What adjustments should be made to the treatment regimen of a patient with hyperglycemia, who is currently taking Basaglar (insulin glargine) 24 units and Novolog (insulin aspart) 4 units before meals?

Insulin Regimen Adjustment for Persistent Hyperglycemia

This patient requires immediate intensification of both basal and prandial insulin—increase Basaglar by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL, and increase Novolog to at least 6-8 units before each meal with systematic titration based on postprandial glucose readings. 1

Critical Assessment of Current Regimen

The current regimen is grossly inadequate for glucose levels consistently in the 200-300 mg/dL range. 1 This patient is receiving only 4 units of prandial insulin per meal, which is far below what's needed for this degree of hyperglycemia. 1 The 24 units of Basaglar may also be insufficient depending on the patient's weight and insulin resistance. 1

Immediate Basal Insulin Adjustment

Increase Basaglar by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL. 1, 2 For glucose levels ≥180 mg/dL, the evidence-based titration algorithm specifically calls for 4-unit increments every 3 days rather than smaller adjustments. 2 If fasting glucose is 140-179 mg/dL, increase by 2 units every 3 days. 2

Monitoring for Overbasalization

Watch for clinical signals that indicate you're approaching the threshold where prandial insulin becomes more important than further basal escalation: 2

• Basal dose exceeding 0.5 units/kg/day 2
• Bedtime-to-morning glucose differential ≥50 mg/dL 2
• Hypoglycemia episodes 2
• High glucose variability 2

When basal insulin approaches 0.5-1.0 units/kg/day without achieving glycemic targets, adding or intensifying prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1, 2

Aggressive Prandial Insulin Intensification

Increase Novolog to 6-8 units before each meal immediately, then titrate by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings. 1, 3 The current 4-unit dose is the recommended starting dose for patients initiating prandial insulin, not for someone with glucose consistently in the 200-300s. 1

Prandial Insulin Titration Algorithm

• Start with 10% of basal dose (approximately 2-3 units if Basaglar is 24 units) OR 4 units per meal, whichever is higher 1
• For this patient with severe hyperglycemia, begin with 6-8 units before each meal 3
• Increase by 1-2 units every 3 days based on postprandial glucose readings 1, 3
• Target 2-hour postprandial glucose <180 mg/dL 3

Foundation Therapy Verification

Ensure the patient is on metformin at maximum tolerated dose (up to 2000-2500 mg daily) unless contraindicated. 1, 2 Metformin should be continued when intensifying insulin therapy as it reduces total insulin requirements and provides complementary glucose-lowering effects. 2 This is frequently overlooked but critical for optimal outcomes. 1

Daily Monitoring Requirements

• Check fasting glucose every morning to guide basal insulin adjustments 2
• Check pre-meal glucose before each meal to assess basal insulin adequacy 3
• Check 2-hour postprandial glucose to guide prandial insulin titration 3
• Reassess every 3 days during active titration 1, 2

Expected Timeline and Outcomes

• Fasting glucose should reach 80-130 mg/dL within 2-4 weeks with proper basal titration 3
• Postprandial glucose should improve to <180 mg/dL within 4-6 weeks with optimized prandial coverage 3
• Total daily insulin requirements will likely stabilize at 0.5-1.0 units/kg/day once proper basal-bolus distribution is achieved 3

Critical Pitfalls to Avoid

Do not continue with 4 units of Novolog per meal when glucose levels are consistently 200-300 mg/dL—this represents severe therapeutic inertia and prolongs exposure to harmful hyperglycemia. 1, 2 Blood glucose in the 200-300s reflects both inadequate basal coverage AND insufficient mealtime insulin. 2

Do not delay intensification—treatment intensification should not be delayed when patients are not meeting individualized treatment goals. 1 Each day of uncontrolled hyperglycemia increases the risk of complications. 1

Do not rely solely on correction insulin—scheduled basal-bolus regimens with proper meal coverage are superior to reactive correction-only approaches. 1, 3

Hypoglycemia Management Protocol

If hypoglycemia occurs (glucose <70 mg/dL): 1

• Determine the cause 1
• If no clear reason, reduce the corresponding insulin dose by 10-20% 1
• Treat with 15 grams of fast-acting carbohydrate 2
• Reassess the regimen immediately 1