Is a regimen of Admelog (insulin lispro) 25 units three times daily plus Tuojeo (insulin glargine) 40 units, increased by 2 units every 3 days until fasting blood glucose is <10 mmol/L, appropriate for a 220‑lb patient with an A1C of 11.1%?

Insulin Regimen Assessment for Severe Hyperglycemia (A1C 11.1%)

Current Regimen Is Profoundly Inadequate

The proposed regimen of Admelog 25 units TID plus Tuojeo 40 units is grossly insufficient for a 220‑lb (100‑kg) patient with an A1C of 11.1%. This total daily dose of approximately 115 units (0.75 units/kg/day basal + 0.75 units/kg/day prandial = 1.15 units/kg/day total) falls well below the 0.3–0.5 units/kg/day minimum recommended for severe hyperglycemia, and the titration schedule of 2 units every 3 days will take months to achieve adequate control, prolonging dangerous hyperglycemia exposure. 1

Evidence‑Based Starting Doses for A1C 11.1%

• Basal insulin (Tuojeo): Start at 0.3–0.5 units/kg/day (30–50 units once daily for a 100‑kg patient), not 40 units, because an A1C of 11.1% indicates severe insulin deficiency requiring immediate aggressive dosing. 1

• Prandial insulin (Admelog): The remaining 50% of total daily dose should be divided among three meals—approximately 10–17 units per meal (30–50 units total prandial), not 25 units TID, to address both fasting and post‑prandial hyperglycemia. 1

• Total daily insulin requirement: For A1C ≥ 9%, guidelines explicitly recommend 0.3–0.5 units/kg/day as the starting point, which translates to 60–100 units/day total for this patient, split 50% basal and 50% prandial. 1

Critical Problems with the Proposed Titration Schedule

• Tuojeo titration of 2 units every 3 days is far too slow when fasting glucose is likely ≥ 180 mg/dL; the American Diabetes Association recommends 4 units every 3 days for fasting glucose ≥ 180 mg/dL to achieve target fasting glucose (80–130 mg/dL) within 2–3 weeks, not months. 1

• The target of "BG < 10 mmol/L" (180 mg/dL) is inadequate; the correct fasting glucose target is 80–130 mg/dL (4.4–7.2 mmol/L), and post‑prandial glucose should be < 180 mg/dL. 1

• Delaying adequate insulin dosing when A1C is 11.1% prolongs exposure to severe hyperglycemia, which increases the risk of long‑term complications and acute metabolic decompensation. 1

Recommended Corrected Regimen

Basal Insulin (Tuojeo)

• Start at 40–50 units once daily at bedtime (0.4–0.5 units/kg for a 100‑kg patient). 1
• Titrate by 4 units every 3 days if fasting glucose remains ≥ 180 mg/dL. 1
• Titrate by 2 units every 3 days if fasting glucose is 140–179 mg/dL. 1
• Target fasting glucose: 80–130 mg/dL. 1
• Stop basal escalation when dose approaches 0.5–1.0 units/kg/day (50–100 units) without achieving targets; at this threshold, intensify prandial insulin rather than continuing basal escalation to avoid "over‑basalization." 1

Prandial Insulin (Admelog)

• Start at 10–17 units before each of the three largest meals (total 30–50 units/day prandial). 1
• Administer 0–15 minutes before meals for optimal post‑prandial control. 1
• Titrate each meal dose by 1–2 units (≈10–15%) every 3 days based on 2‑hour post‑prandial glucose readings. 1
• Target post‑prandial glucose: < 180 mg/dL. 1

Correction Insulin Protocol

• Add 2 units Admelog for pre‑meal glucose > 250 mg/dL. 1
• Add 4 units Admelog for pre‑meal glucose > 350 mg/dL. 1
• Correction doses must supplement—not replace—scheduled basal and prandial insulin. 1

Monitoring Requirements During Intensive Titration

• Daily fasting glucose to guide Tuojeo 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 while actively titrating. 1
• Check A1C every 3 months until stable control is achieved. 1

Foundation Therapy: Metformin Must Continue

• Continue or up‑titrate metformin to at least 1,000 mg twice daily (2,000 mg total) unless contraindicated; metformin reduces total insulin requirements by 20–30% and provides superior glycemic control compared with insulin alone. 1
• The maximum effective daily dose of metformin is up to 2,500 mg. 1
• Do not discontinue metformin during insulin intensification unless contraindicated, as omission raises insulin needs and worsens outcomes. 1

Expected Clinical Outcomes with Corrected Regimen

• Approximately 68% of patients achieve mean glucose < 140 mg/dL with a properly scheduled basal‑bolus regimen at weight‑based dosing, versus 38% when dosing is inadequate. 1
• An A1C reduction of 3–4% (e.g., from 11.1% to ≈7–8%) is achievable within 3–6 months of intensive insulin titration combined with metformin. 1
• Properly implemented basal‑bolus therapy does not increase hypoglycemia risk relative to under‑dosed insulin. 1

Alternative to Further Prandial Escalation: GLP‑1 Receptor Agonist

• If Tuojeo exceeds 0.5 units/kg/day (≈50 units) without reaching targets, consider adding a GLP‑1 receptor agonist (e.g., semaglutide, dulaglutide) instead of further prandial insulin escalation. 1
• The basal‑insulin + GLP‑1 RA combination provides potent glucose‑lowering effects with less weight gain and lower hypoglycemia risk compared with intensified basal‑bolus regimens. 1
• However, for A1C 11.1%, immediate basal‑bolus insulin is preferred to achieve rapid control before considering GLP‑1 RA addition. 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 Tuojeo beyond 0.5–1.0 units/kg/day without addressing post‑prandial hyperglycemia, to prevent over‑basalization and hypoglycemia. 1
• Never rely on sliding‑scale insulin as monotherapy; correction doses must supplement a scheduled basal‑bolus regimen. 1
• Do not discontinue metformin during insulin intensification unless contraindicated. 1

Hypoglycemia Management

• Treat glucose < 70 mg/dL promptly with 15 g of 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
• Provide comprehensive patient education on hypoglycemia recognition, treatment, proper injection technique, and sick‑day management. 1