How to adjust the insulin regimen for a patient with diabetes on 30 units of insulin glargine (long-acting insulin) at bedtime, with an Hemoglobin A1c (HbA1c) level of 11.3 and blood glucose levels ranging from 100 to 388?

Insulin Regimen Adjustment for Severely Uncontrolled Type 2 Diabetes

Immediately increase your insulin glargine to 40 units at bedtime AND add 4 units of rapid-acting insulin (such as lispro, aspart, or glulisine) before each of your three largest meals. 1, 2, 3

Why This Aggressive Approach is Necessary

Your A1c of 11.3% with blood glucose ranging 100-388 mg/dL represents severe uncontrolled diabetes requiring urgent intensification beyond basal insulin alone. 1, 2 When basal insulin exceeds 0.5 units/kg/day (approximately 30-40 units for most adults) and glucose remains elevated, adding prandial insulin is more appropriate than continuing to escalate basal insulin alone. 1, 2

The wide glucose variability (100-388 mg/dL) indicates both inadequate basal coverage AND significant postprandial excursions that cannot be addressed by glargine alone. 1, 2

Specific Titration Protocol

Basal Insulin (Glargine) Adjustment

• Increase glargine by 4 units every 3 days if fasting glucose ≥180 mg/dL 1, 2
• Increase by 2 units every 3 days if fasting glucose 140-179 mg/dL 1, 2
• Target fasting glucose: 80-130 mg/dL 1, 2
• If hypoglycemia occurs without clear cause, reduce dose by 10-20% immediately 1, 2

Prandial Insulin Initiation and Titration

• Start with 4 units of rapid-acting insulin before each of the three largest meals 1, 2, 3
• Increase each mealtime dose by 1-2 units every 3 days based on 2-hour postprandial glucose readings 1, 2, 3
• Target postprandial glucose: <180 mg/dL 2, 3

Critical Threshold: Avoiding Overbasalization

Stop escalating basal insulin when the dose exceeds 0.5 units/kg/day (approximately 35-50 units for most adults). 1, 2 Clinical signals that you've reached this threshold include:

• Basal insulin dose >0.5 units/kg/day 1, 2
• Bedtime-to-morning glucose differential ≥50 mg/dL 1, 2
• Hypoglycemia episodes 1, 2
• High glucose variability 1, 2

Continuing to increase basal insulin beyond this point without addressing postprandial hyperglycemia leads to suboptimal control and increased hypoglycemia risk. 1, 2

Foundation Therapy Verification

Ensure you remain on metformin unless contraindicated, as it should continue even when intensifying insulin therapy. 1, 2 This is the foundation of type 2 diabetes management and should not be discontinued when adding insulin. 1, 2

Monitoring Requirements

• Daily fasting blood glucose monitoring is mandatory during titration 1, 2, 3
• Pre-meal and 2-hour postprandial glucose checks guide prandial insulin adjustments 2, 3
• Reassess A1c in 3 months 2, 3
• Expect A1c reduction to approximately 7.5-8.5% with this regimen 2, 3

Alternative Consideration: GLP-1 Receptor Agonist

Before adding prandial insulin, consider adding a GLP-1 receptor agonist (such as semaglutide or dulaglutide) to your basal insulin regimen. 1 This approach provides similar glycemic efficacy to prandial insulin with lower hypoglycemia risk and beneficial effects on body weight, albeit with greater gastrointestinal side effects. 1 However, given your severe hyperglycemia (A1c 11.3%), the potency of basal-bolus insulin is likely necessary for rapid glucose control. 1, 3

Patient Education Essentials

You must immediately learn:

• Proper injection technique and site rotation 2, 3
• Hypoglycemia recognition and treatment 2, 3
• Self-monitoring blood glucose technique with clear targets 2, 3
• Rapid-acting insulin must be given 0-15 minutes before meals, not after eating 2

Expected Total Daily Insulin Dose

With an A1c of 11.3%, your total daily insulin requirement should be approximately 0.6-1.0 units/kg/day, significantly higher than your current 30 units. 2, 3 For a 70 kg patient, this translates to 42-70 units total daily (basal + prandial combined). 2, 3

Common Pitfall to Avoid

Do not continue increasing glargine beyond 40-50 units without adding prandial insulin. 1, 2 Blood glucose in the 200-300s mg/dL reflects both inadequate basal coverage AND postprandial excursions requiring mealtime insulin coverage. 1, 2 Relying solely on correction insulin ("sliding scale") without scheduled prandial insulin is inadequate for this level of hyperglycemia. 2