What adjustments should be made to a type 1 diabetic patient's Toujeo (insulin glargine) regimen, currently at 28 units daily, to address morning hyperglycemia?

From the Guidelines

To address morning hyperglycemia in a type 1 diabetic patient currently taking 28 units of Toujeo daily, I recommend increasing the Toujeo dose by 2 units (to 30 units daily) based on the guidelines provided by the most recent study 1. This adjustment should be made gradually, with blood glucose monitoring before breakfast for 3-5 days to assess the impact. If morning hyperglycemia persists after this initial adjustment, further increases of 2 units every 3-5 days may be necessary until target fasting glucose levels (typically 80-130 mg/dL) are achieved, as suggested by the guidelines for titrating basal insulin dose based on fasting finger-stick glucose test results over a week 1. The timing of Toujeo administration should remain consistent each day, preferably in the evening, but the guidelines also suggest considering a change in timing from bedtime to morning if necessary 1. Morning hyperglycemia often results from the dawn phenomenon (early morning release of counter-regulatory hormones like cortisol and growth hormone) or insufficient basal insulin coverage overnight. Toujeo has a flat, prolonged action profile lasting beyond 24 hours, making it suitable for addressing overnight glucose control when properly dosed. The patient should continue monitoring for hypoglycemia, especially during the night, as the dose increases. If hypoglycemia occurs, the dose should be reduced by 2 units, following the guideline's recommendation for adjusting the dose if more than two fasting finger-stick values per week are below 80 mg/dL 1. Adjustments to mealtime insulin may also be necessary if the problem persists despite optimized basal insulin. Key considerations include:

• Monitoring fasting glucose levels to guide dose adjustments
• Adjusting the dose based on the guidelines provided for basal insulin titration
• Considering the addition of noninsulin agents if necessary, following the guidelines for patients with inadequate glucose control on insulin therapy alone 1.

From the Research

Adjusting Toujeo Regimen for Morning Hyperglycemia

To address morning hyperglycemia in a type 1 diabetic patient currently on 28 units of Toujeo (insulin glargine) daily, several adjustments can be considered:

• Dose Titration: According to 2, basal insulin doses can be titrated based on self-measured fasting plasma glucose levels, aiming for a target range of 80-130 mg/dL. A simple rule is to gradually increase the dose by 1 unit per day (for NPH, insulin detemir, and glargine 100 units/mL) or 2-4 units once or twice per week until FPG levels remain consistently within the target range.
• Twice-Daily Injections: As suggested by 3, switching to a twice-daily regimen of Toujeo may help resolve morning hypoglycemia and improve glycemic control. This approach may be particularly beneficial for patients experiencing significant morning hyperglycemia despite optimized once-daily dosing.
• Addressing the Dawn Phenomenon: The dawn phenomenon, characterized by an increase in blood glucose levels during the early morning hours, is a common cause of morning hyperglycemia in diabetic patients 4. Adjusting the timing or dose of basal insulin, or using alternative basal insulin preparations, may help mitigate this effect.
• Insulin Pump Therapy: For some patients, insulin pump therapy may offer improved glycemic control and reduced frequency of morning hyperglycemia, as demonstrated by 5. This option may be particularly suitable for patients with type 1 diabetes who experience significant variability in their glucose levels.
• Continuous Glucose Monitoring and Pump Attenuation: The use of continuous glucose monitoring (CGM) and insulin pump attenuation algorithms, such as those described in 6, can help prevent hypoglycemia and improve glycemic control. These technologies can provide real-time glucose data and adjust insulin delivery accordingly, reducing the risk of morning hyperglycemia.

Key Considerations

When adjusting the Toujeo regimen, it is essential to:

• Monitor fasting plasma glucose levels closely to guide dose titration
• Consider the patient's individual needs and response to different basal insulin regimens
• Be aware of the potential for overbasalization and adjust the dose accordingly to avoid hypoglycemia
• Explore alternative therapies, such as insulin pump therapy or CGM, if morning hyperglycemia persists despite optimized basal insulin dosing.