Is my current regimen of glargine insulin (Lantus) 15 units at bedtime, sliding scale Novolog (insulin aspart), and glimepiride (Amaryl) 4 mg BID effective given my blood glucose levels range from 82 to 250 mg/dL and A1c is 9.1%?

Current Regimen Assessment: Inadequate Glycemic Control Requiring Immediate Intensification

Your current regimen is inadequate and requires immediate intensification—with an A1c of 9.1% and blood sugars ranging from 82 to 250 mg/dL, you need both increased basal insulin and addition of structured prandial insulin coverage, not just sliding scale. 1, 2

Critical Problems with Current Regimen

Insufficient Basal Insulin Dose

• Your glargine dose of 15 units at bedtime is far too low for your level of hyperglycemia. 1, 2
• With an A1c of 9.1%, you likely need 0.3-0.5 units/kg/day as your total daily insulin dose, meaning your basal insulin alone should be significantly higher than 15 units. 1, 2
• The American Diabetes Association recommends increasing basal insulin by 4 units every 3 days when fasting glucose is ≥180 mg/dL, which your blood sugar range of 82-250 mg/dL suggests is occurring. 1

Sliding Scale Insulin is Ineffective

• Sliding scale Novolog (correction-only insulin) is strongly discouraged and ineffective for glycemic management—it only treats hyperglycemia reactively rather than preventing it. 1, 3
• You need scheduled prandial insulin before meals, not just correction doses after blood sugars are already elevated. 1, 3

Glimepiride Concerns

• Continuing glimepiride 4 mg BID while intensifying to a complex insulin regimen significantly increases your hypoglycemia risk. 2, 3
• The combination of glimepiride and insulin increases hypoglycemia risk and should be carefully monitored, with consideration of discontinuing the sulfonylurea as insulin is intensified. 2, 3

Recommended Treatment Plan

Step 1: Aggressive Basal Insulin Titration

• Increase glargine by 4 units every 3 days until your fasting blood glucose consistently reaches 80-130 mg/dL. 1, 2
• Continue this titration until fasting glucose is controlled, but recognize that when basal insulin exceeds 0.5 units/kg/day, adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1, 2

Step 2: Add Structured Prandial Insulin

• Replace your sliding scale Novolog with scheduled prandial insulin before meals, starting with 4 units of rapid-acting insulin before your largest meal (or 10% of your basal dose once optimized). 1, 2, 3
• Increase prandial insulin by 1-2 units or 10-15% twice weekly based on 2-hour postprandial glucose readings. 1, 3
• If A1c remains elevated after optimizing one meal, add prandial insulin before additional meals sequentially. 3

Step 3: Foundation Therapy Optimization

• Ensure you are on metformin (unless contraindicated), as it should be continued when adding or intensifying insulin therapy—it reduces total insulin requirements and provides complementary glucose-lowering effects. 1, 2
• Consider adding an SGLT2 inhibitor or GLP-1 receptor agonist to improve glycemic control while minimizing weight gain and hypoglycemia risk. 1, 2

Step 4: Consider Discontinuing Glimepiride

• As you move to a basal-bolus insulin regimen, strongly consider discontinuing glimepiride to reduce hypoglycemia risk. 2, 3
• Sulfonylureas are typically discontinued when more complex insulin regimens beyond basal insulin are used. 3

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration, with reassessments every 3 days during active titration. 1, 2
• Monitor pre-meal and 2-hour postprandial glucose readings to guide prandial insulin adjustments. 1, 3
• Check A1c every 3 months during intensive titration. 1
• If hypoglycemia occurs, reduce the dose by 10-20% immediately and determine the cause. 1, 2

Critical Pitfalls to Avoid

• Do not continue relying solely on sliding scale insulin—this approach will never achieve adequate glycemic control at your A1c level. 1, 3
• Do not delay insulin intensification for months while trying additional oral agents—prolonged exposure to severe hyperglycemia (A1c >9%) increases complication risk. 2, 3
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with prandial insulin—this leads to "overbasalization" with suboptimal control and increased hypoglycemia risk. 1, 2
• Do not stop metformin when intensifying insulin therapy unless contraindicated. 1, 2

Patient Education Essentials

• Comprehensive education on self-monitoring of blood glucose, insulin injection technique and site rotation, and recognition and treatment of hypoglycemia is critically important. 1, 3
• You should be provided with written instructions for insulin dose adjustments based on glucose patterns and supplied with hypoglycemia treatment supplies. 3
• Learn "sick day" management rules and proper insulin storage and handling. 1