What is the treatment recommendation for a 57-year-old male patient with type 2 diabetes (T2D) and hyperglycemia, currently taking metformin (biguanide) 1000 mg twice daily and Lantus (insulin glargine) 15 units at bedtime, who is refusing sliding scale insulin and has a fasting blood glucose level of severe hyperglycemia?

Aggressive Insulin Dose Escalation with Addition of Prandial Coverage Required

This patient requires immediate and aggressive basal insulin titration (increasing Lantus by 4 units every 3 days) combined with the addition of prandial insulin before meals, as a fasting blood glucose of 485 mg/dL indicates profound insulin deficiency that cannot be adequately addressed with basal insulin alone at the current dose. 1

Immediate Medication Adjustments

Optimize Metformin Foundation Therapy

• Increase metformin to 2000 mg daily (1000 mg twice daily is already at target dose, so continue current regimen) unless contraindicated, as metformin must be continued when intensifying insulin therapy to reduce total insulin requirements and provide complementary glucose-lowering effects 1, 2
• Metformin reduces insulin resistance and decreases hepatic glucose production, which is critical for controlling fasting hyperglycemia 3, 4

Aggressive Basal Insulin Titration

• Increase Lantus by 4 units every 3 days until fasting blood glucose reaches 80-130 mg/dL, as this patient's fasting glucose of 485 mg/dL falls into the category requiring 4-unit increments 1
• For patients with severe hyperglycemia (fasting glucose ≥180 mg/dL), the evidence-based titration algorithm specifies 4-unit increases every 3 days 1
• The current dose of 15 units is grossly inadequate for this level of hyperglycemia; this patient likely needs 0.3-0.5 units/kg/day as total daily insulin given the severity 1

Add Prandial Insulin Coverage Immediately

• Start with 4 units of rapid-acting insulin (lispro, aspart, or glulisine) before each of the three largest meals, as blood glucose in the 400s mg/dL indicates both inadequate basal coverage AND postprandial excursions requiring mealtime insulin 1
• Alternatively, use 10% of the current basal dose (approximately 2 units initially, but 4 units is more appropriate given severity) 1
• Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 1
• Rapid-acting insulin must be administered 0-15 minutes before meals for optimal postprandial glucose control 1

Why Sliding Scale Insulin Alone is Inadequate

Sliding scale insulin as monotherapy is explicitly condemned by all major diabetes guidelines and must be discontinued as the sole treatment approach. 1

• Sliding scale insulin treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations 1
• Scheduled basal-bolus regimens are superior to sliding scale monotherapy, with 68% of patients achieving mean blood glucose <140 mg/dL versus only 38% with sliding scale alone 1
• The patient's refusal of sliding scale insulin is actually clinically appropriate, as he needs scheduled basal-bolus therapy, not correction insulin alone 1

Critical Threshold Monitoring

Watch for Overbasalization

• When basal insulin exceeds 0.5 units/kg/day (approximately 29 units for a 57-year-old male of average weight ~70 kg), prioritize intensifying prandial insulin rather than continuing to escalate basal insulin alone 1
• 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

Expected Insulin Requirements

• For this level of hyperglycemia (fasting glucose 485 mg/dL), total daily insulin requirements will likely be 0.3-0.5 units/kg/day or higher 1
• This translates to approximately 21-35 units/day total for a 70 kg patient, split between basal and prandial components 1

Patient Education Essentials

Hypoglycemia Recognition and Treatment

• Teach recognition of hypoglycemia symptoms (shakiness, sweating, confusion, rapid heartbeat) and immediate treatment with 15 grams of fast-acting carbohydrate 5, 1
• Patient must always carry a source of fast-acting carbohydrates 1
• If hypoglycemia occurs without clear cause, reduce insulin dose by 10-20% immediately 1

Insulin Administration Technique

• Proper insulin injection technique and site rotation (abdomen, thigh, deltoid) must be taught to prevent lipodystrophy 5, 1, 6
• Rotate injection sites within the same region from one injection to the next 6
• Lantus should be administered at the same time each day 1, 6

Self-Monitoring Requirements

• Check fasting blood glucose every morning during titration phase 1
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments 1
• Record all glucose values to guide dose adjustments every 3 days 1

Sick Day Management

• Education on "sick day" rules, including when to contact healthcare provider and how to adjust insulin during illness 5
• Insulin storage and handling instructions 5

Common Pitfalls to Avoid

Do Not Delay Insulin Intensification

• Many months of uncontrolled hyperglycemia must be avoided to prevent long-term complications 1
• Not delaying the addition of prandial insulin when blood glucose levels are in the 400s is critical, as this clearly indicates the need for both basal and prandial coverage 1

Do Not Continue Basal-Only Approach

• Continuing to increase basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia leads to suboptimal control and increased hypoglycemia risk 1
• Blood glucose in the 400s mg/dL reflects both inadequate basal coverage AND postprandial excursions requiring mealtime insulin 1

Do Not Discontinue Metformin

• Never discontinue metformin when starting or intensifying insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain 1
• Metformin should be continued even when advancing to basal-bolus insulin therapy 1, 2

Monitoring and Follow-Up Schedule

During Active Titration

• Reassess every 3 days to adjust basal insulin dose based on fasting glucose patterns 1
• Adjust prandial insulin every 3 days based on 2-hour postprandial glucose readings 1
• Daily fasting blood glucose monitoring is essential 1

Contact Healthcare Provider If:

• Fasting glucose remains >180 mg/dL after 2-3 weeks of titration 1
• Basal insulin dose exceeds 0.5 units/kg/day without achieving fasting glucose targets 1
• Any episode of severe hypoglycemia occurs (reduce dose by 10-20%) 1

Long-Term Reassessment

• Check HbA1c every 3 months during intensive titration 1
• Reassess overall glycemic control and medication regimen every 3-6 months once stable 1

Expected Outcomes

With appropriate basal-bolus therapy at weight-based dosing, HbA1c reduction of 2-3% is achievable from current levels, with no increased hypoglycemia risk when properly implemented 1. Good glycemic control can be achieved with aggressive insulin titration combined with metformin, as demonstrated in studies showing HbA1c reductions from >11% to <7% within 6 months 7, 8.