What adjustments should be made to the medication regimen of a patient with poorly controlled diabetes, as indicated by an elevated Hemoglobin A1c level, who is currently taking NovoLOG (insulin aspart) insulin, Lantus (insulin glargine) insulin, Tradjenta (linagliptin), and aspirin (acetylsalicylic acid)?

Aggressive Insulin Intensification Required for Severe Hyperglycemia

This patient with HbA1c 9.3% requires immediate and aggressive insulin dose escalation, with the current basal insulin dose of 40 units daily being grossly inadequate and the sliding scale approach being explicitly condemned by all major diabetes guidelines. 1, 2

Critical Problems with Current Regimen

Basal Insulin Severely Underdosed

• The current Lantus dose of 40 units daily (20 units twice daily) is insufficient for this level of hyperglycemia. 1, 2
• For HbA1c ≥9%, the American Diabetes Association recommends starting doses of 0.3-0.5 units/kg/day as total daily insulin, meaning this patient likely needs 30-50 units/day total at minimum. 2
• The basal insulin should be aggressively titrated by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 1, 2

Sliding Scale Insulin as Monotherapy is Dangerous

• Sliding scale insulin treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations. 2
• The American Diabetes Association explicitly condemns sliding scale as sole treatment, as scheduled basal-bolus regimens are superior. 2
• Studies show that 68% of patients achieve mean blood glucose <140 mg/dL with proper basal-bolus therapy versus only 38% with sliding scale alone. 2

Immediate Medication Adjustments Required

1. Increase Lantus Aggressively

• Increase Lantus to at least 50-60 units daily (can continue twice-daily dosing of 25-30 units each). 1, 2
• Titrate by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL. 1, 2
• Monitor for the critical threshold of 0.5 units/kg/day, at which point adding prandial insulin becomes more appropriate than continuing basal escalation alone. 1, 2

2. Convert Sliding Scale to Scheduled Prandial Insulin

• Discontinue the current sliding scale approach and implement scheduled prandial insulin. 2
• Start with 4 units of NovoLog before each meal (or 10% of basal dose). 1, 2
• Add correction doses as adjunct only: 2 units for glucose >250 mg/dL, 4 units for glucose >350 mg/dL. 2
• Titrate prandial doses by 1-2 units every 3 days based on 2-hour postprandial glucose readings. 1, 2

3. Optimize Foundation Therapy

• Verify metformin is not listed in the current regimen - it MUST be added unless contraindicated. 1, 2
• Metformin should be at least 1000mg twice daily (2000mg total), with maximum effective dose up to 2500mg/day. 2
• Metformin combined with insulin reduces total insulin requirements and provides complementary glucose-lowering effects. 2
• Continue Tradjenta 5mg daily - DPP-4 inhibitors can be maintained with insulin therapy. 3

Expected Outcomes and Monitoring

Glycemic Targets

• Fasting and premeal glucose: 80-130 mg/dL. 1, 2
• Two-hour postprandial glucose: <180 mg/dL. 1, 2
• With appropriate basal-bolus therapy, HbA1c reduction of 2-3% is achievable from current levels. 2

Monitoring Requirements

• Daily fasting blood glucose monitoring is essential during titration. 1, 2
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments. 2
• Reassess every 3 days during active titration, and every 3-6 months once stable. 1, 2

Critical Thresholds and Warning Signs

Watch for Overbasalization

• When basal insulin exceeds 0.5 units/kg/day, adding or intensifying prandial insulin becomes more appropriate than continuing basal escalation. 1, 2
• Clinical signals include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability. 2

Hypoglycemia Management

• If hypoglycemia occurs without clear cause, reduce the corresponding insulin dose by 10-20% immediately. 1, 2
• Treat hypoglycemia at blood glucose ≤70 mg/dL with 15 grams of fast-acting carbohydrate. 2
• Prescription of glucagon for emergent hypoglycemia should be considered. 1

Common Pitfalls to Avoid

Do Not Delay Insulin Intensification

• Many months of uncontrolled hyperglycemia should specifically be avoided to prevent long-term complications. 2
• Delaying insulin therapy in patients not achieving glycemic goals can be harmful. 2

Do Not Continue Inadequate Regimens

• 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
• Do not rely solely on correction insulin - scheduled regimens with basal, prandial, and correction components are required. 2

Do Not Discontinue Oral Medications Abruptly

• Metformin should be continued when adding or intensifying insulin therapy unless contraindicated. 1, 2, 4
• Oral medications should not be abruptly discontinued when starting insulin therapy because of the risk of rebound hyperglycemia. 4

Patient Education Essentials

Critical Teaching Points

• Proper insulin injection technique and site rotation to prevent lipohypertrophy. 2, 4
• Recognition and treatment of hypoglycemia - always carry fast-acting carbohydrates. 2
• Self-monitoring of blood glucose - check fasting and pre-meal values daily during titration. 1, 2
• "Sick day" management rules and insulin storage/handling. 2
• NovoLog must be given 0-15 minutes before meals, not after eating. 2, 4

When to Contact Provider

• Fasting glucose remains >180 mg/dL after 2-3 weeks of titration. 2
• Any episode of severe hypoglycemia requiring assistance. 2
• Basal insulin dose exceeds 0.5 units/kg/day without achieving fasting glucose targets. 2