What is the management plan for a patient with severe hyperglycemia (A1c of 16.0) starting on Lantus (insulin glargine) 20 units at bedtime?

From the Guidelines

For a patient with severe hyperglycemia (A1c of 16.0) starting on Lantus (insulin glargine) 20 units at bedtime, I recommend starting with a lower dose of 10 units per day or 0.1-0.2 units/kg per day, as suggested by the most recent guidelines 1. The initial dose should be titrated weekly by 2 units every 3 days to reach the fasting plasma glucose (FPG) goal without hypoglycemia, as recommended by the 2025 standards of care in diabetes 1. This patient will also need rapid-acting mealtime insulin such as insulin lispro, aspart, or glulisine before meals, typically starting at 4 units per meal, and adjusting based on pre-meal glucose levels and carbohydrate intake. Blood glucose monitoring should be performed at least 4 times daily (before meals and at bedtime), with additional checks if symptoms of hypoglycemia occur. The patient should be educated about hypoglycemia symptoms (shakiness, sweating, confusion) and management with 15g of fast-acting carbohydrates. Lifestyle modifications including consistent carbohydrate intake, regular physical activity, and weight management are essential components of the treatment plan. This intensive approach is necessary because an A1c of 16.0% indicates severe insulin deficiency, and basal insulin alone will not be sufficient to achieve adequate glycemic control. Regular follow-up every 1-2 weeks initially is important to adjust insulin doses safely and effectively, considering clinical signals to evaluate for overbasalization and the need for adjunctive therapies, as suggested by the 2025 standards of care in diabetes 1. Key considerations in managing this patient include:

• Starting with a safe and effective dose of basal insulin and titrating as needed
• Adding rapid-acting mealtime insulin to control postprandial glucose excursions
• Monitoring blood glucose levels regularly and adjusting the treatment plan as needed
• Educating the patient on hypoglycemia management and lifestyle modifications to support glycemic control. Given the severity of the patient's hyperglycemia, it is crucial to prioritize their safety and adjust the treatment plan accordingly, taking into account the potential risks and benefits of different therapeutic approaches, as discussed in the 2017 American Diabetes Association standards of medical care in diabetes 1.

From the FDA Drug Label

1. 3 Initiation of Insulin Glargine Therapy Recommended Starting Dosage in Patients with Type 2 Diabetes The recommended starting dosage of Insulin Glargine 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 management plan for a patient with severe hyperglycemia (A1c of 16.0) starting on Lantus (insulin glargine) 20 units at bedtime is not directly supported by the provided drug label information. However, based on the recommended starting dosage for patients with type 2 diabetes, 20 units once daily may be considered a reasonable starting dose for some patients, but it is higher than the recommended starting dose of 0.2 units/kg or up to 10 units once daily.

• The patient's non-fasting glucose levels should be monitored closely to adjust the insulin dose as needed.
• Blood glucose monitoring should be increased in frequency during changes to the patient's insulin regimen.
• The patient's metabolic needs, blood glucose monitoring results, and glycemic control goals should be considered when adjusting the dosage of Insulin Glargine.
• Dosage adjustments should only be made under medical supervision with appropriate glucose monitoring 2.

From the Research

Management Plan for Severe Hyperglycemia

• The patient has an A1c of 16.0, indicating severe hyperglycemia, and is starting on Lantus (insulin glargine) 20 units at bedtime 3.
• The initial dose of insulin glargine can be adjusted based on the patient's response, with the goal of achieving a fasting blood glucose level between 70-130 mg/dL 3.
• The patient's non-fasting glucose levels should be monitored regularly to assess the effectiveness of the treatment plan and make adjustments as needed 4.

Insulin Therapy

• Insulin glargine is a long-acting insulin analog that provides a steady level of insulin in the body, helping to control blood glucose levels throughout the day 3.
• The use of insulin glargine has been shown to reduce the risk of hypoglycemia compared to NPH insulin, particularly at night 5.
• The patient's insulin dose may need to be adjusted over time to achieve optimal blood glucose control, with the goal of achieving an A1c level below 7% 4.

Monitoring and Adjustments

• The patient's blood glucose levels should be monitored regularly, including fasting and non-fasting levels, to assess the effectiveness of the treatment plan 3.
• Adjustments to the insulin dose should be made based on the patient's response, with the goal of achieving optimal blood glucose control 4.
• The patient should be educated on how to monitor their blood glucose levels, recognize signs of hypoglycemia, and adjust their insulin dose as needed 6, 7.