What adjustments can be made if blood glucose (BG) levels are not at goal with Lantus (insulin glargine)?

Intensifying Treatment When Blood Glucose Is Not at Goal with Lantus (Insulin Glargine)

When blood glucose levels are not at goal with Lantus (insulin glargine), you should first optimize the basal insulin dose through systematic titration, then consider adding other agents such as GLP-1 receptor agonists, SGLT2 inhibitors, or prandial insulin based on the patient's specific needs.

Optimizing Basal Insulin (Lantus) Therapy

Step 1: Proper Dose Titration

• Adjust Lantus dose every 3-4 days based on fasting blood glucose readings 1:

  • Increase by 6-8 units if FBG ≥180 mg/dL
  • Increase by 4 units if FBG 140-179 mg/dL
  • Increase by 2 units if FBG 120-139 mg/dL
  • Increase by 0-2 units if FBG 100-119 mg/dL

• Target fasting blood glucose should be 80-130 mg/dL 1

• Continue titration until target is reached or dose exceeds 0.5 units/kg/day 1

Step 2: Verify Administration Technique

• Ensure proper injection technique with rotation of injection sites 2
• Confirm Lantus is being administered at the same time every day 2
• Check for lipohypertrophy at injection sites which can affect insulin absorption 1

Adding Additional Agents

If blood glucose remains uncontrolled despite optimized basal insulin dosing:

Option 1: Add GLP-1 Receptor Agonist (Preferred)

• Add a GLP-1 receptor agonist before adding prandial insulin 3, 1
• Benefits include weight reduction, lower hypoglycemia risk, and cardiovascular benefits 1
• Fixed-ratio combinations of basal insulin and GLP-1 RA are available 1

Option 2: Add SGLT2 Inhibitor

• Consider adding an SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) 1
• Provides complementary mechanism of action with cardiovascular benefits 3, 1
• May be continued alongside insulin to improve glucose control and reduce insulin requirements 1

Option 3: Add Prandial Insulin

• If A1C remains above target despite optimized basal insulin (with or without other agents), add prandial insulin 3
• Start with one injection at the largest meal of the day 3
• Can progress to multiple daily injections if needed 3

Special Considerations

For High Insulin Requirements

• For patients requiring large doses (>200 units/day), consider U-500 regular insulin, U-300 glargine, or U-200 degludec 1
• Higher concentration insulins may improve absorption and efficacy 1

Medication Combinations

• Always continue metformin when using insulin unless contraindicated 1
• Consider discontinuing sulfonylureas when starting insulin due to hypoglycemia risk 3

Monitoring and Follow-up

• Monitor HbA1c every 3 months to assess overall glycemic control 1
• Target HbA1c <7.0% to decrease microvascular complications 1
• Evaluate for hypoglycemia and adjust therapy as needed 1

Pitfalls to Avoid

• Therapeutic inertia: Delaying intensification when goals aren't met leads to prolonged hyperglycemia 3
• Ignoring postprandial glucose: Postprandial readings >200 mg/dL indicate need for therapy intensification 1
• Overlooking hypoglycemia: Frequent hypoglycemia may indicate need to adjust insulin timing or add agents with lower hypoglycemia risk 1
• Discontinuing metformin: Continue metformin when starting insulin for better outcomes 1

By following this structured approach to intensifying therapy when blood glucose is not at goal with Lantus, you can systematically improve glycemic control while minimizing risks of hypoglycemia and other adverse effects.