What insulin regimen adjustments are recommended for a patient with A1C 9.7 on long-acting insulin 35u bid and short-acting insulin 5u tid?

Insulin Regimen Adjustment for A1C 9.7% with Controlled Fasting and Premeal Glucose

Your patient has excellent fasting and premeal glucose control (80-120s) but an A1C of 9.7%, indicating significant postprandial hyperglycemia that is not being captured by your current monitoring—you need to increase the short-acting insulin doses substantially and add postprandial glucose monitoring. 1, 2

The Core Problem: Hidden Postprandial Hyperglycemia

Your patient's situation reveals a critical disconnect:

• Fasting glucose 80-120 mg/dL and premeal glucose in the 120s suggest adequate basal insulin coverage 1
• A1C 9.7% corresponds to an average glucose of approximately 240 mg/dL 1
• This 120+ mg/dL gap indicates massive postprandial glucose excursions that you're not detecting 2

The current short-acting insulin dose of 5 units three times daily is grossly inadequate for controlling postprandial glucose spikes. 2

Immediate Action Plan

Step 1: Increase Prandial Insulin Aggressively

• Increase the short-acting insulin from 5 units to 8-10 units before each meal 2
• The American Diabetes Association recommends increasing prandial insulin by 1-2 units or 10-15% every 3-7 days based on postprandial readings 1, 2
• At this A1C level (9.7%), you need more aggressive initial increases 2, 3

Step 2: Implement Postprandial Glucose Monitoring

• Check 2-hour postprandial glucose after each meal, especially after the largest meal 2
• Target postprandial glucose <180 mg/dL 2
• This monitoring is essential—you cannot titrate prandial insulin effectively without knowing postprandial values 4

Step 3: Maintain Current Basal Insulin

• Keep the long-acting insulin at 35 units twice daily 1
• The controlled fasting and premeal glucose indicates this dose is appropriate 1
• Do not reduce basal insulin when increasing prandial doses at this A1C level 1

Titration Protocol

Every 3-7 days, adjust based on postprandial readings:

• If 50% of postprandial values are >180 mg/dL: increase that meal's insulin by 2 units 1, 2
• If postprandial values are <90 mg/dL more than twice weekly: decrease that meal's insulin by 10-20% 1
• Continue adjustments until postprandial glucose consistently <180 mg/dL 2

Critical Monitoring Points

• Check A1C every 3 months until target <7% is achieved 1
• Monitor for hypoglycemia, especially 2-4 hours post-meal when rapid-acting insulin peaks 2
• Ensure patient carries 15-20 grams of fast-acting carbohydrate at all times 2

Common Pitfalls to Avoid

Do not rely solely on fasting and premeal glucose to guide therapy when A1C is elevated—this is the exact trap you've fallen into. The A1C of 9.7% proves there is significant hyperglycemia occurring that your current monitoring schedule is missing. 1, 2

Do not use sliding scale insulin alone—your current regimen of fixed prandial doses is correct, but the doses are too low. Sliding scale without adequate scheduled prandial insulin is ineffective. 2, 3

Do not delay intensification—prolonged exposure to A1C >9% significantly increases complication risk. The American Diabetes Association recommends reevaluating and significantly changing treatment when A1C is consistently >8%. 1, 3

Alternative Consideration

If the patient struggles with multiple daily injections or frequent dose adjustments, consider adding a GLP-1 receptor agonist to the regimen, which can improve postprandial glucose control while potentially reducing total insulin requirements and providing cardiovascular benefits. 1, 5, 6 However, at an A1C of 9.7%, insulin intensification remains the priority and most effective approach. 3, 5

Expected Outcomes

With appropriate prandial insulin titration (likely requiring 10-15 units per meal based on the A1C-glucose discrepancy), you should see:

• A1C reduction of 2-3% over 3 months 2, 3
• Postprandial glucose values consistently <180 mg/dL 2
• Maintained fasting glucose control 1

The key is aggressive upward titration of prandial insulin guided by postprandial glucose monitoring—not the fasting and premeal values that are already well-controlled. 1, 2, 3