Stop Escalating Basal Insulin and Add Prandial Coverage
You should stop increasing your basal insulin glargine and instead add rapid-acting insulin before meals, as your current dose of 27 units likely represents overbasalization that will not improve your blood glucose control. 1
Critical Threshold Reached: Signs of Overbasalization
Your situation demonstrates a classic pattern where continuing to escalate basal insulin becomes counterproductive:
- When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, adding prandial insulin is more appropriate than continuing to escalate basal insulin alone 1
- At 27 units, you may already be approaching or exceeding this threshold depending on your body weight 1
- Clinical signals of overbasalization include: basal dose >0.5 units/kg/day, high bedtime-to-morning glucose differential (≥50 mg/dL), hypoglycemia, and high glucose variability 2, 1
- Blood glucose remaining elevated despite increasing basal insulin from 19 to 27 units over a month indicates both inadequate basal coverage AND postprandial excursions requiring mealtime insulin 1
What You Should Do Instead
Add Prandial Insulin Coverage
- Start with 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before your largest meal, or use 10% of your current basal dose (approximately 3 units) 1
- Administer the rapid-acting insulin 0-15 minutes before eating, not after 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
Adjust Your Basal Insulin
- Increase your basal insulin glargine by 4 units every 3 days if fasting glucose ≥180 mg/dL, or by 2 units every 3 days if fasting glucose is 140-179 mg/dL, until fasting blood glucose reaches 80-130 mg/dL 1
- If you experience hypoglycemia, reduce the dose by 10-20% immediately 1
Verify Foundation Therapy
- Confirm you are taking metformin unless contraindicated, as it remains the foundation of type 2 diabetes therapy and should be continued when adding or intensifying insulin 2, 1
What Else to Check
Monitor for Overbasalization
- Check your bedtime-to-morning glucose differential—if it's ≥50 mg/dL, this indicates excessive basal insulin 1
- Track any hypoglycemic episodes (aware or unaware) 2
- Assess glucose variability throughout the day 2
Evaluate Your Insulin Regimen
- Calculate your current dose per kilogram: 27 units ÷ your weight in kg 1
- If this exceeds 0.5 units/kg/day, you've reached the threshold where prandial insulin becomes necessary 1
- Review your fasting glucose patterns versus postprandial patterns to determine if the problem is basal coverage, mealtime coverage, or both 1
Consider Alternative Therapies
- Adding a GLP-1 receptor agonist to your basal insulin regimen can improve A1C while minimizing weight gain and hypoglycemia risk 1
- This is preferred over insulin when possible according to current guidelines 2
Common Pitfall You're Experiencing
Continuing to increase basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia leads to suboptimal control and increased hypoglycemia risk 1. Your persistent hyperglycemia despite escalating from 19 to 27 units demonstrates this exact problem—you're likely experiencing postprandial glucose excursions that basal insulin cannot address 1.