What adjustments should be made to the insulin regimen of a 22-year-old female with type 1 diabetes mellitus on insulin lispro (Humalog) and insulin glargine (Lantus), with an HbA1c of 12.8% and hyperglycemia?

Immediate Aggressive Insulin Intensification Required

This patient requires immediate and aggressive insulin intensification with both basal and prandial insulin, as an HbA1c of 12.8% with glucose of 359 mg/dL represents severe uncontrolled hyperglycemia that warrants basal-bolus therapy from the outset. 1

Critical Assessment of Current Regimen

The current regimen is grossly inadequate:

• Total daily insulin dose: Only 28 units/day (12 units lispro + 16 units Lantus)
• Weight-based calculation: For a 22-year-old female (estimated ~60-70 kg), this represents approximately 0.4-0.47 units/kg/day
• At HbA1c 12.8%, guidelines recommend starting doses of 0.5-1.0 units/kg/day for type 1 diabetes 1
• This patient likely needs 30-70 units/day total to achieve adequate control 1

Immediate Treatment Plan

1. Aggressive Basal Insulin Titration

Increase Lantus by 4 units every 3 days until fasting glucose reaches 80-130 mg/dL 1

• Current dose: 16 units daily
• Target fasting glucose: 80-130 mg/dL 1
• With fasting glucose ≥180 mg/dL (likely given HbA1c 12.8%), increase by 4 units every 3 days 1
• Do not stop escalating until fasting glucose is consistently controlled 1

2. Intensify Prandial Insulin Coverage

The current 4 units TID lispro is insufficient - this needs immediate adjustment:

• Increase each meal dose by 2-4 units immediately 1
• Titrate prandial insulin 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
• For type 1 diabetes, approximately 50% of total daily dose should be prandial insulin 1

3. Expected Total Daily Dose

For adequate control at this HbA1c level:

• Total daily insulin requirement: 0.5-1.0 units/kg/day 1
• Split approximately 40-50% basal (Lantus) and 50-60% prandial (lispro) 1
• For a 60 kg patient: 30-60 units/day total
• For a 70 kg patient: 35-70 units/day total

Critical Monitoring Requirements

Daily self-monitoring of blood glucose is essential during this intensive titration phase 2:

• Check fasting glucose every morning 1
• Check pre-meal glucose before each meal 1
• Check 2-hour postprandial glucose to guide prandial insulin adjustments 1
• Reassess HbA1c every 3 months during intensive titration 1

Expected Outcomes

With appropriate basal-bolus therapy at weight-based dosing, HbA1c reduction of 3-4% is achievable over 3-6 months 1:

• Expected HbA1c after 3-6 months: 8.8-9.8% (still requiring further optimization)
• 68% of patients achieve mean blood glucose <140 mg/dL with proper basal-bolus therapy 1

Essential Patient Education

Comprehensive education is critically important 1:

• Proper insulin injection technique and site rotation 2
• Recognition and treatment of hypoglycemia - carry at least 15g carbohydrate at all times 2
• Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate 1
• Self-monitoring of blood glucose technique 2
• "Sick day" management rules - continue insulin even if unable to eat 2
• Insulin storage and handling 1
• Medical identification (bracelet or wallet card) 2

Critical Pitfalls to Avoid

Never delay aggressive insulin intensification in patients with HbA1c >10% 1:

• Prolonged severe hyperglycemia (months at HbA1c >9%) should be specifically avoided due to increased risk of complications 3
• Do not rely on sliding scale insulin alone - this is explicitly condemned by all major diabetes guidelines 1
• Do not wait weeks between dose adjustments - adjust every 3 days during active titration 1
• If hypoglycemia occurs, reduce the corresponding dose by 10-20% immediately 1

Special Consideration: Injection Technique Review

Given the severe hyperglycemia, review injection technique immediately 2:

• Rotate within one area systematically (e.g., rotating within abdomen) rather than rotating to different areas 2
• Abdomen has fastest absorption rate, followed by arms, thighs, buttocks 2
• Check for lipohypertrophy - areas of lipohypertrophy show slower absorption 2
• Ensure proper subcutaneous injection - intramuscular injection not recommended for routine use 2

Timeline for Reassessment

• Adjust basal insulin every 3 days based on fasting glucose patterns 1
• Adjust prandial insulin every 3 days based on postprandial glucose readings 1
• Clinical follow-up in 2-4 weeks to assess progress and adherence 1
• HbA1c recheck in 3 months to determine if additional intensification needed 1