What long-acting insulin (e.g. glargine) should be added to a patient's current regimen of 70/30 (Novolin 70/30, NPH/Regular insulin) 30 units twice daily, with an Hemoglobin A1c (HbA1c) level of severe hyperglycemia and no insurance coverage?

Switching to NPH Insulin for Cost-Effective Basal Coverage

For a patient on 70/30 insulin 30 units twice daily with an A1c of 12.73 and no insurance, switch to NPH insulin as the long-acting basal component—it is the most cost-effective option and clinically appropriate for this level of hyperglycemia. 1, 2

Immediate Regimen Change

Convert to twice-daily NPH insulin using 80% of the current total daily dose (60 units), distributed as 2/3 morning (32 units) and 1/3 evening (16 units). 3

• The 80% reduction prevents hypoglycemia during transition since you're separating the basal component from the premixed formulation 3
• This split-dose approach provides better 24-hour glucose coverage than once-daily dosing, particularly critical given the severe hyperglycemia (A1c 12.73) 3

Add Prandial Coverage Immediately

Start regular insulin 4 units before each meal (or 10% of basal dose) since the A1c of 12.73 indicates both inadequate basal AND prandial coverage. 1, 3

• With A1c >10%, guidelines recommend immediate basal-bolus therapy rather than basal insulin alone 2
• Regular insulin is the most cost-effective prandial option for uninsured patients, given 30-45 minutes before meals 2

Aggressive Titration Protocol

Increase NPH by 4 units every 3 days if fasting glucose remains ≥180 mg/dL, targeting 80-130 mg/dL. 1, 2

• For fasting glucose 140-179 mg/dL, increase by 2 units every 3 days 1, 2
• If hypoglycemia occurs without clear cause, reduce the corresponding dose by 10-20% immediately 1, 2

Titrate prandial regular insulin by 1-2 units every 3 days based on 2-hour postprandial glucose readings. 1, 3

Why NPH Over Other Long-Acting Insulins

NPH is significantly less expensive than insulin glargine (Lantus) or detemir (Levemir), making it the only realistic option for uninsured patients. 1

• While long-acting analogs (glargine, detemir) have smoother pharmacokinetic profiles with less nocturnal hypoglycemia risk, the cost difference is prohibitive for uninsured patients 1, 4, 5
• NPH provides adequate basal coverage when dosed twice daily, particularly when combined with proper titration 1, 6
• Clinical trials demonstrate NPH achieves similar HbA1c reductions to long-acting analogs when properly dosed 6, 7, 5

Critical Threshold Monitoring

Watch for overbasalization when NPH exceeds 0.5 units/kg/day (approximately 36-40 units for average adult)—at this point, intensify prandial insulin rather than continuing to escalate basal insulin. 1, 2

Clinical signals of overbasalization include:

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

Foundation Therapy Must Continue

Maximize metformin to at least 2000 mg daily (unless contraindicated) when adding insulin—this combination reduces total insulin requirements and provides superior glycemic control. 1, 2

• Never discontinue metformin when starting insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain 1, 2
• Consider discontinuing sulfonylureas to reduce hypoglycemia risk once insulin is initiated 1, 2

Monitoring Requirements

Check fasting blood glucose every morning during titration and pre-meal glucose to guide prandial insulin adjustments. 1, 2

• Reassess every 3 days during active titration to adjust doses 1, 2
• Check HbA1c every 3 months during intensive titration 2
• Monitor for hypoglycemia more frequently given the aggressive titration needed for A1c 12.73 1, 2

Common Pitfalls to Avoid

Do not use a 1:1 conversion from 70/30 to NPH—this provides excessive basal insulin since 70/30 contains both basal (70% NPH) and prandial (30% regular) components. 3

Do not delay adding prandial insulin—an A1c of 12.73 clearly indicates the need for both basal and prandial coverage from the outset. 1, 2

Do not continue escalating NPH beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia, as this leads to overbasalization with increased hypoglycemia risk and suboptimal control. 1, 2

Do not give all NPH at bedtime only—twice-daily dosing (morning and evening) is essential for adequate 24-hour coverage in severe hyperglycemia. 3, 6