What adjustments should be made to the insulin regimen of a patient with HbA1C of 9.6%, FBS < 120 mg/dL, and pre-meal glucose of 100 mg/dL, currently taking 35 units long-acting insulin BID and 5 units short-acting insulin TID?

Insulin Regimen Adjustment for Elevated HbA1c with Controlled Pre-Meal Glucose

The patient is experiencing nocturnal hyperglycemia (overbasalization) and requires redistribution of insulin from basal to prandial coverage—specifically, reduce the long-acting insulin and increase the short-acting insulin doses. 1, 2

Critical Problem Identification

The clinical picture reveals a paradox that indicates overbasalization:

• HbA1c 9.6% indicates poor overall glycemic control requiring intensification 2
• Fasting blood glucose <120 mg/dL and pre-meal glucose ~100 mg/dL are at or near target 1
• Total daily basal insulin dose is 70 units (35 units BID), which is excessive relative to the modest prandial coverage of only 15 units total (5 units TID) 1
• This pattern suggests significant postprandial hyperglycemia is driving the elevated HbA1c, not fasting hyperglycemia 1

The basal insulin dose exceeding 0.5 U/kg/day (and approaching 1 U/kg/day in many patients) signals the need for prandial insulin intensification rather than further basal increases. 1

Immediate Regimen Adjustments

Reduce Long-Acting Insulin

• Decrease the long-acting insulin from 35 units BID to 25-28 units BID (approximately 20-30% reduction) 1, 2
• This prevents nocturnal and inter-meal hypoglycemia while maintaining adequate basal coverage 1
• The current fasting glucose <120 mg/dL indicates the basal dose is already adequate or excessive for overnight control 1

Increase Short-Acting Insulin

• Increase prandial insulin from 5 units TID to 10-12 units before each meal (100-140% increase) 2, 3
• This addresses the postprandial glucose excursions that are likely responsible for the elevated HbA1c 1
• Start with the largest meal first if implementing gradually, typically dinner, then breakfast, then lunch 1

Titration Protocol

• Increase prandial insulin by 1-2 units or 10-15% twice weekly based on 2-hour postprandial glucose readings 3
• Target postprandial glucose <180 mg/dL 3
• If hypoglycemia occurs (glucose <70 mg/dL), reduce the corresponding insulin dose by 2-4 units or 10-20% 3

Monitoring Requirements

• Instruct the patient to check blood glucose before each meal, 2 hours after meals, and at bedtime 2, 3
• Focus monitoring on postprandial values to guide prandial insulin adjustments 1
• Watch for signs of hypoglycemia, particularly 2-4 hours after prandial insulin administration when rapid-acting insulin peaks 3
• Monitor for bedtime-to-morning glucose differential—if morning glucose is significantly higher than bedtime, this confirms inadequate basal coverage; if lower, this confirms overbasalization 2

Medication Reconciliation

• If the patient is taking sulfonylureas (glimepiride, glyburide, glipizide), discontinue them immediately 3, 4
• Sulfonylureas combined with intensive insulin therapy significantly increase hypoglycemia risk 3
• Continue metformin if tolerated, as it provides complementary insulin-sensitizing effects without hypoglycemia risk 1, 3

Follow-Up Timeline

• Schedule follow-up in 2-3 weeks to evaluate response and make additional adjustments 2
• Recheck HbA1c in 3 months to assess effectiveness of the regimen change 2
• Expect HbA1c reduction of 1.5-2.5% with appropriate prandial insulin intensification from this baseline 4

Common Pitfalls to Avoid

• Do not continue increasing basal insulin when fasting glucose is already at target—this leads to nocturnal hypoglycemia and does not address postprandial hyperglycemia 1, 2
• Avoid relying on sliding scale (correction) insulin alone without optimizing scheduled prandial doses—this is ineffective for long-term management 3
• Do not delay insulin redistribution for months while trying other approaches—prolonged exposure to HbA1c >9% increases complication risk 3
• Watch for insulin stacking if giving correction doses too close together (within 3-4 hours) 3

Alternative Considerations if Initial Approach Insufficient

• Consider adding a GLP-1 receptor agonist (liraglutide, dulaglutide, semaglutide) if HbA1c remains >8% after 3 months 2, 4
• GLP-1 receptor agonists can provide additional 1-1.5% HbA1c reduction with weight loss benefits and may allow lower insulin requirements 4
• If adherence to multiple daily injections is challenging, consider switching to twice-daily premixed insulin (70/30 or 75/25) 3