When do I change Lantus (insulin glargine) to twice daily dosing?

When to Change Lantus to Twice Daily Dosing

Lantus (insulin glargine) should be changed to twice daily dosing when the total daily dose exceeds 0.5 units/kg/day, which indicates potential overbasalization and risk of hypoglycemia with once-daily dosing. 1

Clinical Indicators for Switching to Twice Daily Dosing

• Total daily dose threshold: When Lantus dose exceeds 0.5 units/kg/day
• Glycemic pattern indicators:
  • Elevated bedtime-to-morning glucose differential
  • High postprandial-to-preprandial glucose differential
  • Unexplained hypoglycemia episodes
  • High glucose variability throughout the day
  • Inadequate 24-hour coverage with once-daily dosing

Benefits of Twice Daily Dosing

• More consistent basal insulin levels throughout 24 hours
• Reduced risk of hypoglycemic episodes, especially nocturnal hypoglycemia
• Better glycemic control for patients with labile diabetes 2
• More appropriate for insulin-resistant obese patients requiring high insulin volumes 2

Implementation of Twice Daily Dosing

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

1. Divide the total daily dose:

   • Typically distribute as 2/3 in the morning and 1/3 in the evening 1
   • For example: If current dose is 60 units daily, start with 40 units in morning and 20 units in evening

2. Titration strategy:

   • Adjust morning dose based on pre-dinner glucose readings
   • Adjust evening dose based on fasting morning glucose readings
   • Use 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%

Special Considerations

• Insulin glargine should not be mixed with other insulins in the same syringe due to its acidic pH 1
• For patients with type 1 diabetes, Lantus should be used in combination with short-acting insulin analogues for meal coverage 3
• For patients with type 2 diabetes, oral hypoglycemic agents may be continued alongside Lantus 3

Common Pitfalls to Avoid

• Underdosing: Some clinicians hesitate to use adequate insulin doses, leading to suboptimal glycemic control
• Failure to recognize the need for split dosing: Missing the clinical signals that indicate once-daily dosing is insufficient
• Improper dose distribution: Not appropriately dividing the total daily dose between morning and evening injections
• Inadequate monitoring: Not tracking both fasting and pre-dinner glucose levels to guide dose adjustments

By following these guidelines, you can optimize insulin glargine therapy and improve glycemic control while minimizing the risk of hypoglycemia in patients requiring higher insulin doses.