From the Guidelines
To address the progressive increase in daily glucose from 100 to 150 throughout the day, I recommend adjusting the insulin lispro (mealtime insulin) dosing, specifically increasing the pre-lunch dose by 1-2 units and the pre-dinner dose by 2-3 units while maintaining the morning dose, as this approach is supported by the most recent guidelines for managing diabetes in older adults 1. This targeted approach addresses the pattern of rising glucose levels during the day while the current morning control appears adequate. The basal insulin (glargine) dose of 14 units nightly can remain unchanged since the fasting glucose appears well-controlled at around 100 mg/dL. Before implementing this change, ensure the patient is consistently counting carbohydrates and timing insulin administration 15-20 minutes before meals. The patient should monitor glucose levels more frequently after making these adjustments to assess effectiveness and watch for hypoglycemia, particularly in the afternoon and evening. If hypoglycemia occurs, reduce the increased doses by 1-2 units. Key considerations in managing this patient's diabetes include:
- Adjusting insulin doses based on fingerstick glucose testing performed before lunch and before dinner, with a goal of 90–150 mg/dL (5.0–8.3 mmol/L) before meals 1.
- Using a simplified sliding scale for adjusting prandial insulin, such as giving 2 units of short- or rapid-acting insulin for premeal glucose >250 mg/dL (>13.9 mmol/L) 1.
- Considering the addition of other glucose-lowering agents if 50% of premeal fingerstick values over 2 weeks are above goal 1. This approach targets the specific pattern of daytime hyperglycemia while preserving the effective morning control, and is in line with the recommendations for adjusting insulin therapy in patients with type 2 diabetes who are not achieving glycemic goals on optimally titrated basal insulin alone 1.
From the FDA Drug Label
The average age was 55 years. The majority of patients were White (85%) and 54% were male. The mean BMI was approximately 34. 3 kg/m2. The mean duration of diabetes was 11 years. The Insulin Glargine group had a smaller mean reduction from baseline in HbA1c compared to the NPH insulin group, which may be explained by the lower daily basal insulin doses in the Insulin Glargine group (Table 11). Patients or study personnel used an algorithm to adjust the Insulin Glargine and NPH insulin dosages to a target fasting plasma glucose ≤100 mg/dL After the Insulin Glargine or NPH insulin dosage was adjusted, other antidiabetic agents, including premeal insulin were to be adjusted or added.
The patient's average daily glucose is progressively increasing from 100 to 150 throughout the day.
- The current Insulin Glargine dose is 14 units nightly, and the patient is also taking Insulin Lispro 4-6 units TID before meals.
- Considering the patient's increasing glucose levels, it may be necessary to adjust the basal insulin dose, such as increasing the Insulin Glargine dose, to achieve better glycemic control.
- Additionally, the patient's premeal insulin dose may need to be adjusted to address the progressive increase in glucose levels throughout the day.
- It is also important to consider adjusting other antidiabetic agents, such as Trulicity or Jardiance, as part of the overall treatment plan to achieve optimal glycemic control 2.
From the Research
Current Regimen and Glycemic Control
The patient's current regimen includes:
- Insulin Lispro 4-6 units TID before meals
- Insulin Glargine 14 units nightly
- Trulicity 3 mg once weekly
- Jardiance 25 mg daily
- Entresto 24-26 mg twice daily The patient's average daily glucose has progressively increased from 100 to 150 throughout the day, despite an A1c of 7.1.
Potential Adjustments to the Regimen
Based on the provided evidence, potential adjustments to the regimen could include:
- Increasing the dose of Insulin Lispro before meals to improve postprandial glucose control 3
- Considering a premixed insulin lispro regimen instead of separate basal and bolus insulins, as it has been shown to provide a larger reduction in HbA1c 4
- Adjusting the dose of Insulin Glargine to optimize basal insulin control
- Continuing to monitor the patient's glucose levels and adjusting the regimen as needed to achieve optimal glycemic control
Considerations for Adjusting the Regimen
When adjusting the regimen, it is essential to consider the potential risks and benefits of each change, including: