What is the recommended dose increase for Lantus (insulin glargine)?

Lantus (Insulin Glargine) Dose Adjustment Guidelines

The recommended approach for increasing Lantus (insulin glargine) is to add 1-2 units (or 5-10% for those on higher doses) to the daily dose once or twice weekly if fasting glucose levels remain above target, with more modest and less frequent adjustments as the target is approached. 1

Initial Dosing and Titration Algorithm

Starting Dose

• Initial dose for insulin-naive patients: 10 units per day or 0.1-0.2 units/kg/day 2
• For patients with severe hyperglycemia: 0.3-0.4 units/kg/day may be reasonable 1

Titration Process

1. Standard Titration:

   • Increase by 1-2 units once or twice weekly if fasting glucose remains above target 1
   • For patients on higher doses (>30 units), use 5-10% increments instead 1, 2
   • Make smaller, less frequent adjustments as target is approached 1

2. Self-Titration Option:

   • Patients can be taught to adjust their own insulin based on fasting glucose readings 1
   • This requires frequent contact with healthcare provider (phone, email) during titration phase 1

3. Monitoring Requirements:

   • Daily blood glucose monitoring is essential during titration phase 1
   • Reduce monitoring frequency once dose is stabilized 1

Important Considerations

Hypoglycemia Management

• Reduce dose immediately if any hypoglycemia occurs 1, 2
• Typically reduce by 10-20% if hypoglycemia is documented 2
• Elderly patients, those with renal failure, or poor oral intake should start with lower doses (0.3 units/kg/day) to minimize hypoglycemia risk 2

Dose Thresholds

• When basal insulin dose exceeds 0.5 units/kg/day, consider adding prandial insulin 1, 2
• As dose approaches 1 unit/kg/day, prandial insulin addition becomes increasingly necessary 1

Timing Considerations

• Lantus can be administered at any time of day (morning, evening, or bedtime) with similar glycemic control 3
• Morning administration may be associated with lower rates of nocturnal hypoglycemia compared to evening or bedtime dosing 3

When to Consider Adding Prandial Insulin

• When fasting glucose is at target but HbA1c remains above goal after 3-6 months of basal insulin titration 1
• When significant postprandial glucose excursions occur (>180 mg/dL) 1
• When basal insulin dose exceeds 0.5 units/kg/day 1, 2
• When large drops in glucose occur overnight or between meals as basal insulin dose increases 1

Common Pitfalls to Avoid

1. Overly aggressive titration: Increases risk of hypoglycemia; follow the 1-2 unit or 5-10% incremental approach 1

2. Inadequate monitoring: Daily glucose monitoring is essential during titration phase 1

3. Failure to reduce dose when adding prandial insulin: When adding prandial insulin, basal insulin dose should be simultaneously decreased 1

4. Ignoring exercise effects: Exercise increases insulin sensitivity and may require dose reduction before planned physical activity 2

5. Prolonged periods of uncontrolled hyperglycemia: Avoid many months of poor control; consider more aggressive therapy if targets aren't being reached 1

Lantus has been shown to provide effective glycemic control with reduced risk of hypoglycemia (particularly nocturnal) compared to NPH insulin 4, making it a preferred basal insulin option for many patients with type 2 diabetes.