A 60-year-old man with type 2 diabetes on glargine 30 units at bedtime and metformin 1 g twice daily has fasting glucose of 170 mg/dL but postprandial values of 150 mg/dL. His total daily insulin requirement is estimated at 0.5 units/kg. What is the most appropriate next step?

• A Add a sulfonylurea to the current regimen
• B Add a rapid-acting insulin analog at the largest meal
• C Switch to premixed insulin 70/30 twice daily
• D Increase glargine dose to target fasting glucose ✓

Explanation

When fasting glucose is elevated but postprandial values are acceptable on basal insulin, the basal dose should be titrated upward first. The 'basal-first' approach targets fasting hyperglycemia before addressing postprandial excursions. Adding mealtime insulin (B) is indicated when postprandial values remain high after optimizing basal insulin. Premixed insulin (C) is less flexible. Adding a sulfonylurea (A) to basal insulin is not recommended due to hypoglycemia risk.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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