How to titrate the dose of Lantus (insulin glargine) and Actrapid (insulin aspart) for a patient requiring 180 units of insulin per day?

Insulin Titration for a Patient Requiring 180 Units Daily

For a patient requiring 180 units of insulin daily, divide the total dose with 50% as Lantus (90 units) and 50% as Actrapid distributed across three meals (30 units per meal), then titrate each component separately based on blood glucose patterns. 1, 2

Initial Dose Distribution

Basal Insulin (Lantus)

• Start with 90 units (50% of total daily dose) 1
• Administer once daily at bedtime
• If severe nocturnal hypoglycemia occurs, consider splitting into twice-daily dosing (45 units in morning and 45 units in evening) 3

Bolus Insulin (Actrapid)

• Start with 90 units total (50% of total daily dose) 1
• Distribute as 30 units before each meal (breakfast, lunch, dinner)
• Consider adjusting distribution based on meal size and carbohydrate content 2

Titration Algorithm

Lantus (Basal) Titration

• Adjust dose every 3 days based on fasting blood glucose (FBG) patterns 1, 4:
  • FBG ≥180 mg/dL: Increase by 6-8 units
  • FBG 140-179 mg/dL: Increase by 4 units
  • FBG 120-139 mg/dL: Increase by 2 units
  • FBG 100-119 mg/dL: Maintain or increase by 0-2 units
  • FBG <100 mg/dL: Decrease by 2-4 units
  • Any hypoglycemia (<70 mg/dL): Decrease by 10-20% 1

Actrapid (Bolus) Titration

• Adjust each meal dose separately based on 2-hour postprandial glucose (PPG) 1, 2:
  • PPG >200 mg/dL: Increase by 2-4 units
  • PPG 150-200 mg/dL: Increase by 1-2 units
  • PPG 100-150 mg/dL: No change
  • PPG <100 mg/dL: Decrease by 1-2 units
  • Any hypoglycemia: Decrease corresponding meal dose by 10-20% 1

Monitoring Requirements

• Check blood glucose at least 4 times daily 2:
  • Fasting (before breakfast)
  • Before lunch
  • Before dinner
  • At bedtime
• Add occasional 2-hour postprandial checks to evaluate meal coverage
• Evaluate for signs of overbasalization 1:
  • Nocturnal hypoglycemia
  • Large drops between bedtime and morning glucose
  • High glucose variability throughout the day

Special Considerations

Signs to Adjust Insulin Distribution

• If fasting glucose is at target but HbA1c remains elevated: Increase mealtime insulin 1
• If postprandial excursions are large: Increase mealtime insulin for specific meals 2
• If nocturnal hypoglycemia occurs: Reduce evening Lantus dose or split into twice-daily dosing 3
• If consistent pattern of afternoon hypoglycemia: Reduce lunch Actrapid dose

Potential Pitfalls

• Hypoglycemia risk: Most common between midnight and 6 AM; ensure patient carries fast-acting carbohydrates 2
• Weight gain: Monitor weight; consider adding metformin if not contraindicated 2
• Insulin resistance: For patients requiring >1 unit/kg/day, consider adding insulin-sensitizing agents 2
• Inconsistent meal timing: Emphasize importance of consistent carbohydrate intake and meal timing 2

Optimization Strategies

• Consider carbohydrate counting with insulin-to-carb ratios:
  • Breakfast ratio: 1 unit per (300÷180) = ~1.7g carbohydrate
  • Lunch/dinner ratio: 1 unit per (400÷180) = ~2.2g carbohydrate 5
• For persistent hyperglycemia despite optimized insulin, consider adding GLP-1 receptor agonist 2

Remember that such high insulin requirements (180 units) suggest significant insulin resistance. Regularly reassess for factors that may be contributing to insulin resistance, such as infection, medication effects, or obesity, and address these underlying factors when possible.