What adjustments should be made to the treatment plan for an adult patient with type 2 diabetes, currently taking 20 units of Basaglar (insulin glargine), who has consistently elevated blood glucose levels in the range of hyperglycemia?

Immediate Insulin Dose Adjustment Required

Your patient needs an immediate and aggressive increase in Basaglar dose by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL, with strong consideration for adding prandial insulin coverage given the severity of hyperglycemia. 1

Critical Assessment of Current Situation

Blood glucose levels consistently in the 300s mg/dL represent severe hyperglycemia requiring urgent intensification. 1 The current dose of 20 units Basaglar is grossly inadequate for this level of glycemic control. 2

For patients with blood glucose ≥300 mg/dL, the American Diabetes Association explicitly recommends considering insulin initiation regardless of background therapy, and this patient clearly needs aggressive dose escalation. 1

Immediate Dose Titration Protocol

Basal Insulin Adjustment

• Increase Basaglar by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL, as this aggressive titration schedule is specifically indicated when fasting glucose is ≥180 mg/dL. 2, 3
• Continue this titration pattern without delay—waiting longer than 3 days between adjustments unnecessarily prolongs time to glycemic targets. 2
• Daily fasting blood glucose monitoring is essential during this titration phase. 2, 3

Critical Threshold Monitoring

• Watch for the 0.5 units/kg/day threshold—when basal insulin exceeds this amount, adding prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1, 2
• Clinical signals of "overbasalization" include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, and high glucose variability. 1, 2

Consider Adding Prandial Insulin Now

Given blood glucose levels consistently in the 300s, this patient likely needs both basal AND prandial coverage from the outset, not just basal insulin escalation. 1

• Start with 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before the largest meal, OR use 10% of the current basal dose (approximately 2 units initially, though this will increase as basal insulin is titrated). 2, 3
• Titrate prandial insulin by 1-2 units every 3 days based on 2-hour postprandial glucose readings. 2
• Blood glucose in the 300s reflects both inadequate basal coverage AND postprandial excursions requiring mealtime insulin. 2

Foundation Therapy Optimization

Metformin Must Continue

Verify the patient is on metformin at maximum tolerated dose (up to 2000-2500 mg daily) unless contraindicated. 1, 3 Metformin should be continued when adding or intensifying insulin therapy, as this combination provides superior glycemic control with reduced insulin requirements and less weight gain. 2, 3

Consider GLP-1 Receptor Agonist

Before advancing to full basal-bolus therapy, consider adding a GLP-1 receptor agonist to the basal insulin regimen, as combination therapy provides greater glycemic effectiveness with beneficial effects on weight and reduced hypoglycemia risk. 1, 3 GLP-1 receptor agonists are actually preferred over insulin intensification in current guidelines. 1, 3

Alternative Approach: Immediate Basal-Bolus Initiation

For blood glucose consistently ≥300 mg/dL, an alternative evidence-based approach is to start basal-bolus insulin immediately rather than titrating basal insulin alone: 1

• Calculate total daily insulin dose as 0.3-0.5 units/kg/day given the severe hyperglycemia. 2, 3
• Give 50% as basal insulin (Basaglar) once daily. 2, 3
• Give 50% as prandial insulin divided among three meals. 2, 3
• This approach achieves glycemic targets faster and is specifically recommended when A1C >10% or blood glucose ≥300 mg/dL. 1

Monitoring Requirements

• Check fasting glucose daily during titration. 2, 3
• If adding prandial insulin, check pre-meal and 2-hour postprandial glucose to guide adjustments. 2
• Reassess HbA1c every 3 months during intensive titration. 2
• If hypoglycemia occurs, reduce the dose by 10-20% immediately and determine the cause. 2, 3

Common Pitfalls to Avoid

• Never delay insulin intensification in patients not achieving glycemic goals—this prolongs hyperglycemia exposure and increases complication risk. 2, 3
• Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to "overbasalization" with increased hypoglycemia risk and suboptimal control. 1, 2, 3
• Do not discontinue metformin when intensifying insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain. 2, 3
• Do not rely on sliding scale insulin alone—scheduled basal-bolus regimens are superior to sliding scale monotherapy. 2

Patient Education Essentials

• Proper insulin injection technique and site rotation to prevent lipodystrophy. 2
• Recognition and treatment of hypoglycemia with 15 grams of fast-acting carbohydrate. 1, 2
• Self-monitoring of blood glucose and how to use readings for dose adjustments. 2, 3
• "Sick day" management rules and when to contact healthcare provider. 2