What medication and insulin regimen adjustments should be made for a 54‑year‑old woman with type 2 diabetes and hemoglobin A1c 11.3 %, who is currently taking insulin glargine 50 U daily, regular insulin (Novolin) 10 U before each meal, and glipizide 5 mg twice daily?

Insulin Regimen Adjustments for Uncontrolled Type 2 Diabetes

Immediate Medication Changes Required

This patient's current regimen is profoundly inadequate and must be restructured immediately. With an HbA1c of 11.3%, fasting glucose likely exceeding 180 mg/dL, and already on 50 units of basal insulin plus prandial coverage, the patient demonstrates both insufficient basal insulin and inadequate mealtime coverage. 1, 2

Discontinue Glipizide

• Stop glipizide 5 mg BID immediately when intensifying to a basal-bolus insulin regimen to prevent additive hypoglycemia risk. 2 The sulfonylurea adds minimal benefit at this level of hyperglycemia and increases the risk of severe hypoglycemia when combined with intensive insulin therapy.

Aggressive Basal Insulin Titration (Insulin Glargine)

• Increase insulin glargine by 4 units every 3 days until fasting glucose consistently reaches 80–130 mg/dL, given that fasting values are almost certainly ≥180 mg/dL with an HbA1c of 11.3%. 1, 2
• The current 50-unit dose is insufficient; for a typical adult (assuming ~70 kg), this represents only ~0.7 units/kg/day, which is below the expected requirement for severe hyperglycemia. 2
• Critical threshold: When basal insulin approaches 0.5–1.0 units/kg/day (~35–70 units for most adults) without achieving targets, stop further basal escalation and intensify prandial insulin instead to avoid "over-basalization." 1, 2

Intensify Prandial Insulin (Regular Insulin/Novolin)

• Increase Novolin (regular insulin) from 10 units to at least 15–20 units before each meal as an immediate adjustment, recognizing that the current 10-unit dose is grossly inadequate for an HbA1c of 11.3%. 1, 2
• Titrate each meal dose by 2 units every 3 days based on 2-hour post-prandial glucose readings, targeting post-prandial glucose <180 mg/dL. 1, 2
• Administer regular insulin 30–45 minutes before meals for optimal post-prandial control (unlike rapid-acting analogs which are given 0–15 minutes before eating). 1

Add Correction Insulin Protocol

• Implement a correction insulin protocol: Add 2 units of regular insulin for pre-meal glucose >250 mg/dL and 4 units for glucose >350 mg/dL, in addition to the scheduled prandial dose. 2
• Correction doses must supplement—not replace—scheduled basal and prandial insulin; never rely on correction insulin alone. 2

Expected Weight-Based Dosing

• For severe hyperglycemia (HbA1c ≥9%), the American Diabetes Association recommends a total daily insulin dose of 0.3–0.5 units/kg/day, split 50% basal and 50% prandial. 1, 2
• In a 70-kg patient, this translates to 21–35 units/day total, but given the HbA1c of 11.3%, requirements will likely exceed this range, potentially reaching 60–80 units/day total (30–40 units basal, 30–40 units prandial divided among meals). 2

Monitoring Protocol

• Check fasting glucose daily to guide basal insulin adjustments. 1, 2
• Measure pre-meal glucose before each meal to calculate correction doses. 2
• Obtain 2-hour post-prandial glucose after each meal to assess prandial adequacy and guide titration. 1, 2
• Reassess HbA1c every 3 months during intensive titration. 2

Foundation Therapy: Continue Metformin

• Verify the patient is on metformin (not mentioned in the question); if not already prescribed, start metformin at 1000 mg BID (2000 mg total daily) unless contraindicated. 1, 2
• Metformin reduces total insulin requirements by 20–30% and provides superior glycemic control when combined with insulin compared to insulin alone. 2
• Never discontinue metformin when intensifying insulin therapy unless specific contraindications exist (renal impairment, acute illness, tissue hypoxia). 2

Expected Clinical Outcomes

• With properly implemented basal-bolus therapy at weight-based dosing, approximately 68% of patients achieve mean glucose <140 mg/dL versus only 38% with inadequate insulin dosing. 2
• HbA1c reduction of 3–4% (from 11.3% to ~7.3–8.3%) is achievable within 3–6 months with intensive insulin titration. 2
• Properly executed basal-bolus regimens do not increase overall hypoglycemia incidence compared with inadequate sliding-scale approaches when correctly implemented. 2

Critical Pitfalls to Avoid

• Do not delay prandial insulin intensification when pre-meal glucose values are consistently in the 200s with HbA1c 11.3%; this clearly indicates the need for both basal and prandial coverage. 2
• Do not continue escalating basal insulin beyond 0.5–1.0 units/kg/day without addressing post-prandial hyperglycemia, as this leads to over-basalization with increased hypoglycemia risk and suboptimal control. 1, 2
• Never rely solely on correction doses without adjusting scheduled basal and prandial insulin; this reactive strategy is condemned by major diabetes guidelines and causes dangerous glucose fluctuations. 2
• Do not discontinue glipizide abruptly without intensifying insulin; the sulfonylurea must be replaced with adequate insulin coverage to prevent rebound hyperglycemia. 2

Hypoglycemia Management

• Treat any glucose <70 mg/dL immediately with 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if needed. 2
• If hypoglycemia occurs without an obvious cause, reduce the implicated insulin dose by 10–20% immediately. 1, 2

Patient Education Essentials

• Teach proper insulin injection technique and site rotation to prevent lipohypertrophy. 1, 2
• Provide education on hypoglycemia recognition and treatment (symptoms, <70 mg/dL threshold, 15-g carbohydrate rule). 1, 2
• Instruct on "sick day" management: continue insulin even if not eating, check glucose every 4 hours, maintain hydration. 2
• Ensure the patient has glucose monitoring supplies and checks at least 4 times daily during titration. 2