What is the recommended basal-bolus insulin regimen for discharge in a patient currently receiving insulin glargine (long-acting insulin) 12 units at night and Actrapid (rapid-acting insulin, insulin aspart) 4 units in the morning, 12 units in the afternoon, and 14 units at night?

Recommended Discharge Basal-Bolus Insulin Regimen

Continue the current insulin regimen at discharge: insulin glargine 12 units at night, with Actrapid 4 units in the morning, 12 units in the afternoon, and 14 units at night. This represents a well-established basal-bolus regimen with a total daily dose (TDD) of 42 units, split appropriately between basal (29%) and prandial (71%) components 1.

Rationale for Current Regimen

The patient's current regimen provides:

• Basal insulin: 12 units glargine at night (29% of TDD)
• Prandial insulin: 30 units total Actrapid (71% of TDD) distributed across three meals
• Total daily dose: 42 units

This distribution is appropriate for type 2 diabetes, where the typical split is approximately 40-60% basal and 40-60% prandial insulin, though the exact ratio should be individualized based on glucose patterns 1.

Key Considerations for This Regimen

Basal Insulin Component

• The 12 units of glargine provides continuous background insulin coverage throughout the 24-hour period 1
• Glargine can be administered at any time of day convenient for the patient, though consistency in timing is important 2, 3
• For a patient requiring 42 units total daily insulin, 12 units of basal insulin (0.17-0.20 units/kg for a typical adult) is reasonable 1

Prandial Insulin Distribution

• The unequal distribution of Actrapid (4-12-14 units) suggests the patient has higher carbohydrate intake or greater insulin resistance at lunch and dinner 1
• Actrapid (regular insulin) should be administered 30-45 minutes before meals for optimal postprandial glucose control 1
• This timing is critical—unlike rapid-acting analogs that can be given 0-15 minutes before meals, regular insulin requires the longer lead time 1

Monitoring and Titration Instructions

Adjustment Protocol

• Basal insulin titration: Adjust glargine by 2 units every 3 days based on fasting glucose patterns, targeting 80-130 mg/dL 1
• Prandial insulin titration: Adjust each Actrapid dose by 1-2 units every 3 days based on 2-hour postprandial glucose readings, targeting <180 mg/dL 1
• If hypoglycemia occurs without clear cause, reduce the corresponding insulin dose by 10-20% immediately 1

Critical Threshold Monitoring

• Watch for overbasalization: If basal insulin needs to exceed 0.5 units/kg/day (approximately 35-40 units for most adults) to achieve fasting glucose targets, this signals inadequate prandial coverage rather than insufficient basal insulin 1
• Clinical signs of overbasalization include: bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia, and high glucose variability 1

Essential Patient Education

Insulin Administration

• Glargine timing: Administer at the same time each night for consistency 1
• Actrapid timing: Give 30-45 minutes before each meal 1
• Injection technique: Rotate injection sites systematically within one area to minimize absorption variability 4

Hypoglycemia Management

• Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate 1
• Recheck glucose in 15 minutes and repeat treatment if needed 1
• Always carry a source of fast-acting carbohydrates 1

Monitoring Requirements

• Check fasting blood glucose daily during titration 1
• Check pre-meal glucose before each meal to guide Actrapid dosing 1
• Check 2-hour postprandial glucose to assess adequacy of prandial insulin coverage 1

Foundation Therapy Considerations

• Continue metformin unless contraindicated, as this combination provides superior glycemic control with reduced insulin requirements and less weight gain 1
• Consider discontinuing sulfonylureas if present to reduce hypoglycemia risk 1

Common Pitfalls to Avoid

• Do not mix glargine with Actrapid in the same syringe, as glargine's low pH causes coprecipitation of short-acting insulins 5, 3
• Do not give Actrapid at bedtime without close monitoring, as this significantly increases nocturnal hypoglycemia risk 1
• Do not continue escalating glargine beyond 0.5-1.0 units/kg/day without reassessing the prandial insulin doses, as this leads to overbasalization 1
• Do not delay dose adjustments—titrate systematically every 3 days based on glucose patterns rather than waiting weeks between changes 1

When to Consider Regimen Modification

Switching to Twice-Daily Glargine

If the patient experiences persistent nocturnal hypoglycemia with morning hyperglycemia despite dose adjustments, consider splitting glargine to twice daily (typically 2/3 morning, 1/3 evening) 6, 2

Transitioning to Rapid-Acting Analogs

If the 30-45 minute pre-meal timing with Actrapid proves impractical for the patient, consider switching to rapid-acting insulin analogs (lispro, aspart) that can be given 0-15 minutes before meals 1, 3