How should the diabetic regimen be adjusted for a patient with consistently high blood sugar levels, currently on 66 units of glargine (insulin glargine) qam and qhs, and insulin lispro (lispro insulin) 26 units with meals?

Aggressive Insulin Dose Escalation Required for Severe Uncontrolled Hyperglycemia

This patient requires immediate and substantial increases in both basal and prandial insulin doses—the current regimen of 66 units glargine twice daily (132 units total basal) plus 26 units lispro three times daily (78 units prandial) is grossly inadequate given blood glucose levels consistently ranging from 191-439 mg/dL. 1

Immediate Dose Adjustments

Basal Insulin (Glargine) Escalation

• Increase glargine by 10-15% immediately (approximately 13-20 units total), bringing the total daily basal dose to approximately 145-152 units, split as 73-76 units twice daily 1
• Continue aggressive titration by increasing 4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL, as the current fasting values of 240-331 mg/dL indicate severely inadequate basal coverage 1
• With blood glucose ≥180 mg/dL, the evidence-based algorithm specifically calls for 4-unit increases every 3 days rather than the more conservative 2-unit approach 1

Prandial Insulin (Lispro) Escalation

• Increase lispro from 26 units to 32-35 units with each meal (approximately 20-35% increase), as postprandial values of 259-406 mg/dL demonstrate inadequate mealtime coverage 1
• Titrate prandial insulin by 2-4 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 1
• The patient's uncontrolled eating behavior makes robust prandial coverage even more critical 1

Critical Context: Total Daily Insulin Requirements

• This patient likely requires 1.0+ units/kg/day total insulin given the severe hyperglycemia and behavioral challenges 1
• Current total daily dose is 210 units (132 basal + 78 prandial), which may still be insufficient depending on body weight 1
• The typical 50:50 basal-to-prandial ratio is reasonable to maintain, but both components need substantial escalation 1

Avoiding the Overbasalization Trap

Do not continue escalating basal insulin indefinitely without addressing prandial coverage. 1 However, in this case:

• The fasting glucose values (240-331 mg/dL) clearly indicate inadequate basal insulin, so basal escalation is appropriate 1
• The postprandial values (259-406 mg/dL) simultaneously indicate inadequate prandial coverage 1
• Both components require aggressive titration in parallel rather than focusing on one at the expense of the other 1

Monitoring and Titration Schedule

• Adjust basal insulin every 3 days based on fasting glucose values—do not wait longer, as this unnecessarily prolongs time to glycemic targets 1
• Adjust prandial insulin every 3 days based on postprandial glucose readings 2 hours after meals 1
• Daily self-monitoring of fasting and postprandial blood glucose is essential during this aggressive titration phase 1
• Reassess at every clinical encounter for signs of overbasalization (bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, high glucose variability) 1

Foundation Therapy Verification

• Confirm metformin is prescribed unless contraindicated, as it should remain the foundation of type 2 diabetes therapy even with intensive insulin 1
• Consider adding an SGLT-2 inhibitor or GLP-1 receptor agonist to improve control and potentially reduce insulin requirements, though this is secondary to the immediate need for insulin dose escalation 1, 2

Addressing the Behavioral Challenge

While the patient's uncontrolled eating behavior complicates management:

• The insulin regimen must be adjusted to match actual food intake rather than attempting to restrict access to food in a long-term care setting 3
• Consider implementing a carbohydrate-counting approach where prandial insulin doses are adjusted based on estimated carbohydrate intake at each meal 3
• Staff education on administering supplemental correction doses when the patient orders additional food may be necessary 3

Hypoglycemia Prevention

• If hypoglycemia occurs during titration, reduce the corresponding insulin component by 10-20% immediately 1
• Ensure staff and patient have access to at least 15g of rapidly absorbed carbohydrate for hypoglycemia treatment 3
• Given the aggressive dose escalation, vigilance for hypoglycemia is essential, though current glucose values suggest this is not an immediate concern 1

Expected Timeline

• With aggressive titration every 3 days, fasting glucose should reach target (80-130 mg/dL) within 2-4 weeks 1
• Postprandial control may take longer given the behavioral challenges, but should improve substantially with adequate prandial insulin 1
• Reassess the overall regimen after 3-6 months once glucose patterns stabilize 1