What adjustments should be made to a type 2 diabetes patient's regimen of Toujeo (insulin glargine) and Novolog (insulin aspart) if their current dosages are not controlling their blood sugars?

Aggressive Insulin Dose Titration Required for Uncontrolled Hyperglycemia

Your current insulin doses are grossly inadequate and require immediate, aggressive upward titration of both basal and prandial insulin to achieve glycemic control. 1, 2, 3

Immediate Basal Insulin (Toujeo) Adjustments

Increase Toujeo immediately to 20-25 units once daily and continue aggressive titration by 4 units every 3 days until fasting blood glucose consistently reaches 80-130 mg/dL. 1, 2, 3 Your current basal insulin dose is insufficient for most patients with type 2 diabetes, who typically require 0.3-0.5 units/kg/day of basal insulin alone. 2, 3

Titration Algorithm for Toujeo:

• If fasting glucose ≥180 mg/dL: Increase by 4 units every 3 days 1
• If fasting glucose 140-179 mg/dL: Increase by 2 units every 3 days 1
• Target fasting glucose: 80-130 mg/dL 1
• If hypoglycemia occurs: Reduce dose by 10-20% immediately 1

Do not hesitate to exceed 0.5 units/kg/day of basal insulin in your situation, as inadequate basal coverage is the primary driver of your persistent hyperglycemia. 2

Prandial Insulin (Novolog) Optimization

Your mealtime insulin requires significant intensification. 1, 3 Distribute your prandial insulin across all three meals based on carbohydrate content, typically 30-40% at breakfast, 30-40% at lunch, and 30-40% at dinner. 3

Prandial Insulin Titration:

• Start with 4 units of Novolog before each meal (or 10% of your basal dose per meal) 1
• Increase by 1-2 units every 3 days based on 2-hour postprandial glucose readings 1
• Target postprandial glucose: <180 mg/dL 1

Calculate your insulin-to-carbohydrate ratio using the formula: 450 ÷ total daily insulin dose. 1 A common starting ratio is 1 unit per 10-15 grams of carbohydrate. 1

Critical Monitoring Requirements

• Check fasting blood glucose every morning during titration 1, 2
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments 1
• Monitor for signs of overbasalization: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, or high glucose variability 1

Essential Foundation Therapy

Ensure metformin is optimized to at least 1000mg twice daily (2000mg total) unless contraindicated, with a maximum effective dose up to 2500mg/day. 1 Metformin must be continued when intensifying insulin therapy, as it reduces total insulin requirements and provides complementary glucose-lowering effects. 1

When to Consider Additional Therapy

If blood glucose remains poorly controlled despite optimized basal-bolus insulin, consider adding a GLP-1 receptor agonist to improve postprandial control and potentially reduce insulin requirements. 1, 3 This combination provides superior outcomes compared to basal-bolus insulin alone with less weight gain and hypoglycemia risk. 1

Common Pitfalls to Avoid

• Never 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
• Never discontinue metformin when intensifying insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain 1
• Never delay insulin dose adjustments in patients not achieving glycemic goals, as this prolongs hyperglycemia exposure and increases complication risk 1
• Never rely on correction insulin alone—scheduled basal-bolus regimens are superior to sliding scale monotherapy 1

Expected Outcomes

With appropriate basal-bolus therapy at weight-based dosing, you should achieve mean blood glucose <140 mg/dL and an HbA1c reduction of 2-3% from current levels. 1 Daily self-monitoring of blood glucose is essential during the titration phase, with reassessments every 3 days during active titration. 1