Immediate Insulin Intensification Required for Severe Hyperglycemia
Your fasting blood sugar of 380 mg/dL on metformin 30 mg (likely 500-850 mg based on standard dosing) indicates treatment failure requiring immediate addition of basal insulin therapy. 1, 2
Critical First Steps
Start basal insulin (Lantus/glargine) at 10 units once daily OR 0.1-0.2 units/kg body weight, administered at the same time each day. 3 For severe hyperglycemia like yours (FBS 380 mg/dL), consider the higher end of this range (0.2 units/kg/day). 3
Increase metformin to at least 2000 mg daily (1000 mg twice daily) unless contraindicated, as the combination of metformin plus insulin provides superior glycemic control with reduced insulin requirements compared to insulin alone. 1, 4, 5
Aggressive Insulin Titration Protocol
Increase your basal insulin by 4 units every 3 days until your fasting blood glucose consistently reaches 80-130 mg/dL. 1, 3 With a fasting glucose ≥180 mg/dL, the 4-unit increment (rather than 2 units) is specifically recommended for faster glycemic control. 3
Check your fasting blood glucose every morning during titration and record all values to guide dose adjustments. 3
When to Add Mealtime Insulin
If after 3-6 months your basal insulin dose exceeds 0.5 units/kg/day (approximately 35-40 units for most adults) and your blood sugar remains elevated, you will need to add rapid-acting insulin before meals rather than continuing to increase basal insulin alone. 1, 3 This threshold prevents "overbasalization"—a dangerous pattern where excessive basal insulin causes hypoglycemia without improving overall control. 3
Start prandial insulin with 4 units of rapid-acting insulin (Humalog/NovoLog) before your largest meal, then titrate by 1-2 units every 3 days based on 2-hour post-meal glucose readings. 3
Critical Monitoring Requirements
- Daily fasting glucose checks during active titration 3
- HbA1c every 3 months until stable 1, 3
- Target fasting glucose: 80-130 mg/dL 1, 3
- Target HbA1c: <7% for most adults 1
Hypoglycemia Management
If any blood glucose reading is <70 mg/dL, immediately consume 15 grams of fast-acting carbohydrate (4 glucose tablets, 4 oz juice, or 1 tablespoon honey), recheck in 15 minutes, and repeat if needed. 3
If hypoglycemia occurs without clear cause, reduce your insulin dose by 10-20% immediately. 3
Common Pitfalls to Avoid
Never delay insulin initiation when metformin alone fails to control blood sugar—prolonged hyperglycemia increases your risk of cardiovascular disease, kidney failure, vision loss, and premature death. 3, 5
Never discontinue metformin when starting insulin unless you have kidney disease (eGFR <30 mL/min/1.73m²) or other contraindications. 1, 3, 4 The combination is superior to either medication alone. 5
Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing post-meal hyperglycemia with prandial insulin—this causes dangerous glucose fluctuations and increased hypoglycemia risk. 3
Expected Outcomes
With proper insulin initiation and titration at weight-based dosing, you can expect HbA1c reduction of 1.4-2.0% within 3-6 months. 1, 4 Intensive glucose control (HbA1c <7%) reduces microvascular complications by 3.5%, myocardial infarction by 3.3-6.2%, and mortality by 2.7-4.9% over 20 years compared to conventional treatment. 5
When to Contact Your Healthcare Provider
- Fasting glucose remains >180 mg/dL after 2-3 weeks of titration 3
- Any episode of severe hypoglycemia (<54 mg/dL) or inability to treat hypoglycemia yourself 3
- Basal insulin dose exceeds 0.5 units/kg/day without achieving fasting glucose targets 3
- Symptoms of lactic acidosis: unusual muscle pain, trouble breathing, unusual sleepiness, unexplained nausea/vomiting, feeling cold/dizzy, or slow/irregular heartbeat 4