From the Guidelines
For a patient with an HbA1c level greater than 14, the initial dose of Lantus (insulin glargine) should be 0.1 to 0.2 units/kg of body weight per day, which is a safe and simple approach to initiate basal insulin therapy. This recommendation is based on the American Diabetes Association standards of medical care in diabetes, as outlined in the 2017 guidelines 1. For example, a 70 kg patient would start with approximately 7-14 units of Lantus.
Key Considerations
- The dose will need to be titrated based on fasting blood glucose readings, usually increasing by 10% to 15%, or 2 to 4 units, once or twice weekly until the fasting blood glucose target is met 1.
- Patients with very high HbA1c levels often require higher starting doses and may need rapid-acting insulin before meals in addition to Lantus.
- It's essential to monitor for hypoglycemia, especially overnight, and to educate patients about recognizing and treating low blood sugar.
- The physiological basis for starting with this dose is to provide enough basal insulin to suppress hepatic glucose production without causing dangerous hypoglycemia while the patient's insulin sensitivity improves with treatment.
Additional Guidance
- Insulin therapy should be used with metformin and sometimes 1 additional noninsulin agent, considering cost and the potential for hypoglycemia 1.
- Premixed insulin products containing both basal and prandial insulin are another option for patients who may benefit from simpler dosing, but this approach requires a relatively fixed meal schedule and carbohydrate content per meal 1.
- The 2016 American Diabetes Association standards of medical care in diabetes also support the use of basal insulin, such as Lantus, as a starting point for insulin therapy, with a recommended initial dose of 10 units or 0.1 to 0.2 units/kg of body weight 1.
From the FDA Drug Label
2.3 Initiation of Insulin Glargine-yfgn Therapy Recommended Starting Dosage in Patients with Type 2 Diabetes The recommended starting dosage of Insulin Glargine-yfgn in patients with type 2 diabetes who are not currently treated with insulin is 0.2 units/kg or up to 10 units once daily.
The initial dose of Lantus (glargine) for a patient with severely elevated HbA1c levels is 0.2 units/kg or up to 10 units once daily 2.
From the Research
Initial Dose of Lantus for Severely Elevated HbA1c
- The provided studies do not directly address the initial dose of Lantus (glargine) for a patient with an HbA1c level greater than 14% 3, 4, 5, 6, 7.
- However, study 4 mentions that the goal was to achieve a fasting plasma glucose (FPG) of 4.0 to 5.5 mmol/l, and the insulin doses were 68+/-5 and 70+/-6 IU/day in the G+MET and NPH+MET groups, respectively.
- Study 6 states that the combination therapy of metformin and glimepiride plus glargine insulin resulted in a significant improvement in overall glycemic control, with a decrease in HbA1c from 8.7±0.9% to 7.3±0.6%.
- Study 7 compares the efficacy and safety of once-weekly albiglutide with once-daily insulin glargine, with an initial dose of 10 U once a day for insulin glargine, and reports a reduction in HbA1c from 8.36±0.95% to 7.55±1.04%.
- Based on these studies, it appears that the initial dose of Lantus may vary depending on the patient's specific condition and the treatment approach, but a common starting point is around 10 U once a day, with adjustments made based on the patient's glycaemic response 7.
Considerations for Insulin Therapy
- The decision to initiate insulin therapy should be based on individual patient factors, including the severity of hyperglycemia, the presence of symptoms, and the patient's overall health status 5.
- Insulin glargine may be considered as an add-on therapy to oral anti-diabetic drugs, such as metformin and glimepiride, to improve glycemic control 6.
- The choice of insulin regimen and dose should be tailored to the individual patient's needs, with consideration given to factors such as weight, lifestyle, and comorbidities 4, 7.