization

Clinical signals suggesting excessive basal insulin include: 1

• Elevated bedtime-to-morning glucose differential
• Elevated postprandial-to-preprandial glucose differential
• Hypoglycemia (aware or unaware)
• High glucose variability

Consider Adjunctive Therapy

If A1c rises above 7% after dose reduction, rather than simply increasing insulin back to current levels, consider adding a GLP-1 receptor agonist, which can improve glycemic control while reducing insulin requirements and promoting weight loss. 1, 2

Common Pitfalls to Avoid

• Do not maintain current doses simply because they achieved good control—an A1c of 6.2% on 88 units daily insulin suggests overtreatment 1
• Do not reduce doses too gradually—a 10-20% reduction is evidence-based and appropriate 1
• Do not ignore hypoglycemic episodes—even asymptomatic hypoglycemia increases cardiovascular risk and mortality 1
• Do not skip the dose reduction out of fear of losing glycemic control—your current A1c provides a safety margin 1