Adding Prandial Insulin to Severe Hyperglycemia
Yes, initiate Novolog (insulin aspart) three times daily before meals immediately, as the American Diabetes Association specifically recommends starting both basal and mealtime insulin simultaneously when HbA1c ≥10% or blood glucose ≥300 mg/dL. 1, 2
Why TID Prandial Insulin Is Indicated Now
Your patient meets clear criteria for immediate prandial insulin initiation:
- HbA1c of 10.6% exceeds the 10% threshold where both basal and prandial insulin should be started together 1
- Blood glucose over 300 mg/dL represents severe hyperglycemia requiring comprehensive insulin coverage 1, 2
- Lantus 20 units alone is insufficient to control postprandial glucose excursions at this severity level 1, 2
Specific Dosing Protocol for Novolog
Start Novolog at 4-6 units before each of the three main meals (breakfast, lunch, dinner), which represents approximately 10% of the basal insulin dose per meal 2, 3
Titration Algorithm
- Increase each meal's dose by 1-2 units twice weekly based on 2-hour postprandial glucose readings 1, 2
- Target 2-hour postprandial glucose <180 mg/dL 2
- If any blood glucose drops below 70 mg/dL, reduce the corresponding Novolog dose by 10-20% 1, 2
Critical Concurrent Adjustments Required
Optimize the Basal Insulin First
Increase Lantus from 20 units using the 2-unit-every-3-days titration protocol until fasting glucose reaches 100-130 mg/dL, with a maximum dose of 0.5 units/kg/day to avoid overbasalization 1, 2
Reassess Ozempic Dosing
When adding prandial insulin, reduce insulin doses by approximately 10-20% if the patient is on maximum-dose Ozempic, as the GLP-1 RA will continue providing glucose-lowering effects 1
The American Diabetes Association recommends that insulin dosing should be reassessed upon addition or dose escalation of a GLP-1 RA 1
Essential Safety Monitoring
- Check fasting glucose every morning to guide Lantus titration 2
- Check glucose 2 hours after each meal to guide individual Novolog dose adjustments 2
- Monitor for hypoglycemia symptoms and provide glucagon prescription 1
- Educate on hypoglycemia recognition and treatment before starting this regimen 3
Common Pitfall to Avoid
Do not rely on sliding scale insulin alone—the American Diabetes Association strongly discourages using correction-dose insulin as the sole method of treatment 4. Your patient needs scheduled prandial insulin TID, not just PRN corrections.
Expected Outcomes
- HbA1c reduction of 3-4% over 3-6 months with proper titration of this basal-bolus regimen 2
- Fasting glucose should reach 100-130 mg/dL within 2-4 weeks with Lantus optimization 2
- Postprandial glucose control improves within days of starting Novolog TID 2
Future Optimization Strategy
Once HbA1c approaches 8-9%, consider intensifying the Ozempic dose (if not already at maximum) and potentially reducing insulin doses, as GLP-1 RAs are preferred to insulin for long-term cardiovascular and mortality benefits 1