What is the next step in managing a patient with a Hemoglobin A1c (HbA1c) of 9% who is already on basal insulin (12 units) and a sliding scale regimen?

Immediate Insulin Intensification Required

Your patient with HbA1c of 9% on only 12 units of basal insulin plus sliding scale requires immediate aggressive titration of basal insulin and discontinuation of sliding scale monotherapy. 1

Critical Problems with Current Regimen

Your current approach has three fundamental flaws:

• Sliding scale insulin as monotherapy is explicitly condemned by all major diabetes guidelines and shown to be ineffective and potentially dangerous 1, 2, 3
• 12 units of basal insulin is grossly inadequate for an HbA1c of 9% - guidelines recommend starting doses of 0.3-0.5 units/kg/day for patients with HbA1c ≥9%, meaning most patients need 20-40 units/day minimum 1
• Sliding scale treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations 1, 3

Immediate Action Plan

Step 1: Aggressive Basal Insulin Titration (Start Today)

• Increase basal insulin by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL 1
• For HbA1c of 9%, expect to need 0.3-0.5 units/kg/day as total daily insulin dose 1
• Continue metformin unless contraindicated - this combination provides superior glycemic control with reduced insulin requirements 1

Step 2: Replace Sliding Scale with Scheduled Basal-Bolus Regimen

• Discontinue sliding scale insulin immediately 1, 2, 3
• Add prandial insulin coverage: Start with 4 units of rapid-acting insulin before the largest meal, or use 10% of the basal dose 1
• Use correction insulin only as an adjunct to scheduled basal-bolus therapy, not as monotherapy 1

Step 3: Daily Monitoring During Titration

• Check fasting blood glucose every morning to guide basal insulin adjustments every 3 days 1
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments 1
• Target fasting glucose: 80-130 mg/dL 1
• Target postprandial glucose: <180 mg/dL 1

Expected Timeline and Outcomes

Week 1-3: Aggressive Basal Titration Phase

• Increase basal insulin by 4 units every 3 days 1
• Most patients with HbA1c of 9% will need 30-50 units/day of basal insulin 1
• Monitor for hypoglycemia and reduce dose by 10-20% if it occurs 1

Week 4-12: Prandial Insulin Optimization

• Once fasting glucose reaches target (80-130 mg/dL), focus on postprandial control 1
• Titrate prandial insulin by 1-2 units or 10-15% every 3 days based on 2-hour postprandial readings 1
• Critical threshold: When basal insulin exceeds 0.5 units/kg/day without achieving targets, prioritize adding/intensifying prandial insulin rather than continuing to escalate basal insulin alone 1

Month 3: Reassessment

• Recheck HbA1c after 3 months to assess treatment effectiveness 1
• With appropriate basal-bolus therapy, expect HbA1c reduction of 2-3% from current levels 1
• If HbA1c remains >7% after 3-6 months despite optimized insulin, consider adding a GLP-1 receptor agonist 1

Critical Pitfalls to Avoid

• Never continue sliding scale as monotherapy - even temporarily, scheduled basal insulin with correction doses as adjunct only is superior 1, 2, 3
• Never delay basal insulin titration - 75% of hospitalized patients who experienced hypoglycemia had no basal insulin dose adjustment before the next administration, demonstrating the danger of under-adjusting 1
• Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia - this leads to "overbasalization" with increased hypoglycemia risk and suboptimal control 1
• Never discontinue metformin when starting insulin unless contraindicated - this leads to higher insulin requirements and more weight gain 1

Patient Education Essentials

• Hypoglycemia recognition and treatment: Treat at blood glucose ≤70 mg/dL with 15 grams of fast-acting carbohydrate 1
• Proper insulin injection technique and site rotation to prevent lipohypertrophy 1, 4
• Self-monitoring of blood glucose: Daily fasting glucose monitoring is essential during titration 1
• "Sick day" management rules and insulin storage/handling 1

Duration of Current Regimen

Do not continue the current regimen beyond today. The combination of inadequate basal insulin (12 units) and sliding scale monotherapy is ineffective and potentially harmful 1, 2, 3. Immediate transition to aggressive basal insulin titration with scheduled basal-bolus therapy is required to prevent prolonged exposure to hyperglycemia and increased complication risk 1.