From the Guidelines
For a patient with persistent hyperglycemia on Lantus 21 units twice daily, insulin sliding scale, and metformin 850mg, I recommend increasing the Lantus dose by 10-15% (approximately 2-3 units per dose) twice weekly, as suggested by the most recent guidelines 1. This approach is supported by the latest standards of care in diabetes, which emphasize the importance of titrating basal insulin to control fasting hyperglycemia while minimizing the risk of hypoglycemia. When making insulin adjustments, it's crucial to proceed cautiously and monitor blood glucose levels more frequently, particularly before meals and at bedtime, to avoid hypoglycemia. The adjustment should be maintained for 3-5 days before considering further increases, as insulin glargine takes time to reach steady state. Additionally, assessing the adequacy of the basal insulin dose and considering clinical signals for overbasalization, as outlined in recent guidelines 1, can help in evaluating the need for adjunctive therapies. If hyperglycemia persists after this adjustment, further evaluation of the patient's diet, activity level, medication adherence, and potentially adding or adjusting bolus insulin may be necessary. It's also important to set a target for fasting plasma glucose (FPG) and choose an evidence-based titration algorithm to guide further adjustments, ensuring that the patient's glycemic targets are met without increasing the risk of hypoglycemia 1.
From the Research
Adjusting Lantus Dosage for Persistent Hyperglycemia
To address the issue of persistent hyperglycemia in a patient currently on Lantus 21 units twice daily, an insulin sliding scale, and metformin 850mg, we need to consider how adjustments to the Lantus dosage can be made effectively.
Understanding Lantus: Lantus (insulin glargine) is a long-acting insulin analogue that provides a relatively constant basal level of circulating insulin with no pronounced peak 2. It is used to achieve basal insulin supplementation and can be adjusted based on the patient's blood glucose levels as part of an aggressive regimen to achieve near normoglycaemia without incurring episodes of hypoglycaemia.
Adjusting Lantus Dosage: The adjustment of Lantus dosage should be individualized, taking into account the patient's current blood glucose levels and their response to the current insulin regimen. While there is no specific guideline in the provided studies for the exact amount to increase Lantus in the context given, the principle is to adjust the dose based on the patient's glucose monitoring results, aiming for a fasting plasma glucose (FPG) within the target range.
Combination Therapy with Metformin: Studies have shown that combining metformin with insulin (including Lantus) can improve glycemic control and reduce insulin requirements in patients with type 2 diabetes 3, 4. Metformin increases peripheral insulin sensitivity, reduces hepatic gluconeogenesis, and decreases intestinal glucose absorption, which complements the action of insulin.
Considerations for Adjustment:
- The patient's current regimen includes an insulin sliding scale, which is used to correct high blood glucose levels. Adjustments to the Lantus dose should consider the patient's overall insulin needs and how the basal insulin dose interacts with the sliding scale corrections.
- Monitoring for hypoglycemia is crucial when adjusting insulin doses, especially in patients on multiple therapies that can lower blood glucose.
- The goal is to achieve good glycemic control without significantly increasing the risk of hypoglycemia or other adverse effects.
Clinical Decision: The decision on how much to increase the Lantus dose should be based on clinical judgment, considering the patient's response to therapy, their target glucose levels, and the presence of any side effects. It's essential to monitor the patient's glucose levels closely after any adjustments to the insulin regimen and to be prepared to make further adjustments as needed.