What adjustments should be made to the insulin regimen for a patient with an HbA1C of 12.9 on 20 units of long-acting insulin at bedtime and 8 units of short-acting insulin three times a day?

Insulin Regimen Adjustment for A1C 12.9%

This patient requires immediate and aggressive insulin intensification with both increased basal insulin and addition of prandial insulin coverage, as an A1C of 12.9% represents severe hyperglycemia that demands rapid intervention to prevent metabolic decompensation. 1

Immediate Basal Insulin Adjustment

• Increase the long-acting insulin from 20 units to 28-32 units at bedtime (a 40-60% increase), as the current dose is grossly inadequate for this degree of hyperglycemia 1, 2
• Continue titrating basal insulin by 2-4 units every 3 days until fasting plasma glucose reaches 80-130 mg/dL 1
• Set a clear fasting glucose target and use an evidence-based titration algorithm to reach this goal without causing hypoglycemia 1

Critical Addition of Prandial Insulin

The current short-acting insulin dose of 8 units three times daily is insufficient and must be increased immediately. 1

• Increase prandial insulin to 10-12 units with each meal (representing approximately 10% of the anticipated total daily basal insulin dose after initial adjustment) 1, 2
• Titrate each prandial dose by 1-2 units or 10-15% twice weekly based on 2-hour postprandial glucose readings 1, 2
• Target postprandial glucose <180 mg/dL 3
• Post-prandial glucose control is essential at this A1C level, as achieving target A1C requires addressing both fasting and post-meal hyperglycemia 4

Why This Aggressive Approach Is Necessary

• At A1C >10%, insulin is the most effective glucose-lowering agent, and non-insulin agents alone cannot achieve adequate control 2
• Prolonged severe hyperglycemia (A1C >9%) must be specifically avoided due to dramatically increased complication risk 2
• Most oral agents provide <1% A1C reduction, making them insufficient at this baseline 2, 5
• The current total daily insulin dose of approximately 44 units (20 basal + 24 prandial) is far below what is typically needed for adequate control at this A1C level 1

Consider GLP-1 Receptor Agonist Addition

• If not already prescribed and if affordable, add a GLP-1 receptor agonist (such as semaglutide or dulaglutide) to the insulin regimen, as this can provide additional A1C reduction of 0.5-1.0% while reducing insulin requirements and preventing weight gain 1, 2
• GLP-1 RAs have demonstrated superior or equivalent A1C lowering compared to insulin intensification alone in patients with baseline A1C >9%, with the added benefits of weight loss rather than weight gain 5
• A fixed-ratio combination product (such as iGlarLixi or IDegLira) could be considered if switching basal insulin 1

Monitoring Protocol

• Check fasting glucose daily to guide basal insulin titration 1
• Check 2-hour postprandial glucose after each meal to guide prandial insulin adjustments 1, 2
• Consider continuous glucose monitoring (CGM) if available, as A1C alone can be misleading and CGM provides critical information about glucose patterns and hypoglycemia risk 6, 3
• Reassess A1C in 3 months; if still >9%, further intensification is required 2

Critical Safety Considerations

• Prescribe glucagon for emergency hypoglycemia 1
• Provide comprehensive education on hypoglycemia recognition and treatment 2
• For any hypoglycemic episode, reduce the corresponding insulin dose by 10-20% 1
• Ensure proper insulin injection technique and site rotation 7

Common Pitfalls to Avoid

• Do not delay insulin intensification while trying additional oral agents, as this prolongs exposure to severe hyperglycemia and increases complication risk 2
• Do not rely on sliding scale insulin alone without optimizing scheduled basal and prandial insulin, as this approach is ineffective for long-term management 2, 3
• Do not underestimate the required insulin doses at this A1C level; timid dose adjustments will fail to achieve control 1
• If the patient is on a sulfonylurea, strongly consider discontinuing it when moving to this more complex insulin regimen, as it significantly increases hypoglycemia risk without meaningful additional benefit 2, 5

Expected Outcomes

• With appropriate insulin intensification, expect A1C reduction of 3-4% over 3-6 months 2, 5
• The goal is to achieve A1C <7% if this can be done safely without excessive hypoglycemia 1
• Weight gain of 2-4 kg is expected with insulin intensification, which can be mitigated by adding a GLP-1 RA 1, 5