At what dose of Lantus (insulin glargine) do you start splitting to twice daily (BID)?

When to Split Lantus (Insulin Glargine) to Twice Daily Dosing

Lantus (insulin glargine) should be split to twice daily (BID) dosing when the total daily dose exceeds 0.5 units/kg/day, as this indicates potential overbasalization and may lead to hypoglycemia with once-daily dosing. 1

Indicators for Splitting Lantus Doses

When evaluating whether to split Lantus dosing, consider these clinical signals:

• Total daily dose threshold: When basal insulin dose exceeds ~0.5 units/kg/day 1
• Glycemic patterns suggesting overbasalization:
  • Elevated bedtime-to-morning glucose differential
  • High postprandial-to-preprandial glucose differential
  • Hypoglycemia (aware or unaware)
  • High glucose variability throughout the day 1

Implementation of Split Dosing

When transitioning from once-daily to twice-daily Lantus:

1. Calculate the new total dose: Use 80% of the current total daily dose to reduce hypoglycemia risk 2
2. Divide the dose: Typically distribute as 2/3 in the morning and 1/3 in the evening 1
3. Timing: Administer at consistent times approximately 12 hours apart

Titration After Splitting

• Adjust each component of the regimen based on individualized needs 1
• Morning dose: Titrate based on pre-dinner glucose readings
• Evening dose: Titrate based on fasting morning glucose readings
• Use an evidence-based titration algorithm: increase by 2 units every 3 days until reaching target without hypoglycemia 1
• For hypoglycemia without clear cause: reduce the corresponding dose by 10-20% 1

Special Considerations

• In obese, insulin-resistant patients, splitting the dose may be particularly beneficial due to the high volumes of insulin required 3
• In patients with labile type 1 diabetes, twice-daily dosing may provide more effective glycemic control 3
• Patients experiencing morning hypoglycemia despite titration of once-daily Lantus should be considered for twice-daily dosing 4

Benefits of Split Dosing

• Provides more consistent 24-hour insulin coverage 5
• Prevents late afternoon glucose rises that can occur with once-daily dosing 5
• Reduces within-day glucose variability 5
• May help achieve glycemic targets more safely in patients who experience hypoglycemia on once-daily dosing 4

Remember that insulin glargine should never be mixed with other insulins in the same syringe due to its acidic pH 2. Always monitor patients closely after changing insulin regimens to ensure optimal glycemic control and safety.