How to adjust insulin regimen for patient with HbA1c of 11.5 on Lantus (Insulin Glargine) 12 units at bedtime and Novolog (Insulin Aspart) 6 units three times a day?

Aggressive Insulin Dose Escalation Required for HbA1c 11.5%

Your patient's current insulin regimen is grossly inadequate—with an HbA1c of 11.5%, you need to immediately increase both basal and prandial insulin doses and add prandial coverage to additional meals. 1, 2

Immediate Dose Adjustments

Increase Basal Insulin (Lantus)

• Increase Lantus from 12 units to 20 units at bedtime immediately (increase by 4 units every 3 days when fasting glucose ≥180 mg/dL, which is highly likely with HbA1c 11.5%) 1, 2
• Continue aggressive titration by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL 1, 2
• For severe hyperglycemia like this (HbA1c >10%), the patient likely needs 0.3-0.5 units/kg/day as total daily insulin dose 2, 3

Intensify Prandial Insulin Coverage

• Increase Novolog from 6 units to 10 units before each meal immediately 1, 2
• The current 6 units three times daily (18 units total prandial) is insufficient for this degree of hyperglycemia 2
• Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on pre-meal and 2-hour postprandial glucose readings 2

Critical Threshold Considerations

Watch for overbasalization as you titrate: When basal insulin exceeds 0.5 units/kg/day (approximately 25-40 units for most adults), prioritize intensifying prandial insulin rather than continuing to escalate basal insulin alone 1, 2. Clinical signals of overbasalization include:

• Bedtime-to-morning glucose differential ≥50 mg/dL 2
• Hypoglycemia episodes 1, 2
• High glucose variability 2

Foundation Therapy Optimization

Ensure metformin is optimized: The patient should be on at least 1000mg twice daily (2000mg total daily) unless contraindicated 2. Metformin reduces total insulin requirements and provides complementary glucose-lowering effects, and should be continued when intensifying insulin therapy 1, 2.

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration 1, 2
• Check pre-meal and 2-hour postprandial glucose readings to guide prandial insulin adjustments 2
• Reassess HbA1c every 3 months during intensive titration 2
• Assess adequacy of insulin doses at every clinical visit, looking for signs of overbasalization 1, 2

Alternative Considerations

If the patient continues to struggle with glycemic control despite optimized basal-bolus insulin:

• Consider adding a GLP-1 receptor agonist to improve glycemic control while minimizing weight gain and hypoglycemia risk 1, 2
• GLP-1 receptor agonists have shown superior or equivalent HbA1c reduction compared to insulin glargine in patients with baseline HbA1c >9%, with the added benefits of weight loss rather than weight gain 3

Patient Education Essentials

• Teach recognition and treatment of hypoglycemia immediately 2
• Ensure proper insulin injection technique and site rotation 2
• Educate on self-monitoring of blood glucose, "sick day" management rules, and insulin storage and handling 2
• Equip patient with self-titration algorithms based on blood glucose monitoring 2

Common Pitfalls to Avoid

• Do not delay intensification of this regimen—blood glucose levels are clearly indicating the need for both increased basal and prandial coverage 2
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to suboptimal control and increased hypoglycemia risk 2
• Do not wait longer than 3 days between basal insulin adjustments in stable patients, as this unnecessarily prolongs time to achieve glycemic targets 2