What dose of Apidra (insulin glulisine) should be given to a patient with hyperglycemia, taking 60 units of insulin daily, divided between Lantus (glargine) and Apidra (insulin glulisine), with morning glucose 223 mg/dL and afternoon glucose 330 mg/dL?

Immediate Insulin Dose Recommendation

Give 10-15 units of Apidra (insulin glulisine) now for the afternoon glucose of 330 mg/dL, using a correction factor approach, and immediately restructure this patient's entire insulin regimen as the current 50:50 split with only 30 units total daily dose is grossly inadequate. 1

Critical Problems with Current Regimen

This patient's insulin dosing is fundamentally flawed and requires urgent correction:

• Total daily dose of 60 units split 50:50 (30 units Lantus, 30 units Apidra total) is insufficient for someone with persistent hyperglycemia in the 200-300s mg/dL range 1
• Morning glucose of 223 mg/dL indicates inadequate basal insulin coverage - the Lantus dose needs aggressive uptitration 1
• Afternoon glucose of 330 mg/dL after receiving 15 units Apidra and 10 units correction demonstrates either severe insulin resistance or incorrect dosing calculations 1

Immediate Correction Dose Calculation

For the afternoon glucose of 330 mg/dL:

• Using a standard insulin sensitivity factor of 1500 ÷ 60 (total daily dose) = 25 mg/dL per unit 1
• Correction needed: (330 - 120 target) ÷ 25 = 8.4 units, round to 8-10 units 1
• However, given the patient already received correction insulin this morning and remains severely hyperglycemic, consider 10-15 units to account for apparent insulin resistance 1
• Critical warning: Check when the last Apidra dose was given to avoid insulin stacking - if within 3-4 hours, reduce the correction dose by 50% 1

Urgent Regimen Restructuring Required

This patient needs immediate basal insulin intensification:

• Increase Lantus by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL 1
• For fasting glucose ≥180 mg/dL (this patient is at 223 mg/dL), the American Diabetes Association recommends 4-unit increments 1
• The current 30-unit Lantus dose is likely only 0.3-0.4 units/kg/day - most patients with this degree of hyperglycemia require 0.5-1.0 units/kg/day total insulin 1

Prandial insulin dosing needs systematic approach:

• The 15 units Apidra given this morning was clearly insufficient - this suggests either the carbohydrate-to-insulin ratio is wrong or the meal was much larger than anticipated 1
• Prandial doses should be calculated using carbohydrate-to-insulin ratios (typically 1:10 to 1:15 for type 2 diabetes) rather than fixed doses 1
• Start with 4 units of Apidra before each meal or 10% of basal dose (currently 3 units), then titrate by 1-2 units every 3 days based on 2-hour postprandial readings 1

Critical Monitoring and Adjustments

Daily fasting blood glucose monitoring is essential during this titration phase 1

Watch for signs of overbasalization as Lantus increases:

• Bedtime-to-morning glucose differential ≥50 mg/dL 1
• Hypoglycemia episodes 1
• High glucose variability throughout the day 1

When basal insulin exceeds 0.5 units/kg/day (approximately 35-40 units for most patients), prioritize adding or intensifying prandial insulin rather than continuing to escalate basal insulin alone 1

Foundation Therapy Verification

Ensure metformin is continued at maximum tolerated dose (up to 2000-2500 mg daily) unless contraindicated - this reduces total insulin requirements and provides complementary glucose-lowering effects 1

Common Pitfalls to Avoid

Never rely on correction insulin alone to manage persistent hyperglycemia - this patient needs scheduled basal-bolus therapy, not reactive sliding scale approaches 1, 2

Do not delay aggressive insulin titration - blood glucose levels consistently in the 200-300s indicate months of inadequate control and require immediate intensification 1

Avoid "stacking" correction doses - ensure at least 3-4 hours between rapid-acting insulin doses to prevent cumulative hypoglycemia 1