Is it appropriate to increase basal insulin glargine and prandial insulin lispro, add Vitamin D3, and monitor lipid profile without increasing rosuvastatin due to elevated triglycerides in a patient with severe uncontrolled hyperglycemia and vitamin D deficiency?

Insulin Intensification Plan Assessment

Your plan to aggressively increase basal and prandial insulin is appropriate and necessary given the severe hyperglycemia (glucose 464 mg/dL), and you should NOT increase rosuvastatin at this time—the elevated triglycerides (211 mg/dL) will likely improve substantially once glycemic control is achieved. 1, 2

Insulin Dose Escalation Strategy

Your proposed insulin adjustments are clinically sound:

• Basal insulin increase from current dose to 76 units twice daily (152 units total daily) represents appropriate aggressive titration for severe hyperglycemia with fasting glucose in the 240-331 mg/dL range 1
• The 10-15% dose escalation approach aligns with ADA Standards of Care recommendations for insulin titration 1
• Prandial insulin increase from 26 to 32 units per meal is appropriate given the marked hyperglycemia and need for postprandial coverage 1
• Your plan for continued basal titration by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL is guideline-concordant 1, 2

Critical consideration: With total basal insulin now exceeding 0.5 units/kg/day, if A1C remains above target after achieving fasting glucose control, consider adding a GLP-1 receptor agonist rather than further insulin intensification, as this combination provides superior durability of glycemic effect with less weight gain and hypoglycemia 1

Triglyceride Management Decision

Monitor triglycerides without increasing rosuvastatin—do not adjust statin therapy at this time. Here's why:

• Severe hyperglycemia is the primary driver of the elevated triglycerides (211 mg/dL), and improving glycemic control typically results in substantial triglyceride reduction without additional lipid-lowering therapy 3
• The patient's LDL is already at goal (61 mg/dL), and non-HDL cholesterol is within normal limits (103.6 mg/dL), indicating adequate cardiovascular risk reduction from current statin dose 1
• Reassess lipid panel 8-12 weeks after achieving glycemic control (target A1C <7-8%) before considering statin dose adjustment 1
• If triglycerides remain >200 mg/dL after glycemic optimization, then consider fibrate addition rather than statin increase, as fibrates are more effective for isolated hypertriglyceridemia 4

Vitamin D Supplementation

Your vitamin D3 dosing requires adjustment:

• Increase vitamin D3 from 1,000 units twice daily (2,000 units total) to at least 2,000 units daily as a single dose, which is the evidence-based dose for vitamin D deficiency (25-OH vitamin D = 19 ng/mL) in diabetic patients 3
• Consider higher repletion doses (50,000 IU weekly for 8 weeks, then maintenance) given the severe deficiency, though your conservative approach is acceptable 3
• Metformin, if the patient is taking it, enhances vitamin D absorption, so continuation of metformin (if prescribed) supports vitamin D repletion 3

Monitoring Parameters and Safety

Implement these critical monitoring safeguards:

• Point-of-care glucose testing every 4-6 hours initially, increasing to every 1-2 hours if glucose >250 mg/dL or <70 mg/dL 2
• Check basic metabolic panel every 2-4 hours initially to monitor for hypokalemia, as insulin drives potassium intracellularly; replace potassium if <4.0 mEq/L 2
• Establish a hypoglycemia management protocol: if blood glucose <70 mg/dL occurs, reduce the corresponding insulin component by 20-50% 1, 2
• The mildly low sodium (134 mEq/L) and elevated osmolality (297.9 mOsm/kg) are likely secondary to hyperglycemia and should improve with glucose control 1

Critical Pitfalls to Avoid

• Do not use sliding-scale insulin as monotherapy—your basal-bolus approach is correct, as sliding-scale alone is associated with poor outcomes 1, 2
• Avoid premixed insulin (70/30) formulations in this setting due to unacceptably high hypoglycemia rates 2
• Do not aggressively target glucose <140 mg/dL in the acute phase; initial target of 140-180 mg/dL is safer and evidence-based 1, 2
• Ensure prandial insulin is timed appropriately with meals (within 15 minutes before eating) and adjusted based on carbohydrate intake 1

Additional Metabolic Considerations

• The mild hypoalbuminemia (3.1 g/dL) may affect insulin pharmacokinetics but does not require dose adjustment 1
• Normal proBNP (61 pg/mL) and preserved eGFR (109 mL/min) indicate no contraindications to aggressive insulin therapy 1
• If the patient is on metformin, continue it as it improves insulin sensitivity and supports vitamin D absorption 1, 3
• Discontinue sulfonylureas if prescribed to minimize hypoglycemia risk during insulin intensification 1, 5