What adjustments should be made to a patient's current regimen of HumaLOG (insulin lispro) KwikPen and Tresiba (insulin degludec) FlexTouch, who has uncontrolled diabetes despite a high dose sliding scale regimen and twice daily Tresiba injections?

Aggressive Insulin Regimen Intensification Required

This patient requires immediate intensification of both basal and prandial insulin, with the current regimen demonstrating severe inadequacy—the fixed 25-unit prandial doses plus high-dose correction scale combined with split-dose Tresiba totaling 70 units daily is failing to achieve glycemic control. 1

Critical Assessment of Current Regimen

The current approach has fundamental flaws:

• Fixed 25-unit prandial doses four times daily (100 units) plus correction insulin (up to 196 units daily maximum) represents an extremely high total daily dose that suggests either severe insulin resistance or inappropriate dosing strategy 1
• Split-dose Tresiba (30 units AM + 40 units PM = 70 units daily) combined with 100+ units of prandial/correction insulin indicates total daily doses potentially exceeding 170-296 units 1
• When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, continuing to escalate without addressing the underlying regimen structure leads to "overbasalization" with increased hypoglycemia risk and suboptimal control 1

Immediate Regimen Restructuring

Step 1: Calculate Appropriate Total Daily Dose

For severe uncontrolled hyperglycemia, start with 0.3-0.5 units/kg/day as the foundation 1:

• Estimate patient weight to determine appropriate dosing
• If weight unknown, use current total daily dose but redistribute appropriately
• The current regimen's structure (fixed doses + massive correction scale) must be abandoned in favor of a scheduled basal-bolus approach 2

Step 2: Restructure to Proper Basal-Bolus Regimen

Consolidate Tresiba to once-daily dosing:

• Tresiba should be given once daily, not split twice daily—the ultra-long duration of action (>42 hours) makes split dosing unnecessary and complicates titration 1
• Combine the current 70 units into a single daily dose of 70 units, administered at the same time each day 1
• Target 40-50% of total daily dose as basal insulin 1

Convert to scheduled prandial insulin:

• Eliminate the fixed 25-unit doses and replace with individualized meal-based dosing 2
• Start with 4 units of HumaLOG before each meal (breakfast, lunch, dinner) or 10% of basal dose (approximately 7 units per meal) 1
• HumaLOG must be administered 0-15 minutes before meals, not after eating 3

Maintain correction insulin but reduce the scale:

• The current correction scale (8-28 units per increment) is excessively aggressive 1
• Use a more conservative correction scale: 131-180: 2 units; 181-240: 4 units; 241-300: 6 units; 301-350: 8 units; 351-400: 10 units; >400: 12 units and contact provider 1

Step 3: Aggressive Titration Protocol

Basal insulin titration:

• Increase Tresiba by 4 units every 3 days if fasting glucose ≥180 mg/dL 1
• Increase by 2 units every 3 days if fasting glucose 140-179 mg/dL 1
• Target fasting glucose 80-130 mg/dL 1
• If hypoglycemia occurs (glucose <70 mg/dL), reduce dose by 10-20% immediately 1

Prandial insulin titration:

• Increase each meal's HumaLOG dose by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 1
• Target postprandial glucose <180 mg/dL 2
• Adjust each meal dose independently based on the glucose pattern after that specific meal 2

Essential Foundation Therapy

Verify and optimize metformin:

• Metformin must be continued unless contraindicated, even when intensifying insulin therapy 1
• Ensure dose is at least 1000 mg twice daily (2000 mg total daily), with maximum effective dose up to 2500 mg/day 2
• Metformin reduces total insulin requirements and provides complementary glucose-lowering effects 2

Consider adding GLP-1 receptor agonist:

• When basal insulin exceeds 0.5 units/kg/day without achieving targets, adding a GLP-1 receptor agonist improves glycemic control while minimizing weight gain and hypoglycemia risk 4, 1
• Combination basal insulin + GLP-1 RA provides potent glucose-lowering with less weight gain than intensified insulin regimens 1
• When initiating GLP-1 RA, reduce total daily insulin dose by 20% immediately to prevent hypoglycemia 5

Monitoring Requirements

Intensive glucose monitoring during titration:

• Daily fasting blood glucose monitoring is essential 1
• Check pre-meal glucose before each meal to assess basal insulin adequacy 2
• Check 2-hour postprandial glucose after the largest meal to guide prandial insulin adjustments 2
• Reassess and modify therapy every 3-6 months once stable to avoid therapeutic inertia 1

HbA1c monitoring:

• Check HbA1c every 3 months during intensive titration 2
• Continue every 3 months until target achieved 2

Critical Pitfalls to Avoid

Do not continue the current approach:

• Relying on correction insulin (sliding scale) as the primary glucose-lowering strategy rather than scheduled basal-bolus therapy leads to suboptimal control 2
• Fixed prandial doses of 25 units regardless of meal size or carbohydrate content is inappropriate 1
• Split-dosing Tresiba twice daily adds unnecessary complexity without benefit given its ultra-long duration of action 1

Do not delay regimen restructuring:

• Many months of uncontrolled hyperglycemia should specifically be avoided to prevent long-term complications 2
• Therapeutic inertia—failing to intensify therapy when targets are not met—is a major barrier to optimal diabetes management 1

Do not ignore hypoglycemia:

• If any hypoglycemia occurs, reduce the corresponding insulin dose by 10-20% immediately 1
• Prescribe glucagon for emergency use and educate family members on administration 2
• Treat hypoglycemia at blood glucose ≤70 mg/dL with 15-20 grams of fast-acting carbohydrate 2

Patient Education Essentials

Insulin administration technique:

• Proper injection technique with 90-degree angle for subcutaneous administration 2
• Rotate injection sites systematically within one anatomical area to prevent lipodystrophy 2
• HumaLOG must be injected 0-15 minutes before meals for optimal postprandial glucose control 3

Self-management skills:

• Recognition and treatment of hypoglycemia 1
• Self-monitoring of blood glucose technique 2
• "Sick day" management rules 1
• Insulin storage and handling 4
• Carry at least 15 grams of fast-acting carbohydrate at all times 2

Expected Outcomes

With proper regimen restructuring and aggressive titration:

• Fasting glucose should reach 80-130 mg/dL within 2-4 weeks 1
• Postprandial glucose should improve to <180 mg/dL within 4-6 weeks 2
• HbA1c should decrease by 1-2% within 3 months with optimized therapy 2
• Total daily insulin requirements will likely stabilize at 0.5-1.0 units/kg/day once proper basal-bolus distribution is achieved 1