How should I adjust the diabetes regimen for a 69‑year‑old man with type 2 diabetes, hypertension, hyperlipidemia, vitamin‑D deficiency, stable hemoglobin A1c 7.8%, normal estimated glomerular filtration rate, who is currently taking insulin aspart (Novolog) 10 U before breakfast and 5 U at bedtime, insulin glargine (Lantus) 44 U twice daily, semaglutide (Ozempic) 2 mg weekly, and glipizide 10 mg twice daily?

Simplify and Optimize This Complex Insulin Regimen

This patient is severely over-insulinized with a dangerously complex and redundant regimen that must be simplified immediately. 1

Critical Problems with Current Regimen

Your patient is taking:

• Lantus 44 units twice daily = 88 units basal insulin (1.22 units/kg/day for a typical 72 kg patient)
• Novolog 10 units AM + 5 units HS = 15 units prandial
• Total daily insulin: 103 units (1.43 units/kg/day)
• Plus Ozempic 2 mg weekly AND glipizide 10 mg twice daily

This represents massive over-basalization with redundant glucose-lowering agents creating high hypoglycemia risk. 1, 2

Immediate Regimen Simplification (Follow This Algorithm)

Step 1: Discontinue Glipizide Immediately

• Stop glipizide 10 mg twice daily today. The combination of high-dose insulin, GLP-1 RA, and sulfonylurea creates unacceptable hypoglycemia risk. 1, 2
• Sulfonylureas should be discontinued when patients are on established insulin therapy. 2

Step 2: Consolidate to Once-Daily Basal Insulin

Calculate 70% of total current basal dose and give once daily in the morning: 1

• Current total basal: 88 units/day
• New dose: 88 × 0.70 = 62 units Lantus once daily in the morning

Rationale: Twice-daily Lantus dosing at this level indicates the regimen was never properly titrated; consolidation simplifies management and reduces stacking. 1, 2

Step 3: Discontinue Bedtime Novolog

• Stop the 5 units Novolog at bedtime immediately. Rapid-acting insulin should never be given at bedtime—this dramatically increases nocturnal hypoglycemia risk. 1, 2

Step 4: Address Morning Novolog

For the 10 units Novolog before breakfast:

• Since this is ≤10 units, discontinue it and rely on the GLP-1 RA (Ozempic) for prandial coverage. 1
• GLP-1 receptor agonists are the preferred injectable medication and provide superior postprandial control with lower hypoglycemia risk than prandial insulin. 2

Step 5: Continue Ozempic

• Maintain Ozempic 2 mg weekly. This provides excellent postprandial glucose control and weight management. 2

New Simplified Regimen

Lantus 62 units subcutaneously once daily every morning
Ozempic 2 mg subcutaneously once weekly
Discontinue: Novolog, glipizide

Titration Protocol Going Forward

Monitor fasting glucose daily for 2 weeks:

• If ≥50% of fasting values are 90–150 mg/dL: Current dose appropriate 1
• If ≥50% of fasting values >150 mg/dL: Increase Lantus by 2 units every week 1, 2
• If >2 fasting values/week <80 mg/dL: Decrease Lantus by 2 units immediately 1, 2

Critical threshold warning:

• When basal insulin exceeds 0.5 units/kg/day (approximately 36 units for a 72 kg patient) without achieving HbA1c <7.5%, adding back prandial insulin becomes more appropriate than continuing basal escalation. 1, 2
• At 62 units (0.86 units/kg), this patient is already in over-basalization territory, but simplification takes priority given the current dangerous polypharmacy. 1, 2

Expected Outcomes

• HbA1c should remain stable or improve given that total glucose-lowering effect is preserved while hypoglycemia risk drops dramatically. 2
• Weight gain should stabilize or reverse with GLP-1 RA as primary adjunct rather than high-dose insulin plus sulfonylurea. 2, 3
• Hypoglycemia risk decreases by >50% with elimination of bedtime rapid-acting insulin and sulfonylurea. 1, 2

Recheck HbA1c in 3 Months

If HbA1c remains 7.5–8.0%:

• Acceptable target for a 69-year-old with multiple comorbidities. 1
• Continue current regimen.

If HbA1c >8.0%:

• First, titrate Lantus up to 0.5 units/kg/day (36 units) using the protocol above. 2
• If still inadequate, add back prandial insulin: Start with 4 units Novolog before the largest meal, titrate by 1–2 units every 3 days based on 2-hour postprandial glucose. 2

Common Pitfalls to Avoid

• Never continue twice-daily Lantus at these doses—this indicates fundamental misunderstanding of basal insulin pharmacokinetics. 2
• Never give rapid-acting insulin at bedtime as monotherapy or correction—nocturnal hypoglycemia risk is unacceptable. 1, 2
• Never combine high-dose insulin with sulfonylureas—hypoglycemia rates skyrocket. 2
• Never continue escalating basal insulin beyond 0.5–1.0 units/kg/day without addressing postprandial coverage separately. 1, 2

Patient Education Priorities

• Hypoglycemia recognition and treatment: Treat any glucose <70 mg/dL with 15 grams fast-acting carbohydrate. 2
• Injection technique: Rotate sites within same region (abdomen preferred for Lantus). 4
• Timing: Lantus must be given at the same time every morning; Ozempic once weekly on the same day. 2, 4