What adjustments can be made to the treatment plan for a 52-year-old obese female patient with poorly controlled diabetes, currently on Semglee (insulin glargine) 75 units, Trulicity (dulaglutide) 0.75 mg, and Novolog (insulin aspart) 15 units with each meal, presenting with persistent hyperglycemia?

Aggressive Insulin Intensification Required for Severe Hyperglycemia

This patient requires immediate and aggressive insulin dose escalation with addition of prandial insulin coverage, as blood glucose levels of 200-300 mg/dL indicate both inadequate basal insulin and insufficient mealtime coverage. 1

Immediate Basal Insulin Adjustment

Increase Semglee (insulin glargine) by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL. 1 At 75 units for a 107 kg patient, this represents approximately 0.7 units/kg/day, which is already approaching the critical threshold where further basal escalation alone becomes counterproductive. 1

• For fasting glucose ≥180 mg/dL, the American Diabetes Association recommends increasing basal insulin by 4 units every 3 days. 1
• Continue aggressive titration until fasting glucose consistently reaches 80-130 mg/dL without hypoglycemia. 1
• Daily fasting blood glucose monitoring is essential during this titration phase. 1

Critical Problem: Inadequate Prandial Coverage

The current Novolog dose of 15 units with each meal is insufficient for this degree of hyperglycemia and must be increased immediately. 1 Blood glucose in the 200-300 mg/dL range reflects both inadequate basal coverage AND postprandial excursions requiring more aggressive mealtime insulin. 1

Prandial Insulin Intensification

• Increase Novolog to 20-25 units before each meal immediately, then titrate by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings. 1
• Target postprandial glucose <180 mg/dL. 1
• Administer Novolog 0-15 minutes before meals for optimal postprandial glucose control. 1, 2

Critical Threshold Warning: Overbasalization Risk

When basal insulin exceeds 0.5 units/kg/day (approximately 54 units for this patient) and approaches 1.0 units/kg/day (107 units), adding or intensifying prandial insulin becomes more appropriate than continuing to escalate basal insulin alone. 1 This patient is already at 0.7 units/kg/day of basal insulin, indicating that prandial intensification should take priority over further basal escalation. 1

Clinical signals of overbasalization to monitor include: 1

• Basal dose >0.5 units/kg/day (already present)
• Bedtime-to-morning glucose differential ≥50 mg/dL
• Hypoglycemia episodes
• High glucose variability throughout the day

Optimize GLP-1 Receptor Agonist Therapy

Increase Trulicity (dulaglutide) from 0.75 mg to 1.5 mg weekly. 3 This dose escalation can provide an additional HbA1c reduction of 0.3-0.5% while minimizing weight gain and hypoglycemia risk associated with insulin intensification alone. 3

• The combination of dulaglutide and insulin provides complementary mechanisms for improved glycemic control. 3
• GLP-1 receptor agonists reduce total insulin requirements and provide superior glycemic control with less weight gain compared to insulin alone. 1, 3
• After at least 4 weeks at 1.5 mg, consider further escalation to 3.0 mg or 4.5 mg if glycemic targets remain unmet. 3

Foundation Therapy: Metformin

Ensure metformin is prescribed at maximum tolerated dose (2000-2550 mg daily) unless contraindicated. 1, 3 Metformin must be continued as the foundation of therapy even when intensifying insulin, as this combination provides superior glycemic control with reduced insulin requirements and less weight gain. 1, 3

• If not currently on metformin, start immediately at 500 mg twice daily and titrate to 1000 mg twice daily over 1-2 weeks. 1
• Metformin reduces total insulin requirements by approximately 30% when used in combination. 1

Monitoring Requirements

• Check fasting blood glucose daily during basal insulin titration. 1
• Check pre-meal and 2-hour postprandial glucose to guide prandial insulin adjustments. 1
• Reassess HbA1c in 3 months to determine if additional intensification is needed. 1, 3
• Monitor for hypoglycemia and reduce corresponding insulin dose by 10-20% immediately if episodes occur without clear cause. 1

Expected Outcomes

With appropriate basal-bolus intensification combined with optimized GLP-1 receptor agonist therapy, expect: 1

• HbA1c reduction of 2-3% from baseline over 3-6 months
• Fasting glucose reaching 80-130 mg/dL within 2-4 weeks of aggressive titration
• Postprandial glucose <180 mg/dL within 4-6 weeks
• No increased hypoglycemia risk when properly implemented with appropriate monitoring

Critical Pitfalls to Avoid

Do not continue escalating Semglee beyond 0.5-1.0 units/kg/day (54-107 units) without aggressively addressing postprandial hyperglycemia through prandial insulin intensification. 1 This leads to overbasalization with increased hypoglycemia risk and suboptimal control. 1

Do not delay prandial insulin intensification when blood glucose levels are consistently 200-300 mg/dL. 1 This clearly indicates the need for both basal and prandial coverage optimization, not just basal insulin escalation. 1

Never discontinue Trulicity when intensifying insulin. 1, 3 The combination provides superior outcomes compared to insulin intensification alone, with less weight gain and hypoglycemia. 1, 3

Patient Education Essentials

Provide comprehensive education on: 1

• Proper insulin injection technique and site rotation to prevent lipohypertrophy
• Recognition and treatment of hypoglycemia (treat any glucose <70 mg/dL with 15 grams of fast-acting carbohydrate)
• Self-monitoring of blood glucose technique and timing
• "Sick day" management rules
• Insulin storage and handling