Is a regimen of Basaglar (insulin glargine) KwikPen 20 units subcutaneously (SQ) at bedtime and a sliding scale of Humalog (insulin lispro) KwikPen 12 units SQ before each meal sufficient for a 223-pound patient with type 2 diabetes mellitus (DM) and an Hemoglobin A1c (HbA1c) level of 11?

Current Insulin Regimen is Grossly Insufficient for HbA1c of 11%

This regimen of Basaglar 20 units at bedtime plus sliding scale Humalog 12 units before meals is completely inadequate and represents a fundamentally flawed approach to insulin therapy that will not achieve glycemic control. The patient requires immediate intensification to a proper basal-bolus regimen with weight-based dosing and systematic titration.

Critical Problems with the Current Regimen

Basal Insulin Dose is Far Too Low

• For a 223-pound (101 kg) patient with HbA1c of 11%, the American Diabetes Association recommends starting doses of 0.3-0.5 units/kg/day as total daily insulin, meaning this patient needs approximately 30-50 units/day total 1
• The current Basaglar dose of 20 units represents only 0.2 units/kg/day, which is insufficient even for mild hyperglycemia, let alone an HbA1c of 11% 1
• The basal insulin should be immediately increased to at least 30-40 units (0.3-0.4 units/kg/day) and titrated aggressively by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL 1

Sliding Scale Insulin is Condemned by All Guidelines

• Sliding scale insulin as monotherapy for prandial coverage is explicitly condemned by all major diabetes guidelines and shown to be ineffective 1
• The American College of Physicians demonstrates that sliding scale insulin treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations 1
• Scheduled basal-bolus regimens with fixed prandial doses are superior to sliding scale monotherapy, with 68% of patients achieving mean blood glucose <140 mg/dL versus only 38% with sliding scale alone 1

Fixed Prandial Dose is Inappropriate

• The fixed 12 units of Humalog before each meal ignores carbohydrate content and individual meal requirements 1
• Prandial insulin should be calculated using carbohydrate-to-insulin ratios (typically starting at 1:10 or 1:15) plus correction doses based on pre-meal glucose levels 1

Recommended Insulin Regimen

Immediate Basal Insulin Intensification

• Increase Basaglar to 35 units at bedtime (0.35 units/kg/day) immediately 1
• Titrate by 4 units every 3 days if fasting glucose remains ≥180 mg/dL, or by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1
• Continue titration until fasting blood glucose consistently reaches 80-130 mg/dL 1
• When basal insulin exceeds 0.5 units/kg/day (approximately 50 units for this patient), adding or intensifying prandial insulin becomes more appropriate than continuing to escalate basal insulin alone 1

Proper Prandial Insulin Coverage

• Replace sliding scale with scheduled prandial insulin: start with 6 units of Humalog before each meal (approximately 10% of the new basal dose) 1
• Add correction insulin using an insulin sensitivity factor of approximately 1:30-40 (calculated as 1500 ÷ total daily dose) 1
• Titrate prandial doses by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 1

Foundation Therapy

• Ensure the patient is on metformin at least 1000mg twice daily (2000mg total) unless contraindicated, as metformin should be continued when adding or intensifying insulin therapy 1
• Discontinue any sulfonylureas if present to prevent hypoglycemia with intensive insulin therapy 2

Expected Outcomes with Proper Intensification

• With appropriate basal-bolus therapy at weight-based dosing, HbA1c reduction of 2-3% is achievable from current levels, with no increased hypoglycemia risk when properly implemented 1
• The American Diabetes Association reports that proper insulin intensification can achieve mean blood glucose <140 mg/dL in the majority of patients 1

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration, with the patient checking fasting glucose every morning and adjusting accordingly 1
• Check pre-meal and 2-hour postprandial glucose readings to guide prandial insulin titration 1
• Reassess HbA1c every 3 months during intensive titration 1

Critical Pitfalls to Avoid

• Do not continue relying on sliding scale insulin as the primary prandial coverage—this approach is obsolete and ineffective 1
• Do not delay insulin intensification, as many months of uncontrolled hyperglycemia should specifically be avoided to prevent long-term complications 1
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with proper prandial coverage 1
• Recognize and treat hypoglycemia at blood glucose ≤70 mg/dL with 15 grams of fast-acting carbohydrate 1

Alternative Consideration

• If the patient struggles with multiple daily injections, consider adding a GLP-1 receptor agonist to basal insulin to address postprandial hyperglycemia while minimizing weight gain and hypoglycemia risk 1, 3
• Exenatide added to titrated glargine with metformin resulted in similar glycemic control as adding lispro, with weight loss of 2.5 kg versus weight gain of 2.1 kg with lispro 3