What is the next appropriate dose adjustment for a patient with suboptimal blood sugar control on Lantus (insulin glargine) 44 units daily and Lispro (insulin lispro) 6 units at dinner, with Fasting Blood Sugar (FBS) readings of 221, 355, and 216, and postprandial readings before dinner of 135, 372, and 311, and after dinner readings of 174, 363, 374?

Aggressive Insulin Intensification Required Immediately

Your current regimen is severely inadequate for the degree of hyperglycemia present—you need both increased basal insulin AND addition of prandial insulin coverage at all meals, not just dinner.

Critical Assessment of Current Control

Your blood glucose readings demonstrate profound hyperglycemia across all time points:

• Fasting values averaging 264 mg/dL (range 216-355) indicate grossly inadequate basal insulin coverage 1
• Pre-dinner values averaging 273 mg/dL (range 135-372) reflect both insufficient basal coverage and lack of lunch-time prandial insulin 1
• Post-dinner values averaging 304 mg/dL (range 174-374) demonstrate that 6 units of Lispro is completely insufficient for meal coverage 1

The American Diabetes Association target for fasting glucose is 80-130 mg/dL and postprandial glucose <180 mg/dL 2. You are nowhere near these targets despite being on 44 units of Lantus plus dinner Lispro.

Immediate Dose Adjustments Required

Basal Insulin (Lantus) Escalation

Increase Lantus by 4 units every 3 days until fasting glucose consistently reaches 80-130 mg/dL 1. With fasting values ≥180 mg/dL, the evidence-based titration algorithm specifies 4-unit increments rather than smaller adjustments 1.

• Start immediately: Increase to 48 units tonight
• In 3 days: Increase to 52 units if fasting glucose remains ≥180 mg/dL
• Continue this pattern until fasting glucose is controlled 1

Add Prandial Insulin at ALL Meals

Your current approach of only covering dinner is fundamentally flawed. Blood glucose levels in the 200s-300s throughout the day clearly indicate the need for prandial coverage at breakfast, lunch, AND dinner 1.

Starting doses:

• Breakfast: 6 units Lispro (matching your current dinner dose)
• Lunch: 6 units Lispro
• Dinner: Increase to 8 units Lispro (given consistently high post-dinner readings) 1

Administer Lispro 0-15 minutes before each meal 1, 3.

Prandial Insulin Titration Schedule

Adjust each meal's Lispro dose independently every 3 days based on the glucose reading 2 hours after that specific meal 1:

• If 2-hour postprandial glucose >180 mg/dL: Increase that meal's dose by 2 units
• If 2-hour postprandial glucose 140-180 mg/dL: Increase by 1 unit
• If 2-hour postprandial glucose <70 mg/dL: Decrease by 2 units (10-20%) 1

Critical Threshold Warning

You are approaching a critical decision point. At your current weight (assuming approximately 70-80 kg based on typical dosing), 44 units represents roughly 0.55-0.63 units/kg/day of basal insulin alone 1. When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, adding prandial insulin becomes MORE appropriate than continuing to escalate basal insulin alone 1. This is exactly where you are now—further Lantus increases alone will lead to "overbasalization" with increased hypoglycemia risk without improved control 1.

Foundation Therapy Verification

Ensure you are taking metformin at maximum tolerated dose (2000-2550 mg daily) unless contraindicated 1. Metformin must be continued when intensifying insulin therapy, as it reduces total insulin requirements and provides complementary glucose-lowering effects 1. If you're not on metformin or taking a suboptimal dose, this needs immediate correction.

Daily Monitoring Requirements

• Check fasting glucose every morning before breakfast 1
• Check glucose before each meal to guide correction doses 1
• Check glucose 2 hours after each meal to guide prandial insulin titration 1
• Record all values to identify patterns every 3 days 1

Expected Timeline and Outcomes

With aggressive titration following this protocol:

• Fasting glucose should reach target (80-130 mg/dL) within 2-3 weeks of consistent 4-unit increases every 3 days 1
• Postprandial glucose should improve within 1 week of starting three-times-daily prandial insulin 1
• HbA1c reduction of 2-3% is achievable with proper basal-bolus intensification 1

Common Pitfalls to Avoid

Do not continue escalating Lantus beyond 0.5-1.0 units/kg/day (approximately 35-80 units for most adults) without addressing postprandial hyperglycemia with prandial insulin 1. This leads to overbasalization—excessive basal insulin that causes hypoglycemia between meals while failing to control post-meal glucose spikes 1.

Do not rely on correction insulin alone—you need scheduled prandial insulin at each meal, not just reactive correction doses 1. Sliding scale approaches are explicitly condemned by diabetes guidelines as they treat hyperglycemia reactively rather than preventing it 1.

Hypoglycemia Management

Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate, recheck in 15 minutes, and repeat if needed 2. If hypoglycemia occurs without clear cause, reduce the relevant insulin dose (basal or that meal's prandial) by 10-20% immediately 1.