For a patient with type 2 diabetes and hemoglobin A1c 11.1% who is on insulin glargine (Toujeo) 30 U once daily, is adding 5 U insulin lispro (Admelog) twice daily an appropriate regimen?

Admelog 5 Units BID Is Insufficient for A1C 11.1% on Toujeo 30 Units QD

For a patient with type 2 diabetes and A1C 11.1% on Toujeo 30 units once daily, adding only Admelog 5 units twice daily is grossly inadequate and represents dangerous under-dosing that will fail to achieve glycemic control. This regimen provides a total daily insulin dose of only 40 units (30 basal + 10 prandial), which is far below the 0.3–0.5 units/kg/day recommended for severe hyperglycemia (A1C ≥9%), and the 5-unit prandial doses are too small to meaningfully address post-prandial glucose excursions 1.

Critical Problems with the Proposed Regimen

Inadequate Total Daily Insulin Dose

• An A1C of 11.1% indicates severe uncontrolled diabetes requiring immediate basal-bolus therapy with a total daily dose of 0.3–0.5 units/kg/day 1.
• For a typical 70-kg adult, this translates to 21–35 units/day total, but patients with A1C >10% often require substantially more—frequently approaching 0.5–1.0 units/kg/day (35–70 units) to achieve control 1.
• The proposed 40 units total (30 basal + 10 prandial) falls at the lower end of this range and is unlikely to produce meaningful A1C reduction from 11.1% 1.

Prandial Insulin Dose Too Small

• The American Diabetes Association recommends starting prandial insulin at 4 units before the largest meal or 10% of the current basal dose (which would be 3 units in this case, then titrated upward) 1.
• Starting with only 5 units twice daily (10 units total prandial) provides inadequate mealtime coverage for someone with A1C 11.1%, who likely has significant post-prandial glucose excursions exceeding 250–300 mg/dL 1.
• Properly implemented basal-bolus therapy typically requires 50% of total daily insulin as prandial coverage divided among three meals, not just two 1.

Missing Third Prandial Dose

• The proposed regimen provides prandial insulin only twice daily, leaving one major meal (typically lunch) completely uncovered 1.
• For A1C 11.1%, all three major meals require prandial insulin coverage to address the severe hyperglycemia 1.

Evidence-Based Recommended Regimen

Immediate Basal Insulin Adjustment

• Increase Toujeo by 4 units every 3 days until fasting glucose consistently reaches 80–130 mg/dL 1.
• For A1C 11.1%, the basal insulin dose will likely need to reach 0.3–0.5 units/kg/day (approximately 21–35 units for a 70-kg patient, potentially higher) 1.
• Stop basal escalation when the dose approaches 0.5 units/kg/day to avoid over-basalization; further glucose control should come from intensifying prandial insulin 1.

Prandial Insulin Initiation

• Start Admelog at 4–6 units before each of the three largest meals (breakfast, lunch, dinner), not just twice daily 1.
• This provides approximately 12–18 units total prandial insulin divided across three meals, which is more appropriate for severe hyperglycemia 1.
• Administer Admelog 0–15 minutes before meals for optimal post-prandial control 1.

Systematic Titration Protocol

• Increase each meal's Admelog dose by 2 units every 3 days based on 2-hour post-prandial glucose readings, targeting <180 mg/dL 1.
• Increase Toujeo by 4 units every 3 days if fasting glucose remains ≥180 mg/dL, or by 2 units every 3 days if fasting glucose is 140–179 mg/dL 1.
• If any glucose reading falls <70 mg/dL, immediately reduce the implicated insulin dose by 10–20% 1.

Expected Clinical Outcomes

With Proper Basal-Bolus Therapy

• Approximately 68% of patients achieve mean glucose <140 mg/dL with scheduled basal-bolus therapy, compared with only 38% when dosing is inadequate 1.
• An A1C reduction of 3–4% (from 11.1% to approximately 7–8%) is achievable within 3–6 months with intensive insulin titration 1.
• Properly implemented basal-bolus regimens do not increase hypoglycemia incidence compared with inadequate dosing approaches 1.

With the Proposed Inadequate Regimen

• The proposed 5 units BID Admelog will likely produce only a 0.5–1.0% A1C reduction, leaving the patient with A1C around 10–10.5%, which remains dangerously elevated 1.
• Post-prandial glucose excursions will remain largely uncontrolled, particularly after the meal without prandial coverage 1.

Foundation Therapy Considerations

Metformin Optimization

• Continue or maximize metformin to 2000 mg daily (1000 mg twice daily with meals) unless contraindicated 1.
• Metformin reduces total insulin requirements by 20–30% and provides superior glycemic control when combined with insulin 1.
• Never discontinue metformin when intensifying insulin therapy unless specific contraindications exist 1.

Alternative to Prandial Insulin

• If basal insulin exceeds 0.5 units/kg/day without achieving targets, consider adding a GLP-1 receptor agonist instead of or in addition to prandial insulin 1.
• The basal insulin + GLP-1 RA combination provides comparable post-prandial control with less hypoglycemia and weight loss rather than weight gain 1.
• However, for A1C 11.1%, immediate basal-bolus insulin is preferred to achieve rapid control 1.

Monitoring Requirements

During Intensive Titration

• Daily fasting glucose to guide Toujeo adjustments 1.
• Pre-meal glucose before each meal to calculate correction doses 1.
• 2-hour post-prandial glucose after each meal to assess Admelog adequacy 1.
• Bedtime glucose to evaluate overall daily pattern 1.
• Reassess insulin doses every 3 days during active titration 1.
• A1C every 3 months until stable control is achieved 1.

Critical Pitfalls to Avoid

Under-Dosing Errors

• Do not delay aggressive insulin intensification when A1C is 11.1%; prolonged severe hyperglycemia increases complication risk 1.
• Do not rely on inadequate prandial doses (5 units BID) when A1C indicates severe uncontrolled diabetes 1.
• Do not omit the third prandial dose; all three major meals require coverage for A1C 11.1% 1.

Over-Basalization

• Do not continue escalating Toujeo beyond 0.5–1.0 units/kg/day without addressing post-prandial hyperglycemia with adequate prandial insulin 1.
• Clinical signals of over-basalization include: basal dose >0.5 units/kg/day, bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, and high glucose variability 1.

Sliding-Scale Insulin Misuse

• Never rely solely on correction (sliding-scale) insulin without scheduled basal and prandial doses; major diabetes guidelines condemn this reactive approach 1.
• Correction insulin must supplement, not replace, scheduled basal-bolus therapy 1.

Hypoglycemia Management

• Treat any glucose <70 mg/dL promptly with 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if necessary 1.
• If hypoglycemia occurs without an obvious cause, reduce the implicated insulin dose by 10–20% immediately 1.
• Provide comprehensive patient education on hypoglycemia recognition, treatment, proper injection technique, site rotation, and sick-day management 1.