Current Insulin Regimen is Grossly Insufficient for HbA1c of 11%
This patient requires immediate and aggressive insulin intensification—the current regimen of Basaglar 20 units at bedtime with sliding scale Humalog 12 units is completely inadequate for an HbA1c of 11% in a 223-pound (101 kg) patient. 1
Critical Problems with Current Regimen
Basal Insulin Dose is Severely Inadequate
- At 223 pounds (101 kg), this patient is receiving only 0.2 units/kg/day of basal insulin, which is at the absolute minimum starting dose for insulin-naive patients 1, 2
- For an HbA1c of 11%, guidelines recommend starting doses of 0.3-0.5 units/kg/day as total daily insulin (both basal and prandial combined), meaning this patient needs 30-50 units/day total, not just 20 units of basal insulin 1, 2
- The basal insulin should be aggressively titrated by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL 2, 3
Sliding Scale Insulin Alone is Condemned by Guidelines
- Sliding scale insulin as monotherapy is explicitly condemned by all major diabetes guidelines and shown to be ineffective 1
- Sliding scale insulin treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations 1
- Studies demonstrate that only 38% of patients achieve glucose control <140 mg/dL with sliding scale alone versus 68% with basal-bolus therapy 1, 4
This Patient Requires Basal-Bolus Therapy Immediately
- With HbA1c ≥10%, patients require immediate basal-bolus insulin therapy, not basal insulin with sliding scale 1, 2, 3
- The 12 units of Humalog should be converted from reactive sliding scale to scheduled prandial insulin before meals 1
Recommended Insulin Regimen
Immediate Basal Insulin Adjustment
- Increase Basaglar to at least 30-40 units at bedtime (0.3-0.4 units/kg/day) given the severe hyperglycemia 2, 3
- Titrate by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL 2, 3
- Continue titration without arbitrary dose limits—when basal insulin exceeds 0.5 units/kg/day (approximately 50 units), focus shifts to intensifying prandial coverage rather than further basal escalation 1, 2
Convert to Scheduled Prandial Insulin
- Start with 4 units of Humalog before the largest meal, or use 10% of the basal dose (initially 3-4 units) 1, 2, 3
- Add prandial insulin before additional meals sequentially based on postprandial glucose patterns 2, 3
- Titrate prandial doses by 1-2 units or 10-15% twice weekly based on 2-hour postprandial glucose readings 2, 3
- Maintain correction insulin (sliding scale) as a supplement to scheduled insulin, not as replacement 1
Foundation Therapy
- Ensure metformin is continued at maximum tolerated dose (at least 2000 mg/day) unless contraindicated 1, 2, 3
- Metformin reduces total insulin requirements and provides complementary glucose-lowering effects 2, 3
Critical Monitoring Requirements
- Daily fasting blood glucose monitoring is essential during titration 2, 3
- Check HbA1c every 3 months during intensive titration 2
- Monitor for hypoglycemia, especially 2-4 hours after prandial insulin doses 3
- Reassess regimen every 3-6 months to avoid therapeutic inertia 2
Common Pitfalls to Avoid
- Delaying insulin intensification while HbA1c remains >10% significantly increases complication risk 2, 3
- Continuing to rely on sliding scale insulin alone when scheduled basal-bolus therapy is clearly indicated 1
- Failing to titrate basal insulin aggressively enough—4-unit increments every 3 days are appropriate for HbA1c >10% 2, 3
- Not adding prandial insulin when basal insulin alone fails to achieve targets after 3-6 months 1, 2
Expected Outcomes with Proper Intensification
- With appropriate basal-bolus therapy at weight-based dosing (0.4-0.5 units/kg/day total), 68% of patients achieve mean blood glucose <140 mg/dL versus only 38% with sliding scale alone 1, 4
- HbA1c reduction of 2-3% is achievable with proper insulin intensification from current levels 2, 3
- No increased hypoglycemia risk with basal-bolus versus sliding scale when properly implemented 1, 4