What is the required daily insulin dose for a patient with hyperglycemia, currently receiving Apidra (insulin glulisine) with dosages of 12 units at 7am, 12 units in the afternoon, and 20 units at 7pm, and presenting with blood glucose levels of 419mg/dl at 11:30pm, 375mg/dl at 7am, 326mg/dl in the afternoon, and 417mg/dl at 7pm?

Immediate Insulin Regimen Overhaul Required

This patient requires an immediate transition from inadequate rapid-acting insulin monotherapy to a proper basal-bolus regimen, with an estimated total daily insulin requirement of approximately 45-60 units (0.3-0.4 units/kg/day for severe hyperglycemia), split as 50% basal insulin and 50% prandial insulin. 1

Critical Problems with Current Regimen

The current approach of using only Apidra (rapid-acting insulin) without basal insulin is fundamentally flawed and explains the persistent severe hyperglycemia:

• Sliding scale monotherapy is explicitly condemned by all major diabetes guidelines and has been shown to be ineffective, treating hyperglycemia reactively after it occurs rather than preventing it 1
• The patient received a total of 44 units of Apidra over 24 hours (12 + 12 + 20 units), yet blood glucose levels remained between 326-419 mg/dL, demonstrating complete inadequacy of this approach 1
• Scheduled basal-bolus regimens are superior to sliding scale monotherapy, with studies showing 68% of patients achieve mean blood glucose <140 mg/dL with proper basal-bolus therapy versus only 38% with sliding scale alone 1

Recommended Insulin Regimen

Calculate Total Daily Dose (TDD)

For severe hyperglycemia with blood glucose levels consistently >300 mg/dL:

• Start with 0.3-0.5 units/kg/day as total daily insulin dose 1, 2
• Assuming average adult weight of 70-80 kg, this translates to approximately 45-60 units total daily 1

Basal Insulin Component

• Initiate long-acting basal insulin (insulin glargine/Lantus or similar) at 50% of TDD = 22-30 units once daily 1
• Administer at the same time each day (typically bedtime or morning) 1
• Titrate basal insulin by 4 units every 3 days if fasting glucose remains ≥180 mg/dL until reaching target of 80-130 mg/dL 1

Prandial Insulin Component

• Continue Apidra (rapid-acting insulin) but as scheduled doses: 7-10 units before each meal (remaining 50% of TDD divided among three meals) 1
• Start with 4 units before the largest meal or 10% of basal dose, then add to other meals 1
• Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 1

Correction Insulin

• Add correction doses of Apidra using insulin sensitivity factor (ISF) = 1500 ÷ TDD 3
• For TDD of 50 units: ISF = 1500 ÷ 50 = 30 mg/dL per unit 3
• Give 1 additional unit for every 30 mg/dL above target glucose of 130 mg/dL 3

Monitoring and Titration Schedule

• Daily fasting blood glucose monitoring is essential during titration 1
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments 1
• Reassess every 3 days during active titration 1
• If hypoglycemia occurs, reduce the relevant insulin component by 10-20% immediately 1

Critical Threshold Considerations

• When basal insulin exceeds 0.5 units/kg/day (approximately 35-40 units for average adult), focus on intensifying prandial coverage rather than continuing to escalate basal insulin 1
• Watch for signs of overbasalization: bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, high glucose variability 1

Foundation Therapy

• Continue or initiate metformin unless contraindicated, as it reduces total insulin requirements and provides complementary glucose-lowering effects 1
• Target metformin dose of at least 1000 mg twice daily (2000 mg total daily) 1

Expected Outcomes

With proper basal-bolus therapy at weight-based dosing:

• HbA1c reduction of 2-3% is achievable from current levels 1
• Target fasting glucose: 80-130 mg/dL 1
• Target 2-hour postprandial glucose: <180 mg/dL 1
• No increased hypoglycemia risk when properly implemented compared to inadequate sliding scale regimens 1

Common Pitfalls to Avoid

• Do not continue sliding scale insulin as monotherapy - this approach has been definitively shown to be inferior and should be immediately discontinued 1
• Do not delay adding basal insulin - the persistent hyperglycemia despite 44 units of rapid-acting insulin clearly demonstrates the need for basal coverage 1
• Do not wait for "control" before switching regimens - immediate transition to proper basal-bolus therapy is indicated 1
• Avoid "stacking" correction doses - ensure at least 3-4 hours between correction doses to prevent insulin accumulation 1