Is a basal‑bolus regimen of Toujeo (insulin glargine) 40 U once daily plus Admelog (insulin lispro) 6 U before each main meal appropriate for a 220‑lb (≈100 kg) woman with a hemoglobin A1c of 11.1%?

Inadequate Insulin Regimen for Severe Hyperglycemia in Type 2 Diabetes

This insulin regimen is profoundly insufficient and requires immediate intensification to prevent long-term complications. A 220-lb (≈100 kg) woman with an A1C of 11.1% needs approximately 30–50 units/day total insulin (0.3–0.5 units/kg/day), yet the current regimen provides only 58 units/day total (40 U basal + 18 U prandial), which falls at the lower end of the required range and is distributed incorrectly.1

Critical Problems with the Current Regimen

Basal Insulin Dose

• Toujeo 40 units once daily is inadequate for a 100-kg patient with severe hyperglycemia; the starting dose should be 0.1–0.2 units/kg/day (10–20 units) for insulin-naïve patients, but this patient requires 0.3–0.5 units/kg/day (30–50 units) given the A1C ≥9%.1
• The basal dose should be aggressively titrated by 4 units every 3 days until fasting glucose reaches 80–130 mg/dL, not left static at 40 units.1

Prandial Insulin Dose

• Admelog 6 units three times daily (18 units total) is grossly insufficient to cover post-prandial glucose excursions in severe hyperglycemia.1
• For an A1C of 11.1%, prandial insulin should start at ≈10–15 units per meal (30–45 units total daily), representing approximately 50% of the total daily dose.1
• Each meal dose should be titrated by 1–2 units every 3 days based on 2-hour post-prandial glucose readings, targeting <180 mg/dL.1

Basal-to-Prandial Ratio

• The current regimen provides 69% basal and 31% prandial insulin, which is inverted from the recommended 50% basal / 50% prandial split for basal-bolus therapy.1
• This imbalance indicates over-reliance on basal insulin without adequate mealtime coverage, leading to persistent post-prandial hyperglycemia.1

Evidence-Based Insulin Requirements

Total Daily Dose Calculation

• For severe hyperglycemia (A1C ≥9%), guidelines recommend 0.3–0.5 units/kg/day total insulin.1
• In a 100-kg patient, this equals 30–50 units/day minimum, split 50% basal (15–25 units) and 50% prandial (15–25 units).1
• The current 58 units/day is at the lower threshold, but the distribution is incorrect.1

Expected A1C Reduction

• Properly implemented basal-bolus therapy at weight-based dosing achieves A1C reductions of 2–3% (or 3–4% in severe hyperglycemia) over 3–6 months.1
• With the current inadequate regimen, the patient is unlikely to achieve an A1C <9% despite treatment.1

Recommended Immediate Adjustments

Basal Insulin (Toujeo)

• Increase Toujeo to 50–60 units once daily immediately (≈0.5 units/kg/day).1
• Titrate by 4 units every 3 days if fasting glucose remains ≥180 mg/dL.1
• Stop basal escalation when the dose approaches 0.5–1.0 units/kg/day (50–100 units) without achieving targets; at this threshold, intensify prandial insulin instead.1

Prandial Insulin (Admelog)

• Increase Admelog to 10–12 units before each of the three main meals (30–36 units total daily).1
• Administer 0–15 minutes before meals for optimal post-prandial control.1
• Titrate each meal dose by 2 units every 3 days based on 2-hour post-prandial glucose, targeting <180 mg/dL.1

Correction Insulin Protocol

• Add 2 units Admelog for pre-meal glucose >250 mg/dL and 4 units for >350 mg/dL, in addition to scheduled prandial doses.1

Monitoring Requirements

• 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
• A1C every 3 months until stable control is achieved.1

Adjunctive Therapy

Metformin Optimization

• Continue or maximize metformin to 2000 mg daily (1000 mg twice daily) unless contraindicated.1
• Metformin reduces total insulin requirements by 20–30% and provides superior glycemic control when combined with insulin.1

GLP-1 Receptor Agonist Consideration

• If basal insulin exceeds 0.5 units/kg/day (50 units) without achieving targets, consider adding a GLP-1 receptor agonist instead of further basal escalation.1
• This combination offers comparable post-prandial control with less hypoglycemia and weight loss rather than weight gain.1

Expected Clinical Outcomes

• With properly weight-based basal-bolus therapy, ≈68% of patients achieve mean glucose <140 mg/dL, compared with ≈38% on inadequate regimens.1
• An A1C reduction from 11.1% to ≈8–9% is achievable within 3–6 months with intensive titration.1
• Correctly implemented basal-bolus regimens do not increase hypoglycemia incidence compared with inadequate approaches.1

Critical Pitfalls to Avoid

• Do not delay insulin intensification when A1C is 11.1%; prolonged hyperglycemia increases complication risk.1
• Do not continue escalating basal insulin beyond 0.5–1.0 units/kg/day without addressing post-prandial hyperglycemia; this leads to over-basalization and hypoglycemia.1
• Do not discontinue metformin when intensifying insulin unless contraindicated; this leads to higher insulin requirements and worse outcomes.1
• Never rely on sliding-scale insulin as monotherapy; correction doses must supplement scheduled basal-bolus insulin.1

Hypoglycemia Management

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