What is the expected decrease in blood glucose levels with a 5 unit daily increase of Lantus (insulin glargine)?

From the Guidelines

A 5 unit daily increase of Lantus (insulin glargine) is expected to lower blood glucose levels, but the exact decrease is not directly stated in the provided evidence, however, a general guideline for titration is to increase the dose by 1–2 units or 10–15% twice weekly, as stated in the 2023 standards of care in diabetes 1. When considering the impact of a 5 unit daily increase of Lantus on blood glucose levels, several factors come into play, including the individual's insulin sensitivity, body weight, and overall metabolic state.

• The effect of insulin glargine on blood glucose levels develops gradually over a few days as it reaches steady state in the body.
• Individual responses to insulin glargine can vary significantly, with factors such as body weight and insulin resistance influencing the degree of glucose lowering.
• It is crucial for patients to monitor their blood glucose levels more frequently when adjusting their Lantus dose, especially to avoid hypoglycemia, and dose adjustments should be made cautiously, allowing the full effect of the previous adjustment to be observed before making further changes, typically no more frequently than every 3-4 days. The provided guideline suggests a more conservative approach to titration, increasing the dose by 1–2 units or 10–15% twice weekly 1, which implies that a 5 unit daily increase might be more aggressive than recommended, potentially leading to a more significant reduction in blood glucose levels, but also increasing the risk of hypoglycemia.
• Therefore, it is essential to closely monitor blood glucose levels and adjust the dose based on individual response, rather than adhering to a one-size-fits-all approach.
• The glucose-lowering impact of Lantus primarily affects fasting and between-meal glucose levels, rather than post-meal spikes, due to its steady basal insulin level over approximately 24 hours with minimal peaks.

From the Research

Expected Decrease in Blood Glucose Levels

• The expected decrease in blood glucose levels with a 5 unit daily increase of Lantus (insulin glargine) is not directly stated in the provided studies 2, 3, 4, 5, 6.
• However, the studies suggest that insulin glargine can help achieve target blood glucose levels more effectively and safely compared with NPH insulin, due to the reduced risk of hypoglycaemia, especially nocturnal hypoglycaemia 2, 3.
• A study on dosing of insulin glargine in the treatment of type 2 diabetes found that adequate titration of the insulin dose, either by physicians or by patients, can help patients reach treatment goals, including HbA(1c) <7% and FBG <5.5 mmol/L (<100 mg/dL) 4.
• Another study compared the incidence of nocturnal hypoglycemia and glycemic control following bedtime or morning insulin glargine plus glimepiride, and found that once-daily glargine can be administered in a flexible morning or bedtime regimen to achieve good glycemic control without any difference in hypoglycemia 5.
• A non-interventional, multicenter project found that the initiation of treatment with insulin glargine using the basal-bolus regime in patients with previous insulin therapy resulted in a reduction in the incidence of hypoglycemic events, including severe hypoglycemia and severe nocturnal hypoglycemia, and improved metabolic control in patients with diabetes 6.

Dose Titration and Glycemic Control

• The studies suggest that dose titration of insulin glargine is crucial to achieve good glycemic control with minimal hypoglycemia 2, 4.
• A simple titration regimen, such as titrating the daily insulin dose by 0-2,4, or 6-8 IU if mean fasting plasma glucose over the 3 previous days was >or=5.6-<6.7, >or=6.7-<7.8, >or=7.8-<10.0 or >or=10 mmol/L, respectively, can help patients reach target HbA(1c) levels 4.
• Patient-managed dose titration can also be effective, with greater reductions in HbA(1c) found with patient- versus clinic-managed titration [-1.22% vs -1.08%; P < 0.001] 4.

Limitations

• The provided studies do not directly address the question of how much a 5 unit daily increase of Lantus will lower blood sugar levels.
• The studies focus on the efficacy and safety of insulin glargine in achieving target blood glucose levels, rather than the specific effect of a 5 unit daily increase on blood glucose levels 2, 3, 4, 5, 6.