Is a regimen of Admelog (insulin lispro) 25 units three times daily plus Tuojeo (insulin glargine) 40 units once daily adequate for a 220‑lb (≈100 kg) patient with an A1c of 11.1%?

Inadequate Insulin Regimen for Severe Hyperglycemia

This insulin regimen is profoundly inadequate for a 220-lb (100 kg) patient with an A1c of 11.1%. The total daily dose of 115 units (75 units prandial + 40 units basal) represents approximately 1.15 units/kg/day, which falls within expected ranges for severe insulin resistance, but the distribution is fundamentally flawed—this patient requires immediate basal-bolus restructuring with aggressive titration rather than the current fixed dosing.1

Critical Problems with Current Regimen

Insufficient Basal Insulin Coverage

• Tuojeo 40 units once daily provides only 0.4 units/kg/day of basal insulin, far below the 0.5–1.0 units/kg/day threshold where basal escalation should stop and prandial insulin should be added or intensified.1, 2
• For an A1c of 11.1%, guidelines recommend starting doses of 0.3–0.5 units/kg/day as total daily insulin (30–50 units/day for this patient), with basal insulin comprising approximately 50% of this total.1, 2
• Fasting glucose likely remains severely elevated (>180 mg/dL) with only 40 units of basal insulin, indicating the need for aggressive basal titration by 4 units every 3 days until fasting glucose reaches 80–130 mg/dL.1, 2

Excessive and Inappropriately Distributed Prandial Insulin

• Admelog 25 units three times daily (75 units total) represents 0.75 units/kg/day of prandial insulin alone—this is excessive without adequate basal coverage and suggests "reverse over-basalization" where prandial insulin is being used to compensate for insufficient basal insulin.1, 2
• The fixed 25-unit prandial doses ignore individual meal carbohydrate content and fail to account for variable insulin sensitivity throughout the day; breakfast typically requires more insulin per gram of carbohydrate due to counter-regulatory hormones.1, 2
• This approach violates the fundamental principle that basal insulin should comprise 40–50% of total daily dose in type 1 diabetes and approximately 50% in type 2 diabetes requiring basal-bolus therapy.1, 2

Lack of Systematic Titration Protocol

• No evidence of systematic dose adjustment based on glucose monitoring—the regimen appears static despite severe hyperglycemia (A1c 11.1%).1, 2
• Guidelines mandate increasing basal insulin by 4 units every 3 days when fasting glucose ≥180 mg/dL and adjusting prandial insulin by 1–2 units every 3 days based on 2-hour postprandial glucose.1, 2

Recommended Immediate Restructuring

Basal Insulin Intensification

• Increase Tuojeo to at least 50–60 units once daily (0.5–0.6 units/kg) as an immediate starting point, then titrate aggressively by 4 units every 3 days until fasting glucose consistently reaches 80–130 mg/dL.1, 2
• Monitor for clinical signals of over-basalization when basal dose approaches 0.5–1.0 units/kg/day (50–100 units): bedtime-to-morning glucose differential ≥50 mg/dL, hypoglycemia episodes, or high glucose variability.1, 2
• Stop basal escalation at approximately 0.5 units/kg/day (50 units) and shift focus to prandial optimization rather than continuing basal increases beyond this threshold.1, 2

Prandial Insulin Redistribution

• Reduce initial prandial doses to 10–15 units per meal (total 30–45 units/day) to achieve a more appropriate 50:50 basal-to-prandial ratio.1, 2
• Implement carbohydrate-to-insulin ratios starting at 1 unit per 10 grams of carbohydrate (450 ÷ total daily dose), with breakfast often requiring a tighter ratio (1:8 or 1:6) due to dawn phenomenon.1, 2
• Titrate each meal dose independently by 1–2 units every 3 days based on 2-hour postprandial glucose readings, targeting <180 mg/dL.1, 2
• Administer Admelog 0–15 minutes before meals (ideally immediately before eating) for optimal postprandial control.1, 2

Correction Insulin Protocol

• Add correction doses of 2 units for pre-meal glucose >250 mg/dL and 4 units for >350 mg/dL, in addition to scheduled prandial doses—never as a replacement.1, 2
• Calculate individualized insulin sensitivity factor (ISF) as 1500 ÷ total daily dose; for 115 units total, ISF ≈ 13 mg/dL per unit, meaning correction dose = (current glucose – target glucose) ÷ 13.2

Foundation Therapy Optimization

Metformin Continuation

• Verify metformin is continued at maximum tolerated dose (up to 2000–2550 mg daily) when intensifying insulin therapy; metformin reduces total insulin requirements by 20–30% and provides complementary glucose-lowering effects.1, 2
• Never discontinue metformin when adding or intensifying insulin unless specific contraindications exist (renal impairment, acute illness, tissue hypoxia).1, 2

GLP-1 Receptor Agonist Consideration

• When basal insulin approaches 0.5–1.0 units/kg/day without achieving targets, consider adding a GLP-1 receptor agonist (e.g., semaglutide) instead of further prandial insulin escalation; this combination provides comparable postprandial control with less hypoglycemia and weight loss rather than weight gain.1, 3
• GLP-1 RAs in combination with basal insulin demonstrate superior outcomes compared with basal-bolus insulin regimens, with lower hypoglycemia rates and beneficial effects on body weight.1, 3

Monitoring Requirements During Intensification

Daily Glucose Monitoring

• Fasting glucose daily to guide basal insulin adjustments—increase by 4 units every 3 days if ≥180 mg/dL, by 2 units if 140–179 mg/dL.1, 2
• Pre-meal glucose before each meal to calculate correction doses.1, 2
• 2-hour postprandial glucose after each meal to assess prandial adequacy and guide meal-specific titration.1, 2
• Bedtime glucose to evaluate overall daily pattern and detect nocturnal hypoglycemia risk.1, 2

Follow-Up Schedule

• Reassess insulin doses every 3 days during active titration phase.1, 2
• HbA1c measurement every 3 months until stable control is achieved; expect 3–4% reduction (from 11.1% to approximately 7–8%) over 3–6 months with intensive titration.1, 2
• Urgent endocrinology referral if HbA1c remains >9% after 3–6 months of optimization.1

Expected Clinical Outcomes with Proper Regimen

Glycemic Control

• Approximately 68% of patients achieve mean glucose <140 mg/dL with properly implemented basal-bolus therapy, compared with 38% when dosing is inadequate.1, 2
• HbA1c reduction of 3–4% (from 11.1% to approximately 7–8%) is achievable within 3–6 months of intensive insulin titration combined with metformin.1, 2

Hypoglycemia Risk

• Properly implemented basal-bolus regimens do not increase hypoglycemia incidence compared with inadequate sliding-scale approaches when systematic titration protocols are followed.1, 2
• Treat any glucose <70 mg/dL immediately with 15 grams of fast-acting carbohydrate, recheck in 15 minutes, and reduce the implicated insulin dose by 10–20% if hypoglycemia occurs without obvious cause.1, 2

Critical Pitfalls to Avoid

Therapeutic Inertia

• Do not delay insulin intensification when A1c is 11.1%; prolonged hyperglycemia increases complication risk and represents a failure of the current regimen.1, 2
• Do not continue the current fixed-dose regimen without systematic titration based on glucose monitoring—this perpetuates inadequate control.1, 2

Inappropriate Insulin Distribution

• Avoid continuing basal insulin escalation beyond 0.5–1.0 units/kg/day (50–100 units) without addressing postprandial hyperglycemia through prandial insulin optimization; this leads to over-basalization with increased hypoglycemia risk.1, 2
• Never rely solely on correction (sliding-scale) insulin without adjusting scheduled basal and prandial doses; this reactive approach is condemned by major diabetes guidelines.1, 2

Medication Discontinuation

• Do not discontinue metformin when intensifying insulin unless contraindicated; omission increases insulin requirements and worsens outcomes.1, 2