Insulin Regimen Adjustment for Poorly Controlled Diabetes

Assessment and Adjustment of Insulin Regimen

The American Diabetes Association suggests that a patient's A1C of 11% indicates severely uncontrolled diabetes, suggesting the current insulin regimen is inadequate despite using both basal and bolus insulins 1, 2
The current total daily basal insulin dose may be insufficient given the high A1C, with a recommended increase of 10-20% to improve fasting glucose control 1, 2
The fixed prandial insulin dose may not be appropriately matched to carbohydrate intake and pre-meal glucose levels, with a recommended increase based on pre-meal glucose readings and carbohydrate content of meals 3

The American Association of Clinical Endocrinologists recommends increasing the total basal insulin dose by 10-20% to improve fasting glucose control, with a target of reducing A1C to less than 7% 1, 2
Adjusting the morning dose to 24 units and the evening dose to 18 units (approximately 20% increase) can help achieve fasting plasma glucose targets 1
The Endocrine Society suggests setting a fasting plasma glucose target and titrating the evening dose by 2 units every 3 days until reaching target without hypoglycemia 1, 2

The American Diabetes Association recommends increasing the prandial insulin doses based on pre-meal glucose readings and carbohydrate content of meals, with a target of reducing post-meal glucose values to less than 180 mg/dL 3, 2
Starting with increasing each pre-meal lispro dose to 25 units (approximately 25% increase) and further titrating each mealtime dose by 1-2 units or 10-15% twice weekly based on 2-hour post-meal glucose values can help achieve glycemic targets 1, 3

The American Association of Clinical Endocrinologists suggests assessing for adequacy of basal insulin by evaluating overnight and fasting glucose trends, with a recommended adjustment of the basal insulin dose based on these trends 1, 2
Considering clinical signals of overbasalization, such as basal dose greater than 0.5 units/kg/day, elevated bedtime-morning glucose differential, or hypoglycemia, can help optimize basal insulin doses 1

The Endocrine Society recommends considering the addition of a GLP-1 receptor agonist if glycemic targets are not achieved after optimizing basal-bolus insulin, which can improve glycemic control while potentially reducing insulin requirements 1
Ensuring the patient receives comprehensive diabetes self-management education to improve adherence and self-care behaviors is crucial for achieving glycemic targets 4