What is the management plan for a patient starting insulin aspart (novolog) 5 units before meals, while already on Lantus (glargine) 35 units?

Management of Insulin Aspart Addition to Existing Lantus Therapy

Starting insulin aspart 5 units before meals while on Lantus 35 units is an appropriate basal-bolus intensification strategy, but requires systematic titration of both components to achieve glycemic targets. 1

Immediate Management Steps

Continue and Optimize Basal Insulin (Lantus)

• Maintain Lantus 35 units once daily at the same time each day 1
• Titrate Lantus based on fasting glucose patterns: increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL, or by 4 units every 3 days if fasting glucose ≥180 mg/dL, targeting 80-130 mg/dL 1, 2
• If hypoglycemia occurs without clear cause, reduce Lantus dose by 10-20% immediately 1, 2

Prandial Insulin (Aspart) Dosing and Titration

• Administer insulin aspart 0-15 minutes before each meal 1
• Starting dose of 5 units before meals is reasonable, representing either 4 units (standard starting dose) or 10% of basal dose 1, 2
• Titrate each meal's aspart dose independently by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings, targeting postprandial glucose <180 mg/dL 1, 2
• If hypoglycemia occurs, reduce the corresponding meal dose by 10-20% 1

Critical Threshold Monitoring

Watch for Overbasalization

When Lantus exceeds 0.5 units/kg/day (approximately 35-50 units for most adults), prioritize intensifying prandial insulin rather than continuing to escalate basal insulin 1, 2. Clinical signals include:

• Basal dose >0.5 units/kg/day 1, 2
• Bedtime-to-morning glucose differential ≥50 mg/dL 1, 2
• Hypoglycemia episodes 1
• High glucose variability 1

Foundation Therapy Requirements

Continue Metformin

• Metformin must be continued at maximum tolerated dose (up to 2000-2550 mg daily) unless contraindicated 1, 2
• The combination of metformin with basal-bolus insulin provides superior glycemic control with reduced insulin requirements and less weight gain 1, 2

Discontinue Sulfonylureas

• Consider discontinuing sulfonylureas when advancing to basal-bolus therapy to prevent hypoglycemia 2

Monitoring Requirements

Daily Glucose Monitoring

• Check fasting glucose every morning to guide Lantus titration 1, 2
• Check pre-meal glucose before each meal to calculate correction doses if needed 2
• Check 2-hour postprandial glucose after each meal to guide aspart titration 1, 2

Reassessment Schedule

• Adjust insulin doses every 3 days during active titration 1, 2
• Reassess overall glycemic control and HbA1c every 3-6 months once stable 1, 2

Meal Planning and Carbohydrate Management

Carbohydrate Counting

• Learn to count carbohydrates or use another meal planning approach to match mealtime insulin to carbohydrates consumed 1
• Take mealtime insulin before eating 1
• Meals can be consumed at different times when on multiple-daily injection plans 1

Physical Activity Considerations

• If physical activity is performed within 1-2 hours of mealtime insulin injection, the aspart dose may need to be lowered to reduce hypoglycemia risk 1
• Always carry a source of quick-acting carbohydrates 1

Hypoglycemia Prevention and Treatment

Recognition and Treatment

• Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate (glucose tablets, fruit juice, sports drinks, regular soda, or hard candy) 1, 2
• Recheck glucose in 15 minutes and repeat treatment if needed 1
• Always carry a source of fast-acting carbohydrates 1

Dose Adjustment for Hypoglycemia

• If hypoglycemia occurs, determine the cause 1
• If no clear reason, reduce the corresponding insulin dose by 10-20% 1, 2

Common Pitfalls to Avoid

Do Not Continue Escalating Basal Insulin Alone

• Avoid continuing to increase Lantus beyond 0.5-1.0 units/kg/day without adequately addressing postprandial hyperglycemia with prandial insulin, as this leads to overbasalization with increased hypoglycemia risk and suboptimal control 1, 2

Do Not Skip Meals

• Do not skip meals to reduce risk of hypoglycemia when on basal-bolus therapy 1

Do Not Give Rapid-Acting Insulin at Bedtime

• Never administer rapid-acting insulin (aspart) at bedtime, as this significantly increases nocturnal hypoglycemia risk 1, 2

Do Not Discontinue Metformin

• Never stop metformin when starting or intensifying insulin unless contraindicated 1, 2

When to Contact Healthcare Provider

• If fasting glucose remains >180 mg/dL after 2-3 weeks of titration 2
• If Lantus dose exceeds 0.5 units/kg/day without achieving fasting glucose targets 2
• If HbA1c remains above target after 3-6 months despite achieving fasting glucose goals 1, 2
• If recurrent hypoglycemia occurs 1