How should I intensify therapy for an adult with type 2 diabetes whose fasting glucose is 176‑322 mg/dL, midday 186‑476 mg/dL, evening 255‑465 mg/dL, currently on metformin 500 mg daily, semaglutide (Ozempic) 0.5 mg weekly (unable to titrate), insulin glargine (Basaglar) 40 U at night and 100 U in the morning, and sliding‑scale regular insulin (Novolin R)?

Aggressive Insulin Intensification Required for Severe Uncontrolled Type 2 Diabetes

Your current insulin regimen is profoundly inadequate—you need immediate basal-bolus insulin therapy with total daily doses of 0.5–1.0 units/kg/day (approximately 50–100 units/day for your weight), split between basal and prandial insulin, combined with optimized metformin dosing. 1

Critical Problems with Your Current Regimen

Your glucose readings (fasting 176–322 mg/dL, midday 186–476 mg/dL, evening 255–465 mg/dL) represent complete therapeutic failure requiring urgent intervention. 1

• Sliding-scale insulin (Novolin R SSI) as your primary treatment is condemned by all major diabetes guidelines—only 38% of patients achieve mean glucose <140 mg/dL with SSI alone versus 68% with scheduled basal-bolus therapy. 1
• Your total basal insulin dose of 140 units daily (40 units at night + 100 units in the morning) is dangerously high without adequate prandial coverage, creating "overbasalization" with increased hypoglycemia risk and suboptimal control. 1
• Metformin 500 mg daily is grossly underdosed—you need at least 1,000–2,000 mg daily unless contraindicated. 1, 2, 3
• Ozempic 0.5 mg weekly cannot be titrated yet, limiting its glucose-lowering potential. 4

Immediate Medication Changes Required

1. Restructure Your Insulin Regimen

Discontinue the current chaotic regimen and transition to scheduled basal-bolus therapy:

• Basal insulin (Basaglar): Reduce to 60–70 units once daily at bedtime (approximately 0.5 units/kg/day for your weight). 1

  • This consolidates your excessive split-dose basal insulin into a single, more manageable dose.
  • When basal insulin exceeds 0.5 units/kg/day without achieving targets, adding prandial insulin is more appropriate than further basal escalation. 1

• Prandial insulin (rapid-acting): Start 10–12 units of rapid-acting insulin (lispro, aspart, or glulisine) before each of your three largest meals. 1

  • Administer 0–15 minutes before meals for optimal postprandial control. 1
  • This addresses your severe postprandial hyperglycemia (midday 186–476 mg/dL, evening 255–465 mg/dL).

• Correction insulin: Add 2 units of rapid-acting insulin for pre-meal glucose >250 mg/dL and 4 units for glucose >350 mg/dL, in addition to scheduled prandial doses. 1

  • Never use correction insulin as monotherapy—it must supplement scheduled basal-bolus therapy. 1

2. Optimize Metformin Dosing

Increase metformin to at least 1,000 mg twice daily (2,000 mg total) unless contraindicated. 1, 2, 3

• Metformin reduces total insulin requirements by 20–30% and provides superior glycemic control when combined with insulin. 1, 2, 3
• Maximum effective dose is up to 2,550 mg/day. 1
• Never discontinue metformin when intensifying insulin therapy unless contraindicated—this leads to higher insulin requirements and more weight gain. 1

3. Continue Ozempic

• Maintain Ozempic 0.5 mg weekly until you can titrate to 1 mg weekly. 4
• The combination of GLP-1 receptor agonist (Ozempic) with basal-bolus insulin provides superior outcomes compared to insulin alone, with less weight gain and hypoglycemia risk. 1, 4
• Ozempic combined with metformin significantly improves glycemic control, insulin resistance, weight, and lipid profiles. 5, 6

Insulin Titration Protocol

Basal Insulin (Basaglar) Titration

• If fasting glucose is 140–179 mg/dL: Increase Basaglar by 2 units every 3 days. 1
• If fasting glucose is ≥180 mg/dL: Increase Basaglar by 4 units every 3 days. 1
• Target fasting glucose: 80–130 mg/dL. 1
• Critical threshold: When Basaglar approaches 0.5–1.0 units/kg/day (approximately 50–100 units for your weight) without achieving targets, stop further basal escalation and intensify prandial insulin instead. 1

Prandial Insulin Titration

• Check glucose 2 hours after each meal. 1
• If postprandial glucose consistently >180 mg/dL: Increase the insulin dose for that meal by 2 units every 3 days. 1
• Target postprandial glucose: <180 mg/dL. 1

Hypoglycemia Management

• Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate. 1
• If hypoglycemia occurs without an obvious cause, reduce the implicated insulin dose by 10–20% promptly. 1

Glucose Monitoring Requirements

• Check fasting glucose every morning to guide basal insulin titration. 1
• Check pre-meal glucose before each meal to calculate correction doses. 1
• Check 2-hour postprandial glucose to assess adequacy of prandial insulin. 1
• Minimum 4 checks daily during intensive titration. 1

Expected Clinical Outcomes

• 68% of patients achieve mean glucose <140 mg/dL with basal-bolus therapy versus 38% with sliding-scale alone. 1
• HbA1c reduction of 3–4% (e.g., from ~12% to 8–9%) is achievable within 3–6 months with appropriate insulin intensification. 1
• No increase in hypoglycemia incidence when basal-bolus regimens are correctly implemented versus sliding-scale monotherapy. 1
• Semaglutide combined with metformin significantly improves glycemic control, insulin resistance, weight, BMI, and lipid profiles. 5, 6

Critical Pitfalls to Avoid

• Never continue sliding-scale insulin as monotherapy—evidence shows it is inferior and unsafe. 1
• Do not delay prandial insulin addition when pre-meal glucose consistently exceeds 250 mg/dL. 1
• Avoid basal insulin >0.5–1.0 units/kg/day without concurrent prandial coverage—this raises hypoglycemia risk without improving control. 1
• Do not discontinue metformin when starting insulin unless medically contraindicated. 1, 2, 3
• Never give rapid-acting insulin solely at bedtime as a correction dose—this markedly increases nocturnal hypoglycemia risk. 1

Follow-Up Schedule

• 1–2 weeks: Primary care or endocrinology visit to assess glucose control and medication tolerance. 1
• Monthly visits until HbA1c falls below 9%; thereafter every 3 months. 1
• Urgent endocrinology referral required for HbA1c >9% with unstable glucose. 1

Patient Education Essentials

• Insulin injection technique and site rotation to prevent lipohypertrophy. 1
• Hypoglycemia recognition and treatment (symptoms, <70 mg/dL threshold, 15-gram carbohydrate rule). 1
• Sick-day management: Continue insulin even if not eating, check glucose every 4 hours, maintain hydration. 1
• Ketone testing when glucose >300 mg/dL with nausea/vomiting. 1