What are the next steps for a patient with severe hyperglycemia after increasing Lantus (insulin glargine) to 28 units, who is also taking Ozempic (semaglutide), Novolog (insulin aspart), and Metformin?

Aggressive Insulin Titration Required for Severe Hyperglycemia

For a patient with severe hyperglycemia on Lantus 28 units, Ozempic, Novolog, and Metformin, immediately increase Lantus by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL, intensify Novolog dosing based on postprandial readings, and verify Metformin is at maximum tolerated dose (2000-2500 mg daily). 1

Immediate Basal Insulin Adjustment

Increase Lantus by 4 units every 3 days if fasting glucose remains ≥180 mg/dL, or by 2 units every 3 days if fasting glucose is 140-179 mg/dL, until reaching target of 80-130 mg/dL. 1 This aggressive titration schedule is appropriate for severe hyperglycemia and should not be delayed. 1

• Daily fasting blood glucose monitoring is essential during this titration phase to guide adjustments. 1
• If hypoglycemia occurs without clear cause, reduce the dose by 10-20% immediately. 1

Critical Threshold Monitoring

Watch for overbasalization when Lantus exceeds 0.5 units/kg/day (approximately 35-40 units for a typical 70-80 kg patient). 1 Clinical signals include:

• Basal dose >0.5 units/kg/day 1
• Bedtime-to-morning glucose differential ≥50 mg/dL 1
• Hypoglycemia episodes 1
• High glucose variability 1

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

Prandial Insulin Intensification

If fasting glucose is controlled but overall glycemic control remains inadequate:

• Start with 4 units of Novolog before the largest meal or use 10% of the current basal dose (approximately 3 units if Lantus is 28 units). 1
• Titrate Novolog by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings. 1
• Check pre-meal and 2-hour postprandial glucose to guide adjustments. 1

Optimize Foundation Therapy

Verify Metformin is at maximum tolerated dose (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. 1, 2

Continue Ozempic (semaglutide) as the combination of basal insulin plus GLP-1 receptor agonist provides superior outcomes compared to basal-bolus insulin alone, with lower hypoglycemia risk and weight loss rather than weight gain. 1, 3

Monitoring Requirements

• Daily fasting blood glucose during active titration 1
• Pre-meal and 2-hour postprandial glucose to guide Novolog adjustments 1
• Reassess adequacy of insulin doses at every clinical visit 1
• Recheck HbA1c in 3 months to assess overall glycemic control 4

Common Pitfalls to Avoid

Do not delay insulin titration in patients with persistent hyperglycemia, as this prolongs exposure to hyperglycemia and increases complication risk. 1 Timely dose titration is critical for achieving glycemic goals. 1, 2

Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with prandial insulin, as this leads to overbasalization with increased hypoglycemia risk and suboptimal control. 1

Do not discontinue Metformin when intensifying insulin therapy unless contraindicated, as this leads to higher insulin requirements and more weight gain. 1, 2