What is the appropriate diabetes management for an 88‑year‑old woman on sliding‑scale insulin aspart (NovoLog) with an A1c of 7.2% and high hypoglycemia risk?

Appropriate Diabetes Management for an 88-Year-Old Woman on Sliding-Scale NovoLog with A1c 7.2%

Immediately Discontinue Sliding-Scale Insulin as Monotherapy

Sliding-scale insulin (SSI) used as the sole regimen must be stopped immediately and replaced with a scheduled basal-bolus insulin regimen, as SSI monotherapy is explicitly condemned by all major diabetes guidelines and provides no clinical benefit. 1, 2 In hospitalized patients, only approximately 38% achieve mean glucose <140 mg/dL with SSI alone versus 68% with scheduled basal-bolus therapy, and SSI treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations. 1, 2

Establish Individualized Glycemic Targets for This Elderly Patient

For an 88-year-old woman, a less stringent A1c target of 7.5–8.0% is appropriate to minimize hypoglycemia risk while maintaining adequate glycemic control, especially given her high hypoglycemia risk. 1 The current A1c of 7.2% is already near this target, so aggressive intensification would be inappropriate and potentially harmful. 1 Tight glycemic control in older adults with multiple medical conditions is considered overtreatment, and the presence of a single end-stage chronic illness may cause significant symptoms or impairment of functional status and significantly reduce life expectancy. 1

Transition to Simplified Basal Insulin Regimen

Initiate basal insulin (glargine, detemir, or degludec) at 10 units once daily at bedtime or 0.1–0.2 units/kg body weight, which provides continuous background insulin coverage and prevents fasting hyperglycemia. 1, 3, 2 For high-risk elderly patients (>65 years), start with the lower end of this range (0.1–0.25 units/kg/day) to minimize hypoglycemia risk. 1, 3 Basal insulin suppresses hepatic glucose production independent of food intake and is essential even when oral intake is limited. 1, 2

Titrate basal insulin by 2 units every 3 days if fasting glucose is 140–179 mg/dL, or by 4 units every 3 days if fasting glucose ≥180 mg/dL, targeting fasting glucose of 80–130 mg/dL. 1, 3, 2 If any unexplained hypoglycemia (glucose <70 mg/dL) occurs, reduce the dose by 10–20% immediately. 1, 3, 2

Add Correction Insulin Only as Adjunct to Scheduled Basal Insulin

Correction doses of rapid-acting insulin (NovoLog/aspart) should supplement—not replace—scheduled basal insulin. 1, 2 Use a simplified correction protocol: add 2 units for pre-meal glucose >250 mg/dL and 4 units for glucose >350 mg/dL. 1, 3, 2 Never administer rapid-acting insulin at bedtime as a sole correction dose, as this markedly raises nocturnal hypoglycemia risk. 1, 3, 2

Implement Deintensification Strategies for Older Adults

Simplification of complex insulin regimens is recommended to reduce hypoglycemia risk if it can be achieved within the individualized A1c target. 1 When patients are found to have an insulin regimen with complexity beyond their self-management abilities, simplification has been shown to reduce hypoglycemia and disease-related distress without worsening glycemic control. 1 Adjust insulin doses every 2 weeks based on finger-stick glucose testing in older adults receiving palliative care or with limited self-management abilities. 1, 2

Monitoring Requirements and Hypoglycemia Prevention

Check fasting glucose daily during titration to guide basal insulin adjustments. 1, 3, 2 For patients eating regular meals, measure glucose before each meal and at bedtime (minimum 4 times daily). 1, 2 For patients with poor oral intake or NPO status, check glucose every 4–6 hours. 1, 2

Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate, recheck in 15 minutes, and repeat if needed. 1, 3, 2 If hypoglycemia occurs without an obvious cause, reduce the implicated insulin dose by 10–20% before the next administration. 1, 3, 2 Recognize that 75% of hospitalized patients who experience hypoglycemia receive no basal insulin dose adjustment before the next dose, highlighting a critical management gap. 1, 2

Special Considerations for Palliative Care and End-of-Life

In older adults receiving palliative care, the focus should shift to comfort and prevention of symptomatic hyperglycemia (>250 mg/dL) or hypoglycemia rather than tight glycemic control. 1 Providers should initiate conversations regarding the goals and intensity of diabetes care, as strict glucose and blood pressure control may not be consistent with achieving comfort and quality of life. 1 Consider withdrawing or simplifying treatment interventions to be mindful of quality of life, and the decision process may need to involve the patient, family, and caregivers. 1

For stable patients with advanced disease, continue the previous regimen with a focus on prevention of hypoglycemia and management of hyperglycemia, keeping levels below the renal threshold of glucose to prevent hyperglycemia-mediated dehydration. 1 There is no role for A1C monitoring in this population. 1

Critical Pitfalls to Avoid

• Never continue SSI as monotherapy when glucose repeatedly exceeds 180 mg/dL; it is inferior and unsafe. 1, 2
• Do not aim for A1c <6.5% in patients aged ≥65 years, as this intensification increases hypoglycemia risk without proven mortality or quality-of-life benefit. 2, 4
• Avoid using rapid-acting insulin at bedtime as a sole correction dose, which markedly increases nocturnal hypoglycemia risk. 1, 3, 2
• Do not delay dose reduction when hypoglycemia occurs; studies show 75% of hospitalized patients with hypoglycemia receive no basal insulin adjustment before the next dose. 1, 2
• Never fully discontinue basal insulin in insulin-dependent patients, even when NPO, to prevent diabetic ketoacidosis. 1, 2