What is the recommended dose and administration timing for basal insulin, such as Lantus (glargine) or Levemir (detemir)?

Basal Insulin Administration and Dosing

Basal insulin should be initiated at 0.1-0.2 units/kg/day or 10 units once daily, administered at the same time each day, with dose adjustments based on fasting blood glucose levels. 1, 2

Initial Dosing

The recommended starting dose for basal insulin depends on the patient's clinical situation:

• Type 2 diabetes (insulin-naive):

  • 0.1-0.2 units/kg/day or 10 units once daily 3, 1, 4
  • For patients with higher insulin resistance (obesity, infections, open wounds): Consider 0.3-0.4 units/kg/day 5
  • For patients with increased sensitivity (elderly, renal/hepatic impairment): Lower to 0.1 units/kg/day 3, 5

• Type 1 diabetes:

  • Approximately one-third of total daily insulin requirements as basal insulin 1
  • Must be used with prandial insulin 1

Administration Timing

• Administer subcutaneously once daily at the same time every day 1
• For insulin detemir (Levemir):
  • Can be administered once or twice daily 2
  • Once-daily: Administer with evening meal or at bedtime 2
  • Twice-daily: Administer morning dose and evening dose 12 hours apart 2

Injection Sites

• Administer subcutaneously into:
  • Abdominal area
  • Thigh
  • Upper arm (deltoid) 1
• Rotate injection sites within the same region to reduce risk of lipodystrophy 1

Dose Titration

Titration should be based on fasting blood glucose measurements:

• Simple titration rule:

  • Increase dose by 2 units every 3-7 days if fasting glucose remains above target 3, 4
  • Decrease dose by 2 units if fasting glucose falls below 80 mg/dL (4.4 mmol/L) 3

• Target fasting glucose:

  • General target: 80-130 mg/dL (4.4-7.2 mmol/L) 4
  • For older adults or those with comorbidities: 90-150 mg/dL (5.0-8.3 mmol/L) 3

Avoiding Common Pitfalls

1. Overbasalization:

   • Avoid continuing to escalate basal insulin beyond 0.5-1.0 units/kg/day without improvement in fasting glucose 4
   • If basal dose exceeds 0.5 units/kg/day with suboptimal control, consider adding prandial insulin or GLP-1 receptor agonist 3

2. Hypoglycemia risk:

   • Increase monitoring frequency during dose adjustments 1
   • Use lower starting doses in elderly, those with renal/hepatic impairment, or poor oral intake 3

3. Switching between basal insulins:

   • When switching from NPH to glargine: Use same total daily dose 1
   • When switching from twice-daily NPH to once-daily glargine: Use 80% of total NPH dose 1
   • When switching from twice-daily detemir/glargine to degludec: Consider 10-20% dose reduction 6

Special Considerations

• Hospitalized patients:

  • For patients on continuous enteral feeding: Consider dividing total daily dose into every 8-hour administration 5
  • For surgical patients: Give 60-80% of usual basal insulin dose on day of surgery 3

• Older adults:

  • Consider simplified regimen with once-daily basal insulin
  • Target higher fasting glucose (90-150 mg/dL) 3
  • Avoid bedtime rapid-acting insulin 3

Remember that basal insulin should be titrated gradually over weeks to achieve target fasting glucose levels, with careful attention to hypoglycemia risk and individual patient factors.