What is the appropriate initial dose of Basaglar (insulin glargine) and Humalog (insulin lispro) for a 70-year-old patient weighing 168 pounds with poorly controlled diabetes, an HbA1c of 13.2, and currently taking metformin (1000 mg twice a day) and glyburide (10 mg twice a day)?

Initial Insulin Dosing for Severe Hyperglycemia

For this 70-year-old patient with severe uncontrolled diabetes (HbA1c 13.2%), immediate basal-bolus insulin therapy is required, starting with Basaglar 15-20 units once daily at bedtime and Humalog 4-6 units before each of the three largest meals. 1, 2, 3

Calculating the Starting Doses

Basaglar (Basal Insulin) Dosing

Start with 15-20 units once daily at bedtime. 2, 4

• Patient weight: 168 pounds = 76 kg
• For severe hyperglycemia (HbA1c >10%), the recommended starting dose is 0.2-0.3 units/kg/day 2, 3
• Calculation: 76 kg × 0.2 = 15 units (conservative) to 76 kg × 0.25 = 19 units (moderate)
• Given the HbA1c of 13.2%, start with 20 units once daily at bedtime 2, 3
• Continue metformin 1000 mg twice daily unless contraindicated, as this combination reduces total insulin requirements and provides superior glycemic control 1, 2, 3
• Discontinue glipizide immediately when starting basal-bolus insulin, as the combination significantly increases hypoglycemia risk 3

Humalog (Prandial Insulin) Dosing

Start with 4-6 units before each of the three largest meals. 1, 2, 3

• For severe hyperglycemia requiring basal-bolus therapy from the outset, use 0.3-0.5 units/kg/day as total daily insulin dose 2, 3
• Calculation: 76 kg × 0.4 = 30 units total daily dose
• Split: 50% basal (15 units) + 50% prandial (15 units divided among three meals = 5 units per meal) 2, 3
• Start with 5 units Humalog before breakfast, lunch, and dinner 2, 3
• Administer Humalog 0-15 minutes before meals for optimal postprandial glucose control 1, 2

Titration Protocol

Basaglar Titration

Increase by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 2, 3

• For fasting glucose ≥180 mg/dL: increase by 4 units every 3 days 2, 3
• For fasting glucose 140-179 mg/dL: increase by 2 units every 3 days 2, 3
• Target fasting glucose: 80-130 mg/dL 2, 3
• If hypoglycemia occurs without clear cause, reduce dose by 10-20% immediately 2, 3

Humalog Titration

Increase by 1-2 units every 3 days based on 2-hour postprandial glucose readings. 2, 3

• Target postprandial glucose: <180 mg/dL 2, 3
• Titrate each meal dose independently based on glucose 2 hours after that specific meal 2, 3
• If postprandial glucose consistently >180 mg/dL, increase that meal's Humalog dose by 1-2 units 2, 3

Critical Threshold Warning

When Basaglar exceeds 0.5 units/kg/day (38 units for this patient) without achieving glycemic targets, focus on intensifying Humalog rather than continuing to escalate Basaglar alone. 2, 3

• Signs of "overbasalization" include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose drop ≥50 mg/dL, hypoglycemia episodes, and high glucose variability 2, 3
• At this threshold, further Basaglar increases produce diminishing returns with increased hypoglycemia risk 2, 3

Expected Outcomes

With appropriate basal-bolus therapy, expect HbA1c reduction of 3-4% from baseline over 3-6 months. 3

• At HbA1c 13.2%, insulin is the most effective agent, as most oral agents reduce HbA1c by <1% 3
• 68% of patients achieve mean blood glucose <140 mg/dL with proper basal-bolus therapy 3
• The combination of basal-bolus insulin with metformin provides superior control compared to insulin alone 1, 2, 3

Monitoring Requirements

Check fasting glucose every morning and 2-hour postprandial glucose after each meal during the titration phase. 2, 3

• Daily glucose monitoring is essential during active titration 2, 3
• Reassess HbA1c every 3 months until target achieved, then every 6 months 2, 3
• Adjust doses every 3 days based on glucose patterns, not single readings 2, 3

Patient Education Essentials

Provide comprehensive education on insulin injection technique, glucose monitoring, hypoglycemia recognition/treatment, and sick day management. 1, 2

• Teach proper injection technique and site rotation (abdomen, thigh, deltoid) 4
• Rotate injection sites within the same region to reduce lipodystrophy risk 4
• Treat hypoglycemia (glucose <70 mg/dL) immediately with 15 grams of fast-acting carbohydrate 2, 3
• Always carry a source of fast-acting carbohydrates 2
• Never administer Basaglar intravenously or mix with other insulins 4

Common Pitfalls to Avoid

Never delay insulin intensification at this HbA1c level—prolonged severe hyperglycemia (months at HbA1c >9%) increases complication risk. 3

• Do not rely on sliding scale insulin alone, as this treats hyperglycemia reactively rather than preventing it 2, 3
• Do not continue glipizide when implementing basal-bolus insulin, as this significantly increases hypoglycemia risk 3
• Do not discontinue metformin when starting insulin unless contraindicated, as this leads to higher insulin requirements and more weight gain 1, 2, 3
• Do not continue escalating Basaglar beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia with adequate Humalog doses 2, 3

Alternative Consideration

Consider adding a GLP-1 receptor agonist to the basal-bolus regimen after initial stabilization if weight gain becomes problematic. 5, 6

• GLP-1 receptor agonists combined with basal insulin provide comparable HbA1c reduction to basal-bolus insulin with weight loss rather than weight gain 5, 6
• This combination results in fewer hypoglycemic episodes than basal-bolus insulin alone 5, 6
• However, at HbA1c 13.2%, immediate basal-bolus insulin therapy is required first, with GLP-1 RA addition considered after 3-6 months if needed 3