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 dangerous approach that will not achieve glycemic control. The patient requires immediate intensification to a proper basal-bolus regimen with weight-based dosing and systematic titration, not reactive sliding scale insulin.

Critical Problems with the Current Regimen

Sliding Scale Insulin is Explicitly Condemned

• Sliding scale insulin as monotherapy for prandial coverage 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
• Randomized controlled trials demonstrate that basal-bolus treatment improved glycemic control and reduced hospital complications compared to sliding scale insulin regimens in patients with type 2 diabetes 2
• Only 38% of patients achieve mean blood glucose <140 mg/dL with sliding scale alone versus 68% with proper basal-bolus therapy 1

Basal Insulin Dose is Severely Inadequate

• For a 223-pound (101 kg) patient with HbA1c of 11%, guidelines recommend starting doses of 0.3-0.5 units/kg/day as total daily insulin, meaning this patient needs 30-50 units/day total 1
• The current Basaglar dose of 20 units represents only 0.2 units/kg/day—far below the recommended starting dose for severe hyperglycemia 1
• Patients with HbA1c ≥9% or blood glucose ≥300-350 mg/dL should start with basal-bolus insulin immediately, not basal insulin alone 1

Recommended Insulin Regimen

Immediate Basal Insulin Intensification

• Increase Basaglar to at least 30-40 units once daily (0.3-0.4 units/kg/day) given the severe hyperglycemia 1
• Titrate basal insulin by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL 1
• If fasting glucose remains ≥180 mg/dL, increase by 4 units every 3 days; if 140-179 mg/dL, increase by 2 units every 3 days 1

Replace Sliding Scale with Scheduled Prandial Insulin

• Discontinue the sliding scale approach entirely and implement scheduled prandial insulin 2, 1
• Start with 4 units of Humalog before each meal (or 10% of the basal dose, approximately 3-4 units) 1
• Administer Humalog 0-15 minutes before meals, not after eating 1
• Titrate prandial doses by 1-2 units or 10-15% twice weekly based on 2-hour postprandial glucose readings 1

Add Correction Insulin Appropriately

• Calculate insulin sensitivity factor (ISF) using the formula: 1500 ÷ Total Daily Dose 1
• Use correction insulin in addition to scheduled prandial doses, not as a replacement 1
• Avoid "stacking" correction doses—insulin from the previous dose may still be active 1

Foundation Therapy Optimization

Metformin Must Be Continued

• Verify the patient is on metformin at adequate doses (at least 1000 mg twice daily, up to 2500 mg/day) unless contraindicated 1
• Metformin should be continued when adding or intensifying insulin therapy, as it reduces total insulin requirements and provides complementary glucose-lowering effects 1

Consider GLP-1 Receptor Agonist Addition

• Adding a GLP-1 receptor agonist to basal insulin can improve HbA1c while minimizing weight gain and hypoglycemia risk 1, 3
• This combination provides potent glucose-lowering with better tolerability than intensified insulin regimens alone 1

Monitoring Requirements

Daily Self-Monitoring During Titration

• Daily fasting blood glucose monitoring is essential during the titration phase 1
• Check pre-meal glucose before each meal and 2-hour postprandial glucose to guide prandial insulin adjustments 1
• Assess adequacy of insulin dose at every clinical visit, looking for signs of overbasalization 1

Watch for Overbasalization

• Clinical signals include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 1
• When basal insulin exceeds 0.5 units/kg/day (approximately 50 units for this patient), focus on intensifying prandial insulin rather than continuing to escalate basal insulin alone 1

Expected Outcomes with Proper Intensification

Achievable HbA1c Reduction

• HbA1c reduction of 2-3% is achievable with proper insulin intensification from current levels, with no increased hypoglycemia risk when properly implemented 1
• With appropriate basal-bolus therapy at weight-based dosing, 68% of patients achieve mean blood glucose <140 mg/dL 1

Timeline for Glycemic Control

• Basal insulin should reach target fasting glucose within 2-4 weeks with systematic titration every 3 days 1
• HbA1c should be rechecked every 3 months during intensive titration 1

Critical Pitfalls to Avoid

Do Not Delay Insulin Intensification

• Many months of uncontrolled hyperglycemia should specifically be avoided to prevent long-term complications 1
• Delaying insulin therapy in patients not achieving glycemic goals can be harmful 1

Do Not Continue Escalating Basal Insulin Indefinitely

• Continuing to increase basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia leads to suboptimal control and increased hypoglycemia risk 1
• Blood glucose elevations with HbA1c of 11% reflect both inadequate basal coverage AND postprandial excursions requiring scheduled mealtime insulin 1

Do Not Rely on Sliding Scale Alone

• Scheduled insulin regimens with basal, prandial, and correction components are preferred over relying solely on correction insulin 1
• Prolonged use of sliding scale insulin regimens as the sole treatment of hyperglycemic patients is strongly discouraged 2