Insulin Regimen Adjustment for Patients with Elevated HbA1c

Assessment and Adjustment of Insulin Regimen

The American Diabetes Association recommends that an HbA1c of 8.7% indicates suboptimal glycemic control and requires treatment intensification to reduce the risk of diabetes-related complications 2
The current insulin doses are relatively low and provide an opportunity for dose optimization, with the American College of Endocrinology suggesting that increasing the long-acting insulin dose by 4 units (from 10 to 14 units) can help achieve target glycemic control 1
Increasing the short-acting insulin dose from 4 units to 6 units before each meal (50% increase) can also help improve glycemic control, as recommended by the American Association of Clinical Endocrinologists 1

The American Diabetes Association recommends instructing patients to monitor blood glucose before meals and at bedtime to guide further insulin adjustments, with a goal of achieving a fasting glucose level of 90-150 mg/dL 4
The National Kidney Foundation suggests scheduling follow-up in 2-3 weeks to evaluate the response to therapy and make additional adjustments if needed, and re-checking HbA1c in 3 months to evaluate the effectiveness of the regimen change 4

The American College of Endocrinology recommends monitoring for signs of overbasalization (elevated bedtime-to-morning glucose differential, hypoglycemia, high glucose variability) and adjusting the insulin dose accordingly 1

The American Diabetes Association suggests considering the addition of a GLP-1 receptor agonist for patients who do not achieve glycemic targets with insulin adjustments, which can be used in combination with insulin to improve glycemic control 1
The Endocrine Society recommends considering progression to a full basal-bolus plan with insulin before all meals for patients who continue to have elevated HbA1c despite optimized basal-bolus insulin 5