What insulin protocol is appropriate for a 100‑kg patient with severe hyperglycemia (A1C 11.1%) who is currently taking insulin glargine (Tuojeo) 30 U at bedtime?

Insulin Protocol for a 220-lb Patient with A1C 11.1% on Tuojeo 30 Units at Bedtime

Immediate Insulin Intensification Required

This patient requires aggressive basal-bolus insulin therapy starting immediately—not just basal insulin titration—because an A1C of 11.1% indicates both severe fasting hyperglycemia and uncontrolled postprandial glucose excursions that cannot be addressed by basal insulin alone. 1, 2

Calculate Total Daily Insulin Requirement

For a 100-kg patient with severe hyperglycemia (A1C >10%), start with 0.3–0.5 units/kg/day as the total daily dose, which equals 30–50 units/day total. 3, 2 The current 30 units of Tuojeo represents only basal coverage and is profoundly insufficient for this degree of hyperglycemia. 2

Restructure to Basal-Bolus Regimen

Split the total daily dose 50% basal and 50% prandial:

• Basal insulin (Tuojeo): Increase from 30 units to 40–50 units once daily at bedtime (representing 50% of a 80–100 unit total daily dose). 3, 2
• Prandial insulin: Initiate rapid-acting insulin (lispro, aspart, or glulisine) at 4–6 units before each of the three largest meals (totaling 12–18 units prandial coverage). 3, 2

Administer prandial insulin 0–15 minutes before meals for optimal postprandial control. 3

Aggressive Titration Protocol

Basal Insulin (Tuojeo) Titration

• If fasting glucose ≥180 mg/dL: increase by 4 units every 3 days. 3, 2
• If fasting glucose 140–179 mg/dL: increase by 2 units every 3 days. 3, 2
• Target fasting glucose: 80–130 mg/dL. 3, 2
• Critical threshold: Stop basal escalation when dose approaches 0.5 units/kg/day (≈50 units) without achieving targets; at this point, intensify prandial insulin instead to avoid "over-basalization." 3, 4

Prandial Insulin Titration

• Increase each meal dose by 1–2 units (10–15%) every 3 days based on 2-hour postprandial glucose readings. 3, 2
• Target postprandial glucose: <180 mg/dL. 3, 2
• Add correction doses: 2 units for pre-meal glucose >250 mg/dL; 4 units for >350 mg/dL (in addition to scheduled prandial dose). 3

Essential Foundation Therapy

Continue or optimize metformin to at least 1000 mg twice daily (2000 mg total daily dose) unless contraindicated. 3, 2 Metformin reduces total insulin requirements by 20–30% and provides superior glycemic control compared to insulin alone. 3, 2 The maximum effective dose is up to 2500 mg daily. 3

Monitoring Requirements

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

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. 3 An A1C reduction of 3–4% (from 11.1% to approximately 7–8%) is achievable within 3–6 months with intensive insulin titration combined with metformin. 3, 2

Critical Pitfalls to Avoid

• Do not continue escalating Tuojeo alone beyond 0.5 units/kg/day (≈50 units) without adding prandial insulin; this leads to over-basalization with increased hypoglycemia risk and suboptimal control. 3, 4
• Do not delay adding prandial insulin when A1C is 11.1%; this level of hyperglycemia mandates both basal and mealtime coverage from the outset. 3, 2
• Never rely solely on sliding-scale (correction) insulin without scheduled basal and prandial doses; major diabetes guidelines condemn this reactive approach as ineffective and dangerous. 3
• Do not discontinue metformin when intensifying insulin unless contraindicated; omission increases insulin requirements and worsens outcomes. 3, 2

Hypoglycemia Management

Treat any glucose <70 mg/dL promptly with 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if needed. 3 If hypoglycemia occurs without an obvious cause, reduce the implicated insulin dose by 10–20% immediately. 3 Provide comprehensive patient education on hypoglycemia recognition, treatment, proper injection technique, site rotation, and sick-day management. 3

Alternative Consideration: GLP-1 Receptor Agonist

If basal insulin exceeds 0.5 units/kg/day without achieving targets, consider adding a GLP-1 receptor agonist (e.g., semaglutide) instead of further prandial insulin escalation. 3 The basal-insulin + GLP-1 RA combination provides potent glucose-lowering with less weight gain and lower hypoglycemia risk than intensified basal-bolus regimens. 1, 3