What's the next step for a type 2 diabetes patient on 20 units of Lantus (insulin glargine) with an elevated Hemoglobin A1C (HbA1c) level, persistent hyperglycemia, and recently added Ozempic (semaglutide), considering adding Novolog (insulin aspart)?

Aggressive Insulin Intensification Required Immediately

This patient needs immediate and substantial uptitration of basal insulin (Lantus) combined with addition of prandial insulin (Novolog) to address severe uncontrolled hyperglycemia. With an A1C of 10.6% and blood glucose persistently >200-250 mg/dL, this represents severe hyperglycemia requiring basal-bolus insulin therapy, not just basal insulin optimization 1.

Immediate Basal Insulin Adjustment

Increase Lantus aggressively by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL. The current 20 units is grossly inadequate for this level of hyperglycemia 1, 2.

• For patients with fasting glucose ≥180 mg/dL (which this patient likely has given blood sugars "never under 250"), increase basal insulin by 4 units every 3 days 1, 2
• Continue this aggressive titration until fasting plasma glucose consistently reaches 80-130 mg/dL 1, 2
• If hypoglycemia occurs, reduce dose by 10-20% immediately 1, 2

Critical threshold to monitor: When basal insulin exceeds 0.5 units/kg/day (approximately 36 units for a 72 kg patient), adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone 1, 2.

Add Prandial Insulin (Novolog) Now

Yes, add Novolog immediately—this patient clearly needs both basal and prandial coverage given the severity of hyperglycemia. Blood glucose levels persistently >200 mg/dL throughout the day indicate inadequate coverage of both fasting and postprandial glucose 1.

Starting Novolog Regimen

• Start with 4 units of Novolog before the largest meal or use 10% of current basal dose (2 units, though 4 units is more appropriate given severity) 1
• Rapid-acting insulin analogs like Novolog provide better postprandial glucose control than regular insulin 1
• Administer Novolog 0-15 minutes before meals, not after eating 2

Titration Protocol for Novolog

• Increase prandial insulin by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 1
• If postprandial glucose remains elevated after optimizing the first meal, add Novolog before additional meals sequentially 1
• Target 2-hour postprandial glucose <180 mg/dL 1

Optimize Foundation Therapy

Verify the patient is on metformin unless contraindicated—metformin should be continued when adding or intensifying insulin therapy 1, 2.

• If not on metformin, add it immediately as the foundation of type 2 diabetes therapy 1
• Continue metformin even when intensifying insulin, as it reduces total insulin requirements 2

The recently added Ozempic (semaglutide) is appropriate and should be continued as GLP-1 receptor agonists provide complementary glucose-lowering effects with cardiovascular benefits 3, 4.

• Semaglutide added to basal insulin significantly improves glycemic control and reduces body weight 5, 6
• Continue the standard semaglutide titration: 0.25 mg weekly for 4 weeks, then 0.5 mg weekly, with potential increase to 1 mg weekly after at least 4 weeks if needed 3

Expected Outcomes and Monitoring

With appropriate basal-bolus therapy at weight-based dosing, expect HbA1c reduction of 2-3% from current levels 2.

• Daily fasting blood glucose monitoring is essential during titration 1, 2
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments 2
• Reassess HbA1c every 3 months during intensive titration 2

Critical Pitfalls to Avoid

Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia—this leads to "overbasalization" with increased hypoglycemia risk and suboptimal control 1, 2.

• Clinical signals of overbasalization include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 1, 2

Do not delay adding prandial insulin when blood glucose levels are persistently >200 mg/dL—this clearly indicates the need for both basal and prandial coverage 2.

Do not discontinue Ozempic when intensifying insulin—the combination provides superior glycemic control with less weight gain and hypoglycemia compared to insulin intensification alone 1, 5, 6.

Patient Education Requirements

• Recognition and treatment of hypoglycemia: treat at blood glucose ≤70 mg/dL with 15 grams of fast-acting carbohydrate 2
• Proper insulin injection technique and site rotation 1
• Self-monitoring of blood glucose with specific targets 1, 2
• "Sick day" management rules and insulin storage/handling 1